Influencing Care The Nova Scotia P.I.E.C.E.S. Story

1. Influencing CareThe Nova Scotia P.I.E.C.E.S. Story Alzheimer Society Manitoba, 2008 Conference Joanne Collins RSW Challenging Behaviour Program Nova Scotia Department Of Health

2. Today’s Purpose To provide: • Overview Nova Scotia Challenging Behaviour Program • Highlight critical factors in program design • Highlight using the P.I.E.C.E.S. approach to support an integrated model of care

3. Beginnings…. • Sector identified the need for improved services to enhance capacity in care provision particularly complex behaviours • Department of Health responded and established the Challenging Behaviour Working Group in May 2002 • Working Group had representation from LTC, Home Care, Mental Health and DoH • Defined Challenging Behaviour and developed an Approach to Care • Completed majority of tasks in January 2003

4. Agitation & restlessness Anxiety Apathy/failure to participate; withdrawn/crying Defensive behaviour Hearing & seeing things that do not exist Impulsivity Intrusiveness Hoarding and/or rummaging Inappropriate sexual behaviour Resistance to care Suspicious/accusing others Vocally disruptive behaviour Wandering Challenging, or complex behaviours, as a result of dementia or mental illness can include:

5. Behavioural and Psychological Symptoms of Dementia (BPSD) BPSD left untreated has been associated with caregiver burnout, nursing home placement, poor management of co-morbid conditions and excess health care costs.Steel, Cohen, Mansfield, Ballard

6. Challenges of Challenging Behaviour • BPSD significantly impacts quality of life of both the person and caregivers (Finkel SJ) • Caregivers consistently rate BPSD as the most stressful aspect of caring (Jarriot PN) • Is the primary factor for deciding to institutionalize (Steel C, Balestreri) • Approximately 50% of people with Severe Dementia Alzheimers Type experience psychosis, 90% behavioural issues, 7-10% severe (Rabins, Zimmer)

7. Readiness For Change Opportunity Policy Advocates Structural Flexible Organizations Changes 10 Years Sabattier

8. Challenging Behaviour Program

9. Education and Training • Enhance capacity at the organization level in providing service to the older adults with complex cognitive/mental health issues and associated behaviours. • Target group – Nursing Homes, Home Support Agencies, Nursing Agencies, and Continuing Care Offices • Develops the In-house Resource Consultant role

10. P.I.E.C.E.S. Clinical Resource Consultants • Provide case based consultation to IHRC • Educators, coaches, consultants and assist in program development • Facilitate Local Learning Networks • Link to community-based resources and external stakeholders • Promotes linkages between care givers and specialized resources • Ensures a comprehensive assessment is conducted pre/post admission to stabilization service

11. Resource Support and Augmentation • Temporary short term funding. • Alternative short term care provision and intervention to stabilize challenging behaviour • PCRC play a supportive role with requesting agencies and Continuing Care District Offices

12. Stabilization Service • Target Population – Client/Residents who have not benefited from interventions targeting complex cognitive/mental health issues and associated behaviours. • Goal – Assess, stabilize and develop a care plan that will permit the client/resident to be discharged back to the community. • Access through the PCRC

13. Program Design • Step I Gaining multi-Organization and Communities of Interest Support • Step II Engaging the Learners • Step III Education Program • Step IV Support • Step V Maturation from Education to Practice • Step VI Putting the P.I.E.C.E.S. together at the Systems Level

14. Organization Support Academic Institutions Service Organization Communities of Interest Consumers Provincial Gov. Target Learning Org’s Program Design Step I : Gaining Multilevel Organizational/ Communities of Interest and Support Chambers

15. Program Design Step II: Engaging the Learners • Education Program • Engage Senior Leaders • Selecting the learners to fulfill the In- • House Resource consultant role “Peer/Opinion Leaders”

16. The P.I.E.C.E.S. Model Putting the P.I.E.C.E.S Together

17. Putting the P.I.E.C.E.S. ...together Physical, Intellectual, Emotional, Capabilities,Environment, Social, and are the cornerstones of the philosophy and care of the P.I.E.C.E.S. Education Initiative.

18. What is P.I.E.C.E.S.? • A practical, effective approach to change and continuous improvement • Best practices in learning & development • Performance improvement foundation • Provides approach to understanding & enhancing care • Framework, systematic • Team, Dialogue Physical, Intellectual, Emotional, Capabilities, Environmental, Social

19. The P.I.E.C.E.S. Model Provides • Common vision and set of values • Common language and knowledge for communicating across the system • Common yet comprehensive approach for thinking through problems

20. P.I.E.C.E.S.A Model for Changing Practice P.I.E.C.E.S. Enabler Program for Senior Leaders + P.I.E.C.E.S. Education Programs for Professional Staff = Foundation for Practice Change Form foundation for a common vision, common language and a common approach

21. Goals of P.I.E.C.E.S. Program Comprehensive Assessment & Care Planning Integration & Collaborative Care Risk Management Person & Family Current & Emerging Best Practices Interdisciplinary Care Interdisciplinary Care

22. Enabler Program for Senior Leaders • 8 hour program • Target audience: • those in a position to supervise regulated and/or unregulated staff but not involved in direct care (I.e Administrator, DOC) • those in a position to support learners/In-house Resource (I.e Educators)

23. The 40-hour P.I.E.C.E.S. Program Prepares the In-house Resource Person … to serve as a resource to others in the organization by: • promoting a common language, common values, and common way method of thinking through complex problems • modeling P.I.E.C.E.S. competencies • developing P.I.E.C.E.S. competencies in others.

24. Step III The Education • Curriculum development • 3 staged vis-à-vis Dave Davis • Importance of Job Aids • Templates and Tools, Practicality • Reinforcement and Meta Learning

25. Enabler Program Objectives • Familiarize participants with the P.I.E.C.E.S. framework, approach, assessment tools and screening guides taught in the 40-hour program. • Introduce a practical tool to improve observations of the “Team” and teach the importance of knowledge exchange regarding the client/resident • Identify clinical and educational coaching and senior leadership support strategies to support the in-house resource role and others in transferring learning to practice change

26. The Enabler Program Includes Strategies to……. • Flag gaps between current practice and best practice • Select the most appropriate candidates and develop an implementation plan • Explore current approaches to learning and development and performance improvement • Support change efforts • Engage team in collaborative improvement efforts

27. The 40-hour P.I.E.C.E.S. Program • Part 1: 18-hour intensive program of core curriculum • Part 2: Practical application of skills from Part 1 • Part 3: 12-hour consolidation program • Part 4: Post-program support

28. Core Competencies 1. Detect or flag what has changed 2. Use the 3-Q P.I.E.C.E.S. template 3. Be familiar with tools 4. Plan care with others 5. Evaluate care and goals 6. Coach others using U-First collaborative care tool

29. 3-Question Template • Q. 1 What has changed? • Avoid assumptions; think atypical. • Q. 2 What are the RISKS and possible causes? • Think P.I.E.C.E.S. • Q. 3 What is the action? • Investigations • Interactions • Information

30. I P E S C E Collaborative Care Tool U-FIRST! Flag Understanding Support Interact Reflect and Report

31. Tools and Techniques • Abilities: Lawton • Behavior: DOS, Cohen • Cognition: CAM, Clock, Folstein • Distress Caregiver PIECES revisited • Emotional, Depression/Mood; Psychosis (7D)

32. Performance Objectives • 4 objectives which describe outcomes in terms of “on-the-job” performance • Measurable • Achievable over one year

33. Evaluation Strategies • Pre-program assessment • After 3-day and 2-day session • In-class work and observation • On-the-job performance demonstration

34. Support • Service Org • Enabler Program PCRC 3 Roles Case Based Clinical Support Education Linkages Networks Key Change Agents IHRC’s Specialty PCRC System/ Province Community DoH Org (NGO) Step IV Support

35. To change systems we: • Assess the potential for change • Get the whole system in the room • Focus on the future • Structure tasks people can do themselves Marvin Weisbord

36. Commitment From Enablers • Leadership support is critical to success • Support the In-house Resource role • Promote application and integration of new learning into day to day practice • Strengthen learner skills

37. What have we learned? Elements for success of In-house Resource role • Right person(s) selected; peer leader • Support from Senior Leadership, care team • Clinical P.I.E.C.E.S. Resource Consultants • Development of Local Learning Networks

38. Through P.I.E.C.E.S. Education Collaborative Care is enhanced: Individual Team Organization System Training can change individual behaviours Increased collaboration & results at the team level Vision linked to team and individual outcomes Part of a larger program to support system change Accountability to front line

39. P.I.E.C.E.S. Clinical Resource Consultants • Capacity to catch and promote the vision • Clinical background – knowledge of Alzheimer’s Disease and other dementia’s • Coach • Ability to establish and foster collaborative and consultative relationships at the individual, team, organization and system levels • Networking and Team Building • Champion

40. Elements for Success in the System • Translatable and transferable • Framework • Multi-level awareness and support • Intersectoral Community Stakeholder Group • Telepsychiatry • Importance of Local Resources • Ongoing Learning Support • Evaluation

41. Benefits of the P.I.E.C.E. S. Model • Increased capacity among continuing care providers. • A common vision, approach (framework) and language. • A vehicle to link people, ideas and resources at the - Clinical - Service Coordination - Systems Level

42. Step V • Maturation from Education to day-to-day practice Step VI • Putting the P.I.E.C.E.S. together at a systems levelFrom………. Education to Knowledge to Translation and Exchange

43. Thank You Questions? Comments !