Canadian Coalition for Seniors’ Mental Health 3rd National

Conference: The Future of Geriatric Mental Health in Canada

September 3rd 2008

Exploring Knowledge Transfer and Exchange

Implementing Mental Health Guidelines in Long Term Care Homes

Disclosures:Dr. Conn has attended

Advisory boards or

received honoraria from: • Astra-Zeneca• Janssen-Ortho• Lilly• Pfizer• Organon• Lundbeck• Novartis • Wyeth

Dr. Le Clair has attended

Advisory boards for: • Janssen-Ortho• Pfizer• Lundbeck • Wyeth

Ms. Baker and Ms. Walsh have no conflict of interest that may have a direct bearing on the subject matter of this presentation.

Agenda

1:00 – Welcome and Introductions

1:10 – Background on the CCSMH Guidelines Project and Implementation Plan

1:20 – Understanding the Need for Knowledge Translation

1:30 – Approach #1 – Using Provincial Networks

1:50 – Approach #2 - Local Implementation

2:20 – Questions? Comments?

2:30 – Break in Foyer

Objectives

At the end of this workshop, participants willgain further understanding on how to:• Implement best practices in long term care

settings, with an understanding of the process, barriers and vehicles to success;

• Identify ways to build interdisciplinary teams and networks;

• Advocate for quality improvement in their Long Term Care facilities.

CCSMH Guideline Project: Setting the Context

• Funding awarded in Jan. 2005 by Public Health Agency of Canada, Population Health Fund

• Goal: To lead and facilitate the development of evidence-based recommendations for best practice guidelines in areas of seniors’ mental health

Background: The CCSMH Guideline Project

• Assessment & Treatment of Delirium

• Assessment & Treatment of Depression

• Assessment & Treatment of Mental Health Issues in LTC Homes (with a focus on mood & behaviour)

• Assessment of Suicide Risk & Prevention of Suicide

Long Term Care Homes (LTC) in Canada

• 7% of the Canadian population reside in LTC at any one time.

• 40% reside in LTC at some time.• Institutionalization increases with age (38% of

women and 24% of men over 85 live in LTC).• Institutionalization correlates with decline in

ability to perform ADLs & IADLs and with mental health and behavioural challenges.

• “Baby Boomers” will start utilizing LTC in significant numbers around 2020.

Value Proposition

• There is a need to focus on both mental health and mental illness in LTC homes.

• There is significant diversity in the LTC population. • Effective mental health management requires an

interdisciplinary approach.• Relationships among residents, family members

and staff are central in meeting mental health needs.

• The milieu (social and physical environment) can promote or undermine mental health.

Contents of LTC Guidelines

• General Care

• Assessment

• Treatment of Depression

• Treatment of Behavioral Symptoms

• Organizational & System issues

• Current research indicates that typical dissemination plans for clinical guidelines include publication in academic journals and/or mail outs; however these methods seem to have no noticeable impact on practice change.

Rosser, W.W., Davis, D., Gilbart, E. (2001). Promoting effective guideline use in Ontario. Canadian Medical Association Journal, 165(2), 181-182.

Why Is Knowledge Translation Needed?

• Additionally Ouimet et al found that the probability of guideline utilization increased through workshops.

• They also discussed the importance of face-to-face interactions between researchers and decisions makers as an important indicator for guideline utilization.

• This concept of personal interaction was consistently supported throughout the knowledge translation literature.

Ouimet, M., Landry, R., Amara, N., & Balkhodja, O. (2006). What factors induce health care decisionmakers to use clinical guidelines? Evidence from provincial health ministries, regional health authorities,and hospitals in Canada. Social Science & Medicine, 62, 964-976.

Lomas, J. (2000). Using ‘linkage and exchange’ to move research into policy at a Canadian foundation. Health Affairs, 19(3), 236-240.

Innvaer, S., Vist, G., Trommald, M., & Oxman, A. (2002). Health policy makers’ perceptions of their use of evidence: a systematic review. Journal of Health Services Research & Policy, 7(4), 239-244h.

Why Is Knowledge Translation Needed?

ConsumerGroups NGOs

Service Collab-

oration & Local

Opinion Leaders

Govern-ment

Pillars and Partners to Change (Chambers et al )

Areas of Support, and Synergy

Ingredients for Change: A Conceptual Framework Complementing the

Knowledge Translational Exchange Cycle

Evidence or What do we need to do?

Research (Traditional, Population, Epidemiology)

Clinical Experience (Tacit Knowledge)

Patient Experience

Rycroft-Malone, Kitson A, et al

Ingredients for Change: A Conceptual Framework Complementing the

Knowledge Translational Exchange Cycle

Context: How are we going to do it?

Values, Share Vision

Diffusion and Readiness (Individual, Organization, Community)

Rycroft-Malone, Kitson A, et al

(Rogers)

Ingredients for Change: A Conceptual Framework Complementing the

Knowledge Translational Exchange Cycle

Exchange: Who is going to do it? (Facilitation)

Helping enable, rather than telling

Titchens (Critical Companionship)

Rycroft-Malone, Kitson A, et al

Knowledge Translation Cycle

KG KT KA Knowledge Utilization

Person Centred + Evaluation

Knowledge Retrieval

Channels: Consultation, information, learning and development (Technology)

Factors: Evidence, persons, organizations, community

KE

(Sullivan et al)

Readiness and Realizing Change

Knowledge Awareness

Understanding

Belief

Action

D. Joyce

(KUBA)

Dialogue & IdentificationKey Factors Critical to Knowledge Transfer & Exchange

1. Identify strategies you have used to achieve knowledge transfer and exchange.

2. Identify the critical elements or possible strategies to achieve knowledge transfer and exchange.

3. Identify resources you may have for knowledge transfer and exchange.

The Ontario Task Force:

A Provincial Approach to Guideline Implementation

Provincially Supported, Locally Delivered,using existing channels

Ontario Task Force

• The Ontario Task Force was created with the recognition that in Ontario, there are multiple initiatives, associations and programs that exist within long term care. .

The membership of the Ontario Task Force was carefully selected, ensuringthat representatives from all pillars of change were included. Examples ofmembership are listed below:

• Academic – Queen’s University, Alzheimer Knowledge Exchange (AKE)

• NGO’s – Ontario Long Term Care Association (OLTCA), Ontario Association for Non-Profit Homes and Services for Seniors

• Government – Ontario Seniors Secretariat (OSS), Ministry of Health and Long-Term Care

• Clinicians/ Change Champions – Psychogeriatric Resource Consultants (PRCs), Post Alzheimer Strategy

• Consumers – Alzheimer Society of Ontario

• Working with the partners in the Ontario Task Force a pilot project was created (with funding received from the Public Health Agency of Canada) to use the Psychogeriatric Resource Consultants and local networks to implement the guidelines at the local level across the province.

“Local is the KeyRegional/Provincial Support”

Using the Existing Knowledge Transfer Channels

Target Guidelines and Audience

• This pilot implementation project focuses on raising awareness of the CCSMH LTC guideline and increasing the exchange, utilization and retrieval of the guideline recommendations by Psychogeriatric Resource Consultants with their partners.

Cornerstones to Implementation

• Psychogeriatric Resource Consultants (PRC)

• Existing Learning Networks

Methods

Phase 1Introduction

• Introduction of guidelines to PRCs

• Interactive web presentation-guideline development process, understand the levels of evidence and have the opportunity to ask specific questions on recommendations

• Learn about the Ontario Task Force Implementation Project and will be invited to move into Phase 2

Phase I: Using Adobe Connect

• Hosted by the AKE on January 15th, 2008

• 24 attendees

• 20 committed to moving forward in Phase II

Method

Phase 2Awareness

• Invite PRCs to commit to raising awareness of the guidelines within their local Learning Networks (approx. 15-18)

• Participating PRCs will work with Ontario Task Force to decide on materials and resources required.

• Resource Package to be developed

• Feedback• Invitation to participate in Phase 3

Phase II

• Two regional half day meetings facilitated by Kathy Baker in Kingston (Eastern Ontario) and Kitchener (Southwestern / Central Ontario).

• 13 attendees between two days

• Representation from 10 of the 14 LHINS

Regional Meeting Key Messages

• Need to find ‘champions’ in the homes that will be piloting

• Plan to capitalize on existing teams and resources

• Ensure senior leadership support (letters to administrators)

• Create key partnerships (i.e. with GMHOT)

(Bi-level action: Senior leaders and practice change champions)

Regional Meetings: Potential Barriers

• Financial and human resources– staff time– replacement costs for training– people are tapped out already and overworked– partnerships may not be as strong – are people

dependent (people can leave, change roles etc.) – need key players

• LTC is often the place that those with the most complex needs (that don’t fit our present system) are placed

• Working culture has to be ‘change friendly’• Compliance crises

Regional Meeting: Strategies for Raising Awareness + Readiness

Information is needed to raise awareness universally andthen target one or two homes to participate in the evaluation• send a letter to administrators, directors of care, resident care

coordinators • let OANHSS and OLTCA know which homes are participating

as well as compliance advisors• partner and link with education and best practice coordinators

and those responsible fro the staff development and education

• Use existing networks and promote to outreach teams • Have them on hand for ‘in the moment’ learning• CCSMH and team to create a power point presentation

Raising Awareness Resources

• A letter to administrators

• A ‘one pager’ guideline summary

• A content based power point presentation

• Hard copy distribution of the guidelines to staff, teams etc.

Method

Phase 3Application &

Utilization

Start date:Fall 2008

• PRCs (approx. 5-10) to work with Long Term Care Homes that are interested in implementation of guidelines

• Choose aspects of implementation relevant to their LTCH (locally driven, readiness)

• Consideration: Size of the home; culture of the work environment; readiness of the home; senior leadership support

Phase 3: Learning Knowledge Exchange,

Literature/Practice-Based Evidence

• Collaborate with the RNAO and host a workshop on implementation

• Attendees would include PRCs and the ‘champions’ from the selected pilot homes

• Webinars for P.I.E.C.E.S trained staff in the homes

(Enriching the Channels and Capacity for KT)

Method

Phase 4

Knowledge Retrieval

• Qualitative and quantitative reports from PRCs

• Includes data on individual projects, outcomes, developed products and ongoing ability to use guideline recommendations within clinical practices

• Sharing successes/projects and strategies with other PRCs and LTCH in the province

Evaluation

• The purpose of the evaluation; to determine the extent and impact of knowledge awareness, exchange, utilization and retrieval that occurs as a result of implementation activities (e-health, regional awareness + support activities, resource package, and local application projects).

• The process; employ a systems perspective with an emphasis on identifying organizational and institutional opportunities and barriers

Performance Improvement

• A result-driven perspective to work, the workplace, and the worker.

• Doing meaningful work in effective and efficient ways.

The Work of Performance Improvement

Focusing on outcomes.

Taking a systems view.

Adding value.

Working in partnerships.

Factors Supporting Performance

• Clear performance expectations (standards, policy)• Essential support (resources, responsibility, authority,

time)• Clear consequences (reinforcement, incentives,

rewards)• Prompt feedback (how well performance matches

expectations)• Individual capability (physical, mental, emotional

capacity, experience)• Necessary skills and knowledge (training, learning to

perform)

Key Points

• Learners by themselves can’t make the changes

• Training people on what they already know will not improve performance.

• Focus on the gap between current performance and better practices.

Our job is to understand…

• Humans have a large capacity to learn

• The learner is always the start point

• Learning means change… leadership team support is essential

• How to clear the path… need an environment that favours learning and eliminate things that conflict

Start point!

Focus first on what people are expected to accomplish on the job (competency)…

...rather than what people are expected to learn.

(Robinson & Robinson, 2004)

Questions for Discussion