The New-Brunswick Appropriate Use of Antipsychotics (NB-AUA) Collaborative: Improving Dementia Care Across Nursing Homes PROSPECTUS February 2, 2016
The Canadian Foundation for Healthcare Improvement is a not-for-profit organization funded through an agreement with the Health Canada. The views expressed herein do not necessarily represent the views of the Health Canada. 2
Table of Contents Executive Summary... 4 About CFHI and NBANH... 5 About the New Brunswick-AUA (NB-AUA) Collaborative... 5 Benefits of Joining the NB-AUA Collaborative... 6 Why the NB-AUA Collaborative is Important... 6 How the NB-AUA Collaborative Works... 7 Who Should Participate in the NB-AUA Collaborative?... 8 Roles and Team Dynamic... 8 Team and Organization Support... 10 Orientation Webinar... 11 Learning Activities and Core Competencies... 11 Timeline at a Glance... 12 How to Join... 13 APPENDIX A: About CFHI s pan-canadian Reducing Antipsychotic Medication Use in Long Term Care Spread Collaborative (2014-2015)... 14 APPENDIX B: The NB-AUA Collaborative Timeline... 15 3
Executive Summary What is the New Brunswick Appropriate Use of Antipsychotics (NB-AUA) Collaborative? The NB-AUA is a 12-month fully bilingual quality improvement collaborative offered to select nursing homes across New Brunswick to improve dementia care in the province by promoting the appropriate use of antipsychotic medications. The Canadian Foundation for Healthcare Improvement (CFHI) and the New Brunswick Association of Nursing Homes (NBANH) are working together to: reduce inappropriate use of antipsychotics in nursing homes improve the quality and experience of dementia care for nursing home residents, families and staff build individual and organizational capacity in designing, implementing, evaluating, sustaining and spreading patient-centred and data-driven innovations in dementia care Why the NB-AUA Collaborative Is Important: Research shows that antipsychotic medications are minimally effective in managing the psychological and behavioural symptoms associated with dementia and are associated with worsening cognitive functions and serious adverse events. The NB-AUA Collaborative provides solutions to address appropriate prescribing of antipsychotic medications and equips organizations with improvement and change management capacity, enhanced leadership skills and new partnerships across sectors and the province. How the NB-AUA Works: Teams will consist of two to five inter-professional members (as identified in the Expression of Commitment form) and an Executive Sponsor (CEO). Each team member will have specific roles in the design and implementation of the initiative. Team members work collaboratively and gain knowledge and skills to adapt, implement, evaluate, sustain and spread an evidence-based innovation to reduce the inappropriate use of antipsychotic medications and improve dementia care in nursing homes in New Brunswick. All NB-AUA teams participate in an in-person workshop and a series of webinars, led by renowned faculty and improvement experts from across Canada. Teams also benefit from one-to-one coaching, peer-to-peer learning and the online learning community s resources, tools and e-forums. CFHI s Improvement Approach is the framework that guides the design and delivery of the NB-AUA Collaborative. What s the Timeline: Phase I of the NB-AUA will run from March 2016 to March 2017. Who Should Enroll: Organizations with strategic alignment to the goals of this collaborative, strong leadership commitment, and an engaged team of clinical, staff and family champions of the residents at the homes. How to Enroll: Interested organizations are asked to submit a completed Expression of Commitment Form on-line by March 4, 2016 to demonstrate their intent and readiness to participate in the collaborative, and submit a signed Memorandum of Understanding (MOU) by March 11, 2016. Contact Information: For more information about the NB-AUA, please contact: Kaye Phillips, Senior Director, CFHI Christine Quinn, Senior Improvement Lead, CFHI kaye.phillips@cfhi-fcass.ca christine.quinn@cfhi-fcass.ca 613-728-2238 Ext. 366 705-761-3183 4
About CFHI and NBANH The Canadian Foundation for Healthcare Improvement (CFHI) is a not-for-profit organization funded by the Health Canada. CFHI is dedicated to accelerating healthcare improvement by: building leadership and skill capacity to champion and lead improvement enabling patient, family and community engagement and involving those who experience and need care as experts in making and co-designing improvements applying improvement tools and methods to drive measureable results towards better care, better health and better value creating collaborations to spread evidence-informed improvement across Canada The New Brunswick Association of Nursing Homes (NBANH) leads member homes through a united voice advocating excellence in long term care and service delivery in New Brunswick. About the New Brunswick-AUA (NB-AUA) Collaborative The NB-AUA Collaborative builds on the success of CFHI s pan-canadian Reducing Antipsychotic Medication in Long Term Care Collaborative (June 2014-September 2015). Click here to see the video about the Collaborative. Fifty-six long term care facilities across seven Canadian provinces and one territory participated in the pan- Canadian collaborative (See Appendix A). More than half of the targeted residents in this collaborative had their antipsychotic medication discontinued or significantly reduced and experienced additional benefits (See Figure 1). The York Care Centre team in New Brunswick successfully discontinued or significantly reduced antipsychotic medication use along with reduced costs. Figure 1: CFHI pan-canadian Reducing Antipsychotic Medication in Long Term Care Collaborative Results 5
The NBANH and CFHI are working together to help other New Brunswick nursing homes achieve similar results through the NB-AUA Collaborative. Select nursing homes from across New Brunswick are invited to participate in this 12-month fully bilingual quality improvement collaborative. The objectives of the NB-AUA Collaborative are to: reduce inappropriate use of antipsychotics in nursing homes improve the quality and experience of dementia care for nursing home residents, families and staff build individual and organizational capacity in designing, implementing, evaluating, sustaining and spreading patient-centred and data-driven dementia care innovations Benefits of Joining the NB-AUA Collaborative CFHI support to implement, evaluate and spread proven evidence-informed elder-friendly care practices Peer-to-peer networking and exchange among the entire collaborative Monthly team educational webinars Support for performance measurement and evaluation An in-person workshop to foster cross-team learning and sharing Access to a network of expert faculty and coaches who have led appropriate prescribing and patient-centred care initiatives across Canada and internationally Individual coaching to ensure a rapid pace for testing change and troubleshooting, as needed Access to online learning tools and activities Why the NB-AUA Collaborative is Important New Brunswick has an aging population and a rate of antipsychotic use among the elderly that is nearly twice the national average. In 2013, New Brunswick had the highest provincial rate of antipsychotic use in the elderly (98 users per 1,000 population eligible) among public drug plan beneficiaries in Canada, a rate that was nearly two times higher than the national average (comprised of eight provinces) of 55 users per 1,000 eligible. 1 New Brunswick s population is aging at a faster rate than the rest of Canada and based on current trends, by 2020 the New Brunswick population will be a full five years older than the national 1 Tadrous, M., Martins, D., Herrmann, N., Fernandes, K., Yao, Z., Singh, S., Paterson, M., Juurlink, D., Mamdani, M., Gomes. T. (2015). Antipsychotic in the elderly: Final Report Pharmacoepidemiology Unit. Toronto, ON: Ontario Drug Policy Research Network. Retrieved from http://odprn.ca/antipsychotics-in-the-elderly/ 6
average. 2 By 2026, it is projected that citizens 65 years and older will account for 25.7 percent of the total population in New Brunswick. 3 Research shows that antipsychotic medications are minimally effective in managing behavioural issues 4 and are associated with worsening cognitive functions 5 and serious adverse events. Nonpharmacological interventions, such as patient-centred approaches, are encouraged as a first approach to managing the behavioural and psychological symptoms of dementia. 6 How the NB-AUA Collaborative Works Two to five inter-disciplinary teams members and an Executive Sponsor (CEO) participate in the NB-AUA Collaborative. Roles and responsibilities of the team members are outlined below and in the Expression of Commitment. Team members work collaboratively and gain knowledge and skills to adapt, implement, evaluate, sustain and spread patient-centred and data-driven approaches for reducing the inappropriate use of antipsychotic medications improving dementia care. Teams participate in an in-person workshop with all participating NB-AUA Collaborative nursing homes and a series of webinars, led by renowned faculty and improvement experts from across Canada. The learning activities focus on topics such as: Approaches and tools for patient-centred dementia care (e.g. PIECES training) Quality Improvement (QI) tools and methodologies Assessing innovation and spread readiness, and designing achievable spread plans Understanding your population and setting achievable targets Designing performance measurement and monitoring plans and techniques for real-time data collection Designing medication review and responsible antipsychotic titration approaches Engaging leadership, clinicians, staff and families working as a team for care planning Recreational strategies and tools to support residents needs and responsible antipsychotic reduction Analyzing multiple sources of data over time and effective reporting techniques Sustaining the gains and learning from challenges 2 Province of New Brunswick. (2013). New Brunswick population growth strategy 2013-2018. Discussion Paper. Fredericton, NB: Province of New Brunswick. Retrieved from http://www2.gnb.ca/content/dam/gnb/departments/petl-epft/pdf/popgrowth/nbpg_strategy_2013-18.pdf 3 Province of New Brunswick. (2008). New Brunswick s Long Term Care Strategy. NB: Province of New Brunswick. Retrieved from http://www2.gnb.ca/content/dam/gnb/departments/sd-ds/pdf/ltc/longtermcarestrategy-e.pdf 4 Barton, S., Findlay, D., Blake, R.A. The management of inappropriate vocalisation in dementia: a hierarchical approach. Int.J.Geriatr.Psychiatry 2005 12;20(12):1180-1186. 5 Vigen, C.L.P., Mack, W.J., Keefe, R.S.E., Sano, M., Sultzer, D.L., Stroup, T.S., Dagerman, K.S., Hsiao, J.K., Lebowitz, B.D., Lyketsos, C.G., Tariot, P.N., Zheng, L., Schneider, L.S. Cognitive effects of atypical antipsychotic medications in patients with Alzheimer s disease: outcomes from CATIE- AD. Am J Psychiatry 2011; 168:831-839 6 Zuidema, S., Johansson, A., Selbaek, G., Murray, M., Burns, A., Ballard, C., et al. (10 June 2015). A consensus guideline for antipsychotic drug use for dementia in care homes. Bridging the gap between scientific evidence and clinical practice. International Psychogeriatrics, First View, 1-11. available on CJO2015. doi:10.1017/s1041610215000745. 7
Teams also benefit from one-to-one coaching, peer-to-peer learning and the online learning community s resources, tools and e-forums. CFHI staff are the main point of contact for organizations and teams. They also provide coaching support and facilitate information sharing, networking and collaboration among teams and health leaders. CFHI s Improvement Approach is the framework that guides the design and delivery of the NB-AUA Collaborative. Who Should Participate in the NB-AUA Collaborative? Up to 20 teams will be accepted to participate in the NB-AUA Collaborative in 2016. Pending additional funding, a phase II roll-out of the collaborative will take place between 2017-2018. Organizational Characteristics Participating organizations should have: Explicit support of the senior leadership team implementing the innovation. Leaders must be prepared to stay actively connected to the team s work. An available data source to identify residents on antipsychotics and track progress. A resident population that can be identified for intensive improvement related to the innovation. Improvement capabilities at the individual project l and organizational levels are an asset. Ideally, suitable organizations are skilled in using improvement models, running small tests of change, and implementing change. Stakeholder relations with others such as social service agencies, local governments, public health departments, educational institutions, civic, and other non-profit or voluntary organizations focused on improving healthcare for seniors with dementia. Roles and Team Dynamic Executive Sponsor The CEO (or most senior leader in the organization) will serve as an Executive Sponsor and ensure the improvement team has: regular scheduled access to the senior executive team protected time for the collaborative-related work support for, and active engagement in, the organizational or policy change dimensions Senior management supports, and is accountable for, the overall direction, implementation, and management of the project. The CEO and/or relevant Executive Sponsor: co-present, with teams, results and impacts during project progress-reporting webinars participate in activities related to leadership and change management participate in identified coaching calls and on-site meetings 8
Team Membership Team members should have significant responsibility and influence within the organizations. Team membership is multi-professional. Job titles typically include: Nurses Personal support workers Pharmacists Primary care physicians Recreational therapists Other allied health professionals Quality improvement specialist Evaluation and measurement specialist Resident/family member representatives Executive sponsor (e.g. CEO, chief of medicine, vice president, chief operating officer/coo) Team Composition and Expectations Teams are committed to identifying clear roles, responsibilities and full participation in the NB-AUA Collaborative, including completing and submitting the NB-AUA evaluation and performance measurement plan and quarterly reports. Participating teams must include the following: Executive Sponsor 7 : The Executive Sponsor will ensure top-level organizational commitment in all aspects of the implementation and evaluation of the innovation, including access to the senior executive team, protected time for the work, and support for and active engagement in the organizational or policy change dimensions Project Lead: The project lead who has the time, resources and accountability to coordinate and oversee the day-to-day activities of development and execution of the project implementation and spread plan Clinician Champion(s): There is at least one clinician champion, who will work with the project lead and provide necessary clinical support to staff. Multiple clinician site champions can be included, but at least one should be a physician leader (e.g. medical director) Evaluation and Measurement Lead: There is a strong evaluation and measurement component to this collaborative. All teams should have access to staff dedicated to providing performance evaluation and measurement support. Teams should designate someone to support the tracking of project results, as well as quarterly and final reporting. Throughout the collaborative, CFHI will convene the evaluation and measurement leads from each team for coaching calls to discuss common project evaluation and measurement challenges and solutions. Family Member or Resident Representative: At least one family member or resident representative is a member of the team; and 7 In addition to explicit support from the most senior level (e.g. CEO) of the organization, there must be an Executive Sponsor (this person could also be the CEO, or someone who reports directly to the CEO) on the team. 9
Commitment to Quality Improvement: Team members have experience or are committed to building skills in implementing quality improvement initiatives, knowing how to set aims and carrying out well-designed work plans. Team and Organization Support CFHI has an extensive network of health service leaders, researchers, and patients and families that are engaged as experts and advisors for improvement teams. These support functions contain a range of expertise both individually and broadly, and as such, may broker and facilitate introductions between teams and individuals depending on the specific needs of their initiative. To ensure teams set achievable goals, make measurable progress and realize timely results in their improvement work, CFHI provides dedicated support from a number of people, including: Faculty CFHI faculty are renowned Canadian and international experts and organizational leaders who advise CFHI on program design and curriculum development, and who deliver curriculum to participants throughout the program. Faculty provide advice and guidance to teams and are available for consultations with teams on the design, implementation and evaluation of their improvement projects (IPs). For example: Lead Faculty: CYNTHIA SINCLAIR, RN, is a recent graduate of CFHI s EXTRA Program where an intervention project, led by Cynthia and her project partner Joe Puchniak, focused on using data collected with the RAI-MDS tool to improve quality care in the PCH sector and to inform decision-making and strategic planning at both the program and facility levels. The innovation Cynthia and Joe undertook through EXTRA led to the pan Canadian collaborative and is the foundation for this NB-AUA collaborative. Lead Measurement Faculty: LORI MITCHELL, Ph.D., is a researcher with the Winnipeg Regional Health Authority (WRHA) Home Care Program. Lori was a lead faculty for the pan- Canadian collaborative on antipsychotic reduction in long term care and supported the initial Winnipeg Regional Health Authority anti-psychotic initiative. At the WRHA, her primary role is to develop, support and contribute to research, evaluation and quality improvement activities that assist in evidence based decision-making in the Home Care Program. In addition, her work assists quality of care, program performance and policy development. Prior to joining the WRHA, Dr. Mitchell worked for 11 years in academia, conducting gerontological and health services research. Her doctoral training is in Community Health Sciences from the University of Manitoba and graduate training in Gerontology from the University of Waterloo and Simon Fraser University. 10
Coaches Each team has access to a CFHI improvement coach who will be available to support and guide the team throughout the collaborative. Coaches are experienced in long term care and selected for their extensive knowledge and experience leading healthcare improvement. Coaches understand how organizational and regional policy contexts affect innovation, the complexities of leading change in dynamic organizations, are well equipped to help teams anticipate and navigate challenges, and provide insight regarding strategies to gain momentum and support for the improvement initiative. Coaches work directly with the teams throughout the NB-AUA Collaborative in the following ways: touch-base meetings with the team (virtually by video or teleconference) as required; office hours offered via the online learning platform known as the NB-AUA Desktop CFHI Staff CFHI staff are the main point of contact for participating organizations and teams. They are also faculty, provide coaching support, and facilitate information sharing, networking and collaboration among the teams and other health leaders. Orientation Webinar Participating teams attend an orientation webinar, which provides an overview of: the NB-AUA Collaborative, curriculum highlights and key milestone dates core competencies and leadership skills that will be developed roles, responsibilities and expectations for working relationships among teams, faculty, coaches and CFHI staff training on the online learning components of the program and the NB-AUA Desktop Learning Activities and Core Competencies The NB-AUA Collaborative is driven by an interactive adult learning approach designed to support teams along their improvement journey. It includes: A Regional Workshop: An in-person regional workshop to kick-off the collaborative Monthly Webinars: Teams will participate in monthly content webinars The NB-AUA Desktop: Online learning tools, resources and activities Progress Reporting: Regularly scheduled progress reporting webinars where teams will share experiences Coaching: Ongoing support from CFHI faculty, coaches and staff Peer-to-peer support: Networking and collaborative exchange among teams 11
Core Competencies The NB-AUA Collaborative learning activities provide a balance of theory, tools and practical techniques that will build teams capacity in: 1. Identifying and interpreting evidence for improvement: Teams will gain proficiency in identifying and interpreting evidence and data through setting antipsychotic medication reduction targets, spread goals and designing person-centred care approaches. 2. Working collaboratively towards improvement with residents, families, caregivers, communities and inter-professional teams: Teams will gain proficiency working in teams collaborating to design and implement person-centred care practices, medication review protocols and data-driven improvement. 3. Designing and implementing improvement: Teams will understand and apply quality improvement methodology for developing and sustaining strategies to ensure appropriate use of antipsychotic medications and better dementia care. 4. Leading change in complex organizations/environments: Teams will understand and develop proficiency in applying principles of change management across the organization. 5. Measuring, monitoring and reporting improvement: Teams will gain proficiency in using data to set targets, monitor progress, inform care planning, and develop open channels of communication to share information about progress and key results. 6. Planning for spread and sustaining the gains: Teams will gain proficiency in assessing the sustainability and spread of their improvement efforts. Timeline at a Glance The NB-AUA Collaborative will run from March 2016 to March 2017 (Also see Appendix B). Jan. 2016 CEO/DoC Information Session Information Webinar Mar. Feb. Launch EOC Form; MOU Launch & QI Primer Webinars Regional Workshop Apr. May June July Aug. Sept. Oct. Nov. Dec. Baseline Data Coaching Calls Monthly Webinars and Online Learning Platform (April-March) Improvement Implementation Q1 Data Progress Reporting Webinar Coaching Calls Q2 Data Jan. 2017 Feb. Results Webinar Mar. Q3 Data Final Report 12
Key Dates February 2, 2016: CEO/Executive Sponsor information session February 17, 2016: Information webinar for Phase I teams March 4, 2016: Team Expression of Commitment Form due March 11, 2016: Signed Memorandum of Understanding (MOU) due April 2016 (date to be determined): Announcement of Phase I participating teams April 18: Collaborative launch webinar April 26: Webinar: Quality Improvement Primer Spring (2016): Regional workshop April (2016)-March (2017): Monthly content webinars, coaching and NB-AUA Desktop activities October 2016 (date to be determined): Progress reporting webinar March 2017: Final Reports due How to Enroll in the Collaborative Expression of Commitment Form: Interested organizations are asked to submit a completed Expression of Commitment Form to demonstrate their intent and readiness to participate in the collaborative, and implement the innovation. The deadline for submission of the Expression of Commitment Form is March 4, 2016. Memorandum of Understanding: Participating teams are expected to sign a Memorandum of Understanding, which outlines the roles and responsibilities of participants and sponsors, including the NBANH, CFHI and participating organizations. The deadline for submission of the signed Memorandum of Understanding is March 11, 2016. Conflict of Interest Declaration: By completing the Expression of Commitment Form and MOU, the organization and team members confirm that they have reviewed and understood CFHI s Conflict of Interest Policy, including the rules regarding the eligibility of foundation employees, directors and agents. Organizations from which any members of CFHI s Board of Directors, or foundation agents or employees receive remuneration are eligible to apply to this collaborative. Participants must fully disclose any relationship with sitting CFHI board members. For more information about the NB-AUA, please contact: Kaye Phillips, Senior Director, CFHI Christine Quinn, Senior Improvement Lead, CFHI kaye.phillips@cfhi-fcass.ca christine.quinn@cfhi-fcass.ca 613-728-2238 Ext. 366 705-761-3183 13
APPENDIX A: About CFHI s pan-canadian Reducing Antipsychotic Medication Use in Long Term Care Spread Collaborative (2014-2015) 14
APPENDIX B: The NB-AUA Collaborative Timeline The NB-AUA faculty and coaches, in collaboration with the selected teams, will design the project content and facilitate exchange on key topics, including: person-centred care practices tools (titration, huddles) spread plan development, implementation and measurement stakeholder engagement (residents, families, front-line providers) leadership and change management sustaining and further spreading the change data collection and analysis communication strategies Timeline at a Glance* Jan. 2016 Feb. 2016 Mar. 2016 Apr. 2016 May 2016 June 2016 July 2016 Aug. 2016 Sept. 2016 Oct. 2016 Nov. 2016 Dec. 2016 Jan. 2017 Feb. 2017 Mar. 2017 Apr. 2017 Information session for Executive Sponsors/DoC Information webinar session Expression of Commitment Form due Signed MOU deadline Announcement of participating teams Launch of collaborative Regional Workshop Monthly content webinars Coaching calls Data submission (quarterly) Progress reporting & reporting webinar Baseli ne Q1 Q2 Q3 Final reports due and results webinar Online learning community Report back to teams *Timeline to be refined and updated based on the assessed needs of the collaborative participants. 15