Regional Workshop Vancouver, BC June 5, 2014 Breakfast Sessions - PowerPoint PPT Presentation

Your Objectives • What questions would you like to have answered by the end of today? One Question per Post it

Faculty Presentation Johanna Trimble Jane Devji

CLeAR Regional Workshop Lower Mainland June 5, 2014 Johanna Trimble Public Member: Call for Less Antipsychotics in Residential Care (CLeAR) Faculty . Shared Care Polypharmacy Initiative Polypharmacy Reduction Initiative, Fraser Health Authority

Fervid’s “family care team” Johanna, Dale, Fervid and Kathie

Fervid experienced a precipitous mental decline after entering the Care Centre -- we suspected new medications

“Assume that any new symptom you develop upon starting a new drug may be caused by the drug. If you have a new symptom, psychiatric or otherwise, report it to your doctor” www.worstpills.org

Delirium • A temporary, reversible change in consciousness, attention, thinking, memory • acute condition • unpredictable course • subtle symptoms may be unrecognized or confused with dementia

“Ask about changes in your loved one even if no one asks.” http://thisisnotmymom.ca

Fervid’s drug interaction: Seratonin Syndrome ( citalopram, an SSRI antidepressant & tramadol, a pain drug) Seratonin Syndrome Symptoms 1. Cognitive/behavioral: confusion, agitation, lethargy, and coma. 2. Autonomic instability: rapid heart rate, sweating, rise in temperature. 3. Neuromuscular: twitching a muscle or group of muscles, coordination problems. Some of these - noticed by the family - are also symptoms of UTI for which many courses of antibiotics were given, resulting in c. difficile

Medication Review: The family insisted on a meeting and drugs were de-prescribed. Fervid returned to normal cognitively. Fervid over-medicated Fervid back to normal

But…Fervid had lost too much function to return to independent living

We learned a lot from Fervid in her remaining time with us (4 yrs)

“I’ll always take care of you. It sustains me as much as it sustains you. I expect to be a support person all my life, which may not be long, but it’s here to stay.”

The meaning for all of us and our society… Fervid died blessing us. If she had died 4 years earlier of a drug interaction, she would have died not even recognizing us. Include families and patients when planning care. Let’s give care which will allow our elders quality of life and a chance for a meaningful leave-taking for themselves and their loved-ones.

Death is not a medical issue, it is a human issue. This work matters.

SCC Polypharmacy Initiative “It’s (about) quality of life…for my residents. I've seen dramatic differences in the quality of their life when the burden of their medication is reduced...”

Fraser Health: Polypharmacy Reduction in Residential Care

Resources: http://www.rxfiles.ca/rxfiles/Modules/ltc/ltc.aspx

Resources: https://www.agingbraincare.org/tools

Dedicated to Fervid Trimble 1917 - 2008 A picnic in the garden with Fervid

Contact information: isyourmomondrugs@gmail.com

Delta View’s Journey from Drugs to Hugs Presented By Jane Devji, CEO

Removal of Restraints  Our restraint free journey began in 1988  I attended a workshop where the presenter taped three of my fingers on my non dominant hand together to demonstrate to me what a restraint would feel like  This experience inspired me to remove all Physical Restraints from the residents in our facility.  Our next step was, reducing Chemical Restraints from our facility by eliminating the use of PRN antipsychotic medications for behaviours.

Creative Solutions:  By removing restraints, residents were now more active and able to move freely.  We had to be creative about engaging residents with dementia.  Introduced — foot soaks and massages.  Walking program — we walked with the resident outdoors 3-4 times a day.  Incorporated daily activities such as car washing and gardening to give the residents a sense of purpose.  Introduced music therapy, where residents actively participated.  Incorporated Pet Therapy into daily living.

Creative Solutions continued  We began researching facility designs which would better support residents with dementia  (researched models from California, Ohio, Arizona)  We were inspired by the Corrine Dolan Center in Cleveland, Ohio which we based our designs on.  We designed our building to feature two 40 bed units with indoor/outdoor walking loops and expansive gardens around the facility.  (Delta View Habilitation Centre was created on 4 acres of land)

Outdoor Gardens

Delta View Habilitation Centre (DVH)  DVH Opened in July 1991 with a two day conference on Dementia  The conference featured four speakers including Dr. Lynn Beattie, who was the Head of the UBC Alzheimer’s Clinic, as well as Moyra Jones who was well known for creating the Gentle Care Philosophy.  Success of our event was reported in The Vancouver Sun, The Province and CTV News  This Media Coverage highlighted DVH to be a provider of exceptional Dementia Care

Stakeholder Support Our Success relied on attaining trust, belief and support from:  Families  Residents  Physicians  Staff  Surrounding Community

Family Support  To be successful, you must establish and maintain a therapeutic partnership with your families  Ensure there is open communication and transparency with families at all times  the first 72 hours are critical in establishing a solid foundation  We suggest you make proactive phone calls in both the morning, and evening to update and reassure the family on how their loved one is doing.  Discuss and identify what the Resident Needs and Goals are.  Example:  Want the resident to start walking within a month  Review the need for Current Medications  We created Family Support Group: “Friends of Delta View”  We trained staff to be responsive to family needs  We involve family members in Care Conferences, within six weeks of Admission, and Quarterly thereafter.

Your Resident…  We need to know Everything about our Residents  Obtaining Resident’s detailed “Life Story” helped us get to know the Resident on a personal level and understand his or her needs.  We created “My Day” for each resident with family assistance  Resident’s 24 hour day recorded hourly, which outlines Resident‘s preferences  Example: “I like to wake up at 7am and have my coffee and newspaper waiting for me when I have breakfast”

Physician Partnership  We had a good relationship with our physicians, who believed in our philosophy and supported us in reviewing and reducing unnecessary medications.

Staff Support  We needed staff who were caring, creative and flexible.  Staff needed to be resident centered, period.  We required nurses, who were willing to try something different and assist the residents in reducing anti- psychotic medication and manage withdrawal symptoms  We developed flexible routines accommodating the Resident needs and preferences, that still met licensing requirements.  Dr. Lynn Beattie was available on call to assist staff.  Moyra Jones provided Education to all Staff and Families on All Models of Gentle Care

Our Criteria for Admission  Exhibit inappropriate behaviours  High Elopement Risks  Obsessive Pacing  Extreme Paranoia  Excessive Behaviours  Overly Sedated/Medicated

Our first Days... • Initially, I was the only nurse on duty, admitting 15 Residents and communicating with their respective families • I learned a lot about the residents from the Families • By communicating regularly with the families I established unique and strong partnerships • Families were part of the solution on our Journey • Families supported our philosophy of first trying alternate non-pharmacological options before resorting to medications.

Created a Family Information Package  No Physical Restraints  Reduction in Chemical Restraints  What to expect on Admission and first three weeks  Behaviours and how to avoid getting into behaviours  Importance of Hydration and Nutrition  Use of Finger Foods  Regular Toileting and meeting Elimination Needs  Visiting Tips  Creating Comfort Tips for Behaviours or Anticipated Behaviours  Creating Moments of Joy and Memorable Moments Binder for Families to View when Visiting  Visiting other Residents and Encouraging them in their visit, rather than shooing them away

Tips on Therapeutic Relationships Prior to admission provide families with an understanding of our philosophy, always remember the grieving that takes place at  the time of placement. Keep admission day simple and low key. Enjoy a cup of tea with the new resident and family members.  Always phone the family the morning after admission to tell them how the first night went.  Keep them informed! Encourage phone calls. Initiate phone calls to an ailing care giver.  Set up a buddy system with another appropriate family member.  Encourage flexible visiting times and help them understand what is too little or too much for their loved one – (Depending on  adjustment of resident). Make a point of talking to every family member when they visit.  Provide an area for families to visit comfortably.  Help families feel comfortable on the unit and help them adapt to the behavior of other residents.  Always make time for a family member.  Remember a complaining family is a hurting family.  Encourage participation in family group (Friends of Delta View)  Involve family members in care planning.  Provide reassurance – re: appropriate clothing to bring in, lost articles, belongings sometimes shared with other residents.  Encourage participation in education sessions.  Help family understand that this is their unit and encourage participation in projects.  Share with families “ special moments ” that you have had or witnessed regarding their loved one, including  photographs Involve family members in special occasions. 

Resident Life Stories and “KFC”  “Resident’s Life Story” includes:  Early history  Personal Interests  Preferences  Things or Activities that provide comfort  Important Family Members  Important Dates in the Person’s Life  Hobbies and Interests  Favorite Music and Foods

KFC KNOW Me! FOCUS on Me and not on the Task! Who am I?—what are my likes and dislikes?   Provide Person Centered Gentle Care! What is my past history?   Understand Me . Am I experiencing loss of power and control ? What makes me happy?   Make eye contact with me & approach me from the front Understand my dementia and avoid blaming me for my behavior  Speak directly to me. Speak calmly, slowly and clearly Collaborate and Communicate with my Interdisciplinary T eam so   Position yourself at the same level as me you can provide me with the best care  Maintain PRIVACY , RESPECT & DIGNITY. I can only Include my family and friends in discovering who I am  process one thing at a time Know my strengths, and promote my sense of well being. What   Break tasks into steps are my triggers? (know MY supportive interventions)  Offer me choices Use behavior pattern record (ABC) to create and update my   I am unable to express feelings, needs and sensations care plan so it is always current  Understand that I have experienced many losses, including Recognize that all behaviors have meaning (verbal and non-  power and control of my personhood verbal)  Understand that I can’t change, but you can change Anticipate My Needs and Redirect Me  Ask: Am I… CALM & Safe Environment!   Speak to me in a calm manner using a normal tone Thirsty? Hungry?   Always maintain positive & effective teamwork when In pain? Constipated? Needing to go to the bathroom?  working with me Possibly suffering from delirium and/or an infection [i.e. UTI]?   Understand my emotions and help redirect me with positive Finding it too noisy? Assess my environmental triggers approaches   If I am anxious, provide reassurance and validate my feelings Needing more sleep? Tired? Bored? Sad? Lonely?   Provide personal space as needed Invasion of Personal Space   Never argue or insist : “If you don’t insist, I won’t Feeling Anxious and Scared?  resist!” Feeling Depressed?  Experiencing Mental or Medical Illness? 

Our Results...  We were successful in reducing all medications except for Lithium  We reduced the use of “Haldol”  Unchartered Territory at the time  We became known as the Pioneers in Reducing Medications  We reviewed and began reducing some medications within 24hours of Admission  We did not use PRN antipsychotic medication  We withheld medication, if the resident was too drowsy  By End of 2-3 weeks, we started seeing the Real Person  Residents were adequately hydrated and nourished.  Residents seemed happy and their moods were elevated.  Residents wanted to walk outdoors.  Residents appeared more comfortable in view of the Regular Toileting routines and numerous spa baths per week.  Residents benefitted from HUGS-HUGS-HUGS!

Results...  As a result we got funded by the Ministry for 25 Special Care beds which were admitted into our “Special Care Unit.”  Delta View was recognized across Canada as well as Internationally (Spain, Switzerland, Italy, United States) for its philosophy on “Hugs not Drugs”

Remember its all about “Hugs not Drugs”  www.youtube.com/watch?v=hN8CKwdosjE  All it will take you is “one hug”

Rapid Fire Presentations Teams

• Windermere Care Lodge • Cedarview Lodge • Delta View Life Enrichment Centres

WINDERMERE’S ACTION AND IMPROVEMENT TEAM " Together, We Want To Make a Difference"

A Word From our Administrator Ross Sugimoto How does a 214 bed complex care facility balance the physical, social, psychological and safety needs of all its residents and families in an environment where antipsychotics have historically had a significant impact? Windermere Care Centre is looking to challenge its multi-disciplinary team to identify where antipsychotic use is inappropriate and assess how pharmacological and non-pharmacological approaches and interventions can be combined to create positive outcomes. We expect this journey to be challenging, educational, inspirational and rewarding. We also anticipate that together we are able to improve the care we provide and make a positive impact on the lives of our residents and their families. " Together, We Want To Make a Difference"

RESULTS Percent of Residents on an Antipsychotic 40% 35% 30% 25% 20% 15% 10% 5% 0% " Together, We Want To Make a Difference"

CHANGES TESTED • We Track changes ……. Weekly • IDT review with the health care team Monthly • Medication review with the pharmacy and the physicians Annually • Care conferences with the residents, family and Health care team Admissions, Significant changes, and residents returning from acute care • Reviewed as needed Recreation Department is using the Montessori Based programming to reduce anxiety and engage the residents in their choice of activity " Together, We Want To Make a Difference"

LESSONS LEARNED • Hospital admissions result in residents retuning back with new antipsychotic drugs. • New admissions come in with antipsychotic drugs, both regular and PRN and as they are new to the facility, we are unsure about continuing these meds. • Team engagement and support is crucial in achieving set goals and persistence certainly pays. Chug along!! • Celebrate success, even if it is small! • We have introduced and are using the Montessori based recreation program for the resident to allow for more one to one programming. " Together, We Want To Make a Difference"

Cedarview Lodge CLeAR Action and Improvement Team Optimizing the Quality of Life for our Residents

What We Wish for Our Facility/Residents Maximize our residents quality of life by: • Providing person-centered care by learning about what is important to the resident and their family • Identifying non-pharmacological alternative approaches in resolving behavioural concerns such as pain management as the first-line approach to care planning • Working as an Interdisciplinary team in planning and assessing the residents care needs 9-Jun-14 78

Team Goals and Objectives • Improve care for residents who have BPSD by reducing the number of residents who are on antipsychotics • Create opportunities for existing initiatives to work together • Build new skills and knowledge for improvement in residential care 9-Jun-14 79

Approach and Strategy • Identified interested team members (champions) • Implemented monthly team meetings • Provided each unit with a CLeAR binder with tools designed to document and monitor residents in program 9-Jun-14 80

Approach and strategy • Used LEAN methodology to map CLeAR process with team which resulted in: - Establishing CLeAR objectives - Creating roles and responsibilities for team members and staff 9-Jun-14 81

Results 9-Jun-14 82

Delta View’s CLeAR Initiative Team Eliminating inappropriately prescribed anti-psychotics

Aim/Goals Aim: • Get back to our roots! • Continue to gain staff buy in • Educate that all behaviours have meaning Goals/Objectives: • Decrease use by 50% July 2014 and 75% by Dec 2014 84

Changes Tested • Hold Safety Huddle on BPSD algoarithm in each home (discuss one resident on antipsychotic and review tool) • Build standardized BPSD guideline and algoarithm tools into assessment/review process • Introduce Shared Care Polypharmacy Initiative Clinical Algorithm and Anti- psychotics Drug Advisory Sheet 85

• Hand outs with information on Seroquel handed out to nurses at meeting • Creating a no-blame culture and more focus on the system by increasing use of learning boards • Safety huddle on effective communication held - personal goals for all 8 homes discussed in groups • More group work and activities to initiate discussion 86

Lessons Learned • Decreasing one Resident at one time works well as there is more time for 1:1 • Support required from all disciplines to decrease anti-psychotics • All anti-psychotics are restarted (if they are restarted) within 7-10 days of being discontinued • Most support required within 14 day withdrawal period (engage family) 87

Next Steps • Continue to educate staff and families on anti-psychotics and their effects • Implement an informed consent form prior to initiating use of anti-psychotics (under review) • Continue with aromatherapy, music and other non-pharm methods to address behaviours • All behaviours have meaning 88

Break and Storyboard Networking All

Questions to Run On • What are 1 or 2 ideas that stood out for you? Examples you could use and adapt? • What continues to be challenging? Used to document and take notes on specific ideas you might want to try.

Overview of CLeAR Progress, Results and Opportunities Leanne Couves

Your Progress • Table Discussion: What progress has your team made?

Activities Teams are : • Getting organized • Engaging staff • Trying and testing ideas – PDSA Cycles • Starting to show positive results • Sharing documents and questions through webinars

Some Ideas Being Tried 1. Appropriate Antipsychotic Use 2. Best Practice Management with BPSD 3. Culture: Enhance Teamwork/Communication 4. Residental Care Planning Facility 1. Appropriate (B) Improve (C) Communication (A) Use BPSD (B) Non- (C) Use alt. comm. (D) Involve family (A) Environment of (B) Sharing and (C) Administrative (A) Expand "care (B) Implement (C) Individualized Antipsychotic Use medication needs with care team Algorithm & pharmacological and care delivery and caregivers respectful comm. comm. between Leadership team" definition Team Comm. Tools Care Plans assessment Guidelines interventions strategies and teamwork team members Walkarounds              Facility 1    Facility 2 Facility 3       Facility 4       Facility 5  Facility 6           Facility 7 Facility 8          Facility 9    Facility 10 Facility 11 Facility 12              Facility 13 Facility 14 Facility 15 Facility 16       Facility 17 Facility 18          Facility 19     Facility 20 Facility 21                      Facility 22          Facility 23         Facility 24 Facility 25                         Facility 26          Facility 27 Facility 28                   Facility 29          Facility 30 Facility 31          Facility 32           Facility 33          Facility 34 Facility 35 Facility 36                    Facility 37 Facility 38          Facility 39          Facility 40          Facility 41          Facility 42 Facility 43      Facility 44   Facility 45 Facility 46      Facility 47

Source: Saskatoon Health Region

Additional Context • Reporting bias • New admissions are often on anti-psychotics • Teams are working hard to reduce dosage • Residents successfully taken off AP die or are transferred

Additional Measures • Process Measures: • Balancing Measures: – # of residents on a – Number of new admissions reduced dose – Number ER visits for – % of residents on a assessment/treatment of reduced dose BPSD – # care reviews conducted – Number of Falls using BPSD Algorithm – Family/staff satisfaction – # reviews with family &/or – Other measures? caregiver involvement – # BPSD related incidents – Other measures? 97

Real-Time Assessment 1 Non-Starter Team formed. Aim determined. Team attended Learning Session 1. 2 Activity but No Testing Team engaged in data collection and developing changes. No tests of change or evidence of testing within last month. 3 Modest Improvement Testing has begun. There is anecdotal evidence of improvement. 4 Improvement Implementation has begun. Improvements have reached 50% of at least one goal. 5 Significant Improvement 100% of at least one goal is reached. 6 Outstanding Sustainable Results Targets exceeded. Changes spread to larger system.

Challenges & Opportunities • What challenges has your team faced?

Challenges & Opportunities • Connect the aims/goals from the charter to the measures and begin getting data to share your progress, successes and improvement journey • Sharing between teams – Webinars – CLwK