Promising Practices for Management of Challenging Behaviors in VISN-6

1. Promising Practices for Management of Challenging Behaviors in VISN-6 Jorge Cortina, MD, DFAPA Eleanor McConnell, PhD, RN, GCNS, BC Innovators throughout VISN-6 Geriatrics & Extended Care Commentary from Conference Faculty

2. Goals • Highlight current practices in VISN-6 that illustrate key concepts in challenging behavior management • Promote networking among resource people within the VISN • Stimulate learning and ongoing program evaluation • Stimulate strategies for implementing knowledge and skills learned at conference

3. In other words… • Not enough to know what to do…. • How to get it done is just as important. • So…how do we expect you to make use of what we’ve learned here? • Build on success! • Learn from challenges!

4. Approach • Describe innovative VISN-6 programs in action • Showcase key components that illustrate conference concepts • Share evaluation data when available or evaluation plan when not • Invite discussion from conference participants about how this might be useful to their current efforts

5. Behavioral Interventions Note Overview Antecedents Behaviors Consequences

6. BehaviorsChecklist & Textboxes toallow more specific description of behavior

7. Imports key information on possible Antecedents from CPRS & Prompts further documentation of common antecedents in environment

8. Point of Care Decision Support on Common Antecedents & Prompts to use non-pharmacologic interventions before medications

9. BIN Note Lessons Learned • Pilot testing is a good idea…find barriers • Key barriers to its implementation: • Time (to train, to try out) • Work habits • Front line staff accustomed to seeing behavior and taking action – not seeing behavior, doing more careful observation, thinking, and trying things out before calling • Overcoming barriers: • Be prepared for slow going at first • Link use of note to orientation of new staff • Link use of note to other practices (one-on-one or restraint competencies)

10. Behavioral Interventions NoteSummary • Location: Asheville • Contact: Kathryn (Kitty) Hancock, RN, MSN, Nurse Educator • CPRS template developed by VISN-6 Challenging Behaviors Committee • Systematic evaluation • Goals: • Increase use of non-pharmacologic interventions • Reduce use of psychotropic medications • Who implements: Nursing staff • When used: prior to use of PRN medications or restraints • Notable Features • Facilitates implementation of ABC model • Intended to be used prior to requesting/using PRN medication • Developed with VISN-wide input • Why a good idea: • Allows systematic documentation of behaviors, their antecedents, & outcomes of interventions Acknowledge role of Martin Cruz, PharmD, & Jan Cavanaugh, PhD from VISN Challenging Behaviors Task Force 2008

11. Snoezelen Room Salisbury Community Living Center Salisbury, NC

12. What is Snoezelen? • A Multi-sensory experience that uses lighting, projected pictures, music and sounds, textures, aromatherapy, and vibration to stimulate, energize or relax • Several VA CLC’s have implemented this program • Salisbury opened their room Sept 2009 with a grant of $30,000

13. How is Snoezelen Implemented in Salisbury? • Located on the gated Dementia Unit, the Veterans have access as part of their overall treatment plan under staff supervision • Veterans from other units are also brought in as part of their restorative treatment plan • Serves as an alternative to medication to reduce agitation and aggression • Serves to calm providing rest for the wanderers

14. Snoezelen Summary • Location: Salisbury • Contact: BJ Nelson, RN, Nurse Manager & Julie Merrick, OTR • Description: • Multi-sensory stimulation program, originally implemented for those with developmental disabilities • More of the what, who implements, • Goals: • Provide systematic, controlled stimulation to those with severe dementia • When initiated: September, 2009 • Notable Features • Positive intervention whose cognitive function is at a low level (pearls) • Interprofessional approach • Builds on evidence-base borrowed from another population • Why a good idea: • Addresses under-stimulation experienced by veterans with limited cognitive function • Proactive rather than reactive

15. Pre-Service Education on Challenging Behaviors • Location: Fayetteville • Contact: Jan Cavanaugh, PhD, HBPC Mental Health Provider • Description: • Two-hour in-service on basics of managing challenging behaviors during staff nurse orientation. Development of curriculum on challenging behaviors for direct care nursing staff that is implemented during orientation • Goals: • Highlight importance of behavior management skills • Alert new staff to resources available to nursing staff and VA approach • When initiated: 2008 • Notable Features • Sets expectation that challenging behaviors are an important part of care • Gives specific examples of nursing role in managing challenging behaviors • Why a good idea: • Staff exposed to team care expectation when motivation to learn is high • Proactive rather than reactive

16. Overview of Session • Introduction to basic concepts of Cultural Transformation and Community Living Center • HATCH model • Teach basics of Transforming Patient Care to Person-Centered approach • Learn basics of Dementia Care • What is Dementia • Awareness/Sensitivity Training • Positive Approach • Communication/Cueing/Hand under Hand (HuH) • Levels of Dementia and Care Needs • Self Care/Centering/Breath/Relaxation • ABC Model of understanding behavior.

17. Lessons Learned • Psychologists teaching nurses about behavior management • Need to negotiate – can’t be imposed • Able to build on knowledge developed during orientation when psychologist consults on residents with challenging behaviors

18. Challenging Behaviors Education In Nurse Orientation Training • Location: Fayetteville • Contact: Jan Cavanaugh, PhD, HBPC Mental Health Provider Description: • Development of curriculum on challenging behaviors for direct care nursing staff that is implemented during orientation • Goals: • Highlight importance of behavior management skills • Alert new staff to resources available to nursing staff and VA approach • When initiated: 2008 • Notable Features • Sets expectation that challenging behaviors are an important part of care • Gives specific examples of nursing role in managing challenging behaviors • Why a good idea: • Staff exposed to team care expectation when motivation to learn is high • Proactive rather than reactive

19. Special Care Unit in CLC • Location: Hampton • Contact: Martin Cruz, PharmD, , Bev Edmonds, RN • Goals: • Expand access to behavioral health care for Veterans • Reduce use of psychotropics • When initiated: 2007-2008 • Targeted behaviors: • Wandering • Disturbing Inappropriate vocalizations • Physical resistance to ADL care • Sexually inappropriate behavior • Hyperactivity due to delirium • Key Features: • Increased square footage per patient • Secured, keypad exit • Increased hours per resident day • Staff competencies in management of ADL care for CLC residents with behavioral complications of dementia • Weekly rounds by Interdisciplinary team (Medicine, Nursing, Mental Health, SW, Pharmacy)

20. Evaluation FY07 – FY08 Changes in CLC • Increased behavioral care access: • Number of veterans served • Bed-days of care • Improved quality indicators • Antipsychotic use in the absence of psychotic or related conditions • Cut in half from 18.5% to 8.9% • Improved percentile: 50th to 25th Community Living Center Behavioral Workload and Antipsychotic Use After Opening a Special Care Unit Jorge Cortina, MD; Department of Veterans Affairs VISN 6 Increased Staff Cost • Community Living Center Behavioral Workload and Antipsychotic Use after Opening a Special Care Unit • Reported outcomes associated with introduction of a Dementia Special Care Unit have been mixed.1-2 In October of 2007, a new subsection of the Veterans Affairs Community Living Center (CLC) was opened with the intent to enhance the capacity of the CLC to provide care for veterans with behavioral complications from either complications of dementia or severe and persistent mental illness. In particular, the following behaviors were targeted: Wandering, disturbing inappropriate verbalizations, physical resistance of care for Activities of Daily Living, unpremeditated aggression or assaultive behavior, sexually inappropriate behavior, and hyperactivity due to delirium. Essential characteristics of the unit were increasing of the square footage per resident, a more secured, keypad exit, enhanced staffing with respect to hours per resident day and training of direct care staff on the management of and ADL care for CLC residents with behavioral complications of dementia. Additionally, an interdisciplinary team consisting of nursing, social work, pharmacy, mental health and medical providers has been formed and rounds weekly for about 30 minutes per week. • In the year following its opening, the number of residents and Bed Days of Care (BDOC) under behavioral treating specialties (short stay and long term psychiatric care and long stay and long stay dementia care) treated in the CLC has nearly doubled over FY 07 and antipsychotic use in the absence of psychotic or related conditions in the CLC has been cut in half from 18.5% to 8.9% in the same period. Correspondingly, the CLC has advanced from being at the 50th percentile with respect to antipsychotic use to the 25th percentile nationally when measured from Oct 07 to Oct 08. • While these outcomes have not been formally investigated using rigorous research methods, routinely obtained performance improvement and workload data suggest that modification of CLC residential areas and work practices as described above can result increased behavioral workload while paradoxically reducing antipsychotic use. • Journal of Aging and Health, Vol. 20, No. 7, 837-854 (2008)Archives of Gerontology and Geriatrics, Volume 26, Issue null, • Pages 215-224 • FY07 – FY08 Changes in CLC • Doubling of BDOC and residents • Short stay and long term psychiatric care • Long stay and long stay dementia care • Targeted Behaviors • Wandering • Disturbing inappropriate verbalizations • Physical resistance of care for Activities of Daily Living • Unpremeditated aggression or assaultive behavior • Sexually inappropriate behavior • Hyperactivity due to delirium • FY07 – FY08 Changes in CLC • Antipsychotic use in the absence of psychotic or related conditions • Cut in half from 18.5% to 8.9% • Improved percentile: 50th to 25th • Essential Characteristics of Unit • Increased square footage per patient • Secured, keypad exit • Increased hours per resident day • Staff competencies in management of and ADL care for CLC residents with behavioral complications of dementia • Weekly rounds by Interdisciplinary team • (Medicine, Nursing, Mental Health, SW, Pharmacy)

21. Lessons Learned • Environment is a powerful shaper of behavior • Combined physical and social environmental changes • Systematic evaluation suggests that it was effective in reducing psychotropic use.

22. DENs: Dementia Engagement Nooks • Location: Richmond • Contact: Violet Oliver, RN, Nurse manager • Description: • Painted with murals to be less hospital-like • Vets encouraged to spend time there with each other.  • When possible, nurses assigned just to the DEN to direct activities, engage vets in conversation, exercise, painting, reading, etc. • Structured activities planned in advance

23. DENS in Richmond Street to Den Entrance Contains Schedule Structured Activities from 6AM  11PM!

24. Lessons Learned • Since DENS were created • Bedfast days have dropped significantly • Falls have also decreased dramatically.    • More peer-to-peer interaction • Lately we’ve had student volunteers in there with the vets hanging out with them and interacting.

25. Outpatient Dementia Care Team Clinical Demonstration • Location: Durham • Contact: Linda Chilton, RN, MSN, NP; Judith Davagnino, LCSW, MSW Barbara Kamholz, MD; Jack Twersky, MD, • When initiated: 2010 • Notable Features • Behavior management protocols from successful research-based program • Interdisciplinary approach • Intervention targeted to veterans who are living at home • Why a good idea: • Teaches informal caregivers evidence-based behavior management techniques • Proactive rather than reactive • Individualized intervention

26. Description Interdisciplinary, evidence-based dementia care management program Goals: • Delay institutionalization • Improve dementia care management • Reduce caregiver burden • Improve quality of life

27. Target population • Veteran living at home with caregiver • 65 years old and over • MMSE 20 and under • 30 mile radius from Durham VA Medical Center

28. INTERVENTIONS • Home visits • Individualized care plan • Psycho-education • Caregiver support • Problem-solving • Behavior management • Reduction of anticholinergic impacts of patient medication • Case management • Novel Methods: Screening for Delirium and PTSD

29. Examples of Protocols to be Adapted More detailed example Source: Indianapolis Discovery Network for Dementiahttp://www.indydiscoverynetwork.org/(X(1)A(9heKr3V1ywEkAAAANjRkOGQ0NzQtNTJiMC00MWViLWFlYzUtMzM4Nzg4MjNhZTkzt1cVAvUv9D--EZq_OdoXSsbXx_I1)S(ilfxf1abiaickj455bld2n2d))/HABCInitiative.html

30. Summary • Many programs or practices already implemented within VISN 6 that make use of principles discussed in this conference • Speaks to feasibility of implementing non-pharmacological techniques to help in managing challenging behaviors • Opportunity exists to build on successes of others!