Developing a Behavioural Support System for Older Persons with Responsive Behaviours in the South West LHIN. Action Plan: Part B

Transcription

1 Develping a Behaviural Supprt System fr Older Persns with Respnsive Behaviurs in the Suth West LHIN Actin Plan: Part B April 5, 2012 (revisin)

2 Suth West Lcal Health Integratin Netwrk (LHIN) Behaviural Supprts Ontari (BSO) Actin Plan Part B 8. What training and knwledge transfer prcesses are presently in place fr current and future prfessinals t disseminate new knwledge and best practice skills relating t behaviural supprts? There are many existing prcesses that supprt evidence infrmed knwledge transfer int clinical practice amngst current and future health care prviders acrss the Suth West LHIN. Organizatins that prvide direct training/educatin fr healthcare prfessinals include: The Divisin f Geriatric Medicine, Department f Medicine at the University f Western Ontari (UWO) is cmmitted t the advancement f research, teaching and clinical care. The Divisin currently cnsists f nine full-time academic geriatrician educatr/researchers wh prvide supprt and educatin supprt t interdisciplinary health prfessinals, primary care physicians, undergraduate and pst graduate medical students. Educatin, research and clinical care are the crnerstnes f the prgram. The Divisin f Geriatric Psychiatry, The UWO s key rle is t prvide academic leadership within the Schulich Schl f Medicine & Dentistry, UWO. Functinally, the Divisin als cntributes t clinical service prvisin and leadership by engaging the participatin and cntributin f individuals frm a variety f related clinical disciplines. The Divisin is invlved in nging activities fr undergraduate medical educatin fr medical students and pstgraduate educatin in geriatric psychiatry fr residents in the Department f Psychiatry. The Divisin participates in and is an active cntributr t educatin f medical and nursing students at Schulich. Specialized Geriatric Services (SGS), St. Jseph Health Care Lndn (SJHC), prvides a leadership rle fr the Suth Western Ontari Geriatric Assessment Netwrk (SWOGAN), which is made up f the Reginal Geriatric Prgram (RGP) and the Reginal Psychgeriatric Prgram (RPP). Educatin and capacity building acrss bth Suth West LHIN and Erie St. Clair (ESC) LHIN are key functins f the Netwrk. The fllwing cllabrative educatin events are ffered thrugh the SWOGAN Netwrk, SGS, and Geriatric Mental Health Prgram: SGS Interdisciplinary Grand Runds ffered mnthly t primary care, Lng-Term Care (LTC) Hmes, cmmunity agencies and hspital staff. Grand runds are led by SGS (RGP & RPP). An interdisciplinary planning cmmittee has been frmed and made up f a variety f clinicians (Occupatinal Therapy, Nursing, Psychlgy, and Geriatrician). The Grand Rund series is ffered mnthly and has been highly rated by participants. Tpics have included: sleep disrders in the elderly, elder abuse, cntinence, cgnitive impairment and falls preventin. The educatin sessins are cnducted at Parkwd hspital and ffered via Ontari Telemedicine Netwrk (OTN) and webcast. All presentatins are archived n the OTN website fr ne year. Each Grand Rund sessin is evaluated and participants are asked t list future ht tpics they wuld like presented. SGS Fall Educatin Series is a service learning series that is ffered each fall. On average six t eight full-day t half-day sessins are ffered. A planning cmmittee cmprised f crss sectr partners cme tgether t identify the tpics, recruit speakers, plan and rganize the series. Tpics range frm the 3 D s (delirium, dementia and depressin) t pain management fr the frail elderly. Each speaker is evaluated and a final reprt cmpleted. Many sessins within the learning series is ffered via OTN r webcast and is archived fr 2 P age

3 ne year. This event is free fr all participants, and typically attracts 30 t 50 interdisciplinary healthcare prfessinals frm the Suth West LHIN and ESC LHIN. SWOGAN Team Exchange is an annual knwledge exchange event fr lcal and reginal geriatric and geriatric mental health utreach teams prviding care fr the frail elderly acrss Suth West LHIN and ESC LHIN. This event prvides pprtunities fr the clinical teams t cme tgether t share best practices, lessns learned, and fr prfessinal develpment. A Physician and Leadership Breakfast meeting ccurs each year, which cnnects the Primary Care physicians wh supprt the lcal SWOGAN utreach teams with Geriatricians and Geriatric Psychiatrists. Updates n prvincial initiatives, physician educatin and funding pprtunities, best practice guidelines in geriatric care are discussed. Geriatric Medicine Refresher Day is a widely ppular annual educatin event that is in its 26 th year. This event has grwn significantly ver the past several years with ver 500 healthcare prfessinals frm acrss Suthwestern Ontari in attendance. The Geriatric Medicine Refresher Day prvides prfessinals with pprtunity t braden their knwledge base, t refine specific skills, and t meet with thers wh share their cncern in imprving quality care t the elderly. The plenary sessins encurage interdisciplinary investigatin f subjects cmmn t all, while cncurrent sessins prvide medical updates and investigatins f ther tpics in geriatric care. Tpics are selected t appeal t a wide range f care prviders including physicians, nurses, therapists, pharmacists, nutritinists, psychlgists, scial wrkers, researchers, educatrs, Occupatinal Therapists (OT), Physical Therapists (PT) and discharge planners, as well as peple serving primarily in administrative psitins. An interdisciplinary planning cmmittee wrks tgether each year t plan, rganize and successfully implement this event. Geriatric Psychiatry Sympsium is ging in its 10 th year. This is an annual educatin event that prvides healthcare prviders with an pprtunity t learn abut a variety f tpics in geriatric mental health. Tpics are selected t appeal t an interdisciplinary audience, and range frm Md and Anxiety disrders in Elderly, t supprting infrmal caregivers f individuals living with dementia and review evidence-based thinking regarding innvative interventins. Over 125 healthcare prfessinals attend this event yearly. The Sympsium is planned in partnership with SJHC Lndn (Geriatric Mental Health Prgram), Lndn Health Sciences Centre (LHSC) and The UWO (Divisin f Geriatric Psychiatry). Other planning partners include the Alzheimer Sciety, Primary Care Physicians and the RGP. Geriatric Mental Health Prgram, SJHC Lndn, prvides varius activities that supprt educatin and knwledge transfer fr LTC hmes, Hspitals, and cmmunity agencies. The Discharge Liaisn Team (DLT) prvides supprt fr inpatients with cmplex, yet stable mental health needs that n lnger require specialized hspitalizatin as they transitin frm hspital t a LTC hme. The DLT team will assist LTC hme staff in managing the resident s psychiatric symptms, achieve an apprpriate balance f service t create gd cmmunity alternatives t hspitalizatin and prvide quality f life fr the resident in their chsen envirnment. The DLT currently play a key rle acrss the Suth West LHIN in teaching LTC hmes hw t effectively manage lder adults with respnsive behaviurs. Hspitals regular department runds, academic educatin days fr medical staff and nging cntinuing medical educatin Resurce and Behaviur Grup - In 2008, there were cnversatins between health care prviders (HCPs) frm LTC hmes and healthcare prviders frm the Outreach Teams with SGS, SJHC, Lndn regarding the need fr, and an apprach t, increasing n-site capacity t care fr residents with challenging md and behaviur symptms. T gain a greater understanding f the 3 P age

4 needs f health care prviders (HCPs) wrking in LTC hmes and t enable them t effectively respnd t residents with challenging md and behaviur symptms, a select grup f SGS clinicians met with lcal investigatrs t create a research cllabrative. While a large bdy f literature exists n hw t deal with challenging behaviurs in lder adults, there is limited infrmatin n the frnt-line HCPs perspective. The gals f the study An Investigatin f Health Care Prvider s Needs Related t Behaviural Issues in Lng- Term Care were t identify what was needed t imprve care fr LTC hme residents with challenging behavirs and what supprts were needed t prvide quality care t these individuals. Seventeen rural and urban LTC hmes in Middlesex/Lndn were invited t participate and data was cllected frm 12 hmes during 18 audi-taped fcus grups with LTC hme frntline staff. Fcus grups were run during day, evening and night shifts t ensure participatin frm all staff. The research design used a Qualitative Interpretive Descriptive apprach (Thrne et al., 2004). Analysis fcused n cding key phrases and themes that emerged frm the data. Patterns within and between the transcripts were lcated, using a cnstant cmparisn apprach. Six key themes were identified: place, rganizatinal structure, resurces, relatinships, infrmatin cmmunicatin technlgy and cnsequences. Findings als suggest that staff needed mre accessible resurces and that there was a genuine thirst fr knwledge regarding hw t best care fr residents with challenging behavirs. Prmting Knwledge Exchange arund Healthy Aging and Aging at Hme (AAH) Aging ppulatin has implicatins fr researchers, plicy makers and practitiners. In Ontari, a key respnse has been the AAH initiative. T fully infrm this agenda, senirs perspectives are needed. This tw phase study was funded thrugh an Ontari Research Calitin Early Researcher Award. Phase 1: Fall 2009, fcus grups with senirs frm Lndn, Thunder Bay and Kingstn Objective: T understand the meaning f AAH and hme-based supprts frm the perspective f a sample f Ontari senirs Phase 2 Octber, Invitatinal Knwledge Exchange Wrkshp, Lndn, ON, rganized in partnership between SJHC Lndn, Lawsn Health Research Institute Centre fr Studies n Aging and Health, Prvidence Care/Queen's University, Kingstn; Centre fr Educatin and Research n Aging and Health, Lakehead University, Thunder Bay; Graduate Prgram in Health and Rehabilitatin Science (Occupatinal Science), UWO Objectives: T shwcase current research in the AAH discurse T prvide an pprtunity t engage in the AAH discurse T further develp the research base underlying the AAH strategy T prmte linkages between research plicy and practice in AAH Alzheimer Scieties prvide educatin fr patients and families with dementia, particularly thrugh the First Link Prgram which supprts peple with dementia and family/caregivers thrugh individual and family cunseling and supprt grups. Public Educatin Crdinatrs ffer dementia specific educatin t prfessinals wrking with peple with dementia in a variety f settings including lng-term care hmes, cmmunity agencies, supprtive husing and retirement 4 P age

5 hmes. First Link Crdinatrs and Public Educatin Cnsultants are key rles within Pillar 3 f the BSO framewrk. Sme f the training ffered includes: Gentle Persuasive Appraches in Dementia Care (GPA), is an 8-hur interactive wrkshp fr all staff (frm nurses t husekeepers) that care fr persns with dementia. This prgram utilizes a persn-centered apprach, and teaches participants hw t respnd t persns with dementia respectfully and with cnfidence and skill t effectively prevent and/r address respnsive behaviurs assciated with dementia. U-First! is a prven and effective apprach t wrking with peple with dementia. Thrugh dialgue and a case-based apprach, learners will have mre cnfidence in wrking with peple with respnsive behaviurs. Training is especially designed fr peple wrking in cmmunity care, acute care, and lng-term care. U-First stands fr: Understand the behaviur changes in a persn with dementia; Flag pssible changes seen in the persn; Interact with skill and understanding; Reflect and reprt the behavir; Supprt the persn with dementia and their family caregiver; and invlve the Team in caring fr the persn with dementia. Residents First is a prvincial initiative that supprts LTC hmes in prviding an envirnment fr their residents that enhances their quality f life thrugh QI training, tls and resurces custmized t the LTC hme sectr that facilitates cmprehensive and lasting change by strengthening the LTC sectr s capacity fr quality imprvement. Acrss the Suth West LHIN, almst all LTC hmes have reprted sme frm f invlvement with the Leading Quality cmpnent f Residents First which fcuses n helping LTC hme leaders prepare fr the intrductin and spread f quality imprvement thrughut their rganizatin. As part f the Residents First initiative, 25 LTC hmes have started develping team learning cllabratives and quality imprvement training is being ffered t ver 40 staff. All LTC hmes will be required t cmplete a quality imprvement plan. Alzheimer Knwledge Exchange (AKE) perfrms a key rle fr the BSO prject by knwledge brkering, prviding access t evidence based infrmatin, prviding knwledge exchange pprtunities (n-line, in persn, scial media), and supprting the develpment f tpic specific cmmunities f practice. AKE will perfrm a cre cmpnent f an effective educatin and training strategy that will be rlled ut acrss the Suth West LHIN in alignment with Pillar 3. a. What quality imprvement capacity is currently available fr this prgram (i.e. hw many individuals with QI expertise will be supprting BSO within the LHIN?) It is ur aim t ensure all initiatives are guided by ur Client Value Statement I am a unique individual wh wants t live fully with meaning and dignity thrughut my life jurney. Imprvement measures are currently being reprted quarterly t the Suth West LHIN fr the BSS prject. The BSS Steering Cmmittee and Leadership structure, in partnership with the geriatric cperatives, will be develping and implementing a quality imprvement strategy as this was nt incrprated int the BSS prject. An evaluatin cmmittee was frmed in January fr the BSS prject which meets n a regular basis. Quality imprvement will be added t the rle f this cmmittee. A Quality Imprvement Facilitatr will be hired t supprt this cmpnent. The fllwing resurces with knwledge/expertise in quality imprvement will be leveraged: HQO BSO Cach 5 P age

6 BSO Imprvement Facilitatr BSO Prject Lead Directr, Evaluatin and Research, SGS, SJHC Lndn, wh is the Evaluatin Cnsultant fr the BSS prject and Chair f the BSS evaluatin cmmittee Residents First Imprvement Facilitatrs Senirs Health Research Transfer Netwrk (SHRTN) Cmmunity f Practice Primary care prviders and their healthcare prviders invlved in previus quality imprvement initiatives b. What behaviural supprts expertise is currently available t supprt BSO within the LHIN? Acrss the Suth West LHIN, there is numerus behaviural supprts expertise including: Windermere Way, Enhanced Specialized Mental Health Unit, McGarrell Place, Lndn (LTC Hme) The staff wrking within this LTC hme has develped in-depth knwledge and expertise t effectively manage lder adults with respnsive behaviurs. It is anticipated these staff will play a vital rle in facilitating service learning fr LTC hmes, lcal and reginal mbile utreach teams and their care partners. SJHC Geriatric Psychiatry Prgram prvides reginal specialized geriatric psychiatric care fr persns with mderate t severe dementia and cmplex behaviurs in additin t prviding lcal reginal specialized psychiatry resurce teams, such as: Reginal Psychgeriatric Prgram (LTC hme, Hspital and cmmunity fcus), DLT (LTCH and Hspital fcus), Geriatric Mental Health Outreach Team (cmmunity fcus). These specialty utreach services are mandated t prvide cllabrative shared care fr lder adults with cmplex mental health and addictins. Wrking clsely with their lcal supprts, they prvide specialized assessment, cnsultatin, and treatment acrss the Suth West LHIN. Each f these utreach teams are supprted by Geriatric Psychiatrists. In additin, these specialty teams have an educatin and capacity building rle with their partners acrss the care cntinuum. SJHC RGP is affiliated with the Divisin f Geriatric Medicine, UWO. The RGP is an interdisciplinary team which prvides cmprehensive geriatric assessments in hmes, hspitals and lng-term care facilities and prvides recmmendatins t care prviders, families and patients. This utreach team functins t enhance the care f frail elderly individuals thrughut Suthwestern Ontari (acrss Suth West LHIN and ESC LHIN) thrugh clinical cnsultatin, educatin, research, evaluatin and cmmunity develpment. The team als plays a large rle in the educatin f students and health prfessinals acrss the regin. The RGP and RPP specialty utreach teams are part f the SWOGAN. This netwrk links geriatric and geriatric mental health assessment teams in the ten cunties f suthwestern Ontari. The multidisciplinary teams link with lcal resurces t prvide assessment and treatment ptins in r near the client's hme. The BSO initiative will link clsely with the SWOGAN netwrk. Alzheimer Scieties f Lndn-Middlesex, Elgin, Oxfrd, Perth, Hurn, Grey-Bruce prvide educatin fr patients and families with dementia, particularly thrugh the First Link Prgram which supprts peple with dementia and family/caregivers thrugh individual and family cunseling and supprt grups. Public Educatin Crdinatrs ffer dementia specific educatin t prfessinals wrking with peple with dementia in a variety f settings including LTC hmes, cmmunity agencies, supprtive husing and retirement hmes. Alzheimer Outreach Services (ASO) f McCrmick Hme ffers therapeutic recreatinal prgramming fr peple with Alzheimer's disease and related dementias. Their 6 P age

7 interdisciplinary healthcare prviders have highly develped skills and expertise t effectively deal with lder adults with respnsive behaviurs that will be leveraged t facilitate knwledge transfer within the BSO initiative. Schlegel Villages/LTC hmes Glendale Crssing, Lndn, Ontari: In partnership with the Research Institute fr Aging and the University f Waterl, Schlegel Villages are cnducting practical, applied research at the facility and cmmunity level, t imprve care and verall quality f life fr senirs. LTCH staff is prvided with enhanced training related t the health and well-being f lder adults and their families t prmte healthy aging. Develpment f innvative evidence based prgrams within this research envirnment. Suth West Cmmunity Care Access Centre (SW CCAC) Geriatric Resurce Team (GRT) Case Managers prvide cmprehensive geriatric assessments in each lcal area and are supprted by Primary Care Physicians with advanced training in care f the elderly. The Behaviural Supprts System (BSS) Prject, five senirs mental health and addictins respnse teams will be established/enhanced in each area and will cnsist f clinical nurse specialists and allied health (e.g. scial wrk, ccupatinal therapy). The senirs mental health and addictins respnse teams will be supprted by a geriatric psychiatrist. These teams will prvide timely respnse fr referral surces dealing with lder adults with respnsive behaviurs. The Suthern Netwrk f Specialized Care prvides supprts fr adults aging with a develpmental disability that experience mental health and behaviural issues. c. Hw will training effrts be fcused t ptimize the creatin f knwledgeable care teams with bth behaviural and QI capacity? An Educatin Cnsrtium will be develped and lead by SJHC, Specialized Geriatric Psychiatry Services t ensure a LHIN-wide apprach t capacity-building, leveraging existing specialized resurces (Enhanced Psychgeriatric Resurce Cnsultants, DLT, Reginal Mental Health Care Geriatric Outreach Team, RGP, RPP, senirs mental health and addictins respnse teams, Alzheimer s Sciety). Strng linkages and crss-training pprtunities will be develped as new initiatives are implemented. Interdisciplinary mbile utreach teams and specialized reginal geriatric and psychgeriatric teams will cllabrate with partners t create shared learning envirnments, disseminate c-created best practices and prvide cllabrative learning pprtunities fr direct care prviders (LTC hmes, primary care, CCAC). Enhanced Psychgeriatric Resurce Cnsultants (EPRC) will play a leadership rle in building capacity acrss the LHIN, and will wrk clsely tgether t ensure cntinuity. Examples f training effrts include: Onsite case-based educatin and jint care planning Identificatin f LTCH staff wh are PIECES (Physical, Intellectual, Emtinal, Capabilities, Envirnment, Scial and Cultural) trained. These LTC hmes will becme champins within their LTC hme and will receive refresher training in PIECES. PIECES and GPA training will be prvided t all BSO utreach team members, and all ther existing utreach teams. LTC hmes will als receive PIECES training, led and crdinated by the EPRCs. Identificatin f primary care prviders trained in quality imprvement methdlgies that are willing t be early adaptrs will test new tls and prtcls. Lcal imprvement teams will be develped by the Quality Imprvement Facilitatr and will apply quality imprvement prcesses and PDSAs (Plan, D, Study, Act) t develp and test changes prir t final implementatin. 7 P age

8 New BSO utreach teams will be trained by existing specialized utreach teams. Selfdirected learning packages will be develped and a learning mentr assigned. Opprtunities fr jint utreach visits, clinics, and case reviews will be prvided as part f their rientatin. A tw-day BSO/BSS Team Exchange will be rganized early in 2012 as a way t launch the prgram, prvide netwrking pprtunities with the existing teams, and fr educatin and capacity building. Geriatricians and Geriatric Psychiatrists will prvide educatin t Physicians (LTC hme, primary care, etc.) thrugh educatin, mentrship, webinars, case cnferencing, and grand runds. QI capacity frm Residents First Imprvement Facilitatrs and LTC hme staff that participated in Residents First will als be leveraged. d. What knwledge transfer structures/pathways currently exist within the LHIN that can be leveraged in supprt f the BSO prject? In additin t the prcesses previusly mentined, the BSO prject will leverage the fllwing mechanisms t disseminate evidence-based practices, cmmn practices and prtcls t supprt the BSO prject acrss the Suth West LHIN: Suth West Primary Care Netwrk prvides the necessary structure t cnnect primary care prviders in the Suth West and is the primary cnduit fr prgrams and/r rganizatins needing t engage with the regin s primary care prviders. The newly frmed LTC Hme Netwrk will assist the Suth West LHIN when they need cnsultatin/recmmendatins related t LTC hmes. SHRTN and AKE websites and lcal knwledge brkers/librarians are key surces f infrmatin n best practices and current research. The Advanced Gerntlgical Educatin (AGE) enterprise has develped a GPA in Dementia Care educatin prgram. Canadian Dementia Resurce and Knwledge Exchange (CDRAKE) and the Natinal Initiative fr the Care f the Elderly (NICE) prvide educatinal resurces. The SWOGAN will ensure that all educatinal activities cmpliment (nt duplicate) ther effrts at capacity building and that all resurces are shared/maximized fr training; existing cmmunicatin mechanisms are already develped by SWOGAN will be utilized. 9. Describe hw yur Actin Plan builds n current capabilities and capacity (e.g. tls, resurces, partnerships, Aging at Hme initiatives, etc.) Build n what we already have The BSO Prject will be integrated int the existing AAH funded Behaviural Supprts Systems (BSS) Prject. A hub and spke mdel will be utilized t ensure that the BSO LTC hme psitins are integrated int the five existing BSS mbile utreach teams acrss the Suth West LHIN. Specialized reginal supprts (RGP, RPP, Geriatric Psychiatry) will be linked with each f the mbile teams t enhance their ability t prvide a timely respnse fr lder adults with respnsive behaviurs wh live in their wn hmes r LTC hmes. Cmmn assessment tls, reprt templates and care strategies will be utilized by the mbile teams and their care partners. BSO LTC hme-funded staff will supprt LTC hmes nly, which will enhance the existing mbile teams ability t expand int cmmunity and hspital t actively be invlved and supprt transitins acrss care settings. It is expected that access t Geriatric services fr Older Adults with respnsive behaviurs will be crdinated between the fllwing agencies: CCAC Geriatric utreach teams, Nurse-Led LTC hme utreach teams, SGS (RGP, RPP), and Reginal Mental Health (Outreach teams, Discharge Liaisn Team), Geriatric 8 P age

9 Emergency Management (GEM) Nurses, Alzheimer Scieties, Cmmunity Mental Health and Addictins Services. Mbile Teams will als keep abreast f Residents First, Hme First, and Senir Friendly Care initiatives. 10. Hw is sustainability f the service redesign embedded in the prcess thrugh educatin and knwledge transfer and ther mechanisms (e.g. twards the individual, the caregiver, rganizatin, cmmunity, etc.)? Strng leadership and supprt by the Enhanced Psychgeriatric Resurce cnsultants, Reginal Psychgeriatric Prgram, BSS Prject Lead and Imprvement Facilitatr fr quality imprvement and change management will sustain changes made. A BSO quality imprvement and change management plan will need t be develped and implemented acrss the Suth West LHIN. Existing knwledge transfer mechanisms will be utilized and leveraged t cmmunicate the quality imprvement, educatin, and change management plans. BSO Team Exchange events (1 st ne planned fr winter 2012) will be ptimal in sharing best practices and lessns learned in regards t the new service mdels and PDSA results. Sustainability f the BSO will be facilitated by timely measurement within imprvement prjects, clear accuntability and reprting requirements fr health service prviders affiliated with the BSO prgram and rutine mnitring f key indicatrs t ensure the BSO prgram has the attentin and pririty f leaders. 11. Hw will knwledge transfer ccur (e.g. best practices, prtcls, standardizatin, etc.) Knwledge transfer will ccur thrugh frmal and infrmal interactins between healthcare prviders, clients and their families/caregivers in every setting acrss the Suth West LHIN. Quality imprvement will be a key cmpnent that is integrated int the knwledge transfer prcess. The BSO/BSS mbile teams with the supprt f reginal specialty utreach teams (RPP, RGP) will play a pivtal knwledge transfer rle t ensure quality clinical practice at the bedside. They will take n the rles f change agents, mentrs, and knwledge brkers. They will play a rle in facilitating infrmal case-based and service-learning pprtunities fr healthcare prviders in LTC hmes, hspitals, primary care, and cmmunity settings. Thrugh clinical cnsultatin, assessments, treatment, care-planning, and fllw-up, the BSO/BSS mbile teams will facilitate the disseminatin and utilizatin f evidence-based clinical assessment tls and evidence-based appraches t care thrugh demnstratin and mdeling. Over time, healthcare prviders in LTC hmes, hspitals, and cmmunity settings will adpt these appraches, which will imprve the client and caregiver experience. Thrugh the Educatin Cnsrtium and the Geriatric Cperatives, frmal learning activities will be embedded acrss the Suth West LHIN in a crdinated manner. 12. Wh will be the partners fr Knwledgeable Care Team and Capacity Building? The partners fr Knwledgeable Care Team and Capacity Building include: The University f Western Ontari Reginal Psychgeriatric Prgram, SJHC Lndn Reginal Geriatric Prgram, SJHC Lndn Suth Western Ontari Geriatric Assessment Netwrk, SJHC Lndn Reginal Mental Health Care Lndn Discharge Liaisn Team, Outreach Team, SJHC Lndn Prviders f Behaviural Supprt Services (senirs mental health and addictins respnse teams): SJHC Lndn, Lndn Health Sciences Centre, St. Thmas Elgin General Hspital, Wdstck General Hspital, Hurn Perth Health Alliance, Alexander General Marine Hspital, Grey Bruce Health Services 9 P age

10 Suth West Cmmunity Care Access Centres Geriatric Resurce Teams, Nurse Led LTCH Outreach Team, Advanced Hme Care Team Alzheimer Scieties Cmmunity-Based Mental Health and Addictins rganizatins: Thames Valley Addictins Services, Chices fr Change, Canadian Mental Health Assciatin Primary care prviders and netwrks Suth West LHIN LTCH Netwrk Suth West Dementia Netwrk Lng-Term Care Hmes a. Hw have the partners cllabrated n previus prjects? Please refer t 3b abve b. What were the utcmes? Please refer t 3c abve c. List the executive spnsrs wh will have the ptential respnsibility fr meetings, chairing a steering cmmittee, nging leadership and engagement, etc. The C-Chairs f the BSS Steering Cmmittee will have the respnsibility t ensure nging meetings and the deplyment f behaviural staffing psitins fr participating HSPs. d. Describe hw the HSPs will deply staff t meet the established BSO framewrk fr each LHIN BSO resurces will be allcated t supprt system redesign as fllws: LTCH Staff: The hst LTC hme will put ut an expressin f interest t lcal LTC Hmes. Lcal LTC hmes in different gegraphies acrss the LHIN will supprt the applicatins f nursing and PSW staff t prvide services fr a defined perid f time fr the Schedule 1 senirs mental health and addictins respnse teams in surrunding lcal LTC Hmes. Services will be prvided frm the Schedule 1 lcatins r ther LTC hme lcatins in the Suth West LHIN.. A ttal f up t 10 FTE Health Care Persnnel will be allcated acrss the Suth West LHIN t supprt an interdisciplinary BSS/BSO utreach team. T ptimize funding, existing resurces will be leveraged t supprt the enhanced BSO mdel. Prjected staffing cmpliments include: Geriatric Psychiatrist (.8 FTE) t supprt the Suth West LHIN Psychlgist (1 FTE) t supprt the Suth West LHIN Quality Imprvement Facilitatr (1 FTE) t supprt the Suth West LHIN Psychgeriatric Resurce Cnsultant (1 FTE) t supprt suthern prtin f the Suth West LHIN Crdinatr (1 FTE) Scial Wrkers, Alzheimer Scieties (3 FTE) Adult Day Prgrams (2.5 FTE) The abve staffing allcatin is draft as further negtiatins will need t ccur. The BSS Steering Cmmittee and identified hst lng-term care hme will play key rles. 10 P age

11 e. If mre than ne HSP is participating in each LHIN, describe hw each f the psitins will be distributed and prvide yur ratinale. LTC hme Staff: LTC hme-funded staff will be integrated within the existing BSS Outreach Teams which wrk ut f five Schedule 1 Hspitals acrss the Suth West LHIN. The Suth West LHIN cvers a large prtin f Suth Western Ontari frm Lake Erie t the Bruce Peninsula, an area f 21,639 kilmetres. This includes Bruce, Elgin, Grey, Hurn, Middlesex, Nrflk, Oxfrd and Perth cunties. The Suth West LHIN has 78 LTCH, with the highest number f LTC hme beds in Lndn and Middlesex (3247). The Suth West LHIN encmpasses a large gegraphic area with a 69% urban and 31% rural mix. Additinal Healthcare Persnnel: Additinal Healthcare Persnnel will be assigned t SJHC Lndn, Alzheimer Scieties, and Adult Day Prgrams. SJHC Lndn, Reginal Psychgeriatric Prgram will receive the fllwing psitins which will be integrated within existing prgrams and services: Geriatric Psychiatrist (.8 FTE) (will jin existing team f Geriatric Psychiatrists wrking ut f Reginal Mental Health Care Lndn) Psychlgist (1 FTE) t supprt the Suth West LHIN Quality Imprvement Facilitatr (1 FTE) t supprt the Suth West LHIN Crdinatr (1 FTE) Enhanced Psychgeriatric Resurce Cnsultant (1 FTE) t supprt suthern prtin f the Suth West LHIN Alzheimer Scieties will receive (3 FTE) Scial Wrkers t enhance the First Link prgrams Adult Day prgrams will receive (2.5 FTE) fr vernight weekend relief f. Describe the specific rles and respnsibilities f the behaviural staffing psitins Staff rles and respnsibilities will be identified by the BSS Steering Cmmittee Enclse a summary timeline in a separate schedule. (see Appendix B) 14. Outline yur perfrmance, measurement and evaluatin plan. Describe indicatrs and data surces, the calculatin f baseline data fr each, and reprt n prgress tward explicit targets. Backgrund As per the BSO framewrk, the prpsed apprach is designed t: Prmte a better understanding f the client, prgram and system level characteristics that underpin successful integrated health care delivery initiatives; Identify fundamental cntext r design factrs and key transferable lessns t supprt the transfer f innvative and successful prject mdels; and Prduce and disseminate evidence f what has wrked well and identify pprtunities fr imprvement that exist at the prject level t enhance the effectiveness and impact f the strategies being emplyed by the LHINs and their partners. 11 P age

12 The evaluatin strategy will try t determine if these gals have been met. Further, the planned evaluatin will: Establish baseline infrmatin in rder t measure prgress ver time; and Measure the effects f imprvements n clients, family members, prviders, and the health system. Finally, three pririty utcmes have been identified by the Ministry: Reduced resident transfers frm LTC hmes t ERs/hspitals r behaviural units in situatins where the resident can be treated in their LTC hme setting; Delayed need fr mre intensive services (either in the cmmunity r LTC hme setting), thereby reducing admissins t hspital and risk f becming ALC; and Reduced length f stay fr persns in hspital wh can be discharged t a cmmunity r LTC hme setting with apprpriate supprts (i.e. enhanced behaviural resurces). These utcmes will be included in the prpsed evaluatin. Reginal Indicatr Wrking Grup In cnsultatin with the BSO Data, Measurement and Evaluatin Cmmittee and thers as apprpriate, the Suth West LHIN evaluatin cmmittee will wrk with the Hamiltn Niagara Haldimand Brant LHIN, as well as the Erie-St. Clair LHIN and the Wellingtn-Waterl LHIN t identify the best strategies and analytic techniques t answer the prject questins. In additin, prxy indicatrs and ther data surces will be explred. BSO ppulatin Wrking with the BSO Data, Measurement and Evaluatin Cmmittee, the successful BSO evaluatin vendr, and the reginal early adpter LHINs, ppulatin-level indicatrs, that is t say thse that are representative f high-level system utcme measures, will be develped. The gal is t develp measures that wuld be cmparable acrss all LHIN using existing administrative data. First the target ppulatin diagnstic cdes will need t be identified. A number f ICD-10 cdes have been identified. These will be tested by the Ministry-apprved Evaluatin Vendr in January Pssible measures f acute decline that require institutinal interventin that may be impacted thrugh the BSO prject may include: The prprtin f emergency department (ED) r urgent care centre (UCC) visits amng thse 65 r mre years f age that are fr with lder adults with mental health, dementia, r ther neurlgical cnditins (target ppulatin) The prprtin f the ttal in-patient separatins by acute and alternate level f care (ALC) lengths f stay (LOS) fr the target ppulatin The prprtin f the ttal ALC days that are fr the target ppulatin The prprtin f the target ppulatin that returned t their riginal living situatin fllwing an acute care admissins An examinatin f the health care trajectry f a typical persn with the BSO assciated health issues Pssible Data Surces: Natinal ambulatry Care Reprting System (NACRS) 12 P age

13 Discharge Ambulatry Care Reprting System (DAD) Business Intelligence Tl: IntelliHEALTH ONTARIO, Ontari Ministry f Health and Lng-Term Care (available t LHIN data analysts) Challenges Preliminary analyses suggest that very few lder adults are seen in the ED fr ICD-10 cdes thught t be assciated with behaviral issues. This suggests that behaviral issues are grssly underreprted in the NACRS data file. As a result, just using the ICD-10 cdes in the NACRS database t identify thse with behaviral issues will be very challenging. Further, a lwer prprtin f lder adults than wuld be expected are discharged with diagnses thught t be assciated with behaviral issues. This again suggests that such issues are underreprted in the DAD database. Prcess and Outcme Indicatrs LHIN-specific metrics that measure the develpment and the impact f the prpsed senirs mental health and addictins respnse teams will be develped. Fllwing the apprval f the prgram lgic mdel by the prject steering cmmittee, the lcal shrt-term and lng-term data surces will be identified and data cllectin strategies will be develped. It is likely that new data cllectin prcesses will need t be develped in cllabratin with the agencies receiving the service. In additin, it is hped that lcal agencies that serve a similar target ppulatin and cllect data will be able t wrk tgether t develp a cmmn data pl. Fr example, n entry t a lng-term care hme, the SW CCAC cllects additinal data n thse wh have a histry f behaviral issues. In additin, ALC issues will be examined thrugh reprts generated by the SW CCAC as part f their ALC lng-stay reviews. Thrugh Residents First, Health Quality Ontari will be asking LTC hmes t identify and then cnduct quality imprvement prjects, sme f which may deal with residents with respnsive behavirs. The Suthwestern Ontari Reginal Geriatric Prgram Outreach Team cllect infrmatin n clients served thrugh this service. As well, the DLT, a grup that perates ut f RMHC Lndn, prmtes successful transitins between RMHC Lndn and reginal LTC hmes, cllect data n behaviral issues. Infrmatin cllected by the lcal Alzheimer Scieties will als be examined. In additin t the develpment f quantitative indicatrs, additinal infrmatin will be cllected thrugh fcus grups. Interviews with cnsenting family members will help illuminate issues assciated with the health care trajectry f lder adults diagnsed with mental health, dementia r ther neurlgical cnditins. Als, the minutes f the Steering Cmmittee will be reviewed t see if prject milestnes have been met. Challenges The way behaviral issues are captured varies by data surce. It may be very difficult t create crsswalk between ICD-10 cdes, DSM-IV cdes and ther classificatin systems. As a result, the same target ppulatin will nt be identified. Data sharing agreements may need t be develped and signed. Pssible Indicatrs by BSO Framewrk Categries System Crdinatin Family/caregiver satisfactin Patient quality f life Number f repeat assessments 13 P age

14 ALC LOS Interprfessinal Cllabrative Service Delivery Stakehlder awareness f BSO-funded team (pssible cllected thrugh an n-line survey) Stakehlder satisfactin with BSO-funded team (pssibly cllected thrugh fcus grups) Imprved System Capacity % f staff with PIECES, GPA and U-First training in reginal LTC hmes 15. Attach yur budget, wrk plan and resurce plan. The resurce plan will utline hw and where registered nurses and persnal supprt wrkers wuld be utilized. See Appendix B, C, D. HHR spreadsheet is an attached dcument. 16. Wh will be the representatives n the LHIN BSO Steering Cmmittee? Jennifer Speziale, C-Chair, Directr, Geriatric Mental Health, RMHC SJHC Lndn Shelley McCrkell, C-Chair, Executive Directr, Alzheimer Sciety Elgin Dr. Lisa Van Bussel, MD, FRCP, Chair, UWO Divisin f Geriatric Psychiatry, Physician Leader, Geriatric Psychiatry Prgram, Psychiatrist, Reginal Psychgeriatric Prgram, RMHC Lndn Dr. Beth Mitchell, Directr, Mental Health, Lndn Health Sciences Centre Elizabeth McCarthy, Directr, Specialized Geriatric Services, SJHC Lndn Dr. Iris Gutmanis, Directr, Prgram Evaluatin and Research, SGS SJHC Lndn Magdalen Carter, MSW, RSW, Directr, Alzheimer Outreach Services f McCrmick Hme Brenda Lambert, Vice President, St. Thmas Elgin General Hspital Pat Edwards, Directr, Mental Health, Wdstck General Hspital Penny Cardn, Directr, Mental Health, Hurn Perth Health Alliance Cheryl Taylr, Vice President, Alexander General Marine Hspital Leah Hd, Directr, Mental Health, Grey Bruce Health Services Julie Ridgewell, Reginal Educatin Manager, Ontari Telehealth Netwrk Anita Cle, Reginal Client Services Manager - Cmmunity Suth SW CCAC Julie Girard, Team Lead, Planning and Integratin, Suth West LHIN Kelly Simpsn, Behaviur Supprts Prject Lead, Reginal Crdinatr, Reginal Psychgeriatric Prgram, SJHC Lndn Dnna Laduceur, Senir Directr, Client Services fr the Suth West CCAC Lynne Jhnsn, Directr f Lng-Term Care, Cunty f Grey End f Part B 14 P age

15 Appendix A Perfrmance, Measurement, and Evaluatin Plan: Future State Wrking with the Behaviral Supprt System Ontari (BSO) Data, Measurement and Evaluatin Cmmittee (DMEC) as well as the vendr selected by this cmmittee t assist with the evaluatin f the fur Early Adaptr LHIN BSO strategies (Hay Grup Health Cnsulting), a data matrix will be develped. In additin, prcess and utcme indicatrs that map nt this matrix will be cnfirmed. Bth the prvincial and the lcal evaluatin cmmittees will cntinue t lk at the pssibility f an ecnmic impact assessment as well as strategies that will ensure an imprved, sustainable data cllectin system. Perfrmance, Measurement and Evaluatin Plan: Future State Number 16: Dementia prjectins fr the cunties, reginal municipalities, and census divisins f Ontari (using CSHA prevalence data). Rbert W. Hpkins, Ph.D. April 2010 PCCC Mental Health Services Kingstn, Ontari. Perth Cunty Bruce Cunty 15 P age

16 Elgin Cunty Grey Cunty Hurn Cunty 16 P age

17 Middlesex Cunty Oxfrd Cunty Hspitalizatins, Fiscal 2010/ Fr Suth West LHIN residents, wh are 65 r mre years f age, there were a ttal f 34,337 hspitalizatins. 2,166 hspital separatins had the diagnsis f dementia in at least ne f the diagnstic fields. This suggests that 2,166/34,337 r 6.3% f all discharges amng senirs invlved smene living with a dementia. Of acute inpatient discharges with dementia r Alzheimer s Disease in any diagnsis field, 41.7% came frm the cmmunity, and f thse wh came frm the cmmunity, 58.2% were discharged hme. 17 P age

18 Prprtin f all Hspital Separatins amng thse 65 r mre years f age in which dementia was mentined in any ne f the 25 diagnstic fields captured in the Discharge Abstract Database Cunty Ttal # f peple 65+ yrs. f age Ttal # hspital separatins fr thse 65+ yrs. Ttal # hspital separatins fr thse 65+ with a diagnsis f dementia in any diagnstic field % f all hspital separatins fr thse living with dementia Bruce 13,263 3, Elgin 13,434 3, Grey 18,646 4, Hurn 11,283 3, Perth 11,933 2, Haldimnd-Nrflk 2, Oxfrd 17,446 4, Middlesex 66,076 12, Suth West LHIN 154,390 34,340 2, It appears that there is cnsiderable cunty-by-cunty variability in the prprtin f hspital separatins in which dementia was mentined in any f the diagnstic fields. The estimate varied frm a lw f 4.5% f all hspital separatins in Haldimnd-Nrflk t a high f 7.1% in Middlesex/Lndn. Cnsidering that it is estimated that at least 6.5% f the ppulatin aged 65 r mre years have dementia, ne wuld expect that at least 6.5% f thse wh are 65 r mre years f age wh are hspitalized wuld als have dementia. This suggests that levels f identificatin and diagnsis require greater LHIN-wide cnsistency. 18 P age

19 Appendix B Suth West LHIN Actin Plan Summary Timelines and Wrkplan Suth West Funding and Actin Plan Milestnes (Octber -March 31, 2012) Start Date End Date 1st - 15th Oct-11 Nv-11 Dec-11 Jan-12 Feb-12 Mar-12 16th -31st 1st - 15th 16th -30th 1st - 15th 16th -31st 1st - 15th 16th -31st 1st - 15th 16th -29th 1st - 15th 16th -31st Stakehlder Engagement and Overview f the BSO Initiative Nv, Survey sent t LTCH and Outreach Prgrams Nv, Nv, Fcus Grup with Alzheimer Scieties Nv, Nv, Fcus Grup with Adult Day Prgrams Nv, Nv, Cnsultatin with Geriatric Cperatives Oct, Mar, 2012 BSS Steering Cmmittee - Full day meeting Nv, Nv, Presentatin t LTCHs, fllwed by questin and answers Nv, Nv, Telecnferences t update LTCH n BSO prgress Value Stream Mapping Sessin (2 Day - Oct 28th, 29th) Nv, Nv, 2 Page Executive Summary due t CRO Briefing ntes and Reprts fr Suth West LHIN Bard Oct, Presentatin f Executive Summary t CRO, 14 LHINs and PRT cmmittee, Dec 2nd, BSO Actin Plan -Part 1 and 2 due Dec 15th, Nv, BSS Steering Cmmittee - half day meeting Actin Plan feedback frm PRT, CRO, PRT Final Actin Plan signed ff by CEO Pririty Prject Imprvement Teams established Jan, 2012 Mar, 2012 Lead agency fr BSO cnfirmed Jan, 2012 Jan, P age

20 Suth West Funding and Actin Plan Milestnes (Octber -March 31, 2012) Start Date End Date 1st - 15th Oct-11 Nv-11 Dec-11 Jan-12 Feb-12 Mar-12 16th -31st 1st - 15th 16th -30th 1st - 15th 16th -31st 1st - 15th 16th -31st 1st - 15th 16th -29th 1st - 15th 16th -31st Funding received fr BSO LTCH staff and Additinal Health Care Psitins Jan, 2012 Jan, 2012 Stakehlder engagement - Update n BSO prject Feb, 2012 Feb, P age

21 Suth West LHIN GANTT CHART -December -March 2012 Pririty Prject Milestne Pillar Cmpletin date Status Dec Jan Feb Mar Hire BSO cmmunity and LTCH staff x 31-Mar-12 Integrate BSO staff with BSS senirs mental health and addictins respnse teams x 31-Mar-12 Develpment f Educatin Cnsrtium - Develp rientatin, training, educatin fr BSO staff in LTCH and Cmmunity. Cnduct needs assessment and readiness survey fr LTCH and cmmunity) x nging Mdel f Care prject team develped fr senirs mental health and addictins respnse teams integrating BSO LTCH and Cmmunity (BSS prject already started this wrk) x 31-Mar-12 Start date: Jan Start date: Feb Start date: Feb Start date; May 5 5 Crdinated intake and triage (BSS prject already started this wrk) x Start date: May 6 6 Cmmn assessment tls, prtcls, x Start date: May 7 7 Key Stakehlder engagement x Start date: Jan Public Awareness and Scial Marketing x start date TBD LEGEND: BSO Framewrk fr Care Pillars Status 1. System Crdinatin & Management cmplete 2. Integrated Service Delivery: Intersectral and Interdisciplinary In prgress 3. Knwledgeable Care Team and Capacity Building at risk 21 P age

22 Appendix C Suth West LHIN Budget Preliminary Expenditures and Estimates LTC Hme Funded Psitins: RN/RPN: $1,221,800 PSW: $960,000 Emplyee Benefits estimated at 26% in salaries If assume the highest salary rate and 26%, it is estimated that 7 RNs, 8 RPNs and 18.3 PSWs culd be funded. Range f FTE capacity t hire within parameters Additinal emplyee related expenses t be supprted include: WSIB estimated at 3.2% Mileage, technlgy requirements Additinal emplyee related start up csts include: Office furniture/equipment/supplies Additinal Health Care Prfessinals: St. Jseph s Health Care Lndn Geriatric Psychiatrist (.8FTE), Psychlgist (1FTE), Quality Imprvement Facilitatr (1FTE), EPRC (1FTE) and Crdinatr (1FTE) 4.8 FTE Ttal = $753,510 (includes benefits) Alzheimer Scieties 3 FTE Scial Wrkers t enhance First Link Prgram 3 FTE Ttal= $187,560 Adult Day Prgram Overnight Weekend Respite 2.7 FTE (RN/PSW, ther) Ttal =$108, P age

23 Appendix D Suth West LHIN BSO Health Human Resurces Plan A detailed descriptin f hw the up t 16 nursing and the up t 24 persnal supprt wrkers will be utilized is als prvided in respnses t questin 13 abve. LTCH Staff: The Suth West LHIN has 78 LTCH acrss 21,639 square kilmeters The hst LTC hme will put ut an expressin f interest t the lcal LTC hmes. Lcal LTC hmes will supprt the applicatins f nursing and PSW staff t prvide services fr a defined perid f time fr the Schedule 1 senirs mental health and addictins respnse teams funded by the Year 3 AAH initiative in surrunding lcal LTC hmes. A ttal f five senirs mental health and addictins respnse teams have been implemented acrss the Suth West LHIN. Each f the five senirs mental health and addictins respnse teams will include Registered Nurses (RN), Registered Practical Nurses (RPN), and Persnal Supprt Wrkers (PSW). Nursing staff RN/RPN rati has yet t be determined Services will be prvided frm the Schedule 1 lcatins r ther LTC hme lcatins in the Suth West LHIN. The BSO LTC hme-funded staff will prvide a rapid respnse t LTC hme, and be supprted by ther senirs mental health and addictins respnse team members. The EPRC will prvide clinical leadership and educatin and capacity-building, and a Geriatric Psychiatrist will als be accessible LHIN-wide. Additinal Health Care Persnnel: The Suth West LHIN will be hiring apprximately 10 FTE psitins which will be allcated LHIN wide t bth LTCH and cmmunity t supprt an interdisciplinary mbile team respnse. T ptimize funding, existing resurces will be leveraged t supprt the new mdel. Prjected staffing t be recruited with the funding allcated t cmmunity psitins will include: Geriatric Psychiatrist (.8 FTE) Psychlgist (1 FTE) Imprvement Facilitatr (1 FTE) Psychgeriatric Resurce Cnsultant (1 FTE) Crdinatr (1 FTE) Scial Wrkers (3 FTE), Adult Day Prgram (2.5 FTE) Staff will be hired by the fllwing rganizatins: The Geriatric Psychiatrist, Psychlgist, EPRC and Imprvement Facilitatr, and Crdinatr are planned t be emplyees f SJHC Lndn. Specifically, they will becme members f the Reginal Psychgeriatric Prgram, which has a LHIN-wide mandate t prvide clinical cnsultatin, assessment and supprt, educatin and capacity building. Alzheimer Scieties will receive the Scial Wrk psitins. These rles will enhance the First Link prgrams by prviding additinal supprt t families/caregivers in relieving sme f the stress and challenges assciated with caring fr peple with Alzheimer s disease and ther frms f dementia. Adult Day prgrams will receive PSWs and Nurses t prvide weekend vernight respite. 23 P age

24 Appendix E BSS Prject Organizatinal Leadership Structure (Draft) (see next page) 24 P age

25