“What Makes Our Special Care Unit Special ?”

1. “What Makes Our Special Care Unit Special ?” Deer Lodge Centre Dementia Care Unit Maureen Chouinard, Manager of Resident Care Arlis Decorte, Clinical Resource Nurse Nancy Fiebelkorn, Social Worker

2. SCU – Tower, SCU-West • 47 beds on two units • Tower opened in 1988, West opened in 2006 • Higher staff to resident ratio • Units address behaviours, care needs • Male or female; veterans or community applications

3. Philosophy of Care • Equal, individualized, respectful and safe care • A person’s individuality is unique and does not change because of cognitive impairment • Staff are advocates • A specialized environment is required for dementia care • Families have the right to be informed

4. Philosophy of Care (continued) • Specialized skills and abilities are essential • Interdisciplinary team approach • End of life care • Upholding Resident’s Bill of Rights • Effective and efficient use of available resources

5. SCU Admission Criteria • Age • Primary and secondary diagnoses • Environment • Behaviours • Risks

6. How to Access the Special Care Unit at DLC • WRHA Behavioral Panel • Contact the panel secretary at 940-3600 • Access Office is at 490 Hargrave St. • Application should include an A/A form, a Dependency Assessment Supplement and the Behavioral Assessment Supplement. • A brief summary of the resident/client will be submitted along with behavior maps, recent progress notes, consults and lab work.

7. Behavioural PanelPurpose: To facilitate the management of individuals with challenging behaviors in the most appropriate care setting.

8. Behavioural PanelGuiding Principles: • Behaviors are not being managed in their current environments • Existing resources already accessed • Information meets panel criteria and standards • Panel meets monthly • Additional problem-solving may be required to ensure placement in proper environment

9. Behavioural PanelWho Sits on the Panel? • Medical Director of the Rehab/Geriatrics Program • Director of the LTC Access Centre or designate • A representative from a PCH • A representative from the Geriatric Mental Health Team • A CNS for the WRHA long term care program • Access Coordinators • Health care professionals/family who have been integral to managing the individual’s care needs

10. Preadmission Visits • Purpose: • Confirm the information provided by panel • Meet needs of the applicant? • Plan for any special needs or equipment • Meet the applicant and family • Completed by the Social Worker and Unit Manager once accepted by Behaviour Panel • Visit usually within one week, at applicant’s current residence

11. The Interdisciplinary Approach • The SCU at Deer Lodge Centre utilizes an interdisciplinary approach to care. • Weekly meetings • Goal is to review each resident on a quarterly basis. • Post-admission and Annual conferences • All members of the team are available to family • Contact information provided

12. The Interdisciplinary Team Consists of: • The Resident and Family • Attending Physician and Consultant Psychiatrist • Manager of Resident Care • Clinical Resource Nurse • The Nursing Team-RNs, RPNs, HCAs

13. The Interdisciplinary Team Consists of (continued) : • Social Worker • Pharmacist • Physiotherapist • Occupational Therapist • Dietician • Recreation Facilitators • Spiritual Care

14. What Gives Us a Sense of Well-being?-The Bradford Dementia Group

15. Well-Being (continued) What do we need to maintain a sense of well-being? • A sense of control • A sense of who we are • A feeling of safety and security • The ability to communicate with others • The feeling that we are socially included

16. Well-Being(continued) • Having meaningful things to do • Being taken seriously- do others respect and recognize when we feel frustrated, angry, sad, anxious, tired/exhausted, confused, lonely, frightened?

17. Reactive Behaviours • Reactive Behaviour- the way in which a person responds to a specific set of conditions. P.I.E.C.E.S. program • All residents on the Special Care Unit have a behavioural history which has made residing in a regular personal care home setting difficult or impossible.

18. Reactive Behaviours (continued) Reactive behaviours may include: • Restlessness Calling out • Wandering Hoarding • Resistance to Care Agitation • Anxiety Aggression • Withdrawal • Inappropriate Sexual Behaviour

19. Reactive Behaviours (continued) Staff are encouraged and trained to monitor and document reactive behaviour: • Antecedents (Triggers) • Behaviours • Interventions • Consequences

20. Reactive Behaviours (continued)

21. Reactive Behaviours (continued)

22. Key Elements of CareAlzheimer’s Australia, 2003 • Assessment • Individualized Care • Interdisciplinary Team Approach • Programming • Relationships

23. Key Elements of Care(continued)

24. Key Elements of Care(continued) • Communication Skills • Physical Environment • Flexibility in Routines and Practices • Staff Training and Education

25. Communication • Communication with persons who are cognitively impaired may be difficult and frustrating at times for both you and them • Remember that behaviour is a form of communication for residents that have impaired expressive ability

26. Communication Areas to focus on include: • Approach in a gentle manner and identify yourself by name • Maintain eye contact • Provide gentle direction • Do not make an issue of a mistake, they happen • Avoid asking facts

27. Communication Areas to focus on include (continued): • Reduction of distractions and background noise • Reorientation may not work • Appropriate touch • Items and illustrations to convey messages

28. Visiting • May be difficult for families/caregivers – We, by nature, need something from our visits • Love • Reassurance • Support returned to us • Ease of guilt • Confirmation of our decisions • To feel that a connection remains

29. Visiting (continued) • Goals of Visiting • Who should Visit • When to Visit • Where to Visit • What to do when you Visit • Why Visiting may be difficult • Saying goodbye after your Visit • When younger family members Visit

30. Caregiver Support Group • Informal group for families/friends that meet once a month • Connections for them, connections for us • Share questions and information about SCU • Supportive and safe environment • Luncheons

31. Case Study 79 year-old gentleman residing on a general medical hospital ward. • dx of Alzheimer’s/Parkinson’s disease. • hx of resistance and aggression during care, occasionally towards co-residents. • Poor response to psychotropics - oversedation-minimal effect on behaviour.

32. Case StudyCare Plan in General Hospital Setting • 6 staff to provide care • Resident to be restrained on bed utilizing 4 staff, 2 staff to prepare and provide care. • Broda with lap table for meals and rest periods. • Current Rx • Carbamazepine 200mg bid • Trazodone 75 mg od 18:00

33. Case Study Care Plan on SCU - Goals • Gain the resident’s trust. • Create a “resident-friendly” care plan. • Involve resident and family in care planning-create an environment where resident and family have decision-making authority. • Ensure Consistency/reliability.

34. Case StudyCare Plan on SCU - Interventions • ADL Care • Broda chair and table for meals. • “Bath-in-a-bag” products - no tub baths, no showers • Incontinent product-pullup/brief/overnight • Monitoring behaviour on unit • Plan all care - Scheduled………..CONSISTENT

35. Case StudyCare Plan on SCU (continued) • Initially provide 4 staff for care and safety • “Normalized care”, bathroom routine • When resident requires care, approach and “be with” resident • Reapproach after a “break period”, invite him to attend his room with you, or simply walk to room with him. • If care required more urgently, need to be more “matter of fact”

36. Case StudyCare Plan on SCU (continued) • Adjustment to medication following admission • Trazodone Rx on revised care plan: 07:00 - 25 mg. 12:00 - 50 mg. 17:00 - 50 mg.

37. Case Study Care Plan on SCU - Outcomes • 2-3 staff to provide care, dependant on mood - (do not provide care alone) • Aggression with co-residents • Broda chair/table for meals • ADL/Bathing • Ongoing staff education • The challenge of CONSISTENCY

38. End of Life Care • Advance Care Plan/Health Care Directive • Care planning around a progressive illness • What is Comfort Care and its focus? • Pain • Difficulty Swallowing • Lack of Appetite • Labored Breathing • Skin Breakdown • Loving Presence

39. When the Resident No Longer Requires SCU • Resident no longer requires the specialized programs of our unit. • Social Worker prepares the family • Move to another unit in DLC or another facility

40. Barriers to Discharge • Long Wait Lists • History of reactive behavior • Families reluctance to move • Concerns of receiving facility • Small unit vs large unit • Treatment unit vs long-term care unit

41. ConclusionWhat Have We Learned? • The value of the unit staff • Admissions – need to try new things • Environmental challenges • Closed-in vs. open spaces, Wall protection, Decoration • Low stimulus is a great idea but…… • Require a balance between environment and pharmacological treatment