Introduction In 2012, Dr. Samir K. Sinha, the Provincial Lead for the Ontario Senior’s Strategy called for a comprehensive provincial geriatric strategy. This important work was the catalyst for Independence, activity and good health, Ontario’s action plan for seniors, 2013. Ontario Shores has taken great strides to create a service delivery model that aligns with the direction of the Ontario Senior’s Strategy and embrace and embed the Quality Standards for Behavioural Symptoms of Dementia – care for patients in hospitals and residents in long term care homes as published by Health Quality Ontario, 2016. We have achieved success by modifying our care environment, our model of care and the education provided to our staff, patients and families and community partners. Care Environment The evidence based direction on creating a geriatric dementia friendly space came from Code Plus, Physical Design Components for an Elder Friendly Hospital, 2007. We undertook a large scale renovation that improved lighting, flooring and walls, hallways, doors and windows, handrails, wayfinding and signage, acoustic considerations and colour choice to aid with decreasing agitation. Ceiling lifts were added to all patient rooms, doors were fixed so they remain open and a walking path was created around the open nursing station to decrease confusion and frustration for wandering patients. At Ontario Shores, Co-Design is a part of our culture. As such, patients, former patients and their family members attended focus groups and completed surveys to relay what was important to them in a new design. Model of Care The Quality Standards for the Behavioural Symptoms of Dementia care for patients in hospitals and residents in long-term care homes address 14 key areas identified as having significant potential for quality improvement in the care people living with dementia and symptoms of agitation or aggression in Ontario. Below is a description of the 14 Quality Standards and how Ontario Shores is ensuring their viability. Quality Standard 1: Comprehensive Assessment Completing comprehensive assessments are a part of routine practice at Ontario Shores. This is facilitated by our standard intervention set, recurring assessments and re-assessment order. Below is our Dementia Assessment Order & Standard Intervention Set. Quality Standard 2: Individualized Care Plan We have created “My Care Plan: Dementia”. It is a comprehensive patient-centered plan of care which is documented by inter-professional team, including physicians. It is updated and reviewed QSHIFT by nursing and includes initial and most recent scores from comprehensive assessment to track progress and identify areas requiring further care planning. It is reviewed by inter-professional team Q28D during patient conferences and is tracked in our: “Conference Report”. This plan is reviewed with caregivers/SDMs during family meetings which occur within 14 days of admission; this is tracked in our physician Family Meeting-Dementia note. This care plan is also shared with patients/caregivers/SDMs via our HealthCheck Patient Portal for those who have enrolled. Quality Standard 3: Individualized Non-Pharmacological Interventions Non-pharmacological interventions are offered as a part of routine practice by the inter-professional team and are discussed with caregivers/SDMs during family meetings and tracked within the physician Family Meeting-Dementia note. Non-pharmacological interventions incorporated into the plan of care are documented in the My Care Plan: Dementia. Quality Standards 4-6: Indications for Psychotropic Medications/ Titrating and Monitoring Psychotropic Medications /Switching Psychotropic Medications The Neuropsychiatric Inventory is documented Q7Days to assess agitation & aggression as well as risk of harm to themselves and others, level of distress is also indicated within the assessment. Physicians are following CAMH’s medication algorithm for treatment of people living with dementia; this includes beginning at a low dose with gradual increases. Target symptoms are monitored and documented with the Neuropsychiatric Inventory, additionally, physicians are monitoring the scores of the Neuropsychiatric Inventory and using a Dementia Agitation & Aggression Note template to document pharmacological plan. Medications are reviewed at minimum Q28Days in patient conferences; this is tracked in the Conference Report. Within patient conferences the inter-professional team tracks symptom improvement, considers discontinuing medications and switching to alternatives; this is also tracked in the Conference Report. Quality Standard 8: Mechanical Restraint Mechanical restraints are seldom used in our geriatric programs; additional strategies are implemented with the target of zero-restraints for patients with dementia. If a physician places a mechanical restraint order for patient with a diagnosis of dementia, a conflict message will appear and require the physician to override the conflict. Staff on the Geriatric Dementia Unit participated in case based education on restraint reduction in which they reviewed the previous year’s incidents of restraints and determined alternative approaches that could have been implemented. Ontario Shores Restraint (Chemical & Mechanical) and Seclusion Policy and Procedure was updated to include evidence on the contraindication of using a mechanical restraint for agitation or aggression in patients with dementia. Quality Standard 9: Informed Consent The inter-professional team obtains informed consent from the patient/SDM at all points of care as a routine practice. Consent is documented using Ontario Shores’ consent for treatment document. Physicians are prompted to obtain informed consent during the family meeting and this is documented on the Family Meeting-Dementia note. Quality Standard 10: Specialized Interprofessional Care Team Our specialized care team consists of a core team involved daily in the patients care; additionally, referrals are sent to other health care providers for specialized assessments and/or treatment planning. Quality Standard 11: Provider Training and Education The majority of the staff on our geriatric units have received P.I.E.C.E.S. training and this is offered regularly to new hires. Additionally, Ontario Shores is developing scenario based eLearning modules to cover the topics outlined in the quality statement. Staff will be presented with a scenario (can be with a patient or caregiver or inter-professional team) and 4 response options; depending on the response chosen the situation will follow a specific path leading to either a positive or negative outcome. Resources and helpful web links will be embedded throughout the module. Modules will be completed during Clinical Orientation for new hires. Quality Standard 12: Caregiver Training and Education Caregiver education occurs informally on a regular basis as clinically indicated; this is routine practice for our inter-professional team. Additionally, education is provided during the family meetings; this is documented by physicians using the Family Meeting-Dementia note. A comprehensive set of resources have been compiled on a caregiver resource webpage; physicians receive reminders in the family meeting module to refer caregivers to these resources. Quality Standard 13: Appropriate Care Environment Patients admitted to Ontario Shores with a diagnosis of dementia follow a 59-Day Length of Stay care pathway. This includes regular meetings and check-ins with referring source to ensure patient returns to referring location once behavioural symptoms have been successfully treated. We chose 59 days, as the Long-Term Care Homes Act of 2007, Section 138 (b) states that “in the case of a psychiatric absence, the length of the psychiatric absence does not exceed 60 days”. Above is the Integrated Care Pathway for the Geriatric Dementia Unit. As per Quality Standards and Clinical Practice Guidelines, frequent meetings occur throughout the patients stay on GDU. Discharge planning occurs proactively and highly involves the referral source and community supports. Once discharged into the community, our patients and our community partners continue to be supported by Ontario Shores through the Psychogeriatric Resource Consultation Program and the Geriatric and Neuropsychiatry Outpatient Services (GNOS). Follow up after discharge is a key success factor in this model. Forty Eight percent of the patients on GDU come to us from LTC facilities. The second highest referral source at 23% is community general hospitals and upon discharge, over 60% of our patients are transferred to a LTC facility. Engaging our stakeholders, including patients and their families, is therefore paramount when changes to care models are being considered. Ontario Shores collaborated and discussed the new model with all 58 long term care facilities in the Central East LHIN, Lakeridge Health and North York General Hospital. A Memorandum of Understanding was created along with an accompanying take-back agreement, signed by both Ontario Shores and the referring organization. The Memorandum of Understanding clearly outlines that Ontario Shores GDU will provide specialized services to meet the mental health needs of patients with dementia and challenging behaviours that we strive to effectively treat GDU patients in a manner that the majority will transition directly home or other destination; hence those patients transitioning back to acute care is projected to be the exception. Quality Standard 14: Transitions in Care Pre-discharge meetings are held 1-2 weeks prior to discharge to provide approaches to care, updated plan of care, treatment history, potential triggers and contact information of our inter-professional team. Physician discharge summaries are auto-faxed to receiving providers on completion. Social workers track discharge process using Discharge Checklist and ensure appropriate information is shared with the receiving providers. My Care Plan: Dementia is printed by the inter-professional team and provided to receiving providers at transfer of care. Additionally, receiving providers are able to enroll in our HealthCheck Patient Portal to access the most up-to-date plan of care. Data The new mode of care began in September 2017, the re-designed GDU opened on February 9, 2017. The charts above clearly illustrate that GDU has had a drastic decline in active ALC patients and ALC days since September 2017. It is important to note that this new model of care did not lead to a change in re-admission rates. Outcome Measures RAI-MH The interRAI Mental Health (MH) Assessment System is a comprehensive standardized instrument for evaluating the needs, strengths and preferences of adults with mental illness in in-patient psychiatric settings. This instrument allows for assessment of key domains of function, mental and physical health, social support and service use. To decipher if our patients were clinically improved upon discharge, we studied the percentage of patients with dementia and symptoms of agitation or aggression who experienced an improvement in behavioural symptoms between admission and discharge. Our patients showed an overall decrease in symptoms of agitation or aggression upon discharge. Neuropsychiatric Inventory The Neuropsychiatric Inventory (NPI) was developed by Cummings et al. (1994) to assess dementia-related behavioral symptoms which they felt other measures did not sufficiently address. The NPI originally examines 12 sub-domains of behavioral functioning: delusions, hallucinations, agitation/aggression, dysphoria, anxiety, euphoria, apathy, disinhibition, irritability/lability, and aberrant motor activity, night-time behavioral disturbances and appetite and eating abnormalities (Cummings, 1997). The NPI is administrated to caregivers of dementia patients. The caregiver is asked to rate the frequency and severity of the behaviors of that domain based on the most abnormal behavior revealed in the subquestions. Care giver distress is also rated for each domain. Upon study, the NPI is reliable and valid. When studying patients discharged from GDU on or after September 2016, and compairing the highest NPI score to the last NPI score before discharge, we found that the majoirty of our dischargted paitents throughout 2016/17 are showing significant improvement. For both of the two outcome measures above, it is important to note that there is no difference before and after November 2016, when we launched the new GDU and model of care. This indicates that although our patients are staying with us for a shorter duration, there clinical outcomes have not been compromised.
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