A Behavioral Health Model in Long-term Care

1. A Behavioral Health Modelin Long-term Care report on Chandler Hall

3. Introductions LynetteKillen, CEO, Chandler Hall, Project Leader and Advocate Deborah W. Frazer, Ph.D., Original Consultant to develop and implement project Christine Etzrodt, MS, Current Consultant

4. Purpose of the Behavioral Health and Aging Project The purpose of the project is to embed the principles and practices of behavioral health into the very core of long-term care. We want to develop a model of care that is resident-centered, prevention-oriented, integrated, coordinated, replicable, and budget-neutral. We want to share the model with other providers.

5. Focus of The Model Is to Address • Mood (e.g. depression or anxiety) • Behavior (e.g. wandering) • Cognition (e.g. memory or judgment)

6. History • Launched in May 2009, now in the fourth year. • First three years focused on Mood and Behavior; in fourth year we are integrating a cognitive fitness approach. • Funded by The Thomas J. Scattergood Foundation and Friends Foundation for the Aging.

7. Elements of the Chandler Hall Model of Behavioral Health and Aging • Three simultaneous approaches: • Residents: focus on improving mood, behavior and general quality of life, through the Positive Pursuits Program • Direct Care Staff: focus on behavioral health education and job competencies of direct care workers. • Professional Staff: focus on face-to-face integration of medical and behavioral health professionals.

8. Who Was Involved? Model includes all persons with resident contact: • Geriatrician/Medical Director • Director of Nursing, Nurse Practitioners, Social Workers • Geriatric psychiatrist and clinical social worker • Certified Nursing Assistants • Recreation staff • Volunteers • Also included in focus groups and training: housekeeping, food service, security, and transportation staff

9. Exercise program with Hicks and Friends Nursing Home residents Intergenerational Reminisce Time – Music with Frank Sinatra in FNH

10. Features of the Model • The model strives to be culturally competent and innovative. • It addresses behavioral health needs that support seniors in their communities. • It promotes career development in the field of long-term care. • It is a practical application of being “person-centered” • It creates a structure to re-integrate behavioral health services into the larger health care delivery system, recognizing the inter-relationship of physical and behavioral health.

11. Development and Implementation of the Project:A Timeline: 2009-2010 (Investigation) • Change begins at the top: Lynette Killen, CEO of Chandler Hall, leads the project with vision, support and advocacy. • Deb Frazer, PhD, hired for 8 hours/week to research and develop the concept. • Christine Etzrodt, MS, hired as research assistant. • Collected and reviewed existing literature; reviewed existing behavioral health measures; conducted focus groups with staff.

12. Development and Implementation of the Project:A Timeline: 2009-2010 (Preparation) • Chandler’s Board was introduced to the project. • Senior management was engaged to support change. • Established Advisory Committee. • Sent letters to families introducing project and inviting participation. • Created “Feeling Better: A Guide to Mood and Behavior” • Began behavioral health educational program (three ½ hour modules) for all staff who have contact with residents; educational program is now blended into monthly new employee orientation, and is conducted by Chandler Hall’s two social workers and a program coordinator.

13. Integrating Behavioral Health into Long-term Care: A Manual for Providers Of Care for the Aging This Manual was produced in 2012 as part of a project on Behavioral Health and Aging conducted at Chandler Hall Health Services, a Continuing Care Retirement Community located at 99 Barclay Street, Newtown, PA 18940 The project was jointly funded by Friends Foundation for the Aging and The Thomas Scattergood Behavioral Health Foundation. For more information about this Manual, or about the project, contact the Chandler Hall Administration Office at 215-860-4000 x 1501.

14. Implementation of the Positive Pursuits Project: A Timeline: May 2010 through February 2012 • Based on decades of work by Linda Teri, Suzanne Meeks, Kimberly Van Haitsma, and Laura Gitlin connecting improved mood/behavior with opportunity for “pleasant events”. • Residents interviewed by social workers using the Positive Pursuits Assessment to determine what “positive pursuits” the resident would like to engage in; could be group or individual activities; attending a concert or eating chocolate ice cream for dessert every night. • The formal program is put in place for 10 weeks, allowing residents and staff to get used to it. We worked with 8-10 residents and their caregivers at a time.

15. Implementation of the Positive Pursuits Project: A Timeline: May 2010 through February 2012 • A direct care staff “Champion” (enthusiast) was selected from participating groups who would be the “go-to” on the project. • Resident Positive Pursuits Daily Log completed by care staff for the 10 weeks to track participation. • Resident Positive Pursuits Weekly Summary completed by care staff to get a full picture of each resident.

18. Development and Implementation of the Project: A Timeline: May 2010 through February 2012 • Weekly meetings between Christine Etzrodt and care staff to problem solve, plan additions to each resident’s positive pursuits, and act as resource for care staff. • Weekly meetings of “Champions”, social workers, volunteer coordinator, and activities staff developed as additional resource. • After 10 weeks, the residents’ selected positive pursuits are incorporated into care plan and resident continues to enjoy doing them!

19. Research to Date • Data analysis of 128 residents is ongoing, currently collaborating with Drexel University Department of Neuropsychology. • Behavioral issues at Chandler Hall occurred at a very low rate, reflecting generally good management; some analyses could not be done, because there were no occurrences of problem behavior. • Anecdotal reports support the value of behavioral health education, integration, and the deepening of a person-centered, positive pursuits approach with residents.

20. Challenges and Solutions • A Challenge: Integrating Positive Pursuits Project into Chandler Hall’s culture. It was new and it took time; change is always a challenge! • Solution: Providing guidance through weekly one-on-one check in meetings between Christine and the “Champions”. • Solution: Implementation Group meetings: Deb and Christine, social workers, “Champions” as a discussion forum and problem solving group. Giving them a voice.

21. Testimonials: Moses and Karen I would like to introduce you to two of our “Champions” who did an excellent job implementing the Positive Pursuits Project. Share firsthand experience of project, fears, how you got through it, felt more confident handling challenges after participation in project? • Moses • Karen

22. Moses – Testimonial “Positive Pursuits program was an eve-opener and was embraced by staff who shared the belief that their goal is to enrich the everyday lives of residents. The program focused on the importance of knowing the residents individually and not putting them in an activity or program box. For example, I had a resident that did not like to participate in group exercises, but loved to paint so I encouraged her to paint and the result was that her upper body improved its range of motion. By knowing the residents personally you understood what they loved to do before coming to Chandler Hall as well as knowing what new interests they want to pursue. My motto, and what I tell new staff, is to do things at the resident’s speed – which may change from day to day – and not on you speed! Overall, the program encourages flexibility, spontaneity, and adaptability.”

23. Karen- Testimonial “Starting the moment Dr. Frazer presented the program, I knew it was of interest to me. The goal was to get residents more involved with what they loved as well as help prevent depression and inactivity. The greatest learning lesson for me was to learn that for a pursuit to be meaningful and fun, it didn’t require a large group. Some residents preferred individual or small activities like watering flowers, playing games, or playing cards. The role of volunteers matched with residents is important for certain activities – like playing cards. Being aware of the benefit of the program to residents makes it easy to incorporate activities into a care manager’s workday; this is what I share with new care managers when I mentor them.”

24. Testimonials: Dr. Ashish Sitapara • “Over the last few years, I have seen the benefits of the well organized, multi faceted, positive pursuits program. First and foremost involved the collaborative effort and regular meetings with the caretakers, care managers, and the continuous education for staff. It has broken the traditional barriers of communications between care staff. The net result is more relevant information comes to the Wellness Center Clinic upon which the NPs and I make better informed medical decisions for residents. • Another benefit is I haven't prescribed as many antidepressants compared to before the program started. I think the earlier detection and behavioral intervention has led to better outcomes for our residents.”

25. Testimonials: Dr. Magdelana Wiltz “I think what I like best about the project is the personal investment of the direct care worker with the resident. I think it is this relationship that makes the profound impact rather then the content itself. It makes the resident feel valued. Also getting to know our patients at a more personal level creates a sense of community and increases self esteem.”

26. Where Are We Now? • We are currently replicating the Positive Pursuits Project at Medford Leas in Medford, NJ. • Cognitive Fitness Program – Positive Pursuits addresses mood and behavior, this adds final component of cognition. • Additional replication sites currently being explored. • Three Levels of Replication: full replication, Kick-off Support, Resource Tools.

27. Integrating Behavioral Health into Long-term Care: A Manual for Providers Of Care for the Aging Replication This Manual was produced in 2012 as part of a project on Behavioral Health and Aging conducted at Chandler Hall Health Services, a Continuing Care Retirement Community located at 99 Barclay Street, Newtown, PA 18940 The project was jointly funded by Friends Foundation for the Aging and The Thomas Scattergood Behavioral Health Foundation. For more information about this Manual, or about the project, contact the Chandler Hall Administration Office at 215-860-4000 x 1501.

28. Cognitive Fitness Program

29. Cognitive Fitness Program at Medford Leas An 8-week intervention, delivered 3 times per week, 1 hour per session, 16-20 participants. Developed by Gerry Stride, CALA, CSW, Director of Therapeutic Recreation at Medford Leas. A cognitive program designed to improve Mini-Mental State Exam (MMSE) Scores for elderly residents with mild cognitive impairment. The MMSE tests orientation (date, year, month), attention, recall, and language function. Program uses pen and pencil games and activities, as well as social strategies to improve function in the following areas: encoding (storing) short and long-term memory, retrieval, attention, spatial relations, perception, language function, and socialization.

30. Cognitive Fitness Program at Medford Leas Examples of program activities include: Anagrams (word puzzles which are the result of rearranging the letters of a word to produce a new word, for example orchestra can be rearranged into carthorse. Alphabetization, crossword puzzles, and trivia Fact of the Day (e.g. The brain has 100 billion neurons). Participants are asked to recall the fact during the session and in later sessions. Eat something new and different or try a new hairstyle! Preliminary results have showed improvement in Mini-Mental State Scores for each participant. Those who attended more than 75% of classes showed the greatest level of improvement.

31. How Did the Project Evolve Over Time? • Initial concept was symptom-focused • We broadened to include prevention of symptoms. • We embraced the “person-centered culture evolution” movement that is now challenging traditional concepts in long-term care. • Both Positive Pursuits and culture evolution focus on each person individually. They require a deep understanding of each individual’s life story, and current needs and preferences. • The focus is also on opportunity for personal growth, development, and greater contentment.

32. Sustaining the Positive Pursuits Project • Refined a model of behavioral health care that integrates the direct care staff into prevention and treatment. • Meetings to ensure positive results of the project are maintained, and continue to be implemented into the culture at Chandler Hall in new and unique ways. • Making the model and resources available to others

33. Sharing the Tools • Feeling Better: A Quick Reference Guide to Mood and behavior (will be available by mail, at cost) • “How to” Positive Pursuits Manual (will be available as a free download) • Mood and Behavior Training Module (will be available as a free download) • Preparation of paper for publication on the findings of utilizing the Positive Pursuits approach in Chandler Hall’s nursing home and personal care settings. These items will be made available at www.olderpa.org/PositivePursuits in the first quarter of 2013

34. What Do We Conclude? Positive Pursuits Project has had a positive effect on the lives of our residents and the staff who care for them. • Prevents symptoms before they begin. • Gives staff the education and tools they need to help residents. • Gives direct care staff extra professional support when needed. • Increases morale and confidence in ability to perform their jobs, especially in tough situations.

35. Thank You! QUESTIONS?