SOUTH WEST LHIN BEHAVIOURAL SUPPORTS ONTARIO SUSTAINABILITY PLAN FEBRUARY 15 TH, 2013

Transcription

1 SOUTH WEST LHIN BEHAVIOURAL SUPPORTS ONTARIO SUSTAINABILITY PLAN FEBRUARY 15 TH, 2013

2 - 1 - SOUTH WEST LHIN BSO SUSTAINABILITY PLAN DRAFT #5 The South West LHIN BSO Sustainability Plan was developed with a high level of stakeholder engagement and input. Significant steps have been taken to ensure the plan includes the lived experience of individuals and their caregivers. The original BSO action plan and implementation approach was modified from a lead Long-Term Care (LTC) Home secondment model to embedding staff into each LTC Home in the LHIN. In late November 2012, the South West LHIN received the necessary approvals to amend the model and modify the implementation approach. As a result of the model change, Nursing and PSW recruitment was delayed. During the months of December 2012 and January 2013, a large scale recruitment effort resulted in the prompt hiring of the LTC Home embedded BSO staff. Implementation is well underway within each of the 78 LTC Homes. This sustainability plan outlines the necessary steps to shift from the implementation phase to LHIN-wide service delivery and operations. Every effort will be made to continue to enhance the momentum, partnerships, and early successes achieved. SENIOR LEADERSHIP 1a. What leadership and organizational structure at the LHIN level will be in place to sustain the Behavioural Supports initiative? Senior and clinical leadership engagement have been shown to have the greatest impact on sustainability. Strong leadership support is evident within the South West LHIN. In 2010, the South West LHIN formed the Behavioural Supports Systems Steering Committee (see Appendix A). This Steering Committee provides the strategic direction and oversight role for the implementation of the BSO project. 1b. Who has been identified as the leader responsible for sustaining the changes? A shared leadership model is being used within the South West LHIN to ensure sustainability. St. Joseph s Health Care London has been designated to perform the LHIN-wide coordination function of the BSO project. The Executive Sponsors for the BSO project are Sandy Whittall, Integrated Vice President, Mental Health Services, St. Joseph s Health Care London, and Kelly Gillis, Senior Director, South West LHIN. The BSO Steering Committee plays a crucial role in setting strategic direction and providing LHIN-wide oversight of the project. Co-chairs of the Steering Committee: Jennifer Speziale, Director, Geriatric Psychiatry, St. Joseph s Health Care London and Shelley McCorkell, Executive Director, Alzheimer Society Elgin provide ongoing leadership and support. Five Schedule 1 Hospitals who operate the BSO mobile teams are represented on the committee, as well as the Regional Geriatric Program, three LTC Homes, Community Care Access Centre (CCAC), Alzheimer Outreach Services, Ontario Telemedicine Network (OTN), and the LHIN. A Regional Coordinator/Project Lead, Kelly Simpson, employed by St. Joseph s Health Care London, is responsible for project administration, implementation, and sustainability. Dr. Iris Gutmanis is the Evaluation Lead and the Co-Chair of the provincial BSO Data, Evaluation, Measurement Committee (DMEC). The BSO Project Facilitator and Quality Improvement Facilitator will also contribute significant expertise to sustaining the change. Enhanced Psychogeriatric Resource Consultants provide clinical leadership and support to the BSO mobile teams working out of Schedule 1 Hospitals and are charged with identifying opportunities for system-wide change (opportunities for system integration, improved care delivery, and capacity development). These positions work collaboratively to develop and implement standardized assessment tools, care interventions, and capacity-building opportunities to ensure consistency and sustainability. The Geriatric Cooperatives are crucial to our hub-and-spoke model and play a key role to assess where the teams are providing support locally, evaluate where they need to be,

3 - 2 - and how they are going to achieve their outcomes/objectives to sustain the gains. The Geriatric Cooperatives act as medium between frontline health service and the Steering Committee, and are chaired by a member of the Steering Committee to ensure continuity, planning and to facilitate information sharing. The newly formed Long-Term Care Home Network Council has been very supportive of BSO by sharing communications, providing expertise and advice, and recruiting representatives for the Steering Committee. QUALITY IMPROVEMENT 2. What quality improvement (QI) capacity at the LHIN level will continue to be in place to support BSO? Quality Improvement has and will continue to be a key focus of the Steering Committee and the Geriatric Cooperatives. A Quality Improvement Facilitator was hired in January 2013 to assist with the development and implementation of quality improvement strategies across the LHIN. System coordination and integrated service delivery will be a primary focus for sustainability of the BSO project and addressed through quality improvement initiatives such as Value Stream Mapping and Kaizen events (see Appendix B). These initiatives will be focused on intake and triage processes within the BSO virtual teams to improve care delivery and coordination within the South West LHIN. Building on the work done by Health Quality Ontario through the Resident s First strategy, similar quality improvement processes and tools have been leveraged. Education will continue to be provided within the virtual BSO teams relating to quality improvement, leadership and change management, through such events as the BSO Work Plan day and the joint Resident First / BSO education sessions. To enhance sustainability of the BSO project, we have worked with the LTC Homes and Geriatric Cooperatives to develop individualized and sitespecific quality improvement work plans, which helps achieve greater accountability among everyone involved. These work plans will be finalized by March The BSO Evaluation Committee, which was formed in January 2011, will continue to work with both the BSO mobile teams and LTC Homes to develop relevant key indicators that can be measured to evaluate progress. The implementation of the BSO quality improvement work plans will be facilitated through monthly BSO virtual team network teleconference meetings and LTC Home monthly reporting. Additional reporting will be provided to the BSO Steering Committee on a quarterly basis. To ensure consumer engagement within the quality improvement process and work plans, project staff and enhanced psychogeriatric resource consultants have benefitted from Experienced-Based Design (EBD) training to assist to understand the lived experiences of family, residents/clients, caregivers, as well as that of staff who are working with those living with responsive behaviours within various settings across the South West LHIN. The BSO Project team will also be reporting regularly to the South West LHIN Quality Advisory Group on their use of EBD and its impact on the initiative and patient/client experience. MEASUREMENT AND ACCOUNTABILITY 3a. List the key performance measures that will indicate BSO success and sustainability in your LHIN. In the South West LHIN, the BSO program logic model (Appendix C) was used to align provincial pillars, local strategies and overall program goals with process and outcome indicators. Indicators were developed, field tested and evaluated in 2012/13. The BSO evaluation committee has met on a number of occasions to discuss indicator feasibility (burden of data collection), usability, and how much infrastructure is needed to implement the data collection strategies in a consistent manner. In addition, the local evaluation has been informed by: provincial data collection strategies including activity tracking; discussions at the DMEC, notably discussions regarding BSO Legacy indicators; an examination of possible proxy indicators that could be very easily collected (for example: OTN use for BSO if a BSO flag built into the request form); and

4 conversations with the local Quality Improvement Facilitator regarding QI measurement strategies The 2012 evaluation of the geriatric cooperatives, an innovation specific to the South West LHIN, demonstrated the need for improved communication, specifically the need to develop a communication strategy with consistent messaging as well as a common language and more opportunities to engage cross-sectoral partners. These results will be shared widely through a peer-reviewed publication and findings from the Partnership Assessment Tool (a measure that will be used annually) and will continue to inform local Geriatric Cooperative work-plans. Additional evaluations are planned each year (for example, evaluation of: mobile teams, the EPRC role, client and family satisfaction). Indicators that will be used in the South West LHIN are presented in Table 1. Table 1: Proposed BSO Indicators in the South West LHIN Type Description Data Source Process Total # of new referrals to BSO mobile teams Local data system # new and appropriate referrals Local data system # of BSO clients seen Local data system # of BSO clients discharged Local data system # of ADP overnight visits funded through BSO Local data system # of clients seen by Alzheimer Society social workers funded through BSO Local data system # of consultations provided by BSO embedded LTC Home staff Local data system # of BSO clients reviewed using OTN Local data system Outcome Percentage of residents with verbal, physical or social behaviour affecting RAI-MDS others % of LTC Home applications denied due to Responsive behaviours CCAC Rate of acute care hospitalization (clients and episodes) of behavioural DAD and others residents of LTC Homes Number of people newly diagnosed with dementia receiving written and verbal information about their condition, treatment and the support options in their local area. FirstLink Programs offered through Alzheimer Societies 3b. Please outline accountability processes in your LHIN that will ensure service providers continue to deliver on BSO services. Memorandum of Agreements (MOA) will be in place to commit all parties to work in cooperation to develop a behavioural support system for older persons with responsive behaviours across the South West LHIN. The signatories to this MOA are committed to working together and in collaboration with their partners to ensure the MOA is signed by March 31 st, The MOA outlines roles, responsibilities, and accountabilities of all parties. The signatories of the MOA will include the South West LHIN, St. Joseph s Health Care London, BSO Steering Committee and Long-Term Care Homes. In addition, MOA s previously signed in December, 2010 by Schedule 1 Hospitals and St. Joseph s Health Care London, for the Behavioural Supports System (BSS) initiative will be refreshed. All signatories will still be required to fulfill the obligations outlined in the project charter. A decision was made by the Steering Committee to consolidate the BSS project (funded through Aging at Home) into the BSO project. Quarterly reports will continue to be submitted to the South West LHIN in accordance with the reporting schedule. Health service providers will continue to be required to report financial and statistical data. The BSO Project Lead, will consolidate the reports and submit to the LHIN quarterly. A summary of the quarterly reports will be reviewed by the BSO Steering Committee to monitor implementation and progress.

5 - 4 - To ensure sustainability of the embedded LTC Home model, the South West LHIN included the following conditions within each BSO funding letter: Creation of dedicated behavioural support PSW, RPN/RN positions with clearly defined accountabilities and functions; A designated staff person must be assigned to oversee the activities of the BSO LTC Home team; and Behavioural support positions must work in an integrated manner with existing seniors mental health and addictions mobile teams that operate out of Schedule 1 Hospitals, and other specialized resources. Funding letters were signed by LTC Home Administrators, and returned to the LHIN on December 15 th, c. As part of the accountability processes, how will your health service providers measure, review and report on the indicators in 3a. above? How frequently? Health service providers will send to the evaluator aggregate, de-identified monthly data every quarter. Data will be summarized on an excel spreadsheet created by the local evaluator. This information will be shared with the BSO Steering Committee as well as with each regional team. Discussions regarding how to move this from a paper and pencil strategy to a download from the client electronic patient record are currently underway. CAPACITY BUILDING 4. What processes are in place to build capacity this fiscal year and on an ongoing basis? Supporting existing and newly hired health service providers to develop core competencies and to refine and apply evidence-based practice models emerging from the BSO project is a key priority for the South West LHIN. With the recent formation of the BSO teams within LTC Homes, it is a requirement that each Home completes the BETSI tool. Currently, over 75 percent of LTC Homes have completed the tool. To support local decision-making in regard to capacity-building, the BSO capacity-building suite of tools (The BSO Capacity Building Roadmap, The Person- Centred Team-Based Service Learning Framework, The Behavioural Education Training and Supports Inventory, and The Road Ahead) are being utilized. Building upon the results of the BETSI tool, an education blitz is currently being conducted within the South West LHIN, offering Gentle Persuasive Approach (GPA), PIECES, Montessori, and UFirst! Training. To sustain this education, Master coach training is being offered for GPA and PIECES. The geriatric cooperatives will continuously identify educational needs and implementation strategies at the local level. An education collaborative has been formed with the mandate to leverage education strategies LHIN-wide. The collaborative has cross-sector representation. A BSO kick- off event with LTC Homes, mobile teams, and other community-based organizations is planned for February 22, Another knowledge exchange event will be organized in the fall. Sustaining education will be a significant focus that will require a high level of collaboration and commitment from partners. Existing knowledge exchange events offered through the Southwestern Ontario Geriatric Assessment Network (SWOGAN) will be leveraged. Annual education events such as the Fall Education Series, SWOGAN Spring Exchange, Geriatric Psychiatry Symposium, Geriatric Medicine Refresher Day, Monthly Interdisciplinary Grand Rounds will be utilized. 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.

6 - 5 - To spark innovation, cross-lhin collaboration, and sharing of critical success factors needs to be sustained. It is important that all-lhin in-person knowledge exchanges continue to occur on an annual basis to promote capacity-building, quality improvement and research. LHINs should consider securing funds to support two to three people to attend this annual event. Several innovative BSO research projects are currently underway. Sharing research finding with other LHINs is an excellent way to help others achieve sustainability. 6. What provincial tables/collaboratives do you consider vital to sustaining the BSO initiative in your LHIN? The Professional Resource Team (PRT) continues to play a vital role in moving the BSO project forward by surfacing promising practices, identifying and addressing broad system-wide challenges and connecting LHINs to timely and relevant information to inform local implementation. The newsletters summarize current research opportunities and provide vital information on what is happening across the province. The PRT must be sustained. The BSO Access and Flow Collaborative will be a vital committee to maintain as it has focused heavily on the future. This expanded scope of this group extends the focus from centralized intake and access, to access and flow initiatives, including access, navigation, transitions and flow. As access and flow will continue to be a priority for the South West LHIN, membership on this collaborative will allow LHINs to troubleshoot together and share best practices during implementation. To ensure sustainability, it will be important going forward to include BSO as a standing agenda item on the LHIN Collaborative (LHINC) agenda and the provincial Primary Care agenda. 7. How do you imagine your LHIN collaborating with the other LHINs to sustain BSO? On several occasions, the South West LHIN has partnered with the Erie St. Clair LHIN to provide education (e.g. PIECES Master Coaches training, March 2013), and quality improvement workshops (value stream mapping, November 2011). The South West LHIN and Erie St. Clair LHIN are part of the SWOGAN Network which facilitates cross-education and capacity-building across LHINs. Collaborating with other LHINs is an effective way to share limited resources, and develop strong partnerships and linkages beyond typical boundaries. The South West LHIN Evaluation Lead has collaborated with the HNHB LHIN, the local earlyadaptor LHIN buddied with the South West LHIN, and will continue to work with the WW LHIN, the HNHB LHIN, and the Erie St. Clair LHIN with regards to the evaluation strategies. An enhanced online space with chat board to exchange ideas, share documents and best practices would be an effective way to facilitate ongoing collaboration. 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 The client value statement for the South West LHIN is: I am a unique individual who wants to live my life with dignity. Capturing and understanding the lived experience of the individual and the caregiver is a key component of the sustainability plan. Application of the Experienced-Based Design tools with one-on-one interviews with the resident/client, family/caregiver and frontline staff is underway.

7 - 6 - As a wave of new BSO resources are currently being injected into the system, a top priority for the South West LHIN is to focus in on better system integration, coordination, collaboration, and redesign. Strategic partnerships need to be further enhanced between LTC Homes, Alzheimer Societies, CCAC, Adult Day Programs, Specialized Geriatric Medicine and Mental Health Programs. Access and flow is an area that needs further analysis, strengthening and refinement to improve streamlined and coordinated access to a range of services available. Further linkages with primary care and Health Links will be further developed. A primary care engagement strategy will be developed utilizing the BSO checklist of key recommendations. Information technology is a key element of the South West LHIN BSO implementation plan. Significant funds have been invested to purchase videoconferencing equipment through a partnership with the Ontario Telemedicine Network for LTC Homes, hospitals and community agencies. Standardized clinical protocols, assessment practices, care pathways must be developed and evaluated. In addition, other enabling technologies will be explored to improve care for older adults with responsive behaviours, including electronic intake and access portals, handheld devices and tablets (exploring opportunities to partner with the SWCCAC eshift strategy).

8 - 7 - Appendix A - BSO Organizational Chart BSO Project Organizational Leadership Structure South West Local Health Integration Network (LHIN) Behavioural Supports Ontario Steering Committee (Co-Chairs: Jennifer Speziale and Shelley McCorkell) St. Joseph s Health Care (St. Joseph s) LHIN-wide Coordination Project Lead: Kelly Simpson Evaluation Consultant: Dr. Iris Gutmanis St. Joseph s BSO Project Team * QI Facilitator, Project Facilitator, Project Support Analyst, Project Support Admin, Physician Lead, EPRC Long-Term Care 78 LTCHs Approximately 43 FTEs (RN, RPN, PSW) London- Middlesex London Health Sciences Centre Beth Mitchell Behavioural Supports Mobile Team (8 FTEs * BRT and 2.7 * MHT) * EPRC Schedule 1 Hospitals Community Elgin Community Community Community Community Oxford Huron-Perth St. Thomas London Woodstock Huron-Perth Grey-Bruce Elgin General Elgin Oxford Huron Middlesex General Hospital Healthcare Grey-Bruce Alzheimer Hospital Alzheimer Alzheimer Alzheimer Grey Bruce Michelle Alliance Health Services Society Society Society Society Alzheimer Society Deborah Gibson Worsfold Penny Cardno/ Perth Leah Hood Behavioural Behavioural Cheryl Taylor Alzheimer Behavioural Adult Supports Mobile Adult Adult Supports Mobile Behavioural Society Adult Day Supports Mobile Team Day Day Day Program Program Team Program Supports Mobile Team (2.5 FTEs to be Adult Day Program (4 FTEs) Team Program (5 FTEs) hired) * EPRC shared (6 FTEs) * EPRC CCAC * EPRC shared CCAC CCAC CCAC CCAC with Elgin * EPRC GRT with Oxford GRT GRT GRT GRT London- Middlesex Geriatric Cooperative Elgin Geriatric Cooperative Oxford Geriatric Cooperative Huron-Perth Geriatric Cooperative Grey-Bruce Geriatric Cooperative Specialized LHIN-Wide Services: * Regional Geriatric Program * Regional Psychogeriatric Program * St. Joseph s Regional Mental Health Care (RMHC) Discharge Liaison Team and Outreach Team Future State: Enhanced Primary Care Engagement (Family Health Teams, Community Health Centres) Draft February 28, 2013 LEGEND: * Quality Improvement * Enhanced Psychogeriatric Resource Consultant * Behavioural Response Team * Mental Health Team

9 - 8 - Appendix B Gantt Chart South West LHIN GANTT CHART January 2013 December 2013 Priority Project Milestone Pillar Completion date Status Jan Feb Mar 1 1 Hire BSO LTC Home staff 2 2 Completed LTC Home QI Work Plans 3 3 BSO Kick Off - Collaboration Day 4 4 Completed Geriatric Cooperative QI Work Plans 5 5 Experience Based Design approach Kaizen Event Resident First / BSO Quality Improvement Education Formation of the BSO virtual team network 9 9 BSO Collaboration Day Value Stream Mapping x 31-Jan Feb Feb Mar-13 ongoing 28-Mar-13 ongoing 30-May Sep Nov-13 Jan 2013 January 2013 January 2013 February 1, 2013 January 2013 February 1, 2013 February 1, 2013 February 1, 2013 start date: February 1, 2013 LEGEND: BSO Framework for Care Pillars Status 1. System Coordination & Management complete 2. Integrated Service Delivery: Inter-sectoral and Interdisciplinary In progress 3. Knowledgeable Care Team and Capacity Building at risk

10 - 9 - Appendix C - BSO Logic Model Behavioral Support Ontario Program Logic Model COMPONENTS Referral and Intake Care Coordination & Delivery Program Governance, Management & Accountability ACTIVITIES Develop referral process Develop referral form Develop triage protocols Select tools Develop on-call protocols Develop communication strategy (who needs to know about this program) Completed triage Care plan developed and on resident LTCH chart within 48hours of assessment Development of standardized assessment protocols Linkages with regional care providers (F/U) such as CCAC Develop program governance approach and structures Identify subcommittees (evaluation committee, etc.) Hire program manager Hire staff Finalize evaluation strategy MOAs developed & signed TARGETS Residents of LTCHs who are at risk Residents of LTCHs who are at risk EPRCs Geriatric Service Workers Committee members (Steering, Evaluation, etc.) Schedule 1 facilities SHORT-TERM OUTCOMES Referral/intake /triage/on-call processes finalized and in place Referral sources aware of new program Resident contacted by local team within 48 hours of receipt of referral from LTCH Triage tools identified Effective team communication Effective stakeholder communication Existing Model of Care / process maps Process and outcome indicators identified and approved Staff hired Committees established Project staff aware of roles and responsibilities OUTPUTS # and type of patients referred to program # and type of patients seen by program # of sites where referral process is developed and implemented # sites where referral forms developed and implemented # sites with triage protocols developed and implemented # sites with on-call protocols developed and implemented Communication plan in place # people seen within 48hours of receipt of referral # sites using triage tools # of care plans developed by GSW # of care plans implemented by LTCH # of care plans on chart within 48 hours Copy of team s model of care # of team meetings Behavior resolved / situation deescalated Documented communication strategy between LTCHs and local Team # of MOAs in place # of staff hired by each Schedule 1 facility Data sharing agreements between hospitals in place # committee meetings Quarterly reports being generated LONG-TERM OUTCOMES Stakeholder satisfaction with intake and referral process Appropriate referrals LTCH staff are aware of referral criteria; decreased ED admissions Resident gets the right care, at the right time, in the right place Patient/family satisfied with experience Stakeholders satisfied with program Fewer ED admissions Staff satisfaction Integrated data collection system OUTPUTS Stakeholder satisfaction Resident/family satisfaction # of ED admissions by LTCH # ED admissions by LTCH Stakeholder satisfaction Resident/family satisfaction EPRC and GSW satisfaction # of staff change overs in 1 year

11 COMPONENTS System Linkage & Integration Capacity Development Research & Evaluation ACTIVITIES Disseminate OTN RFPs Identification of OTN enhanced LTCH sites Establish local geriatric cooperatives Connect with key Provincial groups Development of education strategy for LTCH staff Identify local capacity re GPA, U FIRST, PIECES Linkages among local, regional and national researchers TARGETS Local stakeholders/care providers who target older adults LTCHs Provincial BSS project LTCH staff Researchers Front-line staff SHORT-TERM OUTCOMES local geriatric cooperatives in place communication between local project members and key provincial projects established Following each educational program, an increase in knowledge PIECES / U First / GPA trained individuals in all LTCHs Identification of researchers (local and national) Development of research / evaluation questions Support for staff who are engaged in quality improvement initiatives OUTPUTS # of meetings to establish local geriatric cooperatives # meetings with OTN # meetings with provincial stakeholders # LTCHs that submitted an RFP # of successful RFPs # LTCHs with staff trained in GPA / PIECES/ U FIRST # of education sessions provided by Team Staff can identify more resources Increased knowledge (Pre / post assessment) # of presentations # of LTCHs with quality improvement initiatives focused on those with responsive behaviors LONG-TERM OUTCOMES Increased system coordination OTN connections in local LTCHs Teams are aware of and using evidencebased guidelines LTCH staff confident in their ability to care for those with responsive behaviors Identification of key resources Publications/reports/posters Grant applications from local teams re responsive behaviors Development of care guidelines for complex residents with responsive behaviors OUTPUTS Development of an ongoing infrastructure (? Community of Practice with SHRTN) # LTCHs with OTN with trained staff Stakeholder satisfaction with system coordination # team members aware of evidence-based guidelines # Team members using evidence-base guidelines Documentation of reference material/resources # LTCH staff confident in their ability to manage patients with responsive behaviors # of publications/grants Development of new care guidelines/additions to existing care guidelines