Influencing CareThe Nova Scotia

P.I.E.C.E.S. StoryAlzheimer Society Manitoba, 2008 Conference

Joanne Collins RSW Challenging Behaviour Program

Nova Scotia Department Of Health

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

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

Challenging, or complex behaviours, as a result of dementia or mental illness can include:

• 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participate; withdrawn/crying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

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

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)

Readiness For Change

Opportunity

Policy Advocate

s

Structural Flexible

Organizations

Changes

Sabattier10 Years

Challenging Behaviour Program

Client

In House Resource Consultant (IHRC)

P.I.E.C.E.S Clinical Resource Consultnat(PCRC)

Resource Support & Augmentation

Stabilization Service

LTC Facilities

HC AgenciesFamily

Care-givers

Staff Education & Training

Continuing Care

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

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

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

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

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

Program DesignStep I : Gaining Multilevel Organizational/

Communities of Interest and Support

Organization Support

Academic

Institutions

Service Organization

Communities of Interest

Consumers

Provincial

Gov.

Target

Learning

Org’s

Chambers

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”

The P.I.E.C.E.S. Model

Putting the P.I.E.C.E.S Together

PPhysical, IIntellectual, EEmotional,

CCapabilities, EEnvironment, SSocial, and are the cornerstones of the

philosophy and care of the P.I.E.C.E.SP.I.E.C.E.S.. Education

Initiative.

Putting the P.I.E.C.E.S. ...together

What is P.I.E.C.E.S.?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

PPhysical, IIntellectual, EEmotional, CCapabilities, EEnvironmental, SSocial

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

P.I.E.C.E.S.P.I.E.C.E.S.A Model for Changing PracticeA Model for Changing Practice

++

Form foundation for a common vision,Form foundation for a common vision, common language and a common approachcommon language and a common approach

P.I.E.C.E.S. Enabler Program for Senior LeadersP.I.E.C.E.S. Enabler Program for Senior Leaders

P.I.E.C.E.S. Education Programs for Professional StaffP.I.E.C.E.S. Education Programs for Professional Staff

Foundation for Practice ChangeFoundation for Practice Change

==

Goals of P.I.E.C.E.S. Program

Comprehensive

Assessment & Care

Planning

Comprehensive

Assessment & Care

PlanningPerson &

Family

Person &

Family

InterdisciplinaryCare

Interdisciplinary Care

Interdisciplinary Care

Current & Emerging Best

Practices

Current & Emerging Best

Practices

Risk Management

Risk Management

Integration & Collaborative

Care

Integration & Collaborative

Care

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)

The 40-hour P.I.E.C.E.S. Program

Prepares the In-house Resource Prepares the In-house Resource Person 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.

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

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

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

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

Core Competencies1. Detect or flag what has changed

2. Use the 3-Q P.I.E.C.E.S.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

3-Question Template

Q. 1Q. 1 What has changed? Avoid assumptions; think atypical.

Q. 2Q. 2 What are the RISKS and possible causes?Think P.I.E.C.E.S.

Q. 3Q. 3 What is the action?InvestigationsInteractions Information

Collaborative Care Tool U-FIRST!

PI

E

CE

S

Understanding Flag

Interact

Reflect and Report

Support

Tools and Techniques

• Abilities: Lawton

• Behavior: DOS, Cohen

• Cognition: CAM, Clock, Folstein

• Distress Caregiver PIECES revisited

• Emotional, Depression/Mood; Psychosis (7D)

Performance Objectives

• 4 objectives which describe outcomes in terms of “on-the-job” performance

• Measurable

• Achievable over one year

Evaluation Strategies

• Pre-program assessment

• After 3-day and 2-day session

• In-class work and observation

• On-the-job performance demonstration

Step IV SupportSupport

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)

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

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

What have we learned?

Elements for success of In-house Elements for success of In-house Resource roleResource role

Right person(s) selected; peer leaderSupport from Senior Leadership, care teamClinical P.I.E.C.E.S. Resource Consultants Development of Local Learning Networks

Through P.I.E.C.E.S.P.I.E.C.E.S. Education Collaborative Care is enhanced:

Individual Team Organization System

Training canchange

individual behaviours

Increased collaboration& results at

the team level

Visionlinked to teamand individual

outcomes

Part of a larger program

to support system change

Accountability to front line

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

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

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

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

Thank You

Questions? Comments !