BSITTCriticalElements&GuidingChecklist-2019 �

Behavioural Supports OntarioSoutien en cas de troubles du comportement en Ontario

Supporting Successful and Sustainable Transitions into Long-Term Care for Older Adults with Responsive Behaviours/Personal Expressions

Critical Elements & Guiding Checklist

Created by the Behavioural Support Integrated Teams (BSIT) Collaborative • Part of Ontario’s Best Practice Exchangewww.behaviouralsupportsontario.cawww.brainxchange.ca

BSITTCriticalElements&GuidingChecklist-2019 �

Contact Information:BehaviouralSupportsOntarioProvincialCoordinatingOfficePhone:1-855-276-6313Email:provincialBSO@nbrhc.on.ca

PermissionsNopartofthisdocumentmaybereproducedwithoutwrittenpremissionoftheBehaviouralSupportsIntegratedTeamsCollaberative,partofOntario’sBestPracticeExchange,BehaviouralSupportsOntario/brainxchange.

ReferencesBehaviouralSupportsOntario(2011)OntarioBehaviouralSupportSystems:AFrameworkforCare.

BehaviouralSupportsOntario(2018)TheBehaviouralSupportIntegratedTeamsTransitionsModel:ADiscussionPaper.

MinistryofHealthandLongTermCare(2015)PatientsFirst:ActionPlanforHealthCare.

RegisteredNurses’AssociationofOntario(RNAO)(2015).Person- and Family-Centred Care.Toronto,ON:RegisteredNurses’AssociationofOntario.

SaintElizabeth(2016).Aguideforimplementingpersonandfamily-centredcareeducationacrosshealthcareorganizations.

BSITTCriticalElements&GuidingChecklist-2019 �

TABLE Of COnTEnTSREPORT BACkGROund ________________________________________________________ 4

ReportPurpose _________________________________________________________ 4

WhatisaTransition? _____________________________________________________ 5

AbouttheBehaviouralSupportIntregratedTeams(BSIT)Collaborative ____________ 5

BSITCollaborativeMembers_______________________________________________ 5

RELEvAnT ThEORETICAL fRAmEwORkS ______________________________________________ 6

SaintElizabeth,2016_____________________________________________________ 6

BehaviouralSupportsOntario,2011_________________________________________ 6

MinistryofHealth&Long-TermCare,2015 ___________________________________ 6

PuTTInG IT ALL TOGEThER: hOw dO ThE fRAmEwORkS COnnECT? _____________________________ 7

TheBSOIntegratedTeamsTransitions(BSITT)Model___________________________ 7

UsingtheBSITTModeltoDevelopaTransitionsintoLTCGuidingChecklist _________ 8

GuIdInG ChECkLIST: ________________________________________________________ 10

PARTA-1:BeforeTransitioningintoLTC_____________________________________ 11

BeforeaBedOfferisMade_________________________________________ 11

PARTA-2:BeforeTransitioningintoLTC_____________________________________ 12

AftertheBedOfferisAccepted_____________________________________ 12

PARTB:OntheDayoftheTransition_______________________________________ 13

BeforeLeavingtoTraveltotheLTCHome_____________________________ 13

AfterArrivingattheLTCHome _____________________________________ 13

PARTC:FollowingtheTransition __________________________________________ 14

IntheFirstfewDays______________________________________________ 14

Followingafewweeks____________________________________________ 14

hYPERLInkEd RESOuRCES In ChECkLIST: ____________________________________________ 15

APPEndIX A CriticalElements’AlignmentwithBSITTModel _____________________ 16-18

BSITTCriticalElements&GuidingChecklist-2019 �

REPORT BACkGROundInthefallof2017,theBehaviouralSupportsIntegratedTeams(BSIT)Collaborativebegantogatherinformationon critical elements for supporting transitions for the Behavioural Supports Ontario (BSO) target population1 into long-term care (LTC) homes.DrawingonthethemesthatemergedfromtheSeptember2015Ontario’sBestPracticeExchangeCatalystEvent,ateachmonthlymeetingthecollaborativememberssharedtheirperspectivesoncriticalelementsforsupportingpersonandfamily-centredtransitionsfromtheirprofessionaland/orlivedexperiences.UsingtheBehaviouralSupportIntegratedTeamsTransitionFramework,membersdiscussedanddeterminedessentialcomponentsthroughouttheexperienceoftransitioningfromeitherthecommunityorhospitalintoaLTChomewhichwereincorporatedintoaguidingchecklist.Allidentifiedcriticalelementsweregroundedinthephilosophyofpersonandfamily-centredcare;includingcreativestrategiesimplementedbyvariousBSOteamsandtheirkeycollaboratorstoovercomepotentialbarriersandchallenges.

Report PurposeThis report is intended to act as a compendium of critical elements for supporting successful and sustainable transitions for those who fall within the BSO target population as they move from either community or hospital into LTC Homes. ThecriticalelementsarepresentedintheformofaguidingchecklistthatcanbeusedbyprofessionalcareprovidersacrossthespectrumofcaretosupportindividualsandtheirfamiliesinthetransitionintoLTC.Thesecareprovidersincludefront-linestaff,management,alliedhealthteammembersandotherrelevantpartnersincludingthosefromtheorganizationthatissendingtheindividual(i.e.,communitypartnersorhospitalpartners)andthoseatthereceivingend(i.e.,atthelong-termcarehome).Thecriticalelementsidentifiedinthisreportcaptureemerging,promisingandbestpracticesthathavebeenimplementedatbothsmallandlargescalesacrossOntario.ManyoftheseelementsmayalsobeusedtoinformqualityimprovementactivitiesaimedatimprovingtransitionsintoLTCandtoaidintheselectionofrelevantprovincialandregional-leveltoolsandresourcestoimprovethesecomplextransitions.

1TheBSOTargetPopulationincludesolderadultspresentingwithoratriskforresponsivebehavioursduetodementia,complexmentalhealth,substanceuseand/orneurologicalconditions.Inadditiontoprovidingdirectsupporttotheolderadults,BSOteamsalsosupportfamilycarepartnersandprofessionalcarestaff.

•ReportBackground

familyInthisdocument,theterm‘family’referstoindividualswhoarerelated(biologically,emotionally,orlegally)toand/orhaveclosebonds(friendships,commitments,sharedhousehold/familyresponsibilities,andromanticattachments)withthepersonreceivingcare.Aperson’sfamilyincludesallthosewhomthepersonidentifiesassignificantintheirlife(e.g.,partner,children,caregivers,andfriends)(RegisteredNursesAssociationofOntario,2015).

BSITTCriticalElements&GuidingChecklist-2019 �

•ReportBackground

what is a Transition?Inthecontextofthisreport,transitionsrefertoasetofactionsdesignedtoensurethesafeandeffectivecoordinationandcontinuityofcareasapersonexperiencesachangeinphysicallocation.Alltransitionsshouldbefacilitatedbasedonacomprehensivecareplanandtheavailabilityofwell-trainedpractitionerswhohavecurrentinformationaboutthepatient’streatment/caregoals,preferences,andhealthorclinicalstatus.Theyincludelogisticalarrangementsandeducationofthepersonandtheirfamily,aswellascoordinationamongthehealthprofessionalsinvolvedinthetransition.Inthisreport,supportingtransitionsspecificallyintoLTCistheprimaryfocusinordertohighlightspecificcriticalelementsthatareuniquetothisoftencomplextransition.

About the Behavioural Support Intregrated Teams (BSIT) CollaborativeTheBehaviouralSupportIntegratedTeams(BSIT)CollaborativeisapartofOntario’sBestPracticeExchangeandsupportedbyBSOandbrainXchange.Itsoverarchinggoalistobringforwardemergingandbestpracticesrelatedtofacilitatingsafe,successfulandsustainabletransitionsacrosssectorsforindividualswithoratriskforresponsivebehaviours/personalexpressions.TheBSITCollaborativeismadeupofagroupofhealthcareprofessionals,leadersandindividualswithlivedexperiencewhomeetonamonthlybasisto:

• Identifythecriticalelementsthatenablesuccessfultransitionsofvarioustypes;usingacombinedteamapproachacrosssectorsandacrossprovidersfromtheperspectiveofpersonswithlivedexperienceandproviderswithinhealthcareteams.

BSIT Collaborative membersAnintegralpartoftheBSITCollaborativeistheparticipationandcontributionsofindividualswithLivedExperience.InadditiontomemberswithLivedExperience,thefollowingorganizationsarerepresentedwithinthecollaborative:

AlbertaHealthServices

AlzheimerNiagaraRegion

AlzheimerSocietyChathamKent

BaycrestHealthSciences

BehaviouralHealthServicesThunderBay

BSO-CentralEast

BSO-CentralWest

BSO-ErieSt.Clair

BSO-HNHB

BSO-Central

BSO-SouthEast

BSO-SouthWest

BSO-MississaugaHalton

•

•

•

•

•

•

•

•

•

•

•

•

•

CentreforEducationandResearchonAgingandHealth(CERAH)

CMHAWaterlooWellington

FamilyCouncilsOntario

HomeandCommunityCare(CentralEast)

HuronPerthHealthcareAlliance

LOFTCommunityServices

NorthBayRegionalHealthCentre

OntarioAssociationofResident’sCouncils(OARC)

ProvidenceCareBehaviouralSupportServices

SchlegelVillages

St.JosephHealthcareLondon

SunnybrookHealthSciencesCentre

•

•

•

•

•

•

•

•

•

•

•

•

BSITTCriticalElements&GuidingChecklist-2019 �

Behavioural Supports Ontario, 2011TheBSO provincial frameworkwasdevelopedasacatalysttorealignandenhancecareforolderadultswithresponsivebehavioursandtheircarepartners.Itisbasedonthreefoundationalpillars:

Pillar1: Systemcoordinationandmanagement(coordinatedcross-agency,cross-sectoralcollaborationandpartnerships)Pillar2:Integratedservicedelivery(interdisciplinaryoutreachandsupportacrosstheservicecontinuum)Pillar3:Knowledgeablecareteamandcapacitybuilding(strengthencapacityofserviceproviders,olderadultsandfamiliesthrougheducationandcontinuousqualityimprovement).

•

•

•

RELEvAnT ThEORETICAL fRAmEwORkSThefollowingframeworkswereselectedtoserveasthekeyframeworkstoinformthedevelopmentoftheBehaviouralSupportIntegratedTeamsTransitions(BSITT)Model.

Saint Elizabeth, 2016Person and family-centred careisanapproachthatacknowledgesthatthosereceiving care, their family, and theircare providers all bring expertise andexperiencetotherelationship.Assuch,this approach is essential in ensuringthat care reflects a person’s individualneedsandgoals.

APersonandFamily-CentredApproach:Focusesonthewholepersonasauniqueindividualandnotjustontheirillnessorcondition.Placesthepersonandtheirfamilyatthecentreoftheircare.Putsthepersonandtheirfamilyattheheartofeverydecisionandempowersthemtobegenuinepartnersintheircare.Fostersrespectful,compassionateandculturallyappropriatecarethatisresponsivetotheneeds,values,beliefs,andpreferencesofthepersonandtheirfamily.Supportsmutuallybeneficialpartnershipsbetweentheperson,theirfamilyandhealthcareproviders.Shiftsprovidersfromdoingsomethingtoorforthepersontodoingsomethingwiththeperson.Ensuresthatservicesandsupportsaredesignedanddeliveredinawaythatisintegrated,collaborative,andmutuallyrespectfulofallpersonsinvolved.

•

•

•

•

•

•

•

•RelevantTheoreticalFrameworks

ministry of health & Long-Term Care, 2015Patients First: Action Plan for Health CareFrameworkisanOntariotransformationalhealthcarestrategy.TheFrameworkisbasedon4keypriorities:

Protect:protectuniversalpublichealthcaresystem–makingdecisionsbasedonvalueandqualityAccess:improveaccess–providingfasteraccesstotherightcare;andConnect:deliveringbettercoordinatedandintegratedcareinthecommunity,closertohomeInform: supportpeopleandpatients–providingtheeducation,informationandtransparencytheyneedtomaketherightdecisionsabouttheirhealth.

1.

2.

3.

4.

BSITTCriticalElements&GuidingChecklist-2019 �

•Puttingitalltogether:HowdotheFrameworksConnect?

PuTTInG IT ALL TOGEThER: hOw dO ThE fRAmEwORkS COnnECT?

The BSO Integrated Teams Transitions (BSITT) model

TheBSOIntegratedTeamsTransitions(BSITT)Modelaimstoserveasabestpracticetoimprovethewaypeopleaccesssafequalitycareastheymoveacrossdifferentcaresettingsanddifferentcareproviders.Itisgroundedonthefoundingprinciplesofpersonandfamily-centredcare,theoriginalBSOFrameworkforCareandthePatientsFirstActionPlan.Itenvisionsanintegratedhealthsysteminwhichprovidersacrossallsectors-long-termcare,acutecare,primary/homeandcommunitycare-arecoordinatedandcollaborativelyworktogether.Theyactivelyinvolvetheolderpersonwithcomplexbehaviouralhealthneedsandtheircarepartnerstoprovidehighqualitycareacrosssectorsandacrossthediseasecontinuum.BSITTisahealthmodelpremisedonthebeliefthat‘teamssupportingteams’incollaborativetransitionalcareequalsbettercareandhealthoutcomes,bettervalueandloweredrisk.Improvingthequalityoftransitionalcarerequiresanintegrated,personandfamily-centred,plannedapproachtocare.Thisnecessitatescross-sectorinterprofessionalteamsworkingtogetherasakeydrivertoimprovetimelyaccesstotherightcarefromtherightproviderclosertohome.

BSITTCriticalElements&GuidingChecklist-2019 �

•UsingtheBSITTModeltoDevelopaTransitionsintoLTCGuidingChecklist

Inadditiontothehostingofconversationsbasedonthethreetimeframes,multipleperspectiveswerealsotakenintoconsiderationinordertoensurethattheendproductwouldreflecttheneedsoftheperson,theirfamilycarepartner(s)andprofessionalcarepartnersatbothendsofthetransition.

TheidentifiedcriticalelementsforsupportingcomplextransitionsintoLTCatallstageswere:

• InvolvementofthepersonandtheirSubstituteDecisionMaker/Familyateachstageofthetransition;

• Communicationandinformationsharingbetweenthe‘sendingsite’andthe‘receivingsite’;

• Developmentofanindividualizedtransitionplanwhichincludestheperson’spreferences,goals,identifiedresponsivebehaviours/personalexpressionsandstrategiestoreduceincidenceofbehaviours/expressions;and

• IdentificationofaLeadforeachstageofthetransitionwhowillactastheprimarycontactformatterspertainingtothetransitionandinitiateactivitiestosupportthetransition.

Followingthesurfacingofthesecriticalelements,theprimaryfocusoftheCollaborative’sdiscussionswastoidentifyhowthesecriticalelementshavebeenorcouldbesuccessfullyactionedintheOntariocontext.Activitiesthatweredeemedapromisingorbestpracticewerethengroupedbytimeframe(i.e.,before,duringorafterthedayoftransition)andthentransformedintoaguidingchecklistforeasiertranslationofknowledgeintopractice.EachoftheelementsincludedintheguidingchecklistisassociatedwithoneormoreofthethreecomponentsoftheBSITTModel.ThisalignmentisdemonstratedinAPPENDIX A.

Trialing the Checklist

Followingthecreationofadraftchecklist,fivepilotsitesvolunteeredtotrialthechecklistwithfuturepatientswhowouldbesoonbetransitioningfromeithercommunityorhospitalintoLTC.Feedbackfromthepilotsiteswascollectedviaanonlinesurvey,directlyontheformand/orduringregularlyscheduledCollaborativemeetings.FeedbackfromthesiteswasthenincorporatedintothefinaldocumenttoensurethattheactivitiesincludedwererelevanttocurrentpracticesamongstteamssupportingtheBSOpopulation.

using the BSITT model to develop a Transitions into LTC Guiding Checklist

Identification of Critical Elements to support Transitions into LTC

TheBSITTModelwasusedtoframediscussionsrelatedtocriticalelementsforsupportingtransitionsintoLTC.Followingthedevelopmentandpresentationofthemodel,Collaborativemembersengagedinaknowledgeexchangeofcriticalelementsthatarenecessaryforsupportingaperson’sjourneyofmovingfromCommunityand/orHospital(i.e.,acutecare)intoLTC.Discussionspertainingtothesurfacingoftheseelementswereseparatedintothreetimeframes:

Before Transitioning into LTC

On the day of the Transition

following the Transition

BSITTCriticalElements&GuidingChecklist-2019 �

Case Study Example: Using the Checklist

Thefollowingcasestudywassubmittedbyoneofthepilotsiteparticipants;demonstratingtheuseofthechecklisttosupportatransitionfromthecommunityintoLTC:

Patient is a 74 year old female with primary Parkinson’s disease and mild dementia who was followed by our Seniors Mental Health Consultative Service and was assessed by our Care of the Elderly physician. The patient’s spouse, who has a diagnosis of Lewy Body Dementia, was deemed ‘crisis for long term care’ due his frequent attempts to leave their home. He was placed initially and she was then deemed ‘crisis’ for spousal reunification at the LTC home that he moved into.

After her spouse moved in, I utilized the before a bed offer is made section of the BSIT checklist which promotes overall preparedness for patient/family. As the identified lead for this stage of supporting the transition, I met with the patient and her family to complete a concise transitional behavioural care plan which focused on the patient’s care preferences, capabilities and person centred strategies/interventions. I also provided information both verbal and written, as suggested by the checklist, regarding the upcoming transition. We were expecting a quick bed offer and therefore at the family meeting we also discussed transportation arrangements, items to bring, the admission paperwork process and the importance of bringing over the counter medications that the patient was taking regularly (Voltaren and Advil for pain) to have them ordered by the receiving facility. Once the bed offer was receivedI liaised with the in-house BSO team at the LTC home and shared a copy of the completed transition plan to the receiving facility as the patient previously signed consent to share personal health information.

As the identified Leadon the day of the transition, I linked with the LTC home team to review the transition care plan to ensure the staff were familiar with patient’s preferences and care needs. This patient was willing to move, and was looking forward to being reunited with her spouse, which was especially helpful as we did not have to plan for scripting or redirection strategies.

A few days after the transition, I visited the LTC home and met with the embedded BSO team as well as checked in with the new resident. I linked with the physiotherapy and recreation therapy teams to review the new resident’s needs and advocate for involvement in their programs. I also spoke with family to provide an update and to follow up regarding any of their questions or concerns. Ultimately, the resident had a successful transition to LTC and she and her family felt well prepared and supported throughout.

Overall, the checklist helped to flag me to complete action items and to consider various resources and options to help support a seamless transition. Not all actions are required for every transition, depending on the patient/family/level of cognitive impairment, however it serves as a guide for staff to support best practices in transitional care support. It also helps to promote enhanced communication between care providers to ensure the timely transfer of key person centred information and to support the family through a very stressful time as care partners.

•UsingtheBSITTModeltoDevelopaTransitionsintoLTCGuidingChecklist

BSITTCriticalElements&GuidingChecklist-2019 �0

GuIdInG ChECkLIST: Supporting Transitions from Acute/Community into Long-Term Care (LTC)

BehaviouralSupportIntegratedTeams(BSIT)Collaborative

ThepurposeofthisGuidingChecklististoprovideasetofactivitiestoguideteamsinactioningcriticalelementsforsupportingsuccessfulandsustainabletransitionsforolderadultspresentingwith,oratriskfor,responsivebehaviours/personalexpressionsastheymovefromeithercommunityorhospitalintoLTCHomes.TheactionslistedintheguidingchecklistcapturepromisingandbestpracticesthathavebeensuccessfullyimplementedatbothsmallandlargescalesacrossOntarioforfacilitatingcomplextransitions.Inadditiontousingthechecklisttofacilitatecomplextransitions,itmayalsobeusedinqualityimprovementactivitiesaimedatimprovingtransitionsintoLTCandtoaidintheselectionofrelevantprovincial/regionaltoolsandresourcestoimprovecomplextransitions.

Thecriticalelementsforsupportingtransitionsfromcommunity/acutecareintoLTCinclude:theinvolvementofthepersonandtheirSubstituteDecisionMaker/Familyateachstageofthetransition;communicationandinformationsharingbetweenthe‘sendingsite’andthe‘receivingsite’;thedevelopmentofanindividualizedtransitionplanwhichincludestheperson’spreferences,goals,identifiedresponsivebehaviours/personalexpressionsandstrategiestoreduceincidenceofbehaviours/expressions;andtheidentificationofaLeadforeachstageofthetransitionwhowillactastheprimarycontactformatterspertainingtothetransitionandinitiateactivitiestosupportthetransition.

GiventhattheidentifiedLeadmaychangethroughoutthetransitionfromoneorganizationtoanotheroroneteammembertoanother,the Guiding Checklist includes a space whereby the Lead can be identified.Inthisspace,Checklistusersmayidentifyaspecificpersonororganizationthatwillactastheprimarycontactandinitiatorofsupportingactionsateachstageofthetransition(e.g.Home&CommunityCareCoordinator,TransitionsClinician,Geriatric/SeniorsMentalHealthClinician,BSOEmbedded/MobileSupportTeamMemberetc.).

Inusingthechecklisttosupportanindividualizedtransition,itisessentialtonotethattheintentionofthischecklistisforittobeusedasaguideandtherefore,itisnotnecessarytocompleteallitemsinthechecklist,nortocompletethemintheorderlistedinordertofacilitateasuccessfultransition.

•GuidingChecklist

BSITTCriticalElements&GuidingChecklist-2019 ��

PART A-1: Before Transitioning into LTC

Before a Bed Offer is madeTeam Lead name: Contact Information:

Actions for Team Lead to consider in initiating with Team members and other health Service Providers

Actions for Team Lead to consider initiating with Person and Sdm/families & Resources to provide

Developandimplementatransitionalbehaviouralcareplanincollaborationwiththeperson,SubstituteDecisionMaker(SDM)/Familyandothercommunitycareproviders.ConsiderinterventionsthatwillalsobeimplementableonceinLTC.Ensurecommunitycareproviderswithincircleofcareareawareofcompletedpersonhoodtoolandbehaviouralcareplan,includingwhereinformationcanbefoundandhowtousetheinformation.

Compileapersonhoodtoolsuitableforthecommunitysector.Resources:GeneralLTCHomePamphlets,Photos&LinkstoVideosOnlineResources:LTCOverview&MovingintoLTCChecklistVisitLTCHomesbeingconsideredandconsiderbringingthisLTCInspectionChecklist.ConsidercoachingtheSubstituteDecisionMaker(SDM)/otherfamilymembersonstrategiestodiscussthemoveintoLTCwiththepersonviaopendialogue.Ifrefusaltomoveisanticipated,considercoachingtheSDMonothereffectivestrategiessuchasnotannouncingthemove.Speakwithfriends/familymembersthatliveinLTCorhavealovedoneinLTCabouttheirexperiences.IfitisknownwhichLTChomethepersonwillmoveinto,considerareferraltothehome’sSocialWorkertodiscusscostandfinancinglogistics.

•GuidingChecklist-PartA

BSITTCriticalElements&GuidingChecklist-2019 ��

PART A-2: Before Transitioning into LTC

After the Bed Offer is AcceptedTeam Lead name: Contact Information:

Actions for Team Lead to consider in initiating with Team members and other health Service Providers

Actions for Team Lead to consider initiating with Person and Sdm/families & Resources to provide

DeterminewhowillactastheLeadinsupportingthetransitionattheLTCHome.LiaisewithLTCHomeLeadtodeterminewhetheraBSOTeamMember/otherstaffisabletovisitthepersonwhileinthecommunity/hospital.Organizeamultidisciplinarycareconferencewithdischargesettingtodiscusstheperson’sbehaviouralcareplanandwhathasworkedwellinthecommunity/hospital.Shareacopyofthecurrenttransitionalbehaviouralcareplan.Ensurefullcircleofcareisawareofplan,includingavailableinformationrelatedtotheperson’spersonhoodthatmayberelevantinthefirstfewdaysfollowingthemove.Considertheperson’spersonhoodandwhethermeetingwithacurrentresidentoftheLTCHome(in-person,viavideoconferenceoroverthetelephone)maybehelpful.Ifso,initiatethisprocesswiththeLTCHomeLead.Supportand/orleadthemedicationreconciliationprocess;includinginformationregardingrecentmedicationchangesrelevanttocurrentresponsivebehaviours.

Resource:MovingDayChecklistOfferameetingtodevelopaplanwiththeSDMforthemove.Completepaperworkthatcanbedoneinadvanceofthedayofthemove.Bringinfamiliaritemsintotheperson’sroombeforethedayofthemove.DetermineonwhatdayandtimethepersonisoftenattheirbestanddiscusspreferredtransitiontimeandrationalewiththeLTChome.Whileaholdingfeemaybecharged,abedcanbeheldfor5daysbeforeitisrequiredthatthepersonmovein.ConsidercoachingtheSDM/FamilyMembersonstrategiestodiscussthemove,includingtechniquestoaddressanticipatedreluctancesuchasscriptingorusingfiblets.DiscusswithSDM/FamilyMembersthepotentialofbringinganadditionalpersonalongsideonthedayofthemovetostaywiththepersonwhileSDMcompletespaperwork.Discusswhatstrategiesmaybehelpfulforleavingthehomefollowingthemove.

•GuidingChecklist-PartA

BSITTCriticalElements&GuidingChecklist-2019 ��

PART B: On the day of the Transition

Before Leaving to Travel to the LTC homeTeam Lead name: Contact Information:

Actions for Team Lead to consider in initiating with Team members and other health Service Providers

Actions for Team Lead to consider initiating with Person and Sdm/families & Resources to provide

ConfirmwiththeLTCLeadthattheyarepreparedandconfirmcontactdetailstobeprovidedtopersonandfamily.PlantohaveafamiliarfaceforboththenewresidentandfamilyuponarrivalattheLTCHome.

ReviewMovingintoLTCChecklist&MovingDayChecklist.Ensurepersonhastakenallnecessarymedicationandthatpainismanaged.EnsureadequatetimetotraveltoLTCHome,includingpotentialplannedstoppedrequiredtocomforttheperson.

After Arriving at the LTC homeTeam Lead name: Contact Information:

Actions for Team Lead to consider in initiating with Team members and other health Service Providers

Actions for Team Lead to consider initiating with Person and Sdm/families & Resources to provide

IntroducepersonandfamilytoLTCBSOStaffMember/TeamScheduletouchpointswithSubstituteDecisionMakerbasedonLTChome’spolicies.

RecommendtoSDMwhenmightbethebesttimetocompletefinalpaper(e.g.,whenpersonisengagedinanactivity,havingameal,etc.)Resource:Residents’BillofRightsResource:(ifavailable)one-pageresourceconsistingofnames,titlesand/orphotosofkeyLTCcontacts,includingtheAdministrator,DirectorandAssociateDirectorofCare,Residents’CouncilRepresentative,FamilyCouncilRepresentative,BSOStaff,etc.

•GuidingChecklist-PartB

BSITTCriticalElements&GuidingChecklist-2019 ��

•GuidingChecklist-PartC

PART C: following the Transition In the first few days

Team Lead name: Contact Information:

Actions for Team Lead to consider in initiating with Team members and other health Service Providers

Actions for Team Lead to consider initiating with Person and Sdm/families & Resources to provide

ReviewtheTransitionalBehaviouralCarePlaninitiatedinthecommunityforadaptationintoLTC.ConsiderinitiatingaDOSand/orCMAItodeterminetheimpactofthetransition(i.e.,changeofenvironmentandsurroundings)hasimpactedthepresenceandseverityofbehaviours.RememberP.I.E.C.E.S.!Determinehowtobestcommunicateand/ordisplayinformationrelatedtotheresident’spersonhood.Ensurethatthestaffwhoaresupportingtheresidentreceiveinformationandtrainingonparticularapproachesandtechniquestobeusedwiththeresident.EncourageotherLTCstafftointroducethemselvestothenewresidentandwelcomethemtothehome(e.g.,activation,dietary,maintenance,etc.)EnsureResidents’CouncilLeaderisintroducedtonewresident.SuggestthatResidentCouncilLeaderprovidepersonwithacalendarofeventsandResidents’Councilmeetingschedule.Whenappropriate,encourageResidents’CouncilLeadertoestablisha‘buddysystem’withanotherresidentwithwhomthenewresidentmayhaveelementsofpersonhoodincommon.Prepareforfirst‘TouchPoint’Meeting5dayspostadmission;liaisewithotherLTCStaffMemberstogainacurrentstatusofthenewresident.

Resource:TipsforSettlinginReviewinformationonpersonhoodformtoensurethatitremainsaccurate;updatingnecessarysectionsbasedonperson’scapabilities,changeininterests,etc.EnsureFamilyCouncilLeaderisintroducedtoFamily/SubstituteDecisionMakerandisprovidedwithmeetingschedule.

following a few weeksTeam Lead name: Contact Information:

Actions for Team Lead to consider in initiating with Team members and other health Service Providers

Actions for Team Lead to consider initiating with Person and Sdm/families & Resources to provide

Monitortheresidents’responsivebehavioursovertimeusingP.I.E.C.E.S.andmodifythebehaviouralcareplanasneeded.Ensurestaffaremadeawareofchangesbeingmadetothebehaviouralcareplan.Prepareforsecond‘TouchPoint’6-12daysfollowingtheadmission;liaisewithLTCStaffMemberstogainacurrentstatusontheresident.DiscussdischargingofresidentfromCommunityCaseloadatthistime.

EnsureFamilyisawareofongoingsupportavailablethroughAlzheimerSocietiesandvariousOnlineGroups.

BSITTCriticalElements&GuidingChecklist-2019 ��

hYPERLInkEd RESOuRCES In ChECkLIST:

Part A-1: Before a Bed Offer is made:

•‘Personhoodtoolsuitableforthecommunitysector’BehaviouralSupportsOntarioLivedExperienceAdvisory(2018)Recommendationstoenhancetheuseofpersonhoodtoolstoimproveclinicalcareacrosssectors.Availableat:https://tinyurl.com/yxcb46mq

•‘LTCOverview’GovernmentofOntario(Apr2019)Long-termcareoverview.Availableat:https://tinyurl.com/y3jaop2u

•‘MovingintoLTCChecklist’AlzheimerSocietyofCanada(Nov2017)Findingtherighthome.Availableat:https://tinyurl.com/y2x3bs5w

•‘LTCInspectionChecklist’ConcernedFriends(2007)Longtermcarehomeschecklist.Availableat:https://tinyurl.com/y6koq6jc

Part A-2: After the Bed Offer is Accepted:

•‘MovingDayChecklist’AlzheimerSocietyofCanada(July2016)Handingmovingday.Availableat:https://tinyurl.com/y2rk9968

Part B: On the day of the Transition:

•‘MovingintoLTCChecklist’AlzheimerSocietyofCanada(Nov2017)Findingtherighthome.Availableat:https://tinyurl.com/y2x3bs5w

•‘MovingDayChecklist’AlzheimerSocietyofCanada(July2016)Handingmovingday.Availableat:https://tinyurl.com/y2rk9968

•‘ResidentsBillofRights’AdvocacyCentrefortheElderly&CommunityLegalEducationOntario(2008)Everyresident:billofrightsforpeoplewholiveinOntariolong-termcarehomes.Availableat:https://tinyurl.com/y3uwpv3l

Part C: following the Transition:

•‘TipsforSettlingin’AlzheimerSocietyofCanada(Aug2018)Tipsforsettlingin.Availableat:https://tinyurl.com/yysgmt7a

BSITTCriticalElements&GuidingChecklist-2019 ��

•APPENDIXA-CriticalElements’AlignmentwithBSITTModel

APPEndIX A

Critical Elements’ Alignment with BSITT model

Timeline Critical Element

Syste

m Co

ordin

ation

&

man

agem

ent

Integ

rated

Serv

ice de

liver

y: Int

ersec

toral

& In

terdis

ciplin

ary

know

ledge

able

Care

Team

s &

Capa

city B

uildin

g

Before a Bed Offer is made:

DiscusswithpersonandfamilywhytransitionintoLTCisnecessaryviaanopenandrespectfuldialogue. P P

Developandimplementatransitionalbehaviouralcareplanincollaborationwiththeperson,familyandothercommunitycareproviders.ConsiderinterventionsthatwillalsobeimplementableonceinLTC.

P P

Ensurecommunitycareproviderswithincircleofcareareawareofcompletedpersonhoodtoolandbehaviouralcareplan,includingwhereinformationcanbefoundandhowtousetheinformation.

P P

Resources:GeneralLTCHomePamphlets,Photos&LinkstoVideosOnline P

Resources: LTCOverview&MovingintoLTCChecklist P

VisitLTCHomesbeingconsideredandconsiderbringingthisLTCInspectionChecklist P

CallConcernedFriends(1-855-489-0146)todiscussLTChomesbeingconsidered.Thisorganizationcanprovideinformationrelatedtoinspectionreportfindingsoverrecentyears.

P P

Speakwithfriends/familymembersthatliveinLTCorhavealovedoneinLTCabouttheirexperiences. P

Compileapersonhoodtoolsuitableforthecommunitysector. P P

BSITTCriticalElements&GuidingChecklist-2019 ��

Timeline Critical Element

Syste

m Co

ordin

ation

&

man

agem

ent

Integ

rated

Serv

ice de

liver

y: Int

ersec

toral

& In

terdis

ciplin

ary

know

ledge

able

Care

Team

s &

Capa

city B

uildin

g

After the Bed Offer is Accepted:

Reinitiateconversationregardingthenecessityofthetransitionwiththepersonandtheirfamily.Consideranychangestocapacity,cognitionandcapabilities.*DeterminewhowillactastheLeadinsupportingthetransitionattheLTCHome.

P

DeterminewhowillactastheLeadinsupportingthetransitionattheLTCHome. P

LiaisewithLTCHomeLeadtodeterminewhetheraBSOTeamMemberisabletovisitthepersonwhileinthecommunity. P

Organize a multidisciplinary care conference with discharge setting to discuss the person’s behavioural care plan and what has worked well in the community/hospital.

P P

Share a copy of the current transitional behavioural care plan and modify if necessary. P

Considertheperson’spersonhoodandwhethermeetingwithacurrentresident(in-person,viavideoconferenceoroverthetelephone)maybehelpful.Ifso,initiatethisprocesswiththeLTCHomeLead.

P P

Ensuremedicationreconciliationprocessiscompleted. P

Resource:MovingDayChecklist P

Completepaperworkthatcanbedoneinadvanceofthedayofthemove. P

Bringinfamiliaritemsintotheperson’sroombeforethedayofthemove. P

DetermineonwhatdayandtimethepersonisoftenattheirbestanddiscusspreferredtransitiontimeandrationalewiththeLTChome.Whileaholdingfeemaybecharged,abedcanbeheldfor5daysbeforeitisrequiredthatthepersonmovein.

P P

•APPENDIXA-CriticalElements’AlignmentwithBSITTModel

BSITTCriticalElements&GuidingChecklist-2019 ��

Timeline Critical Element

Syste

m Co

ordin

ation

&

man

agem

ent

Integ

rated

Serv

ice de

liver

y: Int

ersec

toral

& In

terdis

ciplin

ary

know

ledge

able

Care

Team

s &

Capa

city B

uildin

g

Before Leaving to Travel to the LTC home:

ConfirmwiththeLTCLeadthattheyarepreparedandconfirmcontactdetailstobeprovidedtopersonandfamily. P P

PlantohaveafamiliarfaceforboththenewresidentandfamilyuponarrivalattheLTCHome. P

DiscusswithSubstituteDecisionMakerandFamilypotentialindicationsforwhenmaybethebesttimeandstrategiestoleavetheLTCHomeoncethepersonhasmovedin.

P P

Review Moving into LTC Checklist & Moving Day Checklist P

Ensure person has taken all necessary medication and that pain is managed. P

EnsureadequatetimetotraveltoLTCHome,includingpotentialplannedstoppedrequiredtocomforttheperson. P

After Arriving at the LTC home:

IntroducepersonandfamilytoLTCBSOStaffMember/Team. P

ProvideLTCLeadwithcompletedpersonhoodtooland/orensurethatStaff(includingPrimaryPersonalSupportWorker)arefamiliarwiththeperson’sbackground,interests,likesandpreferences.

P P P

ScheduletouchpointswithSubstituteDecisionMaker,LTCLeadandBSOStaffMember/Team(1)5daysfollowingthemove;(2)within6-12weeksfollowingthemove;and(3)6monthsfollowingthemove.

P P P

RecommendtoSubstituteDecisionMakerwhenmightbethebesttimetocompletefinalpaper(e.g.,whenpersonisengagedinanactivity,havingameal,etc.)

P P

Resource:Residents’BillofRights P P

Resource:(ifavailable)one-pageresourceconsistingofnames,titlesand/orphotosofkeyLTCcontacts,includingtheAdministrator,DirectorandAssociateDirectorofCare,Residents’CouncilRepresentative,FamilyCouncilRepresentative,BSOStaff,etc.

P

•APPENDIXA-CriticalElements’AlignmentwithBSITTModel

BSITTCriticalElements&GuidingChecklist-2019 ��

Timeline Critical Element

Syste

m Co

ordin

ation

&

man

agem

ent

Integ

rated

Serv

ice de

liver

y: Int

ersec

toral

& In

terdis

ciplin

ary

know

ledge

able

Care

Team

s &

Capa

city B

uildin

g

In the first few days:

ReviewtheTransitionalBehaviouralCarePlaninitiatedinthecommunityforadaptationintoLTC.ConsiderinitiatingaDOSand/orCMAItodeterminetheimpactofthetransition(i.e.,changeofenvironmentandsurroundings)hasimpactedthepresenceandseverityofbehaviours.RememberP.I.E.C.E.S.!

P P

Determinehowtobestcommunicateand/ordisplayinformationrelatedtotheresident’spersonhood. P P

Ensurethatthestaffwhoaresupportingtheresidentreceiveinformationandtrainingonparticularapproachesandtechniquestobeusedwiththeresident.

P P

EncourageotherLTCstafftointroducethemselvestothenewresidentandwelcomethemtothehome(e.g.,activation,dietary,maintenance,etc.)

P P

EnsureResidents’CouncilLeaderisintroducedtonewresident.SuggestionsthatResidentCouncilLeaderprovidepersonwithacalendarofeventsandResidents’Councilmeetingschedule.Whenappropriate,encourageResidents’CouncilLeadertoestablisha‘buddysystem’withanotherresidentwithwhomthenewresidentsmayhaveelementsofpersonhoodincommon.

P P

Prepareforfirst‘TouchPoint’Meeting5dayspostadmission;liaisewithotherLTCStaffMemberstogainacurrentstatusofthenewresident. P P

Resource: TipsforSettlingin PReviewinformationonpersonhoodformtoensurethatitremainsaccurate;updatingnecessarysectionsbasedonperson’scapabilities,changeininterests,etc.

P

EnsureFamilyCouncilLeaderisintroducedtoFamily/SubstituteDecisionMakerandisprovidedwithmeetingschedule. P P

following a few weeks:

Monitortheresidents’responsivebehavioursovertimeusingP.I.E.C.E.S.andmodifythebehaviouralcareplanasneeded.Ensurestaffaremadeawareofchangesbeingmadetothebehaviouralcareplan.

P P P

Prepareforsecond‘TouchPoint’6-12daysfollowingtheadmission;liaisewithLTCStaffMemberstogainacurrentstatusontheresident.DiscussdischargingofresidentfromCommunityCaseloadatthistime.

P P

EnsureFamilyisawareofongoingsupportavailablethroughAlzheimerSocietiesandvariousOnlineGroups. P P

•APPENDIXA-CriticalElements’AlignmentwithBSITTModel