Promising Practices for
Management of Challenging
Behaviors in VISN-6
Jorge Cortina, MD, DFAPA
Eleanor McConnell, PhD, RN, GCNS, BC
Innovators throughout VISN-6 Geriatrics &
Extended Care
Commentary from Conference Faculty
Goals
• Highlight current practices in VISN-6 that
illustrate key concepts in challenging behavior
management
• Promote networking among resource people
within the VISN
• Stimulate learning and ongoing program
evaluation
• Stimulate strategies for implementing knowledge
and skills learned at conference
In other words…
• Not enough to know what to do….
– How to get it done is just as important.
• So…how do we expect you to make use of
what we’ve learned here?
– Build on success!
– Learn from challenges!
Approach
• Describe innovative VISN-6 programs in action
• Showcase key components that illustrate
conference concepts
• Share evaluation data when available or
evaluation plan when not
• Invite discussion from conference participants
about how this might be useful to their current
efforts
Behavioral Interventions Note
Overview
Antecedents
Behaviors
Consequences
Behaviors
Checklist
&
Textboxes to
allow more
specific
description of
behavior
Imports key
information on
possible
Antecedents
from CPRS
&
Prompts
further
documentation
of common
antecedents in
environment
Point of Care
Decision
Support on
Common
Antecedents
&
Prompts to use
nonpharmacologic
interventions
before
medications
BIN Note Lessons Learned
• Pilot testing is a good idea…find barriers
– Key barriers to its implementation:
• Time (to train, to try out)
• Work habits
– Front line staff accustomed to seeing behavior and taking
action – not seeing behavior, doing more careful
observation, thinking, and trying things out before calling
– Overcoming barriers:
• Be prepared for slow going at first
• Link use of note to orientation of new staff
• Link use of note to other practices
(one-on-one or restraint competencies)
Behavioral Interventions Note
Summary
•
•
Location: Asheville
Contact: Kathryn (Kitty) Hancock, RN, MSN, Nurse Educator
• CPRS template developed by VISN-6 Challenging Behaviors
Committee
– Systematic evaluation
• Goals:
• Increase use of non-pharmacologic interventions
• Reduce use of psychotropic medications
– Who implements: Nursing staff
– When used: prior to use of PRN medications or restraints
•
Notable Features
– Facilitates implementation of ABC model
– Intended to be used prior to requesting/using PRN medication
– Developed with VISN-wide input
•
Why a good idea:
– Allows systematic documentation of behaviors, their antecedents, & outcomes of
interventions
Acknowledge role of Martin Cruz, PharmD, & Jan Cavanaugh, PhD from VISN
Challenging Behaviors Task Force 2008
Snoezelen Room
Salisbury Community Living
Center
Salisbury, NC
What is Snoezelen?
• A Multi-sensory experience that uses
lighting, projected pictures, music and
sounds, textures, aromatherapy, and
vibration to stimulate, energize or relax
• Several VA CLC’s have implemented this
program
• Salisbury opened their room Sept 2009
with a grant of $30,000
How is Snoezelen Implemented
in Salisbury?
• Located on the gated Dementia Unit, the
Veterans have access as part of their overall
treatment plan under staff supervision
• Veterans from other units are also brought in
as part of their restorative treatment plan
• Serves as an alternative to medication to
reduce agitation and aggression
• Serves to calm providing rest for the
wanderers
Snoezelen Summary
•
•
•
Location: Salisbury
Contact: BJ Nelson, RN, Nurse Manager & Julie Merrick, OTR
Description:
– Multi-sensory stimulation program, originally implemented for those with
developmental disabilities
– More of the what, who implements,
– Goals:
• Provide systematic, controlled stimulation to those with severe dementia
•
•
When initiated: September, 2009
Notable Features
– Positive intervention whose cognitive function is at a low level (pearls)
– Interprofessional approach
– Builds on evidence-base borrowed from another population
•
Why a good idea:
– Addresses under-stimulation experienced by veterans with limited cognitive
function
– Proactive rather than reactive
Pre-Service Education on
Challenging Behaviors
•
•
•
Location: Fayetteville
Contact: Jan Cavanaugh, PhD, HBPC Mental Health Provider
Description:
– Two-hour in-service on basics of managing challenging behaviors
during staff nurse orientation. Development of curriculum on challenging
behaviors for direct care nursing staff that is implemented during
orientation
– Goals:
• Highlight importance of behavior management skills
• Alert new staff to resources available to nursing staff and VA approach
• When initiated: 2008
• Notable Features
– Sets expectation that challenging behaviors are an important part of
care
– Gives specific examples of nursing role in managing challenging
behaviors
• Why a good idea:
– Staff exposed to team care expectation when motivation to learn is high
– Proactive rather than reactive
Overview of Session
• Introduction to basic concepts of Cultural Transformation
and Community Living Center
– HATCH model
• Teach basics of Transforming Patient Care to
Person-Centered approach
• Learn basics of Dementia Care
–
–
–
–
–
–
–
What is Dementia
Awareness/Sensitivity Training
Positive Approach
Communication/Cueing/Hand under Hand (HuH)
Levels of Dementia and Care Needs
Self Care/Centering/Breath/Relaxation
ABC Model of understanding behavior.
Lessons Learned
• Psychologists teaching nurses about
behavior management
– Need to negotiate – can’t be imposed
• Able to build on knowledge developed
during orientation when psychologist
consults on residents with challenging
behaviors
Challenging Behaviors Education
In Nurse Orientation Training
• Location: Fayetteville
• Contact: Jan Cavanaugh, PhD, HBPC Mental Health Provider
Description:
– Development of curriculum on challenging behaviors for direct care nursing staff
that is implemented during orientation
– Goals:
• Highlight importance of behavior management skills
• Alert new staff to resources available to nursing staff and VA approach
•
•
When initiated: 2008
Notable Features
– Sets expectation that challenging behaviors are an important part of care
– Gives specific examples of nursing role in managing challenging behaviors
•
Why a good idea:
– Staff exposed to team care expectation when motivation to learn is high
– Proactive rather than reactive
Special Care Unit in CLC
•
•
Location: Hampton
Contact: Martin Cruz, PharmD, , Bev Edmonds, RN
• Goals:
•
•
Expand access to behavioral health care for Veterans
Reduce use of psychotropics
•
When initiated: 2007-2008
•
Targeted behaviors:
–
–
–
–
–
Wandering
Disturbing Inappropriate vocalizations
Physical resistance to ADL care
Sexually inappropriate behavior
Hyperactivity due to delirium
Key Features:
•Increased square footage per patient
• Secured, keypad exit
•Increased hours per resident day
•Staff competencies in management of ADL
care for CLC residents with behavioral
complications of dementia
•Weekly rounds by Interdisciplinary team
(Medicine, Nursing, Mental Health, SW,
Pharmacy)
Evaluation
FY07 – FY08 Changes in CLC
• Increased behavioral care
access:
– Number of veterans served
– Bed-days of care
• Improved quality indicators
– Antipsychotic use in the absence
of psychotic or related conditions
– Cut in half from 18.5% to 8.9%
• Improved percentile: 50th to 25th
Prevalence of Antipsychotic Use in the Absence
of Psychotic or Related Conditions
60.0%
50.0%
40.0%
FY 07
FY09
30.0%
20.0%
10.0%
0.0%
Percent use
Percentile
Lessons Learned
•Environment is a powerful
shaper of behavior
•Combined physical and social
environmental changes
•Systematic evaluation
suggests that it was effective in
reducing psychotropic use.
DENs: Dementia Engagement Nooks
• Location: Richmond
• Contact: Violet Oliver, RN, Nurse manager
• Description:
– Painted with murals to be less hospital-like
– Vets encouraged to spend time there with each other.
– When possible, nurses assigned just to the DEN to direct
activities, engage vets in conversation, exercise, painting,
reading, etc.
– Structured activities planned in advance
DENS in Richmond
Street to Den Entrance Contains Schedule
Structured Activities
from 6AM  11PM!
Lessons Learned
• Since DENS were created
– Bedfast days have dropped significantly
– Falls have also decreased dramatically.
– More peer-to-peer interaction
– Lately we’ve had student volunteers in there
with the vets hanging out with them and
interacting.
Outpatient Dementia Care Team
Clinical Demonstration
• Location: Durham
• Contact:
Linda Chilton, RN, MSN, NP; Judith Davagnino, LCSW, MSW
Barbara Kamholz, MD; Jack Twersky, MD,
• When initiated: 2010
• Notable Features
– Behavior management protocols from successful researchbased program
– Interdisciplinary approach
– Intervention targeted to veterans who are living at home
• Why a good idea:
– Teaches informal caregivers evidence-based behavior
management techniques
– Proactive rather than reactive
– Individualized intervention
Description
Interdisciplinary, evidence-based
dementia care management program
Goals:
Delay institutionalization
Improve dementia care management
Reduce caregiver burden
 Improve quality of life
Target population




Veteran living at home with caregiver
65 years old and over
MMSE 20 and under
30 mile radius from Durham VA
Medical Center
INTERVENTIONS
 Home visits






Individualized care plan
Psycho-education
Caregiver support
Problem-solving
Behavior management
Reduction of anticholinergic impacts of patient
medication
 Case management
 Novel Methods: Screening for Delirium and PTSD
Examples of Protocols to be Adapted
Source: Indianapolis Discovery Network for
Dementia
http://www.indydiscoverynetwork.org/(X(1)A(9heKr3V1ywEkAAAANjRkOGQ0NzQ
tNTJiMC00MWViLWFlYzUtMzM4Nzg4MjNhZTkzt1cVAvUv9D-EZq_OdoXSsbXx_I1)S(ilfxf1abiaickj455bld2n2d))/HABCInitiative.html
Summary
• Many programs or practices already
implemented within VISN 6 that make use
of principles discussed in this conference
• Speaks to feasibility of implementing nonpharmacological techniques to help in
managing challenging behaviors
• Opportunity exists to build on successes of
others!