Influencing Care
The Nova Scotia P.I.E.C.E.S.
Story
Alzheimer Society Manitoba, 2008 Conference
Joanne Collins RSW
Challenging Behaviour Program
Nova Scotia Department Of Health
Today’s Purpose
To provide:
• Overview Nova Scotia Challenging
Behaviour Program
• Highlight critical factors in program
design
• Highlight using the P.I.E.C.E.S.
approach to support an integrated
model of care
Beginnings….
• Sector identified the need for improved
services to enhance capacity in care provision
particularly complex behaviours
• Department of Health responded and
established the Challenging Behaviour
Working Group in May 2002
• Working Group had representation from LTC,
Home Care, Mental Health and DoH
• Defined Challenging Behaviour and developed
an Approach to Care
• Completed majority of tasks in January 2003
Challenging, or complex behaviours, as a
result of dementia or mental illness can
include:
• Agitation & restlessness
• Anxiety
• Apathy/failure to
participate;
withdrawn/crying
• Defensive behaviour
• Hearing & seeing things
that do not exist
• Impulsivity
• Intrusiveness
• Hoarding and/or
rummaging
• Inappropriate sexual
behaviour
• Resistance to care
• Suspicious/accusing
others
• Vocally disruptive
behaviour
• Wandering
Behavioural and Psychological
Symptoms of Dementia (BPSD)
BPSD left untreated has been associated
with caregiver burnout, nursing home
placement, poor management of co-morbid
conditions and excess health care costs.
Steel, Cohen, Mansfield, Ballard
Challenges of Challenging Behaviour
• BPSD significantly impacts quality of life of
both the person and caregivers (Finkel SJ)
• Caregivers consistently rate BPSD as the most
stressful aspect of caring (Jarriot PN)
• Is the primary factor for deciding to
institutionalize (Steel C, Balestreri)
• Approximately 50% of people with Severe
Dementia Alzheimers Type experience
psychosis, 90% behavioural issues, 7-10%
severe (Rabins, Zimmer)
Readiness For Change
Opportunity
Policy
Advocates
Structural
Flexible
Organizations
10 Years
Changes
Sabattier
Challenging Behaviour Program
Stabilization Service
Staff Education & Training
Caregivers
Family
Resource
Support &
Augmentation
LTC Facilities
Client
HC
Agencies
Continuing Care
In House Resource
Consultant (IHRC)
P.I.E.C.E.S
Clinical
Resource
Consultnat
(PCRC)
Education and Training
• Enhance capacity at the organization level
in providing service to the older adults
with complex cognitive/mental health
issues and associated behaviours.
• Target group – Nursing Homes, Home
Support Agencies, Nursing Agencies, and
Continuing Care Offices
• Develops the In-house Resource Consultant
role
P.I.E.C.E.S. Clinical Resource
Consultants
• Provide case based consultation to IHRC
• Educators, coaches, consultants and assist in
program development
• Facilitate Local Learning Networks
• Link to community-based resources and
external stakeholders
• Promotes linkages between care givers and
specialized resources
• Ensures a comprehensive assessment is
conducted pre/post admission to stabilization
service
Resource Support and Augmentation
• Temporary short term funding.
• Alternative short term care provision
and intervention to stabilize
challenging behaviour
• PCRC play a supportive role with
requesting agencies and Continuing
Care District Offices
Stabilization Service
• Target Population – Client/Residents who
have not benefited from interventions
targeting complex cognitive/mental health
issues and associated behaviours.
• Goal – Assess, stabilize and develop a care
plan that will permit the client/resident
to be discharged back to the community.
• Access through the PCRC
Program Design
• Step I
•
•
•
•
•
Step II
Step III
Step IV
Step V
Step VI
Gaining multi-Organization and
Communities of Interest Support
Engaging the Learners
Education Program
Support
Maturation from Education to Practice
Putting the P.I.E.C.E.S. together at the
Systems Level
Program Design
Step I : Gaining Multilevel Organizational/
Communities of Interest and Support
Organization Support
Academic
Institutions
Communities
of Interest
Provincial
Target
Gov.
Learning
Org’s
Service
Organization
Consumers
Chambers
Program Design
Step II: Engaging the Learners
• Education Program
• Engage Senior Leaders
• Selecting the learners to fulfill the InHouse Resource consultant role
“Peer/Opinion Leaders”
The P.I.E.C.E.S. Model
Putting the P.I.E.C.E.S Together
Putting the P.I.E.C.E.S.
...together
Physical, Intellectual, Emotional,
Capabilities, Environment, Social,
and are the cornerstones of the
philosophy and care of the
P.I.E.C.E.S. Education Initiative.
What is P.I.E.C.E.S.?
• A practical, effective approach to change and
continuous improvement
• Best practices in learning & development
• Performance improvement foundation
• Provides approach to understanding &
enhancing care
• Framework, systematic
• Team, Dialogue
Physical, Intellectual, Emotional, Capabilities,
Environmental, Social
The P.I.E.C.E.S. Model Provides
Common vision and set of values
Common language and knowledge for
communicating across the system
Common yet comprehensive approach
for thinking through problems
P.I.E.C.E.S.
A Model for Changing Practice
P.I.E.C.E.S. Enabler Program for Senior Leaders
+
P.I.E.C.E.S. Education Programs for Professional Staff
=
Foundation for Practice Change
Form foundation for a common vision,
common language and a common approach
Goals of P.I.E.C.E.S. Program
Comprehensive
Assessment &
Care Planning
Integration &
Collaborative
Care
Interdisciplinary
Interdisciplinary
Care
Care
Person &
Family
Risk
Management
Current &
Emerging Best
Practices
Enabler Program for Senior Leaders
• 8 hour program
• Target audience:
those in a position to supervise
regulated and/or unregulated staff
but not involved in direct care (I.e
Administrator, DOC)
those in a position to support
learners/In-house Resource (I.e
Educators)
The 40-hour P.I.E.C.E.S. Program
Prepares the In-house Resource Person
… to serve as a resource to others in
the organization by:
• promoting a common language, common
values, and common way method of
thinking through complex problems
• modeling P.I.E.C.E.S. competencies
• developing P.I.E.C.E.S. competencies in
others.
Step III
The Education
• Curriculum development
• 3 staged vis-à-vis Dave Davis
• Importance of Job Aids
• Templates and Tools, Practicality
• Reinforcement and Meta Learning
Enabler Program Objectives
• Familiarize participants with the P.I.E.C.E.S. framework,
approach, assessment tools and screening guides taught
in the 40-hour program.
• Introduce a practical tool to improve observations of the
“Team” and teach the importance of knowledge
exchange regarding the client/resident
• Identify clinical and educational coaching and senior
leadership support strategies to support the in-house
resource role and others in transferring learning to
practice change
The Enabler Program Includes
Strategies to…….
• Flag gaps between current practice and best
practice
• Select the most appropriate candidates and develop
an implementation plan
• Explore current approaches to learning and
development and performance improvement
• Support change efforts
• Engage team in collaborative improvement efforts
The 40-hour P.I.E.C.E.S. Program
• Part 1: 18-hour intensive program of
core curriculum
• Part 2: Practical application of skills
from Part 1
• Part 3: 12-hour consolidation program
• Part 4: Post-program support
Core Competencies
1. Detect or flag what has changed
2. Use the 3-Q P.I.E.C.E.S. template
3. Be familiar with tools
4. Plan care with others
5. Evaluate care and goals
6. Coach others using U-First collaborative
care tool
3-Question Template
Q. 1 What has changed?
Avoid assumptions; think atypical.
Q. 2 What are the RISKS and possible causes?
Think P.I.E.C.E.S.
Q. 3 What is the action?
Investigations
Interactions
Information
Collaborative Care Tool
U-FIRST!
Understanding
P
S
Support
I
E
Flag
E
C
Reflect and Report
Interact
Tools and Techniques
•
•
•
•
•
Abilities: Lawton
Behavior: DOS, Cohen
Cognition: CAM, Clock, Folstein
Distress Caregiver PIECES revisited
Emotional, Depression/Mood; Psychosis (7D)
Performance Objectives
• 4 objectives which describe outcomes in
terms of “on-the-job” performance
• Measurable
• Achievable over one year
Evaluation Strategies
• Pre-program assessment
• After 3-day and 2-day session
• In-class work and observation
• On-the-job performance demonstration
Step IV Support
Support
Service Org
PCRC
Networks
System/
Province
3 Roles
Enabler
Program
Key Change
Agents
Case Based
Clinical
Support
IHRC’s
Education
PCRC
Linkages
Specialty
Community
DoH
Org (NGO)
To change systems we:
• Assess the potential for change
• Get the whole system in the room
• Focus on the future
• Structure tasks people can do themselves
Marvin Weisbord
Commitment From Enablers
• Leadership support is critical to success
• Support the In-house Resource role
• Promote application and integration of
new learning into day to day practice
• Strengthen learner skills
What have we learned?
Elements for success of In-house Resource
role
 Right person(s) selected; peer leader
 Support from Senior Leadership, care team
 Clinical P.I.E.C.E.S. Resource Consultants
 Development of Local Learning Networks
Through P.I.E.C.E.S. Education Collaborative
Care is enhanced:
Individual
Training can
change
individual
behaviours
Team
Increased
collaboration
& results at
the team level
Organization
System
Vision
linked to team
and individual
outcomes
Part of a
larger program
to support system
change
Accountability to front line
P.I.E.C.E.S. Clinical Resource Consultants
• Capacity to catch and promote the vision
• Clinical background – knowledge of Alzheimer’s
Disease and other dementia’s
• Coach
• Ability to establish and foster collaborative and
consultative relationships at the individual, team,
organization and system levels
• Networking and Team Building
• Champion
Elements for Success in the System
• Translatable and transferable
• Framework
• Multi-level awareness and support
• Intersectoral Community Stakeholder Group
• Telepsychiatry
• Importance of Local Resources
• Ongoing Learning Support
• Evaluation
Benefits of the P.I.E.C.E. S. Model
• Increased capacity among continuing care
providers.
• A common vision, approach (framework) and
language.
• A vehicle to link people, ideas and resources at
the
- Clinical
- Service Coordination
- Systems Level
Step V
•
Maturation from Education to day-to-day
practice
Step VI
•
Putting the P.I.E.C.E.S. together at a systems
level
From……….
Education to Knowledge
to
Translation and Exchange
Thank You
Questions? Comments !