Behavioural Support Systems

1. Behavioural Support Systems Ontario Leadership in Behavioral Health Care OLTCA Conference

4. Why the emphasis on behaviour? Significant issue across the system Impact on person and family/caregiver Pressures across the system e.g. acute, community, LTC, psych > drugs, longer hos Why an emphasis on Behavioral Health Support System W Building a Better System: Caring for Older Individuals with Aggressive Be in LTCHs (2007) LTC Act change � e.g. language to specialized behavl support units Linkage with national and provincial priorities and initiatives

5. Aging Bulge

6. Facts at our Fingertips: Aging / Chronic Disease Chronic Disease 80% over age 45 have a chronic disease In less than 6 years there will be more older person than citizens 0-14 years of age 43% have two or more After Age 50 likelihood of being disabled by diseases doubles every 5 to 7 years www.agingresearch.com

7. The Boom The Boom and the ECHO Aging Dementia and cognitive impairment and chronic disease Behaviour The multiplier and ripple effect on LOS and ALC

8. Behavioral Support System,A Call for Action No . At risk and increasing Challenges across sectors Persons and families deserve better quality experiences Significant costs Recognized best practices Opportunities for leverage of existing initiatives Readiness

9. Behavioural Support systems ;The Numbers at risk 2038 ,a new case of dementia every 2 minutes Cognitive impairment 4X dementia at age 65 More than 80 percent of those with dementia will have behavioural challenges during the course of their illness,

10. As care shifts away from care facilities there will be an increase in informal care.The number of hours spent on informal care is expected to more than triple by 2038.As care shifts away from care facilities there will be an increase in informal care.The number of hours spent on informal care is expected to more than triple by 2038.

11. Challenges across Sectors LTC 65 percent mental health and dementia with mental health disorders Home care 1 in 5 dementia 30% of these have behavioral challenges OHQC reports 17 % in LTC are physically restrained Nurses in hospitals and LTC 34% report physical assaults RPN 47% physical 72%emotional

12. Challenges across Sectors Costs of Dementia now 15 billion projected 115 billion ALC 23 days with dementia average 10 days Survey of Ontario ALC 17%of hospital beds half waiting LTC Recent analysis 53%moderate to severe dementia ,19 % behaviour

14. A Brand New World, Ontario�s New Long � Term Care Homes Act Jane Meadus Summer 2010 Vol 7 ACE  Legislation www.e-laws.gov.on.ca

15. Act / Opportunity A New Concept �Responsive Behaviors� Un-met need Responsive to circumstances

16. Responsive Behaviors Written Approach Screening Protocols Assessment, reassessment and identification of behavioral triggers Written Strategies to prevent, minimize or respond Monitoring; internal protocols Protocols for referrals to specialized resources

17. The Five Cs of Seniors with Complex Needs 12/15/2011 J Sadavoy MSH 2006 Complexity(every person is a Universe of one,(Erickson) Chronicity(opportunity for prevention) Comorbidity(think PIECES) Continuity( need for addressing with the white space) Context.( Community, System, Family)Joel Sadavoy

19. What we know how we act what our system looks like and responds toWhat we know how we act what our system looks like and responds to

23. Introduction The Ontario Behavioural Support System Project aims to improve the lives of older adults with complex and responsive behaviours associated with cognitive impairments due to complex mental health, addictions, dementia, or other neurological conditions and their caregivers. These adults may be living in long-term care homes or in independent living settings or receiving care in acute care environments. The first phase of the project (Jan-Oct 2010) is complete and a report has been prepared Once finalized, the report will be available on the website www.bssproject.ca The presentation today will outline key elements of the report including a brief overview of the project, proposed system model and contemplated next steps.

24. BSS Project Overview Part 1

25. Activities Leading to the BSS Project

26. BSS Project Phases Phase 1 Project leadership was provided by: Co-Executive Sponsors- Bernie Blais, CEO North Simcoe Muskoka Local Health Integration Network (NSM LHIN) and Kenneth Deane, ADM, Health System Accountability and Performance Division, MOHLTC Partners- Alzheimer Society of Ontario (ASO) & Alzheimer Knowledge Exchange (AKE) & Divisions of the Ministry of Health and Long-Term Care (MOHLTC). Supported by- Ontario Health Quality Council Phases 2 (demonstration and testing) and Phase 3 (provincial implementation) are contemplated at this time

27. Different lens ,different meaning and approach Our professional identity began to develop long before we entered into our various educational programs. It started with what you learned in the media, from your family and your friends about the various professions. It became cemented by profession specific language and cultures through your educational process and it continue to mature throughout your career. Because of your profession specific perspective, you are looking at the world through certain theories. These theories cause you to choose certain assessments. Based on your assessments, you choose certain treatments. These treatments lead to certain outcomes. It is the way you see the world that defines your professional identity. Each profession sees things a little differently. This is like the parable of the five blind men encountering an elephant. In this picture, it is half a dozen blindfold scientists. The person who examines the tail may say �It is long and flexible, with a fuzzy end. An elephant is like a rope�. The scientist who encounters the lef may say �It is tall and immovable. An elephant is like a tree�. The person encountering the tusk may say �It is pointy and very hard. An elephant is like a dangerous spear�. In each case, the person has an incomplete idea of what an elephant is. To truly understand what an elephant is, they must do two things. First, they have to acknowledge they may not be seeing the whole picture. With this acknowledgement, they must be able to listen to another person�s assessment and try to integrate that with their own eperience. Our professional identity began to develop long before we entered into our various educational programs. It started with what you learned in the media, from your family and your friends about the various professions. It became cemented by profession specific language and cultures through your educational process and it continue to mature throughout your career. Because of your profession specific perspective, you are looking at the world through certain theories. These theories cause you to choose certain assessments. Based on your assessments, you choose certain treatments. These treatments lead to certain outcomes. It is the way you see the world that defines your professional identity. Each profession sees things a little differently. This is like the parable of the five blind men encountering an elephant. In this picture, it is half a dozen blindfold scientists. The person who examines the tail may say �It is long and flexible, with a fuzzy end. An elephant is like a rope�. The scientist who encounters the lef may say �It is tall and immovable. An elephant is like a tree�. The person encountering the tusk may say �It is pointy and very hard. An elephant is like a dangerous spear�. In each case, the person has an incomplete idea of what an elephant is. To truly understand what an elephant is, they must do two things. First, they have to acknowledge they may not be seeing the whole picture. With this acknowledgement, they must be able to listen to another person�s assessment and try to integrate that with their own eperience.

28. What has informed the first phase? Types of Information Lived Experience �Conversations about Care� over 100 caregivers consulted on how the system should work Lived experience member on BSS leadership team Practice Based information Seniors Health Research Network Community of Practice regional forums regional forums were held over the summer. Facilitated by members of Ontario Health Quality Council and attended by approximately 200 cross sectoral field opinion leaders. Research Rapid Evidence Review- literature review looking at best practices in behavioural support services research focusing on review articles Local, National and International reach Inventory of Projects initial inventory of projects from across Ontario focused on target population Ontario BSS Virtual Advisory Panel 40-50 volunteers who were given opportunity to comment on draft model, rapid evidence review National BSS Initiative 3 meetings with group representing all provinces and territories Conversations with opinion leaders in targeted sectors Acquired Brain Injury; Aging and Developmental Disabilities; ED ALC panel lead; Community Outreach Programs in Addictions; neurological health charities groups; ministry leaders

29. Now is the time for action This is an important target population The numbers of people at risk for responsive behaviours is increasing Significant costs are associated with managing behaviours The person and family require better quality experiences The system needs to change, and current investments should be aligned and integrated for this population For example, investments in Aging at Home, Alzheimer's Strategy, Resident�s First, ED ALC Recognized best practices could be more systematically adopted There is stakeholder readiness to move forward Challenges are experienced across all health sectors and services Already have grassroots support of the SHRTN effort and some system capacity in quality improvement

30. Elements of Proposed system model Part 2

31. Priority Target Population Target Population: older adults with complex and responsive behaviours associated with cognitive impairments due to complex mental health, addictions, dementia, or other neurological conditions and their caregivers. Includes those living in long-term care homes or in independent living settings Note: The vision and guiding principles and overall framework are applicable to other populations with similar challenges such as: individuals with an acquired brain injury, and younger adults with age-related and neurological illnesses.

32. Making a Difference Moving Toward Person and Caregiver Directed care , (before and after the tipping point (how do we get there?) within a generation (25 years) that number could reach between 1 million and 1.3 millionwithin a generation (25 years) that number could reach between 1 million and 1.3 million

33. Principles to Guide System Model Overarching PrincipleThe principle of person and caregiver directed care has been put forward as a key, overarching principle that needs to be reflected strategically as well as in day to day practice. All persons must be treated with respect and accepted �as one is�, the older person and caregiver/family/social supports have a central voice and are the driving partners in the care and life goal decisions. Other proposed relevant principles include: 1. Behaviour is Communication Challenging behaviours can be minimized by understanding the person and adapting the environment or care to better meet the individual�s unmet needs. 2. Diversity Practices must value language, ethnicity, race, religion, gender, beliefs/traditions and life experiences of the people being served 3. Collaborative Care Accessible, comprehensive assessment and intervention requires an interdisciplinary approach which includes professionals from different disciplines, as well as the client and family members, to cooperatively create a joint, single plan of care. Move through the principles then ask for comments, additions, clarificationMove through the principles then ask for comments, additions, clarification

34. Principles to Guide System Model cont. 4. Safety The creation of a culture of safety and well-being is promoted where older adults and families live and visit and where staff work. 5. System Coordination and Integration Systems are built upon existing resources and initiatives and encourage the development of synergies among existing and new partners to ensure access to a full range of integrated services and flexible supports based on need. 6. Accountability and Sustainability The accountability of the system, health and social service providers and funder to each other is defined and ensured Move through the principles then ask for comments, additions, clarification Move through the principles then ask for comments, additions, clarification

35. 3 Pillars of the BSS Model

36. The Essential Elements of each Pillar

37. Proposed Next steps Part 3

38. Main Goals in Moving Forward Improved Patient Experience Primary objective is patient driven care � current system is not patient driven Need to find ways to enhance caregiver supports Improved System Performance We are not measuring system performance in this area- need to develop system indicators Better ways of providing care exist- system requires some standardization of practice and the protocols to support this

39. A Proposed Phase 2: Implementation and TestingSome Assumptions Modest new investment is required to change performance since current investments have provided a good foundation. Many innovative solutions exist, but may not have been evaluated fully or spread across the province. Implementation must incorporate and build on these projects. Standardization of practice through the use and development of guidelines and protocols in key areas is required Ontario needs to continue to take a leadership role nationally on this topic A quality improvement approach is necessary to create the system changes across all sectors and to ensure implementation includes better handoffs, integration and transitions Knowledge exchange occurs during the implementation to facilitate spread of good ideas and ensure timely course corrections Full coordinated evaluation is necessary including system outcomes, creation of indicators and potentially new data collection including all phase 2 projects

41. Tool and Template for Transformation

43. How Wonderful it is that nobody need to wait a single moment before starting to improve the world Anne FrankIf there were no Gaps we would not see the Light (Leonard Cohen) and  Knowledge Speaks and wisdom listens( Jimmy Hendrix)

44. For more information Visit www.bssproject.ca for resources, links and updates E-mail your questions to: bss@alzheimeront.org

45. Questions