North East Behavioural Supports Ontario Sustainability Plan

North East Behavioural Supports Ontario Sustainability Plan

- 2 - NORTH EAST LHIN BSO SUSTAINABILITY PLAN The development of the North East BSO sustainability plan has provided the North East LHIN with an opportunity to engage stakeholders on the Behavioural Supports Ontario (BSO) system of care in the region, solicit input on its future direction, identify potential gaps, and inform stakeholders on its progress so far. Stakeholder engagements for this plan included visits to three of our hub areas (Sudbury, Sault Ste Marie and Timmins) reaching 81 individuals from a variety of sectors including long term care, acute care, CCAC and Community Support Sector. In addition, a formalized sustainability assessment process was initiated with our BSO health service providers. The assessment highlighted the success of the efforts to date, indicated the need to communicate the BSO successes to internal Long Term Care (LTC) home staff; as well as, highlighted the benefits of involving more front line staff and increasing leadership participation in order to sustain the program. Senior and clinical leadership from North Bay Regional Health Centre (NBRHC), in partnership with all BSO health service providers, will serve as the cornerstone of the implementation of a sustainability action plan. The transfer of the quality improvement functions has been considered in this plan and will build on the current planning and implementation of the BSO action plan. Continued commitment from the NELHIN to support and monitor the implementation of the action plan, improvement projects and funding for BSO will be essential to the ongoing success of this system change. SENIOR LEADERSHIP Senior and clinical leadership engagement have been shown to have the greatest impact on sustainability. 1a. What leadership and organizational structure at the LHIN level will be in place to sustain the Behavioural Supports initiative? As outlined in the North East BSO Action plan, the governance of the BSO project will be directed by the Regional BSO Steering Committee (originally named the Governance committee, its title was changed after receiving feedback from BSO providers). The Steering Committee worked to develop comprehensive terms of reference and elected a chairperson to proceed over meetings. Since inception, the committee has met four times and has focused on the development of the electronic referral form, the formation and reporting relationships of the working groups, improvement projects and, most recently, the sustainability assessment. Structurally, the Regional Steering Committee provides the overall accountability for the North East BSO through its working groups: Medical Advisory, System Performance; Lived Experience Network; and Capacity Building. The Medical Advisory group meets on a quarterly basis and to date two formal meetings have been held. The Medical Advisory Committee has identified a Regional Care of the Elderly BSO Champion, Dr. James Chau, and a Regional Geriatric Psychiatrist Champion, Dr. Marie-France Rivard. The goal of the Medical Advisory Group is to focus efforts on NE BSO clients/patients/residents and their care providers receiving the best possible treatment and improved access to service. This will be accomplished through integrated service delivery, system coordination and enhanced capacity building. The System Performance Advisory Group is committed to ensuring integrated service and is aligned with the second pillar, integrated service delivery: Intersectoral and interdisciplinary. This advisory group will be accountable for monitoring of continuous quality improvement standards for BSO across the North East. The system performance group will be comprised of BSO providers at the manager level of organizations and be inclusive of BSO funded positions. For example, the intake process that was adapted in each hub area will be monitored for effectiveness, ease of access and timely service delivery. In addition, the System Performance Group will be responsible for the tracking of appropriate data for quarterly reports in order to sustain meaningful change and measure our service outcomes. Throughout the North East, the Alzheimer's Societies were funded for a Behaviour Support Facilitator (BSF)

- 3 - with primary responsibility to support caregivers. Developing a Lived Experience Network across the North East is a key priority for the BSFs to provide an accessible virtual forum for "people to connect with people" through shared experiences in order to create a strong unified "voice" to report to/advise the NE BSO Steering Committee. The Lived Experience Networks are at beginning stages in engaging key change agents within each hub. The Knowledge Exchange & Capacity Building advisory, co-facilitated by the PRC team and regional coordinator will focus on pillar # 3 by engaging all North East BSO team members and other interested care partners in a virtual shared knowledge exchange to facilitate clinical leadership and implementation of current best practices. Regional Coordinator A foundational component to pillar # 2 of the North East BSO system is the formal establishment of a lead regional clinical structure. As the lead HSP for BSO in the North East, North Bay Regional Health Centre's clinical structure includes a Regional Coordinator, Regional Assistant, and six Regional psychogeriatric resource consultants (PRC) whom act as conduits to unite the clinical integrated response teams in each hub. The Regional Coordinator has overall responsibility for maintaining a regional approach to BSO and adherence to the three pillars. The development of common, LEAN processes; adoption/implementation of system-wide best practice standards; and liaison with specialists and other key partners are some of the focal responsibilities of the Regional Coordinator. The additional linkage is such that the Regional Coordinator also acts the direct manager of the six North East Psychogeriatric Resource Consultants. As our BSO teams are integrated community, hospital and LTC resources; the ability to support the health care system is heightened as the CCAC has a collaborative responsibility for enhanced information and referral in CCAC is a pivotal point of information consolidation and transfer to North East BSO Central Intake. The vision of the various North East BSO access pathways ensures that all doors lead to service. In the North East we have adopted the Integrated Care Lead which will provide older adults with a seamless pathway to BSO services. 1b. Who has been identified as the leader responsible for sustaining the changes? North Bay Regional Health Centre (NBRHC) is the lead BSO health service provider in the North East. Leadership is within the Regional Coordinator position. The Regional Coordinator has been positioned to be the System Manager. The Regional Coordinator will continue to work with all BSO funded health service providers to take a systems approach to the implementation of the new services. To support the coordination of the regional component of BSO, there is a shared leadership model amongst the providers. Through the accountability structures, each health service provider has an equal voice and are partners in care.

- 4 - The BSO health service providers have developed the processes for intake, transitions, personhood assessment which has led to a standardized approach to service provision and ultimately aligning with the BSO pillars and principals. The development of the processes, tools, and resources has all been inclusive activities built through consensus and collaboration. There is an expectation that all BSO funded health service providers will contribute to the development, implementation and sustainability of the BSO system through the Regional Steering Committee. To promote accountability, the expectations are clearly outlined in the funding letters: As a BSO provider, the health service provider will be required to participate in the regional governance of the Behaviour Support System. As equal partners, BSO providers and the lead BSO HSP will sit on the BSO NE Governance Committee and the relationship between BSO providers, the lead BSO HSP and the governance authority will be articulated in the NE BSO Governance Memorandum of Understanding. Key areas of responsibility for the lead provider encompass the development of standardized, common intake, referral and assessment processes. A significant focus has been on the development of the electronic referral form, frequent (twice weekly) clinical huddles in each of our four geographic areas, implementation of the agreed upon intake process, coordinated referrals to specialists and tertiary care. During our stakeholder sustainability engagements, stakeholders were asked if the current structures were adequate and able to support the BSO system. Response from stakeholders varied, but there was overall an agreement that it is adequate and any additional funding should go to front line service. In addition, participants recommended there be a formal alignment to the Health Link in the Cochrane area and that the leaders of providers need to engage more in BSO. The number of clients being served could also determine whether the current leadership structure is adequate, as central intake is a part of the regional support to BSO and as referrals increase, the capacity to quickly triage and process referrals will need to be examined. BSO Clinical Structure PRT Operations Committee Collaborative Tables

- 5 - QUALITY IMPROVEMENT 2. What quality improvement (QI) capacity at the LHIN level will continue to be in place to support the BSO? Members of the BSO Integrated Response Teams have received QI training throughout the year through the Improvement Projects, Kaizen events, IHI QI Open School and in addition all BSO staff will be attending the combined event for Residents First IF training and BSO Kaizen at the end of February, 2013. The North East BSO project has identified the critical importance of the Quality Improvement role. In March of 2012 the North East LHIN sponsored the BSO Regional Coordinator to attend Lean Training in conjunction with the Resource Matching and Referral Project. The training was a four day intensive Green Belt training and the opportunity to join the NE LHIN Lean Community of Practice. The sustainability of quality improvement is a priority for the lead provider NBRHC and as such a commitment has been made to identify a PRC to be the Lead for this function. Although all six PRCs will have opportunities for training in quality improvement, having a lead will ensure continuity and coordination. In addition, the NE LHIN BSO Improvement Facilitator will be responsible for on-going monitoring of the NE BSO indicators and will provide continued support for quality improvement activities, such as kaizen, value stream mapping and PDSA cycles. This QI function for the NE LHIN Improvement Facilitator will represent a 0.2 FTE. MEASUREMENT AND ACCOUNTABILITY 3a. List the key performance measures that will indicate BSO success and sustainability in your LHIN. The work of the North East BSO QI Working Group and the BSO stakeholder engagements held in January and February of 2013 has helped guide the selection of key performance measures that indicate BSO success and sustainability in the North East: Outcome Measures: Rate of acute care hospitalization (clients and episodes) of behavioural residents of LTCHs Rate of CTAS 4/5 ED visits for behavioural residents of LTCHs % of applications to LTC denied due to responsive behaviours # of critical incidents associated with resident behaviour per 100 LTCH beds % of clients that have a change in their behaviour assessment score Family satisfaction with ability to manage behaviours in the home environment Process Measures Total # of referrals to the BSO Integrated Response Team Response time of the Integrated Response Team Number of vacancies within the BSO Integrated Response Teams 3b. Please outline accountability processes in your LHIN that will ensure service providers continue to deliver on BSO services. Our BSO providers will be responsible for reporting on a quarterly basis on the above indicators. Established data sources will be used for outcome measures and BSO team tracking data will be used for the process measures. The BSO Regional Office will report quarterly on additional activity measures to ensure that the Integrated Response Teams are functioning effectively: o the number of client-based services, o the number of provider-based services, o the percentage of eligible BSO referrals, o the percentage of clients who are French-speaking o the percentage of clients with a follow-up review of outcomes o the number of BSO clients that are transferred to ED or Acute Care.

- 6 - A LHIN specific BSO indicator will be included in the 2013-2014 M-SAA refresh and the 2013-2016 L-SAA. NE LHIN Hub Officers are responsible for monitoring all indicators, including the BSO indicator, in the Health Service Providers accountability agreements. In addition, the NE LHIN will require the lead BSO provider to produce an Annual Report on the provision of BSO in the North East. The BSO Annual Report will be informed by on-going stakeholder engagements, led by the lead BSO provider with support from the NE LHIN, and will identify strengths and gaps in the BSO system. 3c. As part of the accountability processes, how will your health service providers measure, review and report on the indicators in 3a. above? How frequently? As part of the NELHIN BSO Quality Improvement Plan, the NE LHIN will collect and review the BSO Outcome and Process measures. The Quarterly BSO Reports will be reviewed by the NE BSO Steering Committee and shared with the NE LHIN Regional ED\ALC Leadership Committee. Any result that is beyond or close to the upper limits will require comments from the Regional BSO Coordinator and the use of quality improvement tools by the BSO teams to address the situation and develop appropriate action steps, as required. The North East BSO Steering Committee will review and provide advice on the proposed actions. The North East BSO Regional Coordinator will report on BSO Integrated Response Team activity indicators to the NE LHIN and the System Performance Working Group, a group that focusses on monitoring performance and operational issues. Any result that is beyond or close to the upper limits will require comments from the Regional BSO Coordinator and the use of quality improvement tools by the BSO teams to address the situation and develop appropriate action steps, as required. The System Performance Working Group will review and provide advice on the proposed actions. The NELHIN BSO Quality Improvement Plan will clearly identify which health service provider will be responsible for reporting on the above indicators on a quarterly basis. Reporting templates will be shared with the HSP to assist in the collection of the indicator data. For the Integrated Response Team activity indicators, a tracking tool has been developed and will be used for all team members. The NE BSO Regional Office will monitor these activity indicators on a monthly basis, allowing the flexibility to address any issues as they occur. As mentioned above, a quarterly report will also be produced that will be shared with the NE LHIN and the System Performance Working Group. Once the team activities are stabilized and processes are working well, the NE BSO Regional Office will collect a sampling of the activity data to ensure that the teams continue to function effectively. Also, as part of the on-going QI activities, BSO improvement teams use the Model for Improvement and will track PDSA cycle data to ensure that the change ideas lead to improvements. PDSA cycles will include all phases of testing, implementation and spread. The QI Lead PRC for the NE BSO system will monitor the PDSA cycles. The NE LHIN BSO IF will provide support to the improvement teams, as required. On-going quality improvement activities will be monitored by the System Performance Working Group. TRAINING 4. What processes are in place to train new staff this fiscal year and on an ongoing basis? A priority focus in the continued implementation of North East BSO will remain on pillar three -- knowledgeable care team and capacity building to ensure sustainable professional development for the North East continues to evolve. An active Knowledge & Capacity Building Advisory Committee will support the sustainability of the training initiatives by providing direction on gaps and opportunities. Training for non-bso Long Term Care homes and the community sector receive training will be essential in spreading the system approach to older adults with responsive behaviours. Utilizing the staff inventory tool all new BSO staff are required to complete an overview of their skills and expertise. The tool is inclusive of the BETSI and the capacity building road map. Using the Road Ahead tool and a sustainable professional development work plan for 2013-14 will be developed.

- 7 - An enabler to the sustainability of Long Term Care home training will be realized through annualized funding of $33,100 from the NE LHIN. This funding will be allocated centrally and the Regional Coordinator will be responsible for the ongoing implementation of accessible formal training opportunities (e.g. P.I.E.C.E.S., U-FIRST!, GPA, GPA Coach, Montessori, Leadership Training etc.). Through extensive training in a critical mass will help to realize significant capacity within the system for the Long Term Care sector. Using the North East LHIN BSO portal the promotion of AKE and SHRTN training will continue. In addition membership on the collaborative and communities of Practice will be expanded to include other members of the BSO teams. From our stakeholder engagements a consist theme emerged reinforcing the need to strength linkages with community colleges, training centres and universities to influence the curriculum. This recommendation was made for non-regulated and regulated positions within health care. Examples of this would be having GPA training in colleges, universities and certificate programs for PSWs. The PRC team has received structured learning sessions through Global Learning. The training that was received supports the PRCs to create workshops, seminars and in-services in interactive and engaging formats. This skill enhancement will assist the PRCs to develop customized workshops for front line employees. An annual calendar will be created by the Regional Coordinator that will bring each of the distinct roles together for professional development and peer support. The Medical Advisory committee, as chaired by Dr. Chau, will lead the way in enhancing capacity through the creation of professional development work plan that will offer virtual CME accredited learning opportunities and network exchange among medical colleagues in the field; COLLABORATION AND COMMUNICATION 5. Please outline recommendations that you have based on your implementation of this initiative in your LHIN area that would help others to achieve sustainability. Key success factors for the NELHIN s implementation of BSO have included: regional coordination; central intake; a system launch with all of the partners in care; hub by hub level process development; the work of a regional coordinator and regional lead provider; and the on-going QI initiatives. With a vast geographic region it has been essential to fully engage the health care system by hub area but at the same time ensure adherence to regional standards. The regional component of BSO has provided the foundation for the implementation with the flexibility of local anomalies. Including NE LHIN Communications on the BSO Project team has assisted in the implementation with the creation of a BSO web page, which continues to store latest documents. The Communications team has also helped build awareness of the system of care in the North East through media releases, CEO blogs, the Healthy Change Award, and a comprehensive educational newsletter which is sent out on a quarterly basis to stakeholders. The newsletter is instrumental in identifying opportunities for system collaboration, highlighting success stories, and reporting quantitative information. Future communications will include the development of a BSO pamphlet to assist in referrals to the program and help generate awareness of BSO. In addition, the development of the NE BSO Portal has offered a mechanism for BSO providers to be connected to information, share information and collaborate on projects. 6. What provincial tables/collaborative do you consider vital to sustaining the BSO initiative in your LHIN? Currently the North East is participating in the BSO Mobile Teams collaborative, Access and Flow Collaborative and most recently the Regional Operations group. Participation in these initiatives will continue in order to improve upon the existing Integrated Response Teams that have been created for the North East. To support the future improvement projects membership in the Specialized Behaviour Units and Primary Care Collaborative will also be sought.

- 8 - BSO Operations will be key to sustainability as it provides the forum for sharing experiences, lessons learned and implementation challenges. The peer support aspect of the Operations table plays an important role in sustainability and provincial connectivity. 7. How do you imagine your LHIN collaborating with the other LHINs to sustain BSO? From its inception the North East BSO Regional Coordinator has been actively involved in the Regional Operations table. This involvement will remain and be strengthened through the ongoing development of the group. Increasing and expanding on the development of specialized communities of practice will assist the BSO team to be more involved at a provincial level. Assist to organize Pan -LHIN sustainability opportunities to bring people together annually (in-person) and engage all key partners (other sectors EMS etc). The North East LHIN would be most interested in assisting to develop a provincial table that would focus on the voice of the lived experience. NELHIN Improvement Facilitator and BSO lead will maintain a network of contacts with other LHIN Improvement Facilitators and Lead to exchange tools, planning activities and evidence based best practices. It will be essential for the NE LHIN to continue to make use of and promote the provincial AKE collaboration space to share reports, resources and current research. ASSESS THE CURRENT STATE AND IDENTIFY REMAINING SERVICE GAPS

8. What are the remaining implementation priorities for 2013 in your LHIN? Refer to the client value statement and any gaps in the patient journey you identified during the value stream analysis completed in Fall 2011. - 9 - As partners in care, we commit to and expect compassionate, timely and person-centred care. For 2013 one of the key priorities for the North East BSO system is to develop a common transition process throughout the region. In October 2012 a two day Kaizen focused on the issue of transition and the follow up to that work took place January 7, 2013. An outcome of the Kaizen was a future state map for transitions a detailed opinion paper on Transition that outlines the necessary functions to support an older adult with responsive behaviours to transition from hospital to a long term care setting. The opinion paper has been a springboard for the improvement project and the key functions will be introduced to the role of the Clinical Behaviour Response Specialist. An improvement team has been created to refine, consult and implement the common transition process. From our November 2011 Value Stream mapping the need for stabilization beds was identified by the participants as a key priority. Different models of service are under consideration and are constrained by mandate and funding. For example converting acute care space into stabilization beds would still require funding for front line staff and programming staff. The current stock of LTC homes does not readily avail opportunities for Specialized Behaviour Support units. With any LTC redevelopment project a readiness assessment for BSO needs to be considered in order to take full advantage of the ability to develop Specialized Behaviour Support Units for Northern Ontario. Recently the North East LHIN has undertaken an initiative to gauge the interest of our local providers to pursue designation of specialized units. A formalized Expression of Interest (EOI) has been developed to determine which long term care homes are interested in specializing. From the BSO planning perspective interest in developing/formalizing units with enhanced safety and specialized behaviour support units will be determined. The successful implementation of the BSO resources across the north east has generated a heightened interest from Long Term Care homes that do not have specific BSO allocations. As opportunities for funding become available the NE LHIN will be allocating additional resources to LTC Homes to implement BSO. For 2013 there will be 5 additional PSWs added to those existing BSO homes that were previously granted single RPN and PSW positions and a new LTC home will be added to the regional system in Sault Ste. Marie with both RPN and PSW resourcing. The strategy for addressing the need to provide BSO coverage across the region is three fold: Provide capacity building through available training opportunities to increase the PIECES trained staff, make GPA a standard for all PSWs and implement U-First where appropriate. Increased access to PRCs through the enhancement of their role and the increased number of positions. (from 3 PRCs for the North East to 6) Test the hub model for Long Term Care homes resources. Work with Cassellholme in North Bay to develop a model of outreach support to other Long Term Care homes in the city and district. Where possible enhance the funding levels for Long Term Care homes to increase the number of BSO staff. A defined written, formal process for outreach to rural and First Nations communities needs to be developed. The formalized, consistent, reliable support to smaller communities through the PRCs is an essential component however gaps in service to the other Clinical Behaviour Response Specialists remains primarily due to the fact that there is no base funding to support the overhead costs to mobilize this resource. Using the NHS Sustainability Model and Guide, a sustainability assessment was carried out with the entire BSO team in the North East, including the North East BSO Steering Committee. A copy of the sustainability assessment was sent in advance and responses were compiled. Results were shared with the group and the survey was reviewed and responses were discussed. The results of the Sustainability Model identified the following areas to improve on sustainability:

- 10 - Process Factor: Credibility of the evidence Staff Factor: Staff involvement and training to sustain the process Organization Factor: Infrastructure for sustainability These results, as well as the gaps identified during the sustainability discussion and the stakeholder engagements, will guide the creation of a sustainability action plan by March 31, 2013. The BSO Regional Coordinator will be responsible for overseeing the implementation of the action plan and will report quarterly on progress to the North East BSO Steering Committee as a standing agenda item. North East BSO Team Score Per Factor Compared to Maximum Possible Score Feb, 2013 Maximum Average Median Infrastructure for sustainability Benefits beyond helping patients Fit with the organizations's strategic aims and culture Credibility of the benefits Clinical leadership Adaptability of improved process Senior Leadership Effectiveness of the system to monitor Staff involvement and training to sustain the Staff behaviours toward sustaining change In the NELHIN there is commitment from all stakeholders to support the ongoing development of programs and services that will support older adults. The development of specialized supports that will address the needs of those older adults and their caregivers that have responsive behaviours is a priority and is reflected in the NE LHIN Integrated Health services plan as outlined in the Transitions of Care priority and the Mental Health priority. On behalf of the NELHIN this sustainability plan is submitted to the Central Reporting Office for review and submission to the Provincial Resource Team. Thank you for your guidance, support and knowledge exchanges through the development of this plan. North East BSO Project Team Valerie Scarfone, BSO Project Lead NE LHIN Monique Lapalme, BSO Improvement Facilitator, NE LHIN Lara Bradley, BSO Communications, NELHIN Monica Bretzlaff, BSO Regional Coordinator, North Bay Regional Health Centre