Promising Practices for Management of Challenging Behaviors in
Promising Practices for Management of Challenging Behaviors in VISN-6 Jorge Cortina, MD, DFAPA Eleanor Mc. Connell, Ph. D, 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, Pharm. D, & Jan Cavanaugh, Ph. D 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, Ph. D, 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 (Hu. H) 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, Ph. D, 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, Pharm. D, , 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 FY 07 – FY 08 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: 50 th to 25 th
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 6 AM 11 PM!
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 research-based 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: üDelay institutionalization üImprove dementia care management üReduce caregiver burden ü 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 Ø Ø
INTERVENTIONS Ø Home visits Ø Ø Ø Individualized care plan Psycho-education Caregiver support Problem-solving Behavior management Reduction of anticholinergic impacts of patient medication Ø Case management Ø Novel Methods: Screening for Delirium and PTSD
Examples of Protocols to be Adapted iled a t e d More mple exa Source: Indianapolis Discovery Network for Dementia http: //www. indydiscoverynetwork. org/(X(1)A(9 he. Kr 3 V 1 yw. Ek. AAAANj. Rk. OGQ 0 Nz. Qt NTJi. MC 00 MWVi. LWFl. Yz. Ut. Mz. M 4 Nzg 4 Mj. Nh. ZTkzt 1 c. VAv. Uv 9 D-EZq_Odo. XSsb. Xx_I 1)S(ilfxf 1 abiaickj 455 bld 2 n 2 d))/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!
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