Behavioural Supports Ontario (BSO)

Transcription

1 Behavioural Supports Ontario (BSO) Presented to: Canadian Home Care Association Summit 2012 Presented by: Cathy Hecimovich - CEO, Central West Community Care Access Centre, Ontario Tuesday, October 23, 2012 In partnership with:

2 Behavioural Supports Ontario Once Upon a Time Lanore had responsive behaviours associated with dementia that were disruptive for other residents in her LTC Home. Recognizing her behaviour was most common before the dinner hour, that Lanore loves reading and that she wants to be social with other residents, BSO trained staff took a Montessori-based approach. Lanore now reads to fellow residents before dinner, and she seems pleased with her newfound purpose. Her responsive behaviors are significantly less common and intense. The early success we ve had has motivated us to continue to expand the Montessori program. We believe programs such as this will have (are having) a significant positive impact to those living in long term care. Laura Holtom, Assistant Administrator Wellington Terrace Long-Term Care Home

3 BSO it s nice to meet you let s get to know each other how many people here today have heard of BSO

4 BSO Overview

5 BSO the need for change the numbers of people at risk for responsive behaviours is increasing challenges are experienced across all health sectors and services the patient and family require better quality experiences there are significant costs associated with managing behaviours there are recognized best practices that could be more systematically adopted there is an opportunity to leverage existing initiatives in Ontario there is a stakeholder readiness for change. 6

6 BSO is a comprehensive system redesign; an approach that breaks down barriers, encourages collaborative work, shares knowledge, fosters partnerships among local, regional and provincial agencies and speaks to a new way of thinking, acting and behaving. BSO is creating a system that ensures people are treated with dignity and respect, in an environment that supports safety for all and is based on high quality and evidence-based care and practices. BSO provides clients with the right care, in the right place and at the right time. BSO is not a new service but rather, a catalyst for change. BSO what is BSO? 7

7 BSO quality at the core Patient- Centered Equitable Efficient Safe Appropriately Resourced Effective Integrated Accessible Quality Focused on Population Health Health Quality Ontario At the core of the BSO Project is the want to create a system that ensures people are treated with dignity and respect in an environment that supports safety for all and is based on QUALITY, evidence-based, patient-centred care and practice. 8

8 BSO seven key s to success 1. Define the complex population. 2. Define the Why and the What through a provincial framework. 3. Provide mechanisms to support How the framework is implemented locally: Knowledge exchange opportunities Improvement Facilitators Quality improvement approaches Risk and change management. 4. Introduce rapid timelines. 5. Embed multi-level accountability. 6. Create / use standardized tools, protocols and measurement to support implementation. 7. Embed continuous channels and processes to connect to, learn from and collaborate with provincial and local initiatives. 9

9 Bringing policy to practice and science to service BSO the Framework The Behavioural Supports Ontario (BSO) project enhances the health care services of older people who live and cope with responsive behaviours linked to cognitive impairments, people at risk of the same, and their caregivers. The BSO model is comprehensive; broad in its inclusion of all points of care and flexible in its application to communities of different sizes: better integration and collaborative transitional services, has resulted in better care, better health outcomes, and better value. Phase 1 Defining the why and the what Phase 2(a) Testing the model & developing the supports, accountability structures and action plans Phase 2 (b) Implementation, exchange and evaluation Pillar 1 System Coordination and Management Pillar 2 Interdisciplinary Service Delivery Pillar 3 Knowledgeable Care Team and Capacity Building 10

10 BSO alignment Behavioural Supports Ontario (BSO) supports Ontario s Action Plan for Health Care by enhancing care for Ontarians with behaviours associated with complex and challenging mental health, dementia or other neurological conditions, when they require it and wherever they live. Ontario s Action Plan Priorities Triple Aim BSO Priorities Alignment Keeping Ontario Healthy Better Access/ Health Improve the health, wellness and experience of the BSO target population their caregivers and families yes Faster Access and a Stronger Link to Family Health Care Better Quality/ Care Improve the capacity for older adults to live independently and reduce admission/readmission rates yes Right Care, Right Time, Right Place Better Value Appropriate use of healthcare dollars yes He s less agitated and more enjoyable to visit because he s more comfortable in his environment. I m glad to finally see the system is working together paying attention to the elderly, especially people with dementia. My father has always been an independent person and this has been very confusing for him. 11

11 BSO is already making a difference and has been cited throughout the Long-Term Care Task Force on Resident Care and Safety, May 2012, including Theme - Advance the Development of Strong Skilled Administrators and Managers The Ministry has invested $40M for specialized health human resources to help care for residents with dementia and challenging behaviours (Behavioural Supports Ontario). Theme - Strengthen the Ability of Staff to be Leaders in Providing Excellent, Safe Care The Ministry is anticipating the knowledge and products that will be generated through the BSO Project, CLRIs and HQO can be leveraged to support the LTC sector to develop streamlined training for the management of residents with complex behaviours. The BSO project has defined standardized core competencies for staff working with residents with complex behaviours that is being applied provincially to recruit the staff through the BSO investments. BSO participants are showing early successes. In the Central LHIN over 850 care providers have received specialized training in the skills needed to care for people with challenging behaviours. Theme - Support Residents With Specialized Needs to Ensure Their Safety and the Safety of Others The LHINs have been playing a key role in the implementation of BSO. The Ministry is committed to working with the LHINs to ensure the smooth implementation of the BSO Project to build Long-Term Care home (LTC) capacity to care for residents with challenging and complex behaviours. Initiatives like BSO will allow us to pilot system redesign to achieve this, including building capacity in all LTC homes, as well as specialized capacity. 12

12 BSO alignment cont d,,, BSO s target population is an integral part of Ontario s Seniors Care Strategy Seniors Care Strategy 14.6% of Ontarians are 65 and older, yet account for nearly half of all health and social care spending. Ontario s older population is set to double over the next 20 years, while its 85 and older population is set to quadruple. Behavioural Supports Ontario People living with complex and chronic health conditions represent 1% of the population, but account for 34% of Ontario s health care budget. BSO s target population falls within the 1%. Notably, Ontario spends $1.2B/yr for inpatient hospital care of patients in the BSO target population. As Ontario s older population increases, the number of Ontarians with dementia is projected to increase 40% by 2020; in some areas of the Province it will increase by as much as 42%in half that time. There are approximately 77,000 Long-Term Care Home residents in Ontario, while the need for Long-Term Care will grow to 238,000 Ontarians in the next two decades. Up to 37% of Ontarians residing in LTC Homes could be maintained at home with community care supports. As the need for long term care grows, so to will the number of older Ontarians of BSOs target population needing to access LTC: at present, 30% of home care clients with dementia exhibit some behavioural symptoms. Over 65% of long-term care residents have dementia or mental health issues. BSO is focused on providing the Right Care, at the Right Time and in the Right Place. 13

13 BSO QI Investment in the beginning In 2011, local service redesign began with quality improvement training and the introduction of improvement science tools & techniques. HQO facilitated LHIN-wide Value Stream Analyses for each LHIN. Sept Sept Nov 7-8 Nov Nov Nov Nov Nov 30-Dec 1 HNHB NSM South East Central East North East Mississauga Halton Toronto Central Waterloo Wellington Central Central West Champlain Erie St. Clair South West North West 14

14 BSO current state mapping that was then Remind ourselves and our teams of the wastes in our current state (Defects, Overproduction, Waiting, Non-utilized brainpower, Transportation, Inventory, Motion, Extra or over-processing), and our obligation to the client to provide service in the least-wasteful way. Silos with no horizontal connections Parallel streams with no vertical connections Lots of great services, but no system Caregivers mapped touch points & emotions (purple) Wastes were mapped in pink. 15

15 BSO future state mapping this is now The value statement as well as the overarching BSO Framework and Lean principles provide the context for the process redesign. You work in my home; I don t live in your workplace Process improvement is intended to create reliable delivery of care. There are often well documented, evidence-based practices that are not applied with regularity. Reliability theory augments lean theory, and guides us with tools to enable failurefree performance over time. Thus we are not looking to create new treatments, but rather to knit together the best practices that exist and embed these into care for every client, every time. 16

16 the action plan in each LHIN describes the entire local investment in behavioural supports what will change, when, and how. BSO pan-lhin action plans the how success measures considered during action plan development included reduced resident transfers from LTC to acute or specialized behavioural units delayed need for more intensive services reducing admissions and risk of ALC reduced length of stay for persons in hospital who can be discharged to a LTC Home with enhanced behavioural resources. BSO funding for HHRs is only one tool at a LHIN s disposal to address service gaps and opportunities for integration BSO also builds on existing initiatives Residents First Aging At Home ER/ALC Investments Provincial Falls Initiative Nurse-Led Outreach Teams 17

17 BSO features structured assistance to all LHINs and extensive knowledge transfer HQO quality improvement curriculum and coaching AKE-sponsored knowledge transfer at the provincial level Buddy system coaching and knowledge transfer locally Centrally coordinated HHR and communications assistance BSO partnerships & knowledge exchange A formal evaluation in four Early Adopter LHINs will assess the BSO Framework and the outcome of BSO investments. LHIN 6 LHIN 7 LHIN 1 LHIN 2 LHIN 3 LHIN 5 LHIN 8 LHIN 11 LHIN 13 LHIN 14 Early Adopter LHIN 9 LHIN Project Lead LHIN Steering Committee Project Working Group Early Adopter LHIN 4 LHIN Project Lead LHIN Steering Committee Project Working Group Early Adopter LHIN 12 LHIN Project Lead LHIN Steering Committee Project Working Group Early Adopter LHIN 10 LHIN Project Lead LHIN Steering Committee Project Working Group Health Quality Ontario (HQO) * Quality Improvement Guidance * Coordination between BSS and other related local QI initiatives * System alignment * QI Evaluation/ measurement Quality Improvement Teams 4 LHIN Early Adopter Steering Committee (SC) Coordination and Reporting Office (CRO) Project Management Provincial Resource Team (PRT) * Resource and Advisory Alzheimer Knowledge Exchange (AKE) Communication and Knowledge Dissemination

18 BSO implementation current state The Ministry of Health and Long-Term Care (MOHLTC) is funding the implementation of the BSO Framework to develop new care pathways and clinical tools, and share these lessons provincewide based on the overarching principle of person- and caregiver-centered care. All 14 LHINs are currently implementing local BSO Action Plans Common tools developed for staff recruitment and development: Capacity Building Roadmap distributed to employers province-wide, and new BETSI inventory and diagnostic tool guides learning and development planning for entire organizations Pan-LHIN collaborative working groups and communities of practice BSO Evaluation - system-level indicators, logic model and proposed process and outcome measures in development. To date, more than 400 new front-line staff have been hired across the province, over 310 longterm care homes have increased their in-house behavioural supports and an estimated 10,000 new and existing front-line staff have received specialized training in techniques and approaches applicable to behavioural supports. 19

19 Community Care Access Centres and BSO

20 Caseloads by Case Manager organized primarily by geography. Case Managers required to be jack of all trades broad knowledge base CCACs & BSO before the client care model more cursory knowledge of a large number of community services, and other partners in the system very mixed and diverse caseloads with a range of client needs caseloads relatively the same size regardless of client mix. 21

21 Case Management Intensity Resource Intensity CCACs & BSO the client care model Complex Palliative Adults Seniors Chronic Community Independence Palliative Adults Seniors Supported Independence Stable At Risk Short Stay Acute, Rehab, Oncology, Wound Well Information & Referral 22

22 Greater specialization of knowledge and skill set each case manager coordinates care for a specialized group of clients Stronger relationships across the system each case manager partners with fewer stakeholders, aligned with specialized populations More intense levels of support CCACs & BSO client & family-centred care in action smaller caseloads for more complex subpopulations = more time per client 23

23 CCACs & BSO case management old to new OLD STORY general caseload mix service providers are reimbursed per visit regardless of client outcomes case managers focused on # of visits and types of services multidisciplinary team work independently to meet client needs CCAC documentation accessible to CCAC staff only PAST Values enhance client experience value for money need for accountability shared decision making with service providers client tells story once integration coordination navigation proven positive client outcomes NEW STORY client care model case managers assigned to a specific population service providers are reimbursed on best practice and achieving client care goals bundled payments case manager focuses on client care milestones and outcome measures based on best practice guidelines case manager increases the focus on system navigation and linking clients with services technology and privacy considerations allow for sharing of information and assessments FUTURE 24

24 The enhanced role of case management and specialized care coordination aligns with and supports the three pillars of BSO system coordination interdisciplinary service delivery CCACs & BSO client care model interplay knowledgeable care team and capacity building 25

25 CCACs & BSO pillar 1 - system coordination This is the pivotal role of our Case Managers and Care Coordinators in CCACs Case Managers have developed relationships with stakeholders across the system; CCM supports stronger relationships with fewer, more specialized care providers e.g. Case Manager develops enhanced relationship with Geriatrician at hospital, Psychogeriatric consultant role, Alzheimer s Society branch, including site visits, interdisciplinary meetings and care conferences Supports collaborative discussions and information exchange around the care plans for individual clients and families facilitates transitions Supports cross system planning for a population with specialized needs. 26

26 CCACs & BSO pillar 2 - interdisciplinary service delivery Physician The more roles on the care team, the more vital the role of CCAC becomes LTC CCAC Hospital ED CCAC becomes the point of information transfer and consolidation across multiple providers in the system, regardless of sector Community Program Ensures everyone is on the same page. 27

27 CCACs & BSO pillar 3 knowledgeable care team & capacity building CCAC is a pivotal point of knowledge transfer around individual clients CCAC can bring stakeholders together to share knowledge and resources to build capacity within system Examples: Headwaters Health Care Centre, William Osler Health System, Alzheimer s Society in Dufferin and Central West CCAC working together to provide Gentle Persuasive Approach training for caregivers in the home. 28

28 BSO Impact BSO WORKS! STREAMWAY VILLA in Cobourg, ON BSO has been credited by OMNI Health Care Pres. & CEO Peter McCarthy for Capacity Building, Education and Training addition of new Beahvioural Specialist Nurse/RPN training and education of new and existing staff: PIECES (physical, intellectual, emotional, capabilities, environment and social), Montessori and U-First training Meaningful Quality Improvement We re taking a more holistic approach at managing responsive behaviours, rather than resorting to medications we ve gone to having almost no restraints in the home as well. We have one resident (who has) restraints and medication use has decreased huge. We were actually very shocked by the results. The results prove that this works. - Sarah Wilson, BSN/RPN intervention analysis tool: staff members write down supportive measures they trial prior to giving a resident medication. They then chart the results. BSO cupboard, a wooden cabinet stocked with sensory objects that preoccupy residents and minimize responsive behaviours. Knowledge Exchange Staff are taking the training they ve been provided a step further by attending conferences and teaching other caregivers from long-term care homes that have not received BSO funding about the best practices they ve learned. RESULTS incidents of responsive behaviours has been cut in half restraint use down to x1 resident medication administration declining. 12

29 let s continue our discussion! discussion