The Science and Art of Behavior Management Kelly

The Science and Art of Behavior Management Kelly Trevino, Ph. D Clinical Psychologist VA Boston Healthcare System GRECC Audio Conference Series July 29, 2010

Acknowledgements Nurse Managers ◦ Annette Couchenour ◦ Steve Mc. Garry ◦ Connie Soule ◦ Mary Farren Nursing Director ◦ Ronald Molyneaux CLC Nursing Staff Medical Staff ◦ Dr. Juman Hijab ◦ Jack Earnshaw Psychiatrists ◦ Dr. Mohit Chopra ◦ Dr. Ronald Gurrera

Outline �Background �The Science ◦ Learning Behavior Model ◦ Person-Environment Fit Model ◦ Need-Driven Behavior Model �The Art ◦ Staff Training ◦ Behavior Management Team (BMT) ◦ Lessons Learned �Behavior Management �Program Implementation

Background � 5. 3 million persons in the U. S. have Alzheimer's Disease 1 � 11 -16 20502 million persons in US will have AD by � In 2004: 136, 174 veterans with dementia using VHA 3 ◦ 2022: 205, 781 � 47% of nursing home residents have dementia 1 ◦ Up to 70% have memory problems 4 � ~66% of community elders and ~77% nursing home elders with dementia have disruptive behavior 5, 6 � Disruptive behavior associated with negative 7 -9

Psychotropic Medications and Restraints �Psychotropic Medication ◦ Limited effectiveness 10 ◦ Negative side effects 11, 12 �Restraints 13 ◦ Higher rate of falls ◦ Negative psychological outcomes

THE SCIENCE

The Science: Learning Behavior Model �Learned relationship between antecedents, behaviors, and consequences (ABCs of behavior management)14 ◦ A=Antecedents=Triggers ◦ B=Behaviors ◦ C=Consequences=Reinforcement or Punishment �Manipulate antecedents and consequences to change behavior ◦ Provide new learning experience �Comprehensive functional analysis important

The Science: Learning Behavior Model �Instrumental Conditioning Principles 15 ◦ Reinforcer contiguity ◦ Response-reinforcer contingency ◦ Reinforcement �Problems with punishment ◦ Negative affective reaction ◦ Focus on avoiding punishment (rather than improving behavior) ◦ Negativity can generalize to other stimuli (person, environment, time)

The Science: Learning Behavior Model �Characteristics of Interventions 16 -18 ◦ Staff education �Topics: Dementia, Psychiatric disorders, Behavior problems, ABCs of behavior management, communicating with persons with dementia �Method: Didactic, discussion, role playing, video case vignettes, handouts ◦ Assistance with care planning ◦ On-site supervision ◦ Increasing resident participation in pleasant events ◦ Peer support ◦ Caregiver problem-solving skills ◦ Exercise program

The Science: Person. Environment Fit � Dementia increases vulnerability to the environment 19 ◦ Stimuli affect people with dementia at a lower threshold � People with dementia have fewer coping resources � Poor fit b/w person and environment impairs functioning and increases disruptive behavior � Intervention ◦ Create a familiar and comforting environment ◦ Stimulate through reliance on remote memory and positive emotions

The Science: Person. Environment Fit �Characteristics of Interventions 20 -22 ◦ Simulated presence therapy ◦ Activity programming �Based on mental and physical abilities �Adjust for mood and behavior �Incorporate periods of stimulation and rest ◦ Individualized music ◦ Environmental modifications ◦ In-home counseling

The Science: Need-Driven Behavior �Normal needs + Abnormal conditions = Disruptive behavior 23 ◦ Behavior is response to unmet need �Adjust environment and build on strengths/preferences of individual to meet and prevent unmet needs ◦ Consider sensory deficits �Treatment Routes for Exploration of Agitation (TREA)24 ◦ Identify correlates of particular behaviors ◦ Provide suggestions for changing the correlates

General Guidelines �Basic principles ◦ Specificity ◦ Individualization ◦ Consistency: Implementation and documentation �Behavior may increase initially ◦ Re-examine plan after 2 -3 days �Behaviors ◦ ◦ are not Voluntary or purposeful Rudeness Due to a “bad attitude” Attempt to make your job difficult

Boston VA CLC THE ART Behavior Management Team (BMT)

BMT: Creation �Recognition of a problem �Weekly interdisciplinary meetings ◦ Psychology, nursing, medicine �Identified: ◦ Problem ◦ Goals ◦ Process ◦ Staff Training ◦ Documentation

Staff Training: BMT What is the BMT ◦ Explain why ◦ Explain how ◦ Get feedback/ideas BMT Documentation ◦ Focus on BMT Shift Note Outcome ◦ ◦ measures Frequency of behaviors Severity of behaviors Referrals to BMT Medications for behaviors ◦ Inpatient psych transfers ◦ Code greens for behaviors ◦ Staff feedback on BMT

Staff Training: Functional Analysis �Prevalence of behaviors �Difficulty of managing behaviors �Define types of behaviors and correlates �DON’T PANIC �ABCs of behavior management �Unmet needs �Questions behaviors for describing context of

ABCs of Challenging Behavior (B) Antecedents (A) Consequences (C)

Staff Training: Creating/Implementing Behavior Plans �Basic principles ◦ Specificity ◦ Individualization ◦ Consistency: Implementation and documentation �Behavior may increase initially ◦ Re-examine plan after 2 -3 days �Behaviors ◦ ◦ are not Voluntary or purposeful Rudeness Due to a “bad attitude” Attempt to make your job difficult �Questions for identifying new ABCs

Behavior Frequency/Severity Start Behavior Plan Time

The Art: Behavior Management Team ◦ BMT Members: �Psychologist �Nursing staff �Nurse manager �MD/PA �Geriatric psychiatrist consulted, as needed �Identification of residents ◦ CPRS consult ◦ Direct communication from staff

The Art: Behavior Management Team �Inclusion criteria ◦ Demonstrate physical and/or verbal behaviors that: �Create potential harm/distress to the resident, staff, other veterans �Are difficult to manage (are not re-directable) � Do NOT refer residents that are an immediate safety risk �Treatment implementation ◦ Functional analysis of behavior ◦ Create behavior plan �Set behavioral goal ◦ Monitor over time ◦ Change as needed ◦ Discharge when goal met 2 consecutive weeks

The Art: Behavior Management Team �Weekly meeting on each unit ◦ Learning circle ◦ “Rounding” ◦ Meet with floor staff and PA, then consult nurse manager �Documentation ◦ BMT Management Plan ◦ BMT Shift Note ◦ BMT Weekly note

The Art: Behavior Management Team Nursing staff observe disruptive behavior BMT creates behavior management plan BMT enters “BMT Management Plan” Nurse (RN) documents behavior AND adds MD/PA as cosignor BMT conducts evaluation BMT consults with direct care staff Nurse consults with MD/PA BMT responds within one business day MD/PA decides to consult BMT MD/PA enters consult for BMT Nursing staff continues to complete “BMT Shift Note “ BMT monitors behavior and consults with treatment team weekly Staff continue to implement behavior plan Behavior goals met: Resident discharged from BMT

BMT Management Plan Primary BMT Member: Reason for Referral: Behavior 1: Goal: Frequency of behavior: Disruptiveness: Not at all A little Type of Behavior: Physical Non-aggressive Extremely Aggressive Verbal Psychology: Psychiatry: Recreation Therapy: Medical: Nursing: Moderately Very much Physical

BMT Shift Note Target Behaviors (from BMT Management Plan): 1. Frequency of behavior this shift: Disruptiveness: Not at all A little Moderately Very much Extremely Times of behavior: Locations of behavior: Antecedents (what happened before): Interventions (what action was taken): Outcomes (Resident’s response to intervention):

BMT Weekly Note Session Type: BMT Rounds Time spent discussing veteran: Review for week of: CONSULTATIONS: ********************************** Behavior: Goal: Frequency of behavior this week: Disruptiveness of behavior this week: Behavior frequency: Percent change from previous week: Disruptiveness: Description of behavior: a. Times: b. Locations: c. Antecedents (what happened before): d. Interventions (what actions were taken): e. Outcomes (resident's responses to intervention): ********************************** NEW RECOMMENDATIONS (based on today’s BMT Rounds): CONTINUED RECOMMENDATIONS (based on previous BMT assessments):

BMT Outcomes � � Participants ◦ ◦ ◦ n=24; Residents of the VA Boston CLC Age: M=74. 75; SD=11. 39 Gender: 95. 8% Male Residential Status: LTC (54. 2%); Rehab (37. 5%); Transitional (8. 3%). Approved by the IRB of the VA Boston Healthcare System. Measures 1. Demographic information: Age, gender, residential status 2. BMT Shift Notes a. ) Frequency of behaviors: b. ) Severity of Behaviors � Method ◦ Medical record review of residents treated in the first six months of BMT implementation (July 28, 2009 -February 1, 2010)

Lessons Learned: Behavior Management �Person-centered care ◦ Implement WITH the resident, not TO the resident �Interdisciplinary ◦ Consider role of MD/PA �Individualization �Consistency �Communication ◦ Team ◦ Ask/Talk to the resident �Dementia-care skills

Lessons Learned: Program Implementation �Identify and include relevant stakeholders ◦ Facility specific ◦ All services ◦ All levels �Union ◦ Include early �Intervention-setting ◦ Resources ◦ Limitations fit

Lessons Learned: Program Implementation �Education ◦ First step to buy-in �Hands-on demonstration ◦ Don’t be afraid to make mistakes �Observe impact and make changes ◦ Be flexible �Sustainability ◦ Repeat education ◦ Leadership support �Policy

Questions

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