In partnership with:
Behavioural Supports Ontario (BSO)
Presented to:
Canadian Home Care Association Summit 2012
Presented by:
Cathy Hecimovich - CEO, Central West Community Care Access Centre, 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
let’s get to know each other
how many people here today have heard of BSO…
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.
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.
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.
Quality Accessible Effective Safe Patient-Centered Equitable Efficient Appropriately Resourced Integrated Focused on Population Health
Health Quality Ontario
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.
BSO |
the Framework
Bringing
policy to practice and
science to service
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
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.”
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.
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
BSO’s target population is an integral part of Ontario’s Seniors Care Strategy
Seniors Care Strategy
Behavioural Supports Ontario
14.6% of Ontarians are 65 and older, yet account for nearly half of all health and social care spending.
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.
Ontario’s older population is set to double over the next 20 years, while its 85 and older population is set to quadruple.
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.
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.
Up to 37% of Ontarians residing in LTC Homes could be maintained at home with community care supports.
BSO is focused on providing the Right Care, at the Right Time and in the Right Place.
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 20-21
HNHB
NSM
Sept 22-23
South East
Central East
Nov 7-8
North East
Nov 14-15
Mississauga Halton
Toronto Central
Nov 16-17
Waterloo Wellington
Nov 21-22
Central
Central West
Champlain
Nov 28-29
Erie St. Clair
South West
Nov 30-Dec 1
North West
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.
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
failure-free 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.
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”
•
Residents First
•
Aging At Home
•
ER/ALC Investments
•
Provincial Falls Initiative
•
Nurse-Led Outreach Teams
the action plan in each LHIN describes…
the entire local investment in behavioural supports
what will change, when, and 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…
Early Adopter LHIN 9 LHIN Project Lead LHIN Steering Committee
Project Working Group
4 LHIN Early Adopter Steering Committee (SC)
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 relatedlocal QI initiatives * System alignment
* QI Evaluation/ measurement
Provincial Resource Team (PRT)
* Resource and Advisory Quality Improvement Teams
LHIN 6 LHIN 7 LHIN 1 LHIN 2 LHIN 3 LHIN 5 LHIN 8 LHIN 11 LHIN 13 LHIN 14
Alzheimer Knowledge Exchange (AKE) Communication and
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
A formal evaluation in four Early Adopter LHINs will assess the BSO Framework and the outcome of
BSO investments.
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
province-wide 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
long-term 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.
Caseloads by Case Manager…
organized primarily by geography.
Case Managers required to be “jack of all trades”…
broad knowledge base
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.
Complex
Community Independence
Well
Chronic
Short Stay
Cas
e
M
an
ag
em
en
t Inte
ns
ity
Res
ou
rce
In
te
ns
ity
• Palliative • Adults • Seniors • Palliative • Adults • Seniors • Supported Independence • Stable At Risk• Acute, Rehab, Oncology, Wound
• Information & Referral
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
smaller caseloads for more complex subpopulations = more time per client
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
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
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
PAST
FUTURE
The enhanced role of case management and specialized care
coordination aligns with and supports the three pillars of BSO…
system coordination
interdisciplinary service delivery
knowledgeable care team and capacity building
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.
The more roles on the care team, the more
vital the role of CCAC becomes
CCAC becomes the point of information
transfer and consolidation across multiple
providers in the system, regardless of
sector
Ensures “everyone is on the same page.”
CCAC
Physician Hospital ED Community Program LTC
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.
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
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.
“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
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