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Behavioural Supports Ontario

Quarterly Report | Q1 2012/13

Period April 1, 2012 – June 30, 2012

In partnership with:

Q1 Project Quarterly Reporting

Behavioural Supports Ontario - CRO

“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 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.”



table of contents

Message from the Project Sponsor ............................................. 4

Executive Summary ...................................................................... 5

Chapter 1 – BSO Overview

1.1 structure ....................................................................................... 6 1.2 alignment ..................................................................................... 7 1.3 coordination and reporting office ................................................. 9 1.4 CRO accountability .................................................................... 17

Chapter 2 – Quantitative Outcomes

2.1 investment in HHR ................................................................. 18 2.2 activity tracking ...................................................................... 23

Chapter 3 – Qualitative Outcomes

3.1 quality improvement .................................................................. 25 3.2 capacity building ........................................................................ 33 3.3 tools for QI / CHARTrunner ....................................................... 35 3.4 lessons learned ........................................................................ 37

Appendix A – LHIN improvement priorities Appendix B – Individual LHIN submissions Appendix C – PRT Update (sample 1-06-12) audience… Project Leads Appendix D – BETSI tool and associated inventory

Introduction

Behavioural Supports Ontario (BSO) exists to enhance services for older adults with complex responsive behaviours - associated with dementia, mental health, addictions and other neurological disorders, providing them with the right care, at the right time and in the right place (at home, in long-term care or elsewhere). Through development and implementation of new models designed to focus on quality of care and quality of life for this vulnerable population, a $40 million provincial BSO investment allows local health service providers (HSPs) to hire new staff-nurses, personal support workers and other health care providers, and to train them in the specialized skills necessary to provide quality care to these residents/clients.

Client-centered and caregiver-directed care where…

Everyone is treated with respect and accepted ―as one is‖

Person and caregiver/family/social supports are the driving partners in care decisions

Respect and trust characterize relationships between staff and clients and care providers.

Supporting principles bring these concepts to life for those making daily decisions about care:

Behaviour is communication

Diversity

Collaborative care

Safety

System coordination and integration

Accountability and sustainability



the best way to predict the future is to invent it

BSO makes a bold prediction: by working together we can reinvent the system of care for seniors across Ontario, their families and caregivers who live and cope with responsive behaviours associated with dementia, mental illness, addictions and other neurological conditions. I am confident that the LHINs, working in collaboration with their respective partners in local communities across the Province, have taken ownership and accountability for meaningful change. We‘re seeing early evidence of BSO‘s impact throughout the system. In the Central LHIN Mobile Support Teams have been working collaboratively with existing outreach services to improve and enhance access mechanisms in an effort to build capacity within the current system. In the Central East LHIN, incidents of responsive behaviours, such as aggression, wandering, physical resistance and agitation, have decreased by more than 50 per cent at Streamway Villa where, in addition, restraint use is down to one resident and medication administration is in decline. And, in the Champlain LHIN, 75 Personal Support Worker ―Champions‖ have been recruited in 62 long-term care homes across the region where they work with new outreach nurses to coach other staff and share skills. BSO breaks down barriers, encourages collaborative work, shares knowledge and builds lasting partnerships that have resulted in new ways of thinking, acting and behaving. Wherever I go people approach me to talk about BSO and, while it certainly fills me with a great sense of pride, it allows me to be mindful of what it took – more appropriately who it took, to get to this point. BSO‘s success requires that we acknowledge the thousands of people who are working flat out to make it happen. And let‘s remember, this level of engagement has come voluntarily, driven by the belief there must be a better way. From my vantage point there is no turning back. We have come too far in a short period of time. Our task moving forward, as we spread BSO deeper into communities across the province, will be to ensure we create a system of lasting, sustainable change. I‘ve always believed that what you leave behind is what counts. For those who have been intimately involved in this project your contributions to BSO are an integral part of lasting and meaningful change. This is your legacy. Thank you for your contribution to health system transformation.

Bernie Blais CEO NSM LHIN BSO Project Sponsor



executive summary

BSO continues to create a system of care across the Province and enhance services for a vulnerable population – older adults with complex and responsive behaviours associated with dementia, mental illness and other neurological disorders, and the families, health-care providers and practitioners who support them. In pursuit of this goal, the BSO community made notable gains during the Q1 reporting period.

This report, built around three main sections - Project Overview, Quantitative outcomes and Qualitative outcomes - provides for a broad understanding of BSO‘s current state as of June 30, 2012.

CRO spread information, knowledge and awareness about the project during Q1, drawing more than 1000 participants to presentations at five health sector conferences, targeted meetings and webinars. LHIN-led dialogues and the launch of new BSO services dramatically increased awareness of the project and multiplied the number of people engaged in BSO‘s development. Feedback has been consistent: people are not only interested in BSO, they want to participate as well.

Throughout Q1, CRO and the LHINs continued to support local Health Service Providers in their efforts to recruit the best possible staff for this initiative. As of June 30, 2012, 391.6 new FTEs had been recruited province-wide. In addition, approximately 4000 examples of training in the specialized skills required of behaviour supports were reported, one third of them people trained in the community sector.

Also in Q1, LHINs agreed to standardized definitions of their major BSO investments to better reveal trends and common approaches across LHIN boundaries. A picture of project-wide resource deployment and relative priorities began to emerge. Agreed nomenclature and definitions that apply in all LHINs are a crucial first step toward an accurate tally of BSO services by type and function.

Supporting all aspects of the Project, BSO‘s communities of practice and collaborative work groups have continued to work effectively through Q1. LHINs continue to test and refine processes, and to show creativity and innovation along the way. Proven new tools, care pathways and approaches to clinical integration are emerging in large numbers, and the pace of change is accelerating.

“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 is working.”

– Sarah Wilson, Behavioural Specialist Nurse, Streamway Villa

“It’s been a journey, an opportunity. I’ve learned, observed and experienced what triggers certain behaviours of residents. We have to listen, respect, understand and care. It all comes down to our approach.”

- Justina Gaston, PSW Champion, Villa Marconi (Ottawa)

“It was so encouraging seeing a willingness to disagree… persevere and then arrive at a collaborative solution. When we polled participants at the beginning of the events, few people had ever met one another or worked together yet, by the end all had contributed to an amazing piece of work. The opportunity to co-create serves not only to expedite progress, but also build relationships that will foster ongoing growth.”

- Susan Taylor, HQO

Getting at the Root BSO strives to provide the right care, at the right time and in the right place. For Mrs. S. a frequent visitor to an ER in the HNHB LHIN, the right care was about getting at the situational root cause associated with her physical and mental symptoms including increased agitation, verbal aggression, delirium and malnutrition. At the request of the ER team the BSO team met with Mrs. S. to complete a cognitive assessment and identify her specific care needs. The assessment revealed limited financial resources to meet the most basic of needs. Not only had she not eaten for the previous three weeks, but could no longer afford her rent either. In the six months prior to BSO involvement, Mrs. S. accessed the hospital 12 times i.e., bi-monthly, and had no formal or informal supports at the time of referral. Over a six week period, the BSO team connected Mrs. S. with local food banks; obtained a grocery store gift card to buy what could not be obtained from the food banks; submitted an application to an affordable retirement home that provides meals for less than her current rent; and connected her with the city‘s Trusteeship Program to assist her in managing her finances. With BSO involvement, having been connected with services that care for her situational health – in this case the root cause - in addition to caring for her physical and mental health, Mrs. S. has not accessed the hospital in over a month, and has maintained her quality-of-life and level of independence while on the wait list for a room in a retirement home which is affordable on her income. She is supplied with food through both food banks (which she has accessed twice) and is receiving assistance in managing her debt. “I am so thankful for everything they have done for me. I have never had anyone help me this much before. Once I get back on my feet I am going to donate to the food banks to show my appreciation for all that I have been given.‖

– Mrs. S.



1.1 structure

The North Simcoe Muskoka (NSM) LHIN is accountable to the MOHLTC for leading the Behavioural Supports Ontario (BSO) Project. In partnership with the Alzheimer Society of Ontario (ASO), Alzheimer Knowledge Exchange (AKE), and supported by Health Quality Ontario (HQO), project coordination and reporting is being led by the Coordinating and Reporting Office (CRO), NSM LHIN. CRO is responsible for the implementation and evaluation of the BSO Project, ensuring consultation, liaison and oversight throughout Phase 2 implementation. Committee structure includes...

Coordination and Reporting Office (CRO): this Advisory Committee has oversight on the BSO Project and authority to make project-level decisions.

Provincial Resource Team (PRT): a clinical resource and advisory body for the CRO. Education & Training SubGroup: provides resources for the province and LHINs designed to implementation of BSO Action

Plans; notably, capacity enhancement through learning, knowledge transfer and development programs.

Four LHIN Early Adopter Steering (FLEAS) Committee: a table for problem-solving and joint strategy among the four early adopters to

support successful implementation. *All 14 LHINs participate at alternating meetings on subjects of common interest.

Data, Measurement and Evaluation Committee (DMEC): provides strategic direction to the Impact Assessment (―Evaluation‖) of the

BSO Project‘s implementation phase (August 2011 – December 2012). In addition, the DMEC provides subject matter expertise, strategic

direction and recommendations regarding project evaluation to FLEAS.

Chapter 1

BSO overview



Health Human Resources (HHR) Committee [dissolved end-June 2012]:

facilitated and supported the provincial recruitment process for hundreds of BSO-

funded health human resources. The committee completed its mandate on June

26, passing responsibility for BSO capacity-building and sustainability to a

Capacity Building Community of Practice forum hosted by AKE. Outstanding HHR

issues of a provincial nature will continue to be dealt with through CRO.

Communications and Knowledge Exchange Working Group: provides subject

matter expertise, strategic direction and recommendations to FLEAS and the

CRO on all matters related to communications and knowledge exchange.

Long-Term Care Provider Advisory Council: a monthly forum for

representatives of the Ontario Long-Term Care Association (OLTCA), Ontario

Association of Non-profit Homes and Services for Seniors (OANHSS), Ontario

Long-Term Care Physicians (OLTCP), the Ontario Association of Community

Care Access Centres (OACCAC) and the CRO. Members collaborate with BSO

on matters related to long-term care homes (LTCHs) and CCACs with the goal of

improving support to the BSO population.

1.2 alignment

Focused on providing the right care at the right time and in the right place, BSO aligns with the current direction and priorities of our Provincial Government. The BSO Framework (Page 8) and subsequent service redesign mirror recommendations put forward in recent research and reports, resulting in better care, better health and better value.

Key alignments include…

Ontario’s Action Plan includes the following priorities: keeping Ontario healthy,

faster access, stronger link to family health care and right care - right time - right place.

The Provincial Budget allocates resources to meet the needs of the population living with complex and chronic health conditions (the 1% of the population that currently takes 34% of Ontario‘s health care budget) The target population of BSO is the population identified in the 1% - those living with health challenges, including cognitive, functional and mental illness.

The Drummond Report makes recommendations for those individuals living with complex and chronic health conditions.

The Institute for Healthcare Improvement (IHI) Triple Aim Framework keeps the focus centred on the population‘s care needs while working together to achieve better health, better care, better value for the health system supporting this population.

Letter of Thanks

From: Bernie Blais To: HHR committee

It gives me great pleasure to recognize the significant contributions you have made to the BSO Project as a member of the Health Human Resources Committee. At a time when programs, organizations, agencies and facilities are continually competing for the same finite pool of talent, this Committee, a collaborative cross-section of LHIN and Long-Term Care Home expertise, was given the responsibility to facilitate and support a recruitment process for the hiring of health professionals across the province. Together you broke down barriers, encouraged collaborative work, shared knowledge and built lasting partnerships that have resulted in new ways of thinking, acting and behaving. You are to be commended and congratulated for this accomplishment. I am proud of this project for many reasons. Healthcare is about people and that is how the success of BSO will be measured. You and your colleagues on the Health Human Resources Committee gave your time and knowledge freely to ensure this group of Ontarians, their families and caregivers, can receive the support they deserve. Your work is making a difference in the lives of so many others. I‘ve always believed that what you leave behind is what counts. Your contribution to BSO is an integral part of lasting and meaningful change. This is your legacy. Thank you for your contribution to health system transformation. The best way to predict the future is to invent it! Sincerely, Bernie Blais



Report of the Long-Term Care Task Force on Resident Care and Safety called for enhanced staff training in responsive behaviours

that aligns with the BSO program in Recommendation 8. In addition, BSO directly addresses Recommendations 6 (Develop strong skilled

managers and administrators), 13 (Direct-care staffing in Homes) and 14 (Support residents with specialized needs).

Dr. David Walker and Professor G. Ross Baker’s Reports (2011) recommending system redesign to meet this population‘s needs. Notably, BSO is committed to improving the capacity for older adults to live independently and reduce readmission rates; thereby resulting in a better care experience for older adults and their families.

“Cross-System Responsiveness to Special Needs Populations - The ministry should support creation of special units/programs in the community and LTC homes for seniors with special needs. Targeted investments should focus on adding new human resources specialized in responsive and challenging behaviours in LTC homes, developing and deploying mobile behaviour teams, and expanding services in the community.”

Walker (2011) / Caring for Our Aging Population

The Expert Lead for Ontario’s Seniors Care Strategy, Dr. Samir Sinha, will consult broadly in Q2 on how to support seniors at home and reduce hospital readmissions and pressure on long-term care homes. BSO is a key mechanism to achieve these goals for some of the most vulnerable seniors in the health care system.

To ensure a better use of health care dollars, the service redesign component of the BSO project leverages existing investments to enhance care for the BSO target population. This process supports the objectives of multiple government priorities including…

Ontario‘s Action Plan for Health Care (Matthews)

Enhancing the Continuum of Care (Baker)

Commission on the Reform of Ontario‘s Public Services (Drummond)

Provincial strategies including Seniors, Residents First and Aging at Home

Excellent Care for All Act

BSOs Framework for Care



1.3 coordination and reporting office

project-level activities and accomplishments (milestones)

April 2 BSO presentation at annual OLTCA conference.

April 10 CRO adds a full-time Strategic Communications Specialist with responsibility to implement the provincial communication plan for province-wide audiences, and to assist 14 LHINs with their responsibility for local key messages to local audiences.

April 18 BSO briefing for the Ministry‘s Chief Nursing Officer and ADMs of Negotiations and Accountability Management, Health System Accountability and Performance, Health System Strategy and Policy, and Health Human Resources Strategy.

April 24 BSO presentation to CCAC CEOs. CEOs nominated Cathy Hecimovich (CW CCAC) to represent them at future BSO discussions.

April 26 BSO presentation at annual Ontario Geriatric Association conference.

May 8 BSO presentation at annual OANHSS conference.

May 24 BSO poster at Ontario Home Care Association annual conference.

May 29 Coordinated LHIN news releases announcing local BSO achievements and next steps. Seven local news stories were generated.

May 30 Launch of NSM LHIN‘s internet ―Healthline,‖ including a BSO microsite compiling behavioural resources and access points for people living in NSM LHIN. Follow the link: http://www.behaviourchange.ca/

May 31 BSO presentation (Bernie Blais, NSM LHIN, and Lisa Van Bussel, St. Joseph‘s Health Centre London) at annual South West LHIN Quality Symposium.

June 6-7 HQO provided in-person training for BSO Improvement Facilitators.

June 19 BSO presentation and panel discussion (Matt Snyder, CRO, David Harvey, ASO, Cathy Hecimovich, CW CCAC) at the annual OACCAC conference.

June 22 All-LHINs webinar to introduce the BETSI inventory and diagnostic tool.

A Web of Information

In early January a small working group of dedicated North Simcoe Muskoka providers came together with the goal of assisting families, caregivers and health service providers, access information that would help them recognize significant changes in behaviour. These behaviour changes could be the result of many factors including illness, health conditions, aging, life situations or events. In some cases, individuals may develop a variety of dementias or other neurological conditions that damage parts of the brain. NSM is proud of their new Behavioural Support System (BSS) webpage www.behaviourchange.ca, a tool that will provide North Simcoe Muskoka residents with information and resources to help better recognize, assess and understand the cause of these behavioural changes, the steps that might be taken next and what supports and services are available in the community – and beyond. www.behaviourchange.ca is a go-to website to learn not only about some behaviours that cause concern for many but also tried and true management techniques and interventions easily applied in a variety of settings. Self-assessment tools are included with resources directly linked to assist residents in becoming familiar with a list of knowledgeable services and supports.

http://www.behaviourchange.ca/

http://www.akeresourcecentre.org/files/BSOResources/Toronto%20Central.pdf




new project supports

Coordinated processing for 12/13 HSP allocations: CRO, 14 LHINs and three Branches of the MOHLTC coordinated review, approval and flow of LHIN funding for BSO to health service providers ahead of funding cut-off dates in April. The Ministry agreed future APTS requests will be checked against the summary spreadsheets they received in April unless the LHIN submits a new spreadsheet that surpasses the old.

Education & Training Subgroup (PRT): PRT convened members of its expert network to develop the BETSI tool, an education & training framework that complements the BSO Roadmap for staff development. The Subgroup is a cross-sectoral team of thought leaders and practitioners who met several times in Q1, and will reconvene in September to explore additional needs related to education and training.

Activity Tracking: CRO worked with HQO, PRT, Hay Group and the 14 LHINs to identify which BSO initiatives occur in multiple LHINs, and begin to measure them against the same yardsticks. Agreed nomenclature and definitions that apply in all LHINs are a crucial first step toward an accurate tally of BSO services by type and function. In future, reliable province-wide counts of BSO initiatives can also be the basis for impact assessment, cost comparison and projections of return on investment.

CHARTrunner software access for 14 LHINs: CRO sponsored 2-year licenses that allow access to Improvement Facilitators and designated people in all LHINs. HQO provided training for the use and application of the software, which allows planners to generate graphing and run charts using data from their own local change projects.

BETSI education inventory and diagnostic tool: The Education & Training Subgroup of PRT completed the Behavioural Education & Training Supports Inventory (BETSI) for release at a webinar June 22.

BSO collaboration with Residents First: The ―Behaviours‖ change package of Residents First and BSO target the same objectives in many of the same LTC homes. To enhance integration between the two, HQO recruited Mississauga Halton, Central West and North Simcoe Muskoka LHINs to pilot a BSO case study (knitting a home together with the local BSO mobile team) as part of the training component for Residents First planned in August 2012.

BSO spread in community: CCACs were key players locally during Action Plan development in Fall 2011, and early successes from this effort are emerging in the field. CRO highlighted these approaches in a memo to all LHINs and will facilitate new pilots for their spread to additional LHINs. A wide range of opportunities to engage the community sector in BSO remain available in all LHINs.

BETSI BETSI includes a complete list of responsive behaviours training, plus a decision tree, to guide organizations to the most appropriate mix of learning and development options. Coupled with the Capacity Building Roadmap developed in January, and the Person-Centred Team-Based Service Learning Framework developed in March, BETSI completes the picture of learning and development needs in any organization. High quality tool/resources that

supports long-term sustainable change.

Enables LHINs to focus capacity building investments on local needs; maximize their ROI.

Demonstrate money well spent and appropriately spent on capacity building investments that are sustainable and adaptable to other projects/initiatives.

Supports a system that treats people

with dignity and respect, in an environment that is based on quality evidence-based, patient-centered care and practice and, most importantly, supports safety for all.



When a “Walk” is not a “Wander”

In the Central LHIN, Behavioural Support Services – Mobile Support Teams (BSS-MSTs) have been working collaboratively

with existing outreach services to improve and enhance existing access mechanisms in an effort to build capacity within the

current system.

Since launching the community component of the BSS-MSTs across Central LHIN in early June, eight clients living in the

community have received support including ―Bob‖, a gentleman in his 70s diagnosed with moderate Alzheimer‘s. Due to

concerns about wandering behaviour and in an effort to alleviate the considerable angst of both his wife and family, Bob was

referred to a BSS-MST by the Geriatric Outreach Team.

Bob regularly leaves the family home early in the morning before anyone else is awake and returns late in the afternoon. The

angst felt by his family is out of genuine concern for his safety; where does he go, is he lost, hurt, in danger or worse? And,

while they have tried to discourage his behaviour, he simply refuses to comply.

Central LHIN‘s BSS-MST arranged for a PSW to join Bob on a few of his excursions. It was discovered that his wandering

ways were anything but. He has a regular routine, is well known by many individuals in the community - in particular at all the

places he frequents during his time away from home and clearly demonstrates that he has a full grasp of place and time while

out and about.

Bob likes to go for walks… he does not wander; at least not according to the clinical definition.

The PSW was able to reassure the family that at this time, Bob poses little risk to himself or others, and documented his

routine so the family has a record of his regular movements in case he failed to return one day. For his part, Bob agreed to

register with York Regional Police Vulnerable Person Registry and to wear an identification bracelet provided by Safely

Home. A referral was made to the Alzheimer Society of York Region to support caregiver and family and look at other

resources that might be helpful for client and loved ones.

With BSS-MST involvement, Bob‘s safety was enhanced and perhaps as importantly, the angst felt by his family was significantly reduced. For now, a walk is not a wander…. It‘s just a walk; a walk that Bob enjoys every day.



individual LHIN action plans (links)

Final, CEO-signed Action Plans have been submitted by all LHINs to CRO. All 14

Plans are available in the BSO Collaboration Space and on LHIN websites.

Central

Central East

Central West

Champlain

Erie St. Clair

Hamilton Niagara Haldimand Brant

Mississauga Halton

North East

North Simcoe Muskoka

North West

South East Part A | Part B

South West Part A | Part B

Toronto Central

Waterloo Wellington

provincial resource team (PRT)

During Q1, the PRT was responsible for surfacing promising practices, identifying and addressing broad challenges and connecting LHINs to timely and relevant information so as to inform local implementation. To meet this mandate the PRT implemented a new integrated process during this quarter.

Surfacing Promising Practices

Process… During Q1 the PRT aimed to surface local promising practices so that other LHINs could learn from and build on the success of others. To enable this, each LHIN was invited to join a PRT meeting for 30 minutes. During this time LHIN leads presented to PRT members 1-2 promising practices that were emerging in their area. PRT members were able to respond to these practices, suggest additional considerations and recommend new partnerships to explore.

Examples… Promising practices spanned all three pillars of the BSO Framework for Care. Some examples include:

Exploring new partnerships with academic institutions, emergency service

providers or the primary care sector to identify synergies and areas for

collaboration (system coordination & management)

Embedding therapeutic recreation roles in mobile teams (interdisciplinary

service delivery)

Developing capacity building self assessments for new hires (capacity building).

Warming Up to BSO at Frost Manner

Responsive behaviours are quickly disappearing at Frost Manor, thanks largely to staff members using their supportive measures training and Behavioural Supports in Ontario (BSO) protocols. Administrator Connie Daly says a heightened sense of awareness amongst staff members about the need to mitigate responsive behaviours by using the available tools has made a big difference. The term ―supportive measures‖ refers to an OMNI Health Care program and corporate value that‘s aimed at developing an individualized approach to care to help residents live to their full potential. This program has been successful at addressing responsive behaviours for many years. ―As soon as there is a behaviour, we act,‖ Daly tells the OMNIway during a recent visit to Frost Manor. ―We have a quality-improvement team and their biggest focus has been responsive behaviours. I did supportive measures training in February, and we reviewed the program, and we‘ve been working with the doctor, and the quality-improvement team has been great — everybody‘s on board.‖ When a responsive behaviour does occur, staff members can also turn to BSO protocols. For example, one protocol is checking a resident‘s urine to make sure there isn‘t a urinary tract infection that‘s causing agitation. The home‘s medical adviser is also called upon to check a person‘s medication, Daly adds. Frost Manor is also working with the Whitby-based Ontario Shores Centre for Mental Health Sciences, which is providing consultations as necessary, the administrator notes. Another BSO recommendation Frost Manor is using is a whiteboard listing people who are exhibiting behaviours, so staff members can chart the behaviours and post the recommended interventions. “So, when a (responsive behaviour) happens, (staff knows) to do this, or to do that, or don’t give them their bath if there has been a challenge on a bath day,” Daly says, adding the team is “on it right away” to prevent responsive behaviours.

http://www.akeresourcecentre.org/files/BSOResources/Central%20Final_Dec.16.2011.pdf

http://www.akeresourcecentre.org/files/BSOResources/SE%20Part%20A.pdf

http://www.akeresourcecentre.org/files/BSOResources/BSO%20capacity%20building%20roadmap.pdf

http://www.akeresourcecentre.org/files/BSOResources/Champlain.pdf


http://www.akeresourcecentre.org/files/BSOResources/HNHB%20BSO%20Report%20Final.pdf

http://www.akeresourcecentre.org/files/BSOResources/Central_East_LHIN_BSO_Executive_Summary.pdf

http://www.akeresourcecentre.org/files/BSOResources/Central%20West.pdf

http://www.akeresourcecentre.org/files/BSOResources/NSM%20Action%20Plan%20Final.pdf

http://www.akeresourcecentre.org/files/BSOResources/Mississauga%20Halton.pdf

http://www.akeresourcecentre.org/files/BSOResources/WW.pdf

http://www.akeresourcecentre.org/files/BSOResources/SE%20Part%20B.pdf

http://www.akeresourcecentre.org/files/BSOResources/Erie%20St.%20Clair.pdf

http://www.akeresourcecentre.org/files/BSOResources/SW%20Part%20B.pdf

http://www.akeresourcecentre.org/files/BSOResources/North%20West.pdf

http://www.akeresourcecentre.org/files/BSOResources/North%20East.pdf



Addressing Challenges

Process… During each LHIN update to PRT, Leads were encouraged to bring forward any emerging issues that PRT may be able to assist with. PRT members responded to these issues by taking into consideration the local contextual elements and suggesting resources, processes or new partnerships for consideration. Throughout this process, PRT recognized that some challenges were being identified by multiple LHINs and / or were large enough issues to require further provincial action. In these cases, PRT facilitated subsequent action, exchange and response to address these challenges from a broader perspective.

Examples… Privacy & Confidentiality - One LHIN identified that as they were planning to integrate services across organizations and sectors; some partners had raised concerns about privacy and confidentiality of information. These concerns had in fact brought implementation to a halt. Recognizing that many LHINs were implementing similar models of cross-organizational service delivery, PRT facilitated a subsequent dialogue on the topic. Improvement Facilitators from all LHINs were invited to help identify the broad issues at the root of these concerns. Through this exchange the group…

Identified that, though many LHINs encountered these same concerns regarding

privacy and confidentiality, implementation had not been held up in any other

LHIN

Recognized that these issues could arise in the future as implementation

continues and agreed to reconvene if needed

Shared strategies used in their own area to address these issues.

In follow up, the original LHIN contact applied strategies shared during this exchange and later confirmed that the issues have now been resolved.

Connecting LHINs to Timely and Relevant Information

To build on the principal of knowledge exchange, which is embedded throughout all levels of the BSO project, the PRT has implemented a second new process this quarter: The PRT Update. During LHIN updates (detailed earlier) there was a lot of information being shared at the provincial PRT table, but no process yet established to mobilize the flow of this information back out. After each PRT meeting, the group now disseminates a 1-page ―Update‖ that is emailed to all LHIN Leads. The purpose of these updates is to connect LHINs with practical, timely and relevant information to inform implementation. Where other knowledge dissemination processes in the project focus on broad project messaging, this focuses more precisely on considerations to immediately improve system coordination, service delivery and capacity building at the local level. Each PRT Update includes…

A highlight of 2-3 promising practices or provincially relevant areas of discussion

―Tips & Tricks‖ from PRT (e.g. practical strategies to consider during

implementation)

Links to resources shared during PRT meetings.

The PRT is happy to provide an example of a complete PRT update as Appendix C. .

Making Sense of it All The Toronto Central LHIN BSO strategy is situated within a complex health system environment with many different agencies involved in the delivery of services as well as 37 LTC homes. As such comprehensive stakeholder engagement, involvement and relationship building has been a critical success factor bringing about sustainable systemic change. And it starts with effective leadership. Since assuming the BSO lead role in January 2012, Baycrest has facilitated training opportunities for close to 250 LTC staff. Full day workshops have included U First , Gentle Persuasion, and Non Violent Crisis Intervention training as well three day workshops in Montessori training offered in collaboration with the Baycrest Centre for Learning, Research and Innovation in LTC. Developing the role and function of the new LTC outreach team has been a collaborative effort with representatives of LTCHs, GHMOTs, CASS, COPA, PRCs, NLOTs, T-BSU, LTC-BSOT, Baycrest, Health Quality Ontario, and the TC LHIN. These stakeholders came together for a common purpose – to optimize coordination and integration of available resources to best meet client need. This approach will and has had a positive impact/benefit on the client, families, caregivers, LTCH and system resources. As a result of taking the time to gather input from all stakeholders, processes have been streamlined, roles clarified and services aligned to system gaps.

The time and effort put into this approach – into making sense of a complex landscape – has enabled alignment of resources and will help drive long-term success and

sustainability.



knowledge exchange

With the transition of the BSO project from planning to implementation, the Alzheimer Knowledge Exchange (AKE) created an in-depth plan to support knowledge exchange within the BSO project in order to: Facilitate the change process that accompanies implementation

Surface, build upon and spread promising practices and innovations

Lay the groundwork for sustainability beyond December 2012.

The plan includes five key objectives including…

Support existing and newly hired health service providers to develop core competencies and to refine and apply practice models emerging from the BSO project by:

Assessing the learning and support needs of service providers and developing recommendations and a plan for meeting these needs that

draws on available resources (e.g. AKE, CRO, PRT, HQO)

Implementing activities to support health service providers core competency development (e.g. Knowledge Dissemination sessions,

access to resources, development of Communities of Practice (CoPs), creation of task groups to address specific needs).

Build the capacity of families to effectively participate in the care of persons experiencing responsive behaviours by:

Facilitating conversations with families, LTCHs, community service provider organizations and other stakeholders to better understand

how family involvement in care for persons with responsive behaviours can be enhanced

With the Alzheimer Society, CMHA, COPA, Parkinson Society, Family Councils and other partners implementing activities to support

effective family involvement in care (e.g. skill development, access to resources, enhancing service provider understanding of the

importance of family involvement, creation and dissemination of tools that facilitate the participation of families in care planning and

provision).

Identify and disseminate best practice concepts, tools and resources by:

Working with the CRO, PRT and HQO to identify best practices in behavioural support with promise for improving practice

Identifying a collection of resources related to behaviours and behavioural supports and making them accessible on the BSOProject.ca

and AKE Resource Centre

Hosting Knowledge Dissemination sessions for a more in-depth look at key best practices.

Provide Knowledge Transfer and Exchange (KTE) support to BSO Collaboratives by:

Providing Knowledge Broker support and access to technology to facilitate the work of BSO Collaboratives

Assessing the need for CoP(s) to support emerging priority topic areas across the BSO project

Integrating the existing AKE Primary Care CoP with the BSO primary care work as needed.

Develop KTE capacity within local service networks by:

Identifying local leads/ teams to act as network and clinical or field-based KTE champions to further develop KTE within their regions

Bringing together KTE champions to develop skills in KTE, share local KTE successes and identify and problem-solve local KTE

challenges.



To support implementation of this plan the AKE worked with CRO to establish a Communications and Knowledge Exchange sub-committee with representation from various LHINs and provider organizations. The Communications and Knowledge Exchange plans were integrated through this committee and steps for executing this plan with assistance of the committee have begun.

alzheimer knowledge exchange Q1 milestones Worked with CRO to develop and implement a survey for LHINs and other provincial stakeholders to share information about

current capacity building activity and needed supports from BSO provincially:

54 stakeholders across all 14 LHINs completed this needs assessment with primary representation from the LHIN level

Respondents identified a variety of needs including the requirement for provincial support, a want for knowledge exchange

events (webinars, workshops), enhanced awareness of and access to resources to support individual learning, self-directed

learning through online learning and exchange and online exchange opportunities for new staff to connect with each other

Used the results from this survey to plan for provincial support including:

Development of a BSO Capacity Building Community of Practice to foster ongoing knowledge exchange related to local

capacity building activity

Creation of an updated Capacity Building Roadmap to support capacity building planning beyond 6 months on the job

Gathered and shared locally developed HHR self-assessment tools with other LHINs to build on existing resources

Worked with CRO to identify three priority areas and begin planning for Knowledge Dissemination sessions:

Behavioural Education and Training Supports inventory (BETSI) Tool

Community Spread

Interim BSO Evaluation Results

Created and distributed the BSO E news to disseminate knowledge and resources among internal BSO stakeholders

Highlighted BSO updates in the AKE newsletter with a distribution of more than 3000

Prepared and submitted abstracts for various conferences and assisted with planning and preparation of presentations for OLTCA, OAHNSS and OHCA conferences

Collected and shared resources and tools on the BSO collaboration space and public BSO website

Managed the BSO Collaboration space including:

Planning for and beginning re-design of the Collaboration Space for easier navigation and use by members (including the

purchase of a new Subscription service that provides email notifications of updates to pages of the site that users have

subscribed to)

Hosting a Knowledge Dissemination session for internal BSO stakeholders to demonstrate use of the Collaboration Space

This session was recorded and has been archived as a resource for current and new users of the space

Managed the public BSO website to support dissemination of knowledge and resources related to BSO to the public

Worked with CRO and BSO Collaborative leads to understand and plan support for the knowledge exchange needs of each

group, dedicating a total of three days per week Knowledge Broker support to BSO Collaboratives

Planned for integration of the Mobile Response Teams, Centralized Intake and Behavioural Support Unit Collaboratives which

have many common themes and goals by assigning a single Knowledge Broker to work with these groups and ensure cross-

pollination between groups.

Planned and hosted a Knowledge Dissemination session with the Ontario Long Term Care Physicians (OLTCP) about the impact

of BSO for Physicians in Long Term Care.



“It Works… It Really Works!” Incidents of responsive behaviours, such as aggression, wandering, physical resistance and agitation, have decreased more than 50 per cent at Streamway Villa in the past month, restraint use is down to one resident and medication administration is declining. These successes have been largely made possible by the Cobourg long-term care home‘s participation in the Behavioural Supports in Ontario (BSO) project. Through the BSO project, Streamway Villa has hired registered practical nurse/behavioural specialist nurse Sarah Wilson and provided her and personal support worker Shannon LeBlanc with training to offer supports to residents prone to responsive behaviours. These residents generally have conditions related to addiction, brain injury and Alzheimer‘s disease or related dementia. The BSO project also has enabled staff members to attend educational sessions aimed at reducing responsive behaviours, thanks to funding from the Central East Local Health Integration Network (LHIN). This includes PIECES (physical, intellectual, emotional, capabilities, environment and social), Montessori and U-First training. Wilson and LeBlanc have implemented best practices, such as the intervention analysis tool, where staff members write down the supportive measures they trial prior to giving a resident medication. They then chart the results. This tool has also contributed to the successes. ―We‘re taking a more holistic approach at managing responsive behaviours, rather than resorting to medications,‖ says Wilson. ―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 is working.‖ Money received from the funding has also gone towards building what Wilson and LeBlanc call a ―BSO cupboard,‖ a wooden cabinet stocked with sensory objects that preoccupy residents and minimize responsive behaviours. These objects include everything from dolls to magazines individually suited for residents. For example, there is one resident who was an avid fisherman, so there are fishing magazines in the cabinet for him to read. ―We are trying to get it across that this is working,‖ says Wilson.

“Prior to having a responsive behaviour we give him a magazine that he enjoys reading, and it’s amazing, you don’t have the behaviour anymore,” says Wilson. Wilson and LeBlanc are also 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.



BSO impact assessment (BSO evaluation)

During the first quarter of 2012/13, one focus of the BSO DMEC has been reviewing the Phase 1 deliverable report provided at the end of March. The DMEC has examined the baseline measurement results and provided advice to the HayGroup to support refinement of measurement approaches and evaluation indicators for the final evaluation report. The DMEC has recommended that some indicators in the evaluation indicator matrix be modified or eliminated, but has also identified new indicators that better reflect the actual BSO initiatives being implemented in the EA LHINs.

The Hay Group consultants have been consulting with the EA LHINs re their BSO initiatives and their internal measures of BSO impact. The goal is to ensure that the qualitative indicator data collection is not overly burdensome, and that the evaluation indicators are aligned with the EA LHIN internal measures where appropriate. Improvement Facilitators leading the quality improvement effort in EA LHINs were invited to present their work to the DMEC and the consultants are incorporating their QI indicators in the evaluation indicator matrix where appropriate.

The DMEC has consulted with experts in qualitative assessment to investigate opportunities to expand the qualitative data collection to incorporate ―lived experience‖ of the providers and clients in the EA LHINs, and focused data collection (i.e. interviews and focus groups) will be used to add this dimension.

The DMEC has recommended that the MOHLTC incorporate the algorithm developed to identify the BSO target population in ED (NACRS) and acute inpatient (DAD) data. In the second quarter of 2012/13 MOHLTC IntelliHealth analysts will replicate the Hay Group analysis and test the feasibility of incorporating a ―BSO client filter‖ in IntelliHealth. This would greatly simplify the ability of IntelliHealth users to measure and monitor the impacts of BSO initiatives on the target population in acute care hospitals.

The DMEC has reviewed and refined its terms of reference and membership to ensure that they can provide informed advice to the consultants. The DMEC has also discussed the potential legacy of the BSO evaluation project, and is considering approaches to ensuring that the measurement tools and assessment of BSO initiative impacts will be available to the field after the formal conclusion in December 2012 of the evaluation project.

1.4 CRO accountability

CRO spread information, knowledge and awareness about the project during Q1, drawing more than 1000 participants to presentations at five health sector conferences, targeted meetings and webinars. LHIN-led dialogues and the launch of new BSO services dramatically increased awareness of the project and multiplied the number of people engaged in BSO‘s development. Feedback has been consistent: people are not only interested in BSO, they want to participate as well.

MOHLTC instructions to CRO Complete Continuing

Role

Implement the BSO committee structure and provide secretariat support

Develop and ratify a Memorandum of Understanding among 14 LHINs and CRO

Support development of a local Action Plan in each LHIN

Convene October and December 2011 knowledge transfer events

Receive LHIN Action Plans and report to the Ministry after confirming (1) the template is completed in full and that (2) the Provincial Resource Team has determined that the Action Plan is consistent with the BSO Framework

Coordinate multiple project partnerships (HQO, AKE, PRT, etc)

Select common core metrics during Action Plan development with Early Adopter LHINs

Deploy BSO resources to support Action Plan implementation in each LHIN

Provide guidance to LHINs to ensure consistent application of the BSO Framework

Monitor and report on the development of new care pathways and clinical tools

Coordinate transfer of knowledge and lessons learned from Early Adopter to Next 10 LHINs

Quarterly and ad hoc reporting to the Ministry as described in Schedule ―D‖ of the CRO funding letter

Coordinate the BSO impact assessment

Make available to all LHINs the qualitative information on key barriers, enablers and lessons learned throughout the successive stages of BSO implementation

Table 1.4.1 – CRO Accountability



Both Qualitative and Quantitative outcomes are important to BSO for distinct reasons. Quantitative outcomes, such as those provided in Section 2 of this report, provide statistical and/or numerical understanding of where the project is positioned against a variety of its targets/deliverables i.e., patient impacts, HHR recruitment and the training of both new and existing staff. The information that follows paints a numerical picture of BSO.

2.1 investment in HHR

The MOHLTCs $40.37M Provincial BSO investment has focused on the hiring, by local Health Service Providers (primarily long-term care homes), of new staff – Nurses, Personal Support Workers and other health professionals, and the training of both new and existing staff in the specialized skills necessary to provide quality care to Ontarians with complex behaviours. Each LHIN‘s Action Plan outlined a local implementation approach to deploy a range of specialized behavioural supports across the care continuum. There were three general approaches that emerged: Lead/host LTC Home Model for Mobile Outreach Teams Allocation at the individual LTC Home level Specialized Behavioural Support Units

While approaches vary depending on geography and existing resources, the overall objectives are the same - maximize services for persons with challenging and complex behaviours associated with dementia, mental illness and other neurological disorders. These approaches were detailed in the last quarterly report submitted to the ministry April 30, 2011- (see Behavioural Supports Ontario Q4-Quarterly Report January 1,2012 – March 31,2012. Section 2.3 HHR Investment pp 20 – 29)

Chapter 2

quantitative



HHR hires During Q1, LHINs continued to support local Health Service Providers to ensure the best possible BSO staff are recruited for this initiative.

As of June 30, 2012, a total of 391.6 FTEs had been recruited province-wide, an increase of 129.3 over the total 262.3 FTEs reported at fiscal 2011/12 year-end. This represents a 33% increase from March 31 to June 30, bringing the project to 67% of its province-wide recruiting target.

Detailed information about FTE commitments and new hires in each LHIN is recorded in Table 2.1.1. Note that a small reduction in LHIN targets has been recorded, with the total projected FTE count now estimated at 581.9 (down from 592.17 in the previous quarterly report). This adjustment reflects the market salaries of the selected Health Service Providers in the various geographic LHIN areas of the province.

recruitment delays and mitigation Recruitment Delays

Despite best efforts, many LHINs experienced delays hiring their targeted HHR. CRO followed up with LHIN Project Leads to uncover specific causes, organized as follows under four main reasons…

Shortage of Resources

Recruitment challenges for nursing in some parts of the province

especially Northern and rural areas

Challenges with hiring part-time contract positions for both nursing

and PSWs.

Delayed agreements

LHIN-HSP negotiations were slowed in winter 2012 by disagreement over the

funding available for non-wage costs. Almost all agreements were concluded

early this spring, largely by adding funds from non-BSO sources to the BSO

allocation. Those HSPs are recruiting now

Union issues have delayed agreements with 2 LTCHs.

Staged Recruitment

Recruitment in most LHINs is staged; a manager or coordinator is hired first

at an HSP, who then leads recruitment of the others. This approach is

especially common for new service teams and in ―host‖ or ―lead‖ homes

where an Action Plan concentrates local resources.

Change or Delays with Service Provider

Several LHINs were unable to reach agreement with a HSP they intended to

fund. Restarting negotiations with another HSP introduced several months of

delay for positions that had been earmarked for those employers.

All LHINs are reporting that they will meet the ministry expectation of hiring their allotted FTEs by December 31, 2012.

We are the Champions With funding from the Behavioural Supports Ontario project, the Champlain LHIN has created the unique new role of ―Personal Support Worker Champion‖ in all 62 long-term care homes across the region. In total, 75 Champions have gone through a training program designed to enhance and augment their skills in meeting the needs of residents with complex and challenging behaviours. The Champions work with 13 new behavioural support outreach nurses and coach other staff in their long-term care homes to build more capacity and share skills. “It’s been a journey, an opportunity,” says Justina Gaston of her new role as a PSW Champion at Villa Marconi in Ottawa. “I’ve learned, observed and experienced what triggers - certain behaviours of residents. We have to listen, respect, understand and care. It all comes down to our approach.” Since receiving training this past March, Justina has become less task-oriented and as a result, the team is now focused on implementing a variety of client-centred, comprehensive approaches to individual care. Thanks to enablers such as weekly, Monday morning in-home committee meetings that allow the team collectively to share knowledge and information, Villa Marconi has already enjoyed a number of success stories to date. While BSO is transforming care across Ontario, PSW Champions are transforming the cultures of long-term care homes across the Champlain region, enabling organizations and staff to think differently about how to manage complex and challenging behaviours.



Mitigation

As of June 30, 2012, three LHINs had recruited fewer than 50% of their HHR target. CRO is working with each to support the LHIN‘s local mitigation strategy. All three intend to recruit the largest portion of new health human resources in Q2, with all hiring complete before the Ministry‘s deadline of December 31, 2012.

North West: The NW LHIN Regional Behavioural Health Service lead agency completed recruitment and training in June for the key Regional Coordinator role, clearing the way in Q2 for large-scale recruitment of mobile resources, the first client contacts for the new System Navigator role, implementation of a LHIN-wide training strategy, and planned quality improvement activities. Recruitment for the staffing for the Specialized Behavioural Support Unit will move forward recognizing that Ministry approval to designate the facility under the LTCHA has not yet been confirmed. That resource will be used to support education and training of individuals working with behavioural clients in multiple settings. A local LTC Home closure will introduce additional pressure on the BSO effort in NW LHIN. CRO and NW LHIN will work closely to mitigate any risks identified through the implementation process.

Erie St. Clair: Recruitment delays arose when the LHIN was unable to reach agreement with a Health Service Provider named in the local Action Plan, and union issues delayed agreements with two more. In the first case ESC negotiated an agreement with another LTC home in the region, Copper Terrace, and recruitment is about to begin. Positions there will be advertised internally with new staff expected on the job in late-September. To mitigate the second issue ESC adjusted the implementation model and the deployment of BSO FTEs to adopt a form of the ―hub and spoke‖ model seen elsewhere in the BSO project. Two lead homes, Aspen Lake (City of Windsor) and Richmond Terrace (County of Essex), worked with their unions to address contentious issues and raise staff awareness of BSO, encouraging acceptance of the BSO project not just in those two homes but across the LHIN. Internal recruitment will occur in lead homes this summer to hire in September, and 16 other homes will hire the remaining PSW & Nursing FTEs by early Fall.

South West: The approved local Action Plan describes a unique operational approach to mobile teams capacity in the LHIN that will (1) support truly interdisciplinary care for people with responsive behaviours, (2) permanently and progressively enhance staff capacity in organizations throughout the LHIN and (3) provide effective coverage across the LHIN‘s large geography. In August 2012 an expression of interest (EOI) process will be administered by St. Joseph‘s Health Care London to purchase the services of local Long Term Care Home RN and PSW staff to work on the hospital‘s mobile team for a one- to two-year period. Recruitment in those homes selected through the EOI is planned for September, with mobile teams operational in Q3. CRO and SW LHIN will work closely to mitigate any risks identified through the implementation process.

recruitment strategies and tools

In the Q4 Report, a number of strategies and tools were outlined by the HHR Committee to assist LHINs with their recruitment efforts. This included the following: Development of 12 Core Competencies Standardized Job Descriptions and Job Postings Standardized competency based interview questions Review and sharing of Memoranda of Understanding between the LHIN and HSPs and between agencies Targeted online advertising to support recruitment In January, the Alzheimer‘s Knowledge Exchange (AKE) in collaboration with the HHR Committee developed a Capacity Building Roadmap for health service providers to use primarily with the new BSO staff. The purpose was to provide a framework for service providers to organize their approach to training new staff as they built their knowledgeable care teams. It aligned training activities in the first 6 months with the 12 Core Competencies.

Based on the feedback and effectiveness of the tool, the Capacity Building Roadmap Part 2 is being developed in order to continue the framework for the time period post 6 months for new BSO staff. The anticipated completion date for developing this sequel to the Roadmap is end of September. (See Capacity-Building 3.2) The HHR Committee has now disbanded having completed its mandate of facilitating and supporting the recruitment process for the hiring of health professionals across the Province. A number of key members have transitioned to other Committees responsible for capacity building such as the Capacity-Building Community of Practice led by AKE and the Education & Training Subgroup of PRT. Bernie Blais, Project Sponsor, sent recognition letters to members acknowledging their significant contributions to the BSO initiative.



Behavioural Supports Ontario - Update on FTE Hires and Numbers Trained Updated: June 30, 2012

Action Plan

Hired as of Number of

Staff Trained in any LTC

Home (April - June)

Number of

People Trained in Community

(Nurse, PSW or allied health, April - June)

FTE Commitments

June 30, 1012

LHIN

Nurse FTEs (LTC only)

PSW FTEs (LTC only)

Add'l FTE

Total FTE Commitment

Nurse FTEs (LTC only)

PSW FTEs (LTC only)

Add'l FTE Total

Erie St. Clair

12.0 18.0 9.0 39.0

0.0 0.0 8.0 8.0

220

South West 15.0 18.0 10.3 43.3 0.0 0.0 5.5 5.5 133 88

Waterloo Wellington 12.4 14.4 7.9 34.7

11.6 12.6 6.0 30.2

7

31

* Hamilton Niagara Haldimand Brant 19.0 22.0 15.0 56.0

19.0 22.0 15.0 56.0

174

574

Central West 10.0 10.5 6.0 26.5 7.0 7.0 5.0 19.0 250 292

Mississauga Halton 13.5 22.0 10.0 45.5

11.5 20.5 10.0 42.0

91

10

Toronto Central 12.9 18.7 11.5 43.1

10.4 5.2 9.5 25.1

101

3

Central 20.0 22.1 15.0 57.1 14.8 9.6 14.8 39.2 13 24

Central East 20.2 22.5 14.0 56.7

20.2 22.5 4.0 46.7

South East 11.1 17.1 6.6 34.8

12.0 18.0 .5 30.5

168

64

Champlain 16.8 20.2 10.4 47.4 12.2 16.2 7.5 35.9 75 6

** North Simcoe Muskoka 10.0 13.0 10.2 33.2

6.0 6.0 9.2 21.2

556

5

North East 13.0 20.0 10.0 43.0

10.0 12.0 7.3 29.3

830

303

North West 5.9 9.0 6.7 21.6 0.0 0.0 3.0 3.00 0 1

TOTALS

191.8 247.5 142.6 581.9

134.7 151.6 105.3 391.6

2618

1401

Note: Shading denotes Early Adopter

Table 2.1.1 – FTE Hires and Numbers Trained

* Note: all positions staffed in HNHB as of March 30th, 2012. Turnover and attrition may occur in any one position after this date and will not be reflected here.

** Future NSM reporting will show all positions staffed as of July 26, 2012. Turnover and attrition may occur in any one position and will not be reflected here.

CRO continues to track the metrics related to numbers hired through the Eclipse tracking tool and is now collecting the data on a quarterly basis



BSO Commands Attention The idea of command and control is what keeps soldiers alive and is ingrained in a soldiers psyche from day one. If it sounds intense, it is. That is why, with dementia having established a beachhead in Granville‘s life, it should be of no surprise th is former soldier has reverted to an often unfiltered and uncontained version of his former self. It is largely who he is. With his family unable to cope with increasingly complex needs, Granville was fortunate to have found a long-term care facility in Brampton (Central West LHIN) better able to take care of him but, not without initial difficulty as his behaviours were both physically and verbally aggressive. Working with limited time frames and scopes of expertise, staff had difficulty understanding how to manage his behaviour. Thanks to Marcia Sterling, Practice Leader for the BSO Project, whose only job it is to help people like Granville and the staff that supports him, all that has since changed. By drawing on the expertise of Extendicare‘s Psychogeriatric Resource Consultant (PRC), another newly created role under the BSO project, Marcia was able to identify triggers to Granville‘s‘ assertive behaviour, giving her a better understanding of his needs and knowledge; education she has since passed on to staff who care for Granville, and the result of which is a collaborative approach to better care. Granville is now more relaxed, doesn‘t yell out orders, engages in light and interesting conversation and even eats his meals without incident. Notably, his family visits have taken a turn for the better. ―He‘s less agitated and more enjoyable to visit because he‘s more comfortable in his environment,‖ says Steven his son. ―I‘m glad to finally see the system is paying attention to the elderly, especially people with dementia. My father has always been an independent person and this is very confusing for him.‖ Granville has a long fight ahead of him but, with BSO in the thick of it, he now commands attention for the right reasons.



2.2 activity tracking LHINs agreed to standardized definitions of their major BSO investments to better reveal trends and common approaches across LHIN boundaries. A first set of indicators were also selected, to be expanded and enhanced in future reporting cycles. A picture of project-wide resource deployment and relative priorities begin to emerge. Agreed nomenclature and definitions that apply in all LHINs are a crucial first step toward an accurate tally of BSO services by type and function. In future, reliable province-wide counts for a wider range of BSO initiatives will facilitate impact assessment, cost comparison and projections of return on investment.



Where quantitative outcomes depict an at-a-glance summary of what is happening, qualitative outcomes provide the how. Section 3 paints the picture of how the project is responding to immediate realities, anticipating upcoming needs and immediately applying lessons learned to accelerate and sustain change.

3.1 quality improvement

impacts of HQO coaching and leadership

Building Local Improvement Capacity In late February, Health Quality Ontario (HQO) worked with the Improvement Facilitators from all 14 LHINs to establish priorities and to develop a 2012-13 Integrated Quality Improvement (QI) Workplan. Implementation began in April with biweekly webinars designed to sharpen the skills of the BSO Improvement Facilitators who were trained in 2011-12. Each month, one webinar focused on Applied QI Science, while the other addressed Measurement for Improvement. To provide experience in facilitating discussion of the material and in applying it to BSO efforts, HQO arranged for a local Improvement Facilitator to co-host each call.

In June, 25 participants from across the province attended a 2-day training session hosted by HQO. The aim of the session was to continue to build the skills of local Improvement Facilitators through the application of Quality Improvement Science principles to the Behavioural Supports Ontario initiative. Participants explored Experience Based Design (a methodology that embraces the co-design of the future state with clients and caregivers), Change Leadership, Spread, Sustainability and Data for Improvement (building, displaying, interpreting QI data using Shewhart control charts).

Accelerating Improvement through Kaizen Events

A kaizen event is a structured team exercise facilitated by a process flow expert which focuses on creating more value and less waste in a given activity or process. A kaizen event involves knowledge creation, and allows a team to move from concept to action. Participants in a kaizen event are the people who do the work since they are the ones who understand the flow and the context for the change better than

Chapter 3

Qualitative



anyone else. This also serves to truly engage staff, physicians and caregivers in co-creating the desired future state – far more powerful than any after-the-fact efforts to secure ―buy in‖. Kaizen events are typically 1-5 days in duration depending on the complexity of the process and availability of people to engage in this type of concentrated work. The scope of the event is adjusted based on these factors. Each event is aimed at making rapid improvements and documenting standard work. During the event, participants document the process to deliver care and develop the tools needed. They test them, study and make recommendations to improve. Then they make those changes and repeat the cycle as many times as time allows.

With a solid foundation to this rapid cycle approach to improvement established between January and March 2012, LHINs continued to develop and test tools and processes through kaizen events facilitated by HQO. Events were held in four LHINs, with coaching to local Improvement Facilitators to enable them to lead subsequent events:

1. North East (May 9-10, 2012): 2-day kaizen event focused on creating access and flow of clients to new resources available through the Responsive Behaviour Team and its integration with existing services (PRCs etc).

2. Central West (May 9-11, 2012): three consecutive 1-day kaizen events focused on determining how the mobile teams across the Central West LHIN can best fit and link with the existing pieces. Day 1 day focused specifically on the teams within Long Term Care, Day 2 the teams within community and Day 3 the team‘s role. Work was based on learning from partner LHIN kaizen events related to BSO mobile teams and the existing processes and tools used by mobile teams within the Central West LHIN area.

3. South West (May 24-25, 2012): 2-day kaizen event focused on determining how the care provided to individuals through the five SW LHIN mobile teams can be best delivered by a collaborative care team and, where needed, smoothly transitioned. Transitions may include to another mobile team in another geographic area within the LHIN, to additional service providers and to the original care team.

4. Waterloo Wellington (June 19 and 21, 2012): During this 2-day session, participants determined the process and resources/tools for an integrated service/system in partnership with primary care for specialized geriatric services across their LHIN.

Since each LHIN is using the work from previous events to inform their efforts, a linkage was created from the kaizen events to the most closely associated Collaborative Working Group. HQO established a template to share products and reflections from the experience of participating in an event, leveraging the Collaborative Working Groups as the forum to share. The process recommended that the host LHIN post documents to the AKE Collaborative Space to expedite their use. Tables 3.1.1 through 3.1.2 provide a synopsis of the tools and processes developed through kaizen events that were facilitated by HQO.

Generating Measurement for Improvement

Presentations of data for improvement from the four early adopter LHINs were enthusiastically received by the DMEC Committee, and generated lively discussion, with comments like ―Impressive work!‖; ―Stories to inform entire sector...‖; ―This is a goldmine of information!‖; ―Extremely valuable...out of BSO and QI [we can] focus on this approach driven by evidence and performance improvement‖.

If You Build it They Will Come Great plans are built on strong foundations. Hosting an impressive series of 35 BSO education and training events for a total of 220 cross-sectoral participants the ESC LHIN is staying the course with their Action Plan, building a strong foundation upon which lasting and meaningful change can, is and will continue to be built. Participants responded with great enthusiasm at the opportunity to enhance their knowledge and skill set with the collective goal of providing better care for individuals often referred to as ―hard to serve‖ and, with a clear thirst for more QI knowledge, providers remain keen to move ahead with clinical collaborative groups that will form the back bone for implementing inter-sectoral discussions about ―shared clients‖. “It was so encouraging to see a willingness to disagree… persevere and then arrive at a collaborative solution,” says Susan Taylor of Health Quality Ontario. “When we polled participants at the beginning of the (Kaizen) events, few people had ever met one another or worked together yet, by the end all had contributed to an amazing piece of work. The opportunity to co-create serves not only to expedite progress, but also build relationships that will foster ongoing growth.”

Rather than being labeled as ―hard to serve,‖ it is the goal of ESC that the BSO client population, a vulnerable group who often have no voice, be treated with greater respect and understanding through the provision of quality client-centred care, To its credit, ESC is building lasting and meaningful change and for its effort… ―they‖ – clients and families will come… and they will be better off for having done so.



To help each LHIN tell the story of their improvement journey, Improvement Facilitators displayed data in Shewhart charts, a methodology that elevates the rigour of measurement for improvement as it guides the teams to differentiate between ―common cause‖ (random) variation and the ―special cause‖ variation we are looking for in our work. Creation, analysis, interpretation and synthesis of these charts using CHARTrunner has been a newly acquired skill for the Improvement Facilitators, and is one that can be transferred to future initiatives.

Leveraging Synergies between Residents First and BSO

BSO and Residents First initiated partnership with the North Simcoe Muskoka, Mississauga Halton and Central West LHINs to host two 3-day events in late August. Two days of Residents First Quality Improvement Facilitator Training, followed by a 1 day event to explore the application of quality improvement knowledge, skills, and tools will advance the mutual goal of improving the lives of residents with responsive behaviours.

Targeted toward both Long Term Care staff and BSO partner organizations, these events are intended to foster relationships and reinforce a broad understanding that we are creating an integrated team working together for the resident, and that Residents First, BSO Support Teams, and Long Term Care home teams, are working collaboratively. We know that behavioural support best practices provide positive resident outcomes through early identification and prevention, and that using the Residents First Responsive Behaviours Change package to generate consistent internal support will make for predictable consultations with BSO Teams. In September, the findings from these PDSA (Plan-Do-Study-Act) cycles will be shared with all LHINs to all for learning and exploration of opportunities for continued synergy.

Next Steps…from Implementing to sustaining

“The challenge is not starting, but continuing after the initial enthusiasm has gone”

- J. Ovretveit 2003

In June, Improvement Facilitators were introduced to the Sustainability Model. Created by the National Health Service Institute for Innovation and Improvement, the model provides a structured, evidence-based framework for discussion of ten key factors known to be critical to the sustainability of an initiative. While a score is generated by the team, there is equal value in the process of sharing the various perspectives of participants ranging from senior leaders to clinicians to front line providers. Once complete, it is recommended that teams select 1-3 factors with the greatest gap between their current score and the potential score, and use these as the focus for concentrated efforts to build sustainability. Results and reflections will be shared by the Improvement Facilitators during their September 4th webinar.

NHS Institute for Innovation and Improvement Sustainability Model



BSO collaborative working groups

Primary Care

As the first Early Adopter LHIN to establish a committee for Primary Care, HNHB‘s ‗lead‘ role facilitated a collaborative environment for knowledge exchange among other EA LHINs focused on the development of the Primary Care Toolkit. Between April - June 2012, the HNHB has worked to incorporate changes to the Primary Care Toolkit, based on feedback received during the first test of change. The changes made to the Toolkit include: Addition of an Introduction, Revised Safety Checklist Revised flow diagram to apply the tools in two 15 minute primary care visits Removing the Functional Assessment Tools Incorporating laboratory/Investigations component into the flow diagram Adding an Environment component to the Potentiating Factors List Changing Treatment/Management component, removing medication doses from the Pharmacological Interventions Phase two of the collaboration will entail developing the scope (initial draft attached) and Terms of Reference for the Primary Care Collaborative commencing in September, as agreed by the LHIN Leads. HNHB will facilitate obtaining information Provincially from Primary Care regarding gaps in supports and services through a survey, environmental scan and the continued implementation of HNHB improvement initiatives. Through the summer, HNHB will develop a survey to be sent to Primary Care by all 14 LHINs, to understand gaps and opportunities to better serve the BSO population. Simultaneously, an environmental scan will assist in determining the number and models of ‗geriatric-type assessment clinics‘ within the LHIN, and the number of physicians that have access to this type of resource. The Collaborative will invite all LHINs to participate in sharing knowledge and learning, as a means to facilitate accelerated improvements. Issue/Risk: A key risk identified with the posting of the Toolkit for use is the copyright issues that apply to two assessment tools recommended by the experts and included in the tool kit during testing phase. Prior to posting the tool kit on line the HNHB LHIN has obtained a legal opinion. As a result, the tool will be revised to replace the caregiver burden tool and provide the link to two tools that are copyrighted.



Centralized Intake

Between April and June the Enhanced Access/Centralized Intake Working group, led by NSM LHIN, has developed and approved Terms of Reference, an inventory of initiatives and common measures. The group met bi-weekly for one hour and was assigned a knowledge broker to assist the group. The group has developed an inventory of activities, determined which ones are similar in concept, developed common definitions and common measures. Many of the LHINs involved in the group are there for information only (i.e. do not have active projects in this area) and are there to learn from those LHINs who are a little further ahead. Moving forward, the focus will now turn to sharing lessons learned, success stories and impact to clients and families.

Table 3.1.1 - Tools and processes developed at kaizen events facilitated by HQO. Items marked with an asterisk (*) were new in Q1.

Mobile Support Team: Collaborative Working Group

Facilitated by the SE LHIN and supported by the Alzheimer Knowledge Exchange (AKE) and Health Quality Ontario (HQO), an Inter-LHIN Collaborative has been established that has engaged all 14 LHINs and draws upon the expertise of members, Knowledge Experts and individuals skilled in improvement science. The Knowledge Exchange platform and channels that have been developed include a Collaborative Exchange space on the AKE website to link people, ideas and resources, regular Cross-LHIN webinars, a dedicated Knowledge Broker, and linkages with provincial and national knowledge exchange networks, including Seniors Health Knowledge Network, the Canadian Dementia Knowledge Exchange Network, Mental Health Commission and the Canadian Coalition for Seniors‘ Mental Health.

Moving into the first quarter of 2012-13, teams continued to develop and refine the tools and processes that would enable LHINs to translate concept to action for Mobile Support Teams/Mobile Response Teams in the Community and in Long Term Care Table 3.1.2.

Interestingly, two new models emerged at kaizen events during this quarter – Integrated Response Team (North East) and Specialized Geriatric Services (Waterloo Wellington). These LHINs elected to redesign service delivery models to incorporate new BSO resources within existing teams Table 3.1.3, while at the same time, seizing the opportunity to understand and minimize variation across the LHIN. Table 3.1.4 outlines refinements and new developments related Transitions from Mobile Support Teams/Mobile Response Teams and support across the continuum. The network has developed a Mobile Team Matrix to identify the scope, depth, breadth and reach of inter-agency collaborations to enable a standard mobile team concept to be defined for the province. Specific cluster models have been identified as well as skill-building needs.

Tools and Processes Developed Developed in Q4

Central West North East South West Waterloo Wellington

Referral and intake process algorithm * New!

Referral Form

Standardized referral from for SMHA team, CCAC GRT and Alzheimer’s team *

New!

Spectrum of Outreach services – criteria to call

Community Service Involvement Tool (CSI tool) *

New!

Central Intake – one number to call (by hub)

Intake and Triage Form * New!

Risk Triage Referral Tool

Decision Algorithm: MST deployment

Process map for BSO team services * New!

Safety Plan – Immediate Safety and Care Plan

Behavioural Plan including risk algorithm



The Mobile Team Matrix has also provided a mechanism for the identification and development of specific performance indicators related to these service models. Relevant evidence, practice-based knowledge has been exchanged through the Collaborative, ensuring the collective wisdom of the LHIN leaders is surfaced and that fidelity in terms of approach is supported for this foundational vehicle to implement the three pillars of the BSO project.

Table 3.1.2 - For refinements to Mobile Support Teams in Community and Long Term Care: Tools and processes developed at kaizen events facilitated by HQO. Items marked with an asterisk (*) were new in Q1.

“Mobile Support Team”/”Mobile Response Team” - Care in Community Tools and Processes Developed Developed

in Q4 Central West North East South West Waterloo

Wellington Crisis process * New!

Non-crisis process * New!

Flow chart for PRC consultation request * New!

PRC intake consultation request form * New!

PRC communication tool * New!

PRC functions/role * New!

SBAR to communicate to Centralized Intake

Strategies and Interventions (care) plan

Transition Tool/Plan

Debrief and evaluation of plan

“Mobile Support Team”/”Mobile Response Team” - Care in Long Term Care Homes



Criteria for LTCH to contact Mobile Team

Template for key discussion points at case conference *

New!

Core Functions of BSO Champion * New!

Role of the BSO Network Coordinator * New!

Decision tree to access additional support * New!

New behaviours flow map * New!

Responsive behaviour tool bag * New!

Process flow from acute care to LTCH and to home/community *

New!

SBAR to communicate to Centralized Intake

Team composition

Treatment Plan

Debrief with staff and evaluation of plan



Table 3.1.2 - For new delivery models that emerged in Q1: Tools and processes developed at kaizen events facilitated by HQO. Items marked with an asterisk (*) were new in Q1.

“Integrated Response Team” Tools and Processes Developed Developed


Wellington Integrated Response Team – Introduction * New!

Collaboration Structure * New!

Regional Needs Assessment * New!

Regional Meeting Calendar * New!

Quick Reference – Team Membership/Roles * New!

Goals for the Behaviour Support Team * New!

Role of Virtual Team * New!

RACI (Who is Responsible, Accountable, Consulted, Informed for various functions?) *

New!

“Specialized Geriatric Services”



Eligibility criteria and list of other services * New!

Education at primary care level * New!

Communication to primary care * New!

Criteria for case conference * New!

Criteria for home visit * New!

Identify access to information – e.g. assessment tools *

New!

R.I.S.K.S. tool/urgency from PIECES + mental health *

New!

Process for booking directly with SGS worker * New!

Role of SGS workers by regions * New!

“Givens” for referrals * New!

Algorithm for home vs. Clinic * New!

Assessment tool (harmonized) * New!

Assessment process in day programs, LTCH * New!

Template for recommendations * New!

Description of who leads implementation of the care plan *

New!

Care plan outline (within 24 hours) * New!

Toolkit: smart phone, OTN etc * New!

Plan to support to virtual team and share knowledge *

New!



Table 3.1.4 - Transitions and Support across the Continuum: Tools and processes developed at kaizen events facilitated by HQO. Items marked with an asterisk (*) were new in Q1

Behavioural Support Units (collaborative)

The BSU Collaborative Working Group has been busy meeting on a bi-weekly basis to discuss the creation of Behavioural Support Units within other LHINs in the province, and to discuss areas for collaboration and information sharing. The group is attended by all stake holders that have proposed BSUs in their LHIN (Toronto Central, Central, Champlain, North Simcoe Muskoka). HQO is regular member of the group and others such as the PRT, CRO and Ministry of Health have been included as required. Significant work has been accomplished over the course of Q1. The Group has developed a common definition of a BSU and activity measures that are proposed for use by all BSUs. At the June 22 teleconference, the MOHLTC was invited to discuss the need for measures that would be used going forward to evaluate the efficacy of the units. Good discussion ensued and the group is currently finalizing a list of proposed client outcome measures in order to obtain approvals for the units. The group is also looking at data collection and presentation, the idea being that the group would like to be able to collect data that is currently available instead of creating another collection method. Work continues with HQO in presenting data using the Chartrunner software. The software has been used to successfully display length of stay data from Sheridan Villa SBSU- both clinical and wait time for placement after meeting clinical goals. The group is looking forward to obtaining the MOH special designation for the units. Five LHINs submitted their respective BSU applications to the MOHLTC the first week of April 2012. To date no designations have been awarded. due to the pending approvals and also fact that units will require existing residents to be placed elsewhere to allow units to open, staff hired for the BSUs are not functioning in their BSU roles in all locations. As a result of delayed designation, the impacts of the BSU in each LHIN‘s are not likely to be realized until Q3 or Q4 of 2012/13. Group participants have shared materials developed for operation of the unit such as operating policies, manuals etc. Once the units are functioning, the discussions at the collaborative group can expand to include access, flow and operational issues.

Transition from “Mobile Support Team”/”Mobile Response Team” Tools and Processes Developed Developed


Wellington Documented process for transitioning to Long Term Care *

New!

SBAR with PIECES for helping with transitions *

New!

Transfer back to LTCH communication guide * New!

Pre-discharge meeting & contingency plan

Transition planning process

Client Information Package

Consult with external resources

Capacity Building for LTC and Community

Across the Continuum



Education and Capacity Building * New!

Communication Strategy

Q&A through Collaborative Working Group



3.2 capacity building

The third pillar of the BSO Framework for Care speaks to capacity building and a knowledgeable care team as critical components to support service redesign. The vision for how BSO would support each of these components at a project level is to provincially link and align capacity building elements, but do so in a way that enables LHINs to adapt components based on the learning needs and unique context of their region.

During Q1 there has been a local focus on training new staff, and a provincial focus on linking education and training strategies within a broad capacity building mandate. While addressing these immediate activities, the BSO project has also been planning for anticipated needs as implementation continues.

Unspent HHR for Training Backfill, Training Counts

Last fiscal year, the Ministry agreed with the interpretation of using surplus BSO salary funding to backfill for staff attending behavioural supports training in order to increase the number participating in education/training sessions. As a result, over 3,500 staff attended BSO related sessions in Q4 of 2011/12 and the current report finds BSO funding supported at least 3,900 more examples of staff training in Q1 of 2012/13. While the main goal continues to be the recruitment of new hires, the opportunity to train more front-line staff has contributed to fostering better person-centred care for residents/clients with challenging behaviours.

The Ministry granted LHINs the same latitude this fiscal year to use unspent HHR funding for backfill when non-BSO staff attend behaviour training that meets the objectives of the BSO initiative. (eg P.I.E.C.E.S., Gentle Persuasive Approach, Montessori etc). The same rules of 2011/12 again apply in 2012/13 for the use of unspent/ surplus base funding for PSWs and other healthcare professionals. This use of unspent funds, as in 2011/12, does not apply to the nurse allocation specific to Long-Term Care homes. The funding policy also clearly indicates that the new BSO base funding cannot be used to support operating or education costs (eg. training materials, courses, administration).

Education and Training Subgroup

The Education & Training Subgroup is a blue-ribbon panel of 22 key leaders representing both health and safety sectors from across the province. The group was established to provide resources for the LHINs to implement their BSO action plans for capacity enhancement through learning, knowledge transfer and development programs. Through an online capacity building survey the LHINs identified several broad areas where provincial coordination and support were needed. In particular, LHINs were struggling with how to choose education and training programs to best enable staff to care for clients with responsive behaviours in a way that is safe and person-centred. To meet this initial need, the Education & Training Subgroup indentified that Phase 1 of their work would focus on developing the Behavioural Education Training and Supports Inventory (BETSI) Framework. This tool, further detailed below, is built from the existing Dementia Educational Needs Assessment (DENA) and includes an expanded perspective for the broader BSO target population. Behavioural Education Training and Supports Inventory (BETSI)

Capacity Building can take many forms – it can be informal, such as ‗teaching in the moment‘ opportunities and case-based learning, or it can be formal education initiatives, such as workshops. Released in June 2012, the BETSI Framework & Program Inventory (Appendix D) defines and organizes education and training opportunities for an entire organization. Used in parallel with the Capacity Building Roadmap, it is a comprehensive decision making framework and program inventory that will strengthen the capacity of planners to choose the most appropriate education programs and effectively support the application of new knowledge into practice. BETSI assists users to determine whether they need education; whether they are able to support practice change; what educational opportunities are available to them; the components necessary to ensure effective implementation and to sustain investments; and, how these programs align with the BSO target population, core competencies and service functions. The BETSI Framework takes into account continuous improvement and long-term sustainability. It is also an ongoing ―check and balance‖ that supports local decision making – not only during the influx of new hiring but also as changes occur due to turnover, service provision and ongoing learning needs. Divided in two parts, to facilitate and promote the translation of ―knowledge-to-practice, the Framework, should be used by those who need to make decisions about what education is required to manage and better serve the target population, and also by those who provide collaborative care for the target population and make education-related decisions.

http://www.akeresourcecentre.org/files/BSOResources/SW%20Part%20A.pdf



The use of BETSI, to match local education needs and readiness with appropriate training programs, allows planners and organizations to ensure efficient use of their training resources, while notably enabling their teams to provide clients with the right care, at the right time and in the right place. BETSI is the guarantee that capacity building investments are targeted correctly and scaled appropriately. To get BETSI in the hands of those who will benefit most from its use the tool will be rolled out across the province through a variety of channels including a series of ‗how to‘ webinars, designed to showcase its effectiveness and usefulness. In addition, the tool has been shared with national partners and networks whose members serve older adults with responsive behaviours; an approach that highlights Ontario‘s leadership role to a national audience. Planning for Ongoing Support

An online needs assessment distributed early in the first quarter identified that the current provincial strategies and resources to support local capacity building activities are not only well received, but also being applied at the LHIN-level. Looking ahead, the project has made significant gains during Q1 to set the foundation for the next phase of support. In the coming months the project will support the following province-wide activity:

Capacity Building Community of Practice: Supported by the Alzheimer Knowledge Exchange, this Community of Practice will bring together those with a role in local BSO Capacity Building activities to raise awareness of other capacity building strategies happening across the province, build on and adapt the work of others, and collaborate to develop common resources, tools and processes. Person Centred Team Based Service Learning Framework: This model, developed in the South East LHIN, was designed as an overarching framework to guide capacity enhancement/ learning activities and service delivery for health care providers working in the behavioural health sector. In the coming months, the BSO project will work to link this framework to other capacity building resources developed to date and share the tool on a provincial platform. Capacity Building Roadmap II: The BSO project has committed to developing a sequel to the Capacity Building Roadmap. This resource will help LHINs make capacity-building decisions for new hires beyond the current Roadmap‘s 6-month horizon, taking into account a new recruit‘s learning and development goals during their first 18 months on the job. Education and Training Subgroup, Phase 2: (Fall 2012) of the Education & Training Subgroup will aim to strengthen and expand on Phase 1 activities. Where Phase 1 focused primarily on education & training needs in the long term care sector, Phase 2 will address the emerging education needs of those caring for individuals in other sectors (e.g. primary care, community care, acute care etc.). The group will target activities based on feedback from the LHINs.

High Quality Tools for Capacity Building Enhancement



3.3 tools for quality improvement: CHARTrunner

In June 2012, Health Quality Ontario initiated the first in a series of training sessions to familiarize Improvement Facilitators with CHARTrunner, a user-friendly Statistical Process Control software application. This software allows teams to generate Shewhart Control Charts, a methodology generally considered to be the ―gold standard‖ for evaluating quality improvement efforts.

In recognition of the normal variation that occurs over time, Shewhart Charts like the Individuals Charts below direct the attention to the times

where there was something different in the environment (highlighted by the software with red data points). This ―special cause variation‖

prompts a team to investigate and study the underlying circumstances, and informs future Plan-Do-Study-Act cycles.

These activity measures from the Specialized Behavioural Support Unit demonstrate early evidence of an increase in the number of

discharges per month. Not surprisingly, after a short lag time, there was an increase in the number of admissions. From an improvement

perspective, it is important for the team to understand the reason for this apparent change in flow so that it can be enhanced and replicated.

Further analysis within the PDSA cycles allows the teams to conduct pareto analyses to understand the discharge disposition of residents

from the unit. With 53% (19 of 36) discharges to another unit within the host long term care home, it was apparent to the team that there was

an opportunity to build processes to enhance placement across all homes within their LHIN rather than continuing to be reliant on the host

home.

As the Improvement Facilitators become more competent and confident with this methodology, the rigour of measurement for improvement

increases substantially. As noted in section 3.1, the Early Adopter LHINs presented their improvement data to the Data Measurement and

Evaluation Committee in June 2012, thereby advancing the awareness and alignment between measurement for improvement and

measurement for evaluation.



Once Upon a Time

Lanore, a 90 year old resident in one of our special care areas, has a diagnosis of dementia and was referred to the Behaviour Supports Team due to daily restless behaviour that included getting into other residents space, singing loudly and other socially disruptive responsive activities. The impact on other residents in the neighborhood was that the neighborhood became chaotic and resulted in other residents becoming restless and agitated. Through assessment and observation, Joanne and Julie noted that this behaviour was most notable around 4pm. They set out to find a Montessori based activity that would satisfy the residents need to be social while keeping a calmer environment.

Montessori-Based Dementia Programming is a method of working with older adults living with cognitive and/or physical impairments by engaging them in activities that provide purpose and meaning. It has been shown to increase levels of engagement and participation in activities of persons with dementia. It has also been shown to improve many aspects of the quality of life and decrease responsive behaviours.

Joanne decided to trial Lanore ―hosting‖ a reading program for other residents. Daily at 4pm Lanore would be provided with her Montessori reading material and up to 10 residents would be gathered around to listen to her read. Lanore stays engaged in this activity for 30 minutes per session. This activity seems to satisfy Lenore‘s need to be social and she seems pleased with this new purpose. Lenore‘s daily responsive behaviors have decreased in frequency and intensity since the Behaviour Supports PSW began working with her and have now been eliminated. Once Lanore is set up with her books (and audience!) the program virtually runs itself.

―The early success that we have had has motivated us to continue to expand the Montessori program,‖ says Laura Holtom, Assistant Administrator – Wellington Terrace Long-Term Care Home. ―We believe that programs such as this will have a significant positive impact to those living in long term care.‖ The environment is noticeably calmer during this time with less responsive behaviours exhibited by other residents. Lanore‘s daily responsive behaviours have now been eliminated (from daily to 0). Joanne has trained other staff on the Montessori activities and the supplies can be accessed at all times. After seeing the success with Lanore and others, staff are energized about using Montessori in their own practice.



3.4 lessons learned

Throughout implementation LHINs continue to test and refine processes. This includes identifying lessons learned and areas for improvement. Some lessons can be applied to future provincial or local projects; others can be addressed immediately. The following examples of lessons learned have been provided by LHINs throughout Q1 and represent learning across system management, service delivery and capacity building implementation strategies. These lessons include short statements as well as more comprehensive examples of how lessons learned will have a positive impact going forward.

Inter-Organization Agreements & Processes

Ensure that funding letters are out to municipalities sooner to get the proper approvals Data collected in the different sectors needs to be properly defined so that we are measuring and comparing the same indicators.

Lesson Learned Part 2 of the Behavioural Assessment Tool (BAT) should be used as a standardized internal referral tool.

Background Summary Utilizing Part 2 of the Behavioural Assessment Tool (BAT) as a referral tool reduces the need for a separate referral tool

within the long-term care homes and has increased staff awareness to initiate new interventions and participate in collaborative problem solving.

Benefit for Future Use Staff are introduced to the critical thinking to identify behaviours, behaviours are clearly communicated to the BSO team, and duplication of effort and the need for additional paperwork is eliminated.

Lesson Learned Privacy impact assessment (PIA) on a mobile program can be a lengthy process that may delay deployment. Due to our complex MST model (6 employers, multiple work sites, privacy regulations required by HIC), a PIA was requested.

Background Summary Although a PIA is a working document, the team‘s process had to meet a minimum privacy standard before the teams were allowed to deploy. At the end of a Kaizen, the team submitted a PIA for review (2 day collective process). Scrutinized were the processes in community and LTC, the forms, and the method of hand-off for every document with health information. Work intensity related torefining forms for approval pre team deployment to use in referrals.

Benefit for Future Use The benefit of this experience is that as PIAs become more commonly required, LHINs can become familiar with the process to meet the requirements more easily. This can be achieved by involving the expertise, such as Privacy officers at the beginning.

Lesson Learned The critical development of collaborative inter-agency agreements to ensure bilateral role alignment and accountability has been found to be critical to systems redesign – especially with a hub-and-spoke model.

Background Summary A hub and spoke model fosters a systems redesign through Mobile Teams with a lead agency and mobile inter-institutional service delivery. Leadership and administrative agreement co-created by partner institutions with the lead agency has enabled a process to provide increasing awareness and understanding as well as agreement on collaborative approaches. This has been invaluable in terms of supporting the mutual responsibility of agencies in development and moves from a ―working on‖ to ―working with‖ approach.

Benefit for Future Use This provides a critical success factor to ensure support for implementation of policy and practice and a process has enabled clear role definition and mutual accountability.

Project Funding

BSO is a large scale change project and having resources to support a person dedicated to the system redesign process is important. In the future, large scale system redesign projects need to have financial resources to have dedicated resources to lead this process

The need for additional resources to service the BSO clients. Some agencies needed additional capacity that was not funded (RPN instead of RN in LTCs, or the need for specific resources (specific BSO case managers). The lack of operation dollars impact on many BSO participants

It is critical to the success of a large project such as BSS to ensure that adequate resources are committed right up front (e.g. a knowledgeable and committed group of service providers to develop the Action Plan and to oversee and guide the implementation of the project, (an Implementation Coordinator to oversee the day-to-day project tasks/activities and ensure that deliverables were met on time and within budget; and a skilled and experienced internal team to manage the project).

The ministry funding for Early Adopter LHINs was instrumental in the ability to develop new processes and resources for system redesign and to create the new resources.



Lesson Learned Operational funding should be split into 2 years for Early Adopter LHINs

Background Summary

Funding support was unable to be fully utilized in 2011/2012 creating financial pressures for roll out in 2012/13. The need to put the infrastructure in place, create action plans, design new models of care and initiate implementation created time pressures and required the implementation and roll out across sectors to be conducted in the second year without operational funding.

Benefit for Future Use Spread the funding for projects across 2 fiscal years so that the team can plan and implement effectively without unnecessary time and financial pressures.

Project Timelines

The realistic length of time to provide orientation to new staff take approximately 2-3 weeks and required a full-time commitment from leadership to provide the training. This was compounded by the fact that the large number of staff to be hired was staggered requiring at least two rounds of orientation, which has been a large time and financial commitment. In the future, these timelines need to be incorporated in addition to the time it takes to hire staff before a new program can be implemented

Despite having carried out numerous presentations to the LTCH administrators with regards to BSO requirements in the home, the lesson learned would be to take even more time in educating agencies on the roles of any newly hired personnel in a future project

Highly unionized environments can cause some animosity and some individuals are hesitant to change practice and routine especially when suggestions are coming from a peer. Having this insight would have altered the timelines for implementation but would have reduced the time spent clarifying the BSO goals, objectives and the regional strategy

Having the Coordinator position filled prior to filling other HHR positions may delay timelines but will ultimately ensure the Coordinator can be involved in other hiring and that this process will lead to a more successful implementation in the long run

Issues such as a legal review of contracts and MOUs for implementations that span multiple organizations add to the timelines but will achieve long-term change

Flexible implementation schedules are vital.

Lesson Learned A realistic length of time for clinical change in practices is predicted to be 8 months. It is not realistic to put clinicians from three different counties in one room and expect them to embrace‖ and implement change immediately.

Background Summary

To further outline why this is not realistic……most clinical teams (across Ontario) are connected to Physicians or Psychiatrists. We are turning the system – upside down and driving change from a bottom up approach. This is totally against the grain of older clinicians who are use to receiving a job description, some info for implementing practices and then turned loose to ―do their job‖. We are embracing partnerships, leveraging higher clinical skill sets – including having various disciplines working to their fullest scope. Psychiatrist and Physicians may not embrace change quickly as many have a ―show me‖ attitude.

Benefit for Future Use Knowing this to be true the LHIN has made it clear to all BSO and external providers that we will implement small test of change through our Clinical Collaborative Tables. We will have our LTC Lead Homes go out to their Buddy Homes with the Geriatric Mental Health Outreach Teams. After five clients have been seen – we will regroup – what worked – what didn‘t and what at the regional level do we need to change to further support our clinicians.

Lesson Learned When new models of care are being introduced it is essential to align timelines to complete recruitment and training with the implementation, ramp up and rollout of new service models. This will ensure that resources are optimized while taking into consideration program development and adjustments based on early outcomes and evaluations.

Background Summary The LTCH Mobile Team staff (41 FTE) were hired and trained over a three month period, during the development phase and early testing of the mobile team model occurred. By April 1, 2012 all of the teams were ready to serve residents throughout the LHIN. However, it took approximately 2-3 months to ramp up the implementation of the model, specifically related to receiving the signed MOUs from LTCHs, orientating LTCHs on the model and services available, developing intake processes, establishing relationships with existing outreach teams, including clarification of roles and responsibilities, and receiving sufficient number of referrals to support the full complement of Staff.

Benefit for Future Use Recognizing the introduction of new service models, depending on the service and model, may require a longer ramp-up period before optimal demand and capacity is achieved. New programs and/or strategies should consider a staged implementation plan ensuring resources are fully optimized and the successful implementation of program/strategy is achieved.



Lesson Learned The realistic length of time to deploy new HHR funding, from initial planning to actual hire is approximately six to eight months.

Background Summary

Initial times werethree months.

Benefit for Future Use Realistic time-lines can be built into the planning process

Capacity Enhancement Hiring the BSO teams prior to implementation of the model for training purposes and for model development has allowed the BSO team time to ―gel‖ as a group. This opportunity has given the team a controlled environment to practice their work, perfect their craft and learn about the expectations of BSO members.

Lesson Learned Primary care physicians‘ capacity around dementia and responsive behaviours is limited and needs to be improved.

Background Summary During the physician engagement session that was held in the MH LHIN it was evident that the physicians need more training on how to assist the person with responsive behaviours. The use of clinical pathways needs to be developed and implementation of the interRAI primary care screener.

Benefit for Future Use Physician will have the capacity to manage clients better in the initial stages of the disease process therefore providing better access to services and possible prevention of ER visits.

Lesson Learned Capacity enhancement aligned and driven by day-to-day practice delivery.

Background Summary Education and learning often result in no change in practice as well as misalignment with the skills and functions required in day-to-day service delivery. Capacity enhancement leaders assisted in defining the Provincial Core Competencies and a framework for person-directed team-based service learning (PCTBSL) benefits for future use. Realignment of capacity building approaches from education to practice to a mechanism that supports practice identification through use of quality improvement and value stream mapping to inform education, will allow future service redefinition, design and education that will support the service outcomes defined. This will obviate the mismatch that often occurs through learning to practice.

Lesson Learned Change in the culture from the expert model to the collaborative care model, supporting leaders and managers to develop needed skills and support for the new approach to policy and practice.

Background Summary Traditional approaches have employed an expert opinion-driven approach to service delivery redesign and development. Moving to a service inter-agency collaborative care approach dictates the development of a partnership with mutual respect of all participants in the development and redesign. Traditional development has been based on more expert or traditional literature research and has not involved an evidence-informed process bringing evidence from the lived experience, practice-based evidence and traditional knowledge from research. The authentic partnership development and design approach provides a significant divergence from traditional approaches and therefore, dictates new skills in senior leaders and managers.

Benefit for Future Use:

Need to re-skill our present experts, fostering increasing collaborative knowledge and skills and a need to assist participants and existing managers to develop an understanding and skills in the use of new approaches, including among others, conversational leadership and non-hierarchical leadership approaches.

Lesson Learned: Lack of skills in knowledge exchange and improvement science.

Background Summary: Clinical skills and traditional leaders in service delivery in health care have not been aware of nor developed skills in knowledge exchange and improvement science.

Benefit for Future Use: Awareness and improved skills by practicing clinicians and their leaders will enable service change to occur, providing them with the knowledge and skill base for change and change leadership.

Communication & Stakeholder Engagement Through the implementation phase of BSO it became evident that our community engagement strategy would have been more effective if

we included broader key partners in a more concerted way. This should have been done following our engagement with the BSO providers. Initializing this type of strategy would have minimized the resistance and provided more accurate information. This holds especially true for those health service providers that are connected to this population.



Identification of initial roles and responsibilities would have made the implementation process smoother. For example, the Behaviour Support Facilitators were hired and ready to receive clients prior to any other team members as they were the first to be recruited and hired

Some LTCHs want an immediate or quick fix to the situational crisis and there is some expressed disappointment that the BSS-MSTs are not an emergency service; it is imperative that BSO reinforce integrated service delivery to leverage existing resources

There continue to be misconceptions, misunderstandings and rumours about BSO within the provider community therefore continuous communication is key

In the early stages of development of the mobile team model, LTCH were hesitant to speak to their front line staff about the project out of fear staff would quit to join the team. The lack of communication to the front line staff created some uncertainty in the homes about the role of the BSO team which was apparent during the PDSA testing in homes (modeling)

Communications to all providers and within working groups could be enhanced Enhanced involvement of lived experience throughout is key Although it is not necessarily a new lesson, through the QI Working Groups we have put into practice the knowledge that one should

involve the people that work on the frontlines that know and do the clinical work in the field and are most aware of how the system works (or not) across agencies and across sectors in developing new processes and in changing practices – this has resulted in high enthusiasm for the BSS project and shared accountability for its successful implementation

Communication both with direct and indirect stakeholder is important to keep the project moving forward and reduce barriers.

Lesson Learned Communication strategies are key to local implementation and buy-in.

Background Summary It was challenging to develop a LHIN wide communication strategy that kept all of the community support agencies, long-term care homes, Family Health Teams, and the Cooperatives informed of the evolving BSO project.

Benefit for Future Use A centralized, coordinated LHIN wide communication strategy may have been helpful in preventing the ―parking lot conversations‖ that happen with any system redesign.

Lesson Learned Stakeholder engagement, involvement and relationship building is a critical success factor.

Background Summary One LHIN has a complex system of service provision for seniors with mental health, addictions and behavioural issues which have not been formally coordinated under one umbrella. This LHIN also has 37 LTCH within its boundaries, making stakeholder engagement a challenge in a short period of time.

Benefit for Future Use Formal incorporation of this component into plans including recognition of complexity unique to each LHIN.

Lesson Learned A model and funding for physician engagement and involvement is a critical success factor.

Background Summary Physician input and participation is required for interdisciplinary care. Physicians receive fee for service funding so anytime required of physicians for an initiative like this is not compensated.

Benefit for Future Use Recognition of the role of primary care providers in LTC and funding built into plans.

Lesson Learned The role of the PRC is required and valuable to assist with developing measureable and valuable PIs within each LTCH.

Background Summary The PRC knows the LTCH staff, the strengths of each home and challenges relating to responsive behaviours. Working collaboratively with the BSO –IF who provides the knowledge transfer in relation to PDSA cycles, measureable outcomes and indicators, the PRC can coach and work directly with the BSO Champions in developing the Residence First AIM statement and work plan. The PRC‘s credibility, trust, and integrated team work with each LTCH-BSO Champion assisted with the successful implementation of BSO within a remarkable time line.

Benefit for Future Use: The development of a PRC work plan into the roll out of the BSO-IF role/function with LTC Homes. It is evident the role of the PRC will assist with the PI sustainability plan and knowledge transfer across the LTCH sector.



Quality Improvement With the support of HQO, several kaizen events and hundreds of volunteer hours from 80+ experienced workers on the seven QI working

groups, we have heightened the awareness of Lean methodologies across the LHIN and perhaps more importantly, there is a much deeper

understanding about how ―small tests of change‖ can positively impact their work and the patient/client experience through continuous

improvement – this new learning has built capacity in the region and will be sustained as new knowledge across projects beyond BSO/BSS in

the years to come.

Lesson Learned Need to allow for a start up period but also need to re-establish the commitment to quality improvement so that early developments continue to make gains.

Background Summary Although all stakeholders have the best intention to incorporate and sustain continuous improvement activities, early efforts have been focused on implementation and start up. Maintaining momentum on quality improvement is a challenge.

Benefit for Future Use Establish a formal schedule for quality improvement activities within 6 months of start up.

Lesson Learned Incremental evolutionary data-driven development.

Background Summary Planning and meetings to support change in health care have been the norm in health care redesign and delivery. This has often resulted in cumbersome and drawn out processes with very little change over time. The application of a quality improvement approach using incremental steps using the PDSA model provides a mechanism to break this latency barrier.

Benefit for Future Use Value stream mapping, PDSA and other quality improvement tools embedded into the process of change will clearly assist in evolutional incremental outcomes.

Exchange

LTCH staff enjoy smaller groups in order to feel more comfortable learning and sharing

Linking with other regional initiatives is critical Having a phased-in system launch with frequent regional knowledge exchange events would assist in the buy in and assisted with change

management strategies.

Lesson Learned There is a need for more connection of the BSO staff across the province to share ideas and learn from each other.

Background Summary The month end report received from the homes identifies this as a common theme amongst the homes.

Benefit for Future Use Knowing this the CRO may want to consider a ―meeting‖ of the staff hired either in person or on a webinar format.

Lesson Learned Inter-Agency Mobile Teams is a vehicle for capacity enhancement and service improvement driven by ―the receiver‖ of services through employment of value stream mapping.

Background Summary The Provincial BSO framework provided a clear identification of the whys and whats for the BSO initiative. The hows were defined by practice-based leaders and authentic partnership planning driven by the readiness and priorities and analysis of impact of the receiving sector in the initial case, the LTC sector.

Benefit for Future Use Priority LTC-driven exchange enables commitment by the sector, defines areas of high potential success and defines priority actions based on impact readiness and ease of implementation, therefore, providing improved success in terms of achieving transformational change.

Lesson Learned Value of inter-LHIN collaborations.

Background Summary The traditional approach has been to define a framework at the Provincial level with implementation in each of the local or regional areas. The benefits of knowledge exchange and collaboration to ensure fidelity across the Province with the policy has not traditionally occurred. This approach often provides significant diversity and frustrates the effective evaluation of invested funding.

Benefit for Future Use Knowledge exchange across LHINs as demonstrated through the Mobile Collaborative has fostered a mechanism for fidelity in terms of understanding and implementation of the BSO framework, provided a mechanism for co-creation of effective strategies for implementation and has enabled cross-LHIN learning and a basis for effective provincial coherent evaluation.

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