collaborative research grant initiative: mental …...directions for further research include...

Collaborative Research Grant Initiative: Mental Wellness in Seniors and Persons

with Disabilities

SEED/Bridge Fund Final Report

March 30, 2012 - Terry Zibin

Understanding D

ischarge Challenges for Seniors w

ith a Mental

Illness by Understanding System

s Lim

itations

Alberta Addiction and Mental Health Research Partnership Program 2

EXECUTIVE SUMMARY Transitioning of seniors with dementia and/or mental illness from the Seniors Mental Health Program (SMHP*) to a Central Zone - Continuing Care facility** is a complex process, involving the need for multifaceted discharge planning to ensure a successful discharge/placement.

This project explores the perceptions of stakeholders regarding barriers to discharge/placement for seniors with a dementia and/or mental illness along the continuum of care and also identifies areas for improvement related to the successful transitioning of these seniors. The project consisted of a mixed method research approach that focused on collecting and analyzing quantitative and qualitative data through surveys and focus groups. The most common barriers identified along the continuum of care and corresponding areas of improvement were:

• Staffing: Need to increase staffing levels • Education: Need for continuous mental health education • Environment: Development of specialized environments (services/units/facilities) for

clients with complex needs • Management of Challenging Behaviors • Mental Health Support/Follow-Up: Improved provision/access to mental health

support/follow-up in communities (especially rural) • Management/Planning: Cross-boundary leadership/management between Addiction &

Mental Health Services (A&MH) and Seniors Health Results from this project have implications for policy and practice (e.g. collaborative/integrated managed care approaches) and may facilitate dialogue between stakeholders, decision and policy makers to support the “Aging in the Right Place” strategy. Directions for further research include investigating models of specialized care for seniors with complex mental health needs, environmental layouts to promote safety and security and the collective-efficacy of rural communities to address the needs of these seniors. * SMHP is a program at The Centennial Center for Mental Health & Brian Injury (CCMHBI) under Addiction & Mental Health (A&MH) and serves individuals generally over the age of 65 who have a dementia and/or mental illness.

** A Continuing Care facility includes the designated Supportive Living (SL) levels of SL3, SL4, SL4D (Dementia) and Long Term Care (LTC).

Collaborative Research Grant Initiative: Mental Wellness in Seniors and Persons with Disabilities

Final Report – Understanding Discharge Challenges for Senior’s with a Mental Illness by Understanding Systemic Limitations


RESEARCH OVERVIEW Objective(s) The objectives of this project are:

1. Determine the barriers to discharge for seniors with a dementia and/or mental illness from the SMHP (CCMHBI) to Continuing Care – Central Zone, along the continuum of care.

2. Identify areas for improvement related to the successful transitioning of seniors with a dementia and/or mental illness from the SMHP to Continuing Care – Central Zone, along the continuum of care.

Background Problem Description: Transitioning of seniors with dementia and/or mental illness from the SMHP to a Continuing Care facility can be a complex process, involving the need for collaborative/integrated discharge planning to ensure a successful discharge/placement.

Seniors with dementia and/or mental illness are often a clinical challenge for caregivers as they may present with a combination of psychiatric issues, behavioral difficulties, functional limitations (ADLs/IADLs) and medical needs. As a result, placement options are limited and the process of securing appropriate care in the community can be difficult to arrange, resulting in longer hospital stays.

A Housing Needs Assessment Report completed by A&MH – Central Zone (June 2009) identified the following difficulties related to the transition process for patients determined ready to leave the SMHP:

• Staff/patient ratios in Continuing Care facilities that impact the ability of staff to effectively meet the complex needs of seniors ready to leave the SMHP

• Continuing Care facility staff lacking the necessary skills, knowledge and experience to work with these seniors

• Long wait lists for Continuing Care facilities and financial and/or legal issues that delay placement and extend stays in the SMHP

• Possible assumptions made by staff involved (e.g. Continuing Care facility staff may have preconceived perceptions regarding working with seniors with a dementia and/or mental illness and SMHP staff may not complete an application for placement because they believe the patient will not be accepted due to Continuing Care’s criteria for acceptance)

Systemic limitations related to the transition process affect the ability of seniors to obtain “timely access to care” and the “provision of care in the most appropriate setting”. Increased wait times for admission to the SMHP (due to no available beds) and subsequent wait time for placement in a Continuing Care facility disrupt patient flow as beds are blocked and cannot be accessed by individuals who are need of these services. Importance of Addressing the Problem: In a review of the literature, it is clear that housing for seniors will become an increasing issue, as seniors constitute the fastest growing population in Canada. In 2001, Canada’s first baby boomers reached the age of 65, accounting for close to 15% of the Canadian population. By 2031, it is projected this will increase to between 23% and 25% of the total population (Statistics Canada Daily, 2005; Hill et al, 1996). It is estimated that between 10% and 15% of community-living seniors suffer from depressive symptoms (Conn, 2002) and that 8% of seniors over the age of 65 have a dementia, with this rate increasing to more than 25% for those 80 years of age and over (Canadian Study of Health and Aging, Working Group, 1994). Studies show that 80 to 90% of seniors living in a long term care setting have some form of mental disorder (CCSMH Fact Sheet: Focusing on Long Term Care Settings). As seniors age, the possibility of requiring some type of institutional care also increases. Factors predicting the risk for institutionalization of people with dementia include the type of dementia (i.e. Alzheimer’s Disease), the severity of disabilities experienced by the person with dementia and caregiver factors such as the caregiver’s age, health, relationship to the person requiring care (specifically if not a


spouse or child), the level of caregiver burden they experience and their desire/willingness to institutionalize (Hebert et. al. 2001, Wood et. al. 2003). When comparing community dwelling elderly with and without a dementia, Schoenmakers, et. al. (2008) found that those with a dementia were 4.5 times more likely to be admitted to a psychiatric facility and 14 times more likely to be admitted to a nursing home. Behavioural disturbances such as aggression, agitation and wandering contributed significantly to the decision for institutionalization in the group with dementia. Elevated physical and medical levels of care required by this group, along with high staff turnover rates and shortages, affect the quality of care they receive. Brodaty et al (2003) in a study of 253 nursing staff, found that residents with dementia were perceived more negatively than positively. Behaviors noted to be the most difficult to deal with and viewed as being more deliberate (as opposed to symptoms of the illness) included those identified as aggressive, uncooperative and unpredictable in nature. As Alberta Health Services (AHS) focuses on the indicator of “Access and Appropriate Services” (2010-2015 Health Plan: Improving Health for All Albertans, AHS), it is important to address the systemic limitations related to the discharge/placement process. Service responses identified as required under this AHS indicator include taking “actions that will result in reduced service wait times”, introduction of “a coordinated, evidence and system based approach to improvements in access and system patient flow” and to “reduce unnecessary variance in practice and standardize care”. Approach and Methods Ethics approval for this project was received from the Community Research Ethics Board of Alberta (CREBA), on May 4, 2011. Approval for implementation of the project was gained from the Alberta Health Services (Central Zone) Research Committee on May 19, 2011. The project, conducted from May 4, 2011 to November 30, 2011, was a collaborative effort on behalf of the SMHP (CCMHBI) and Seniors Health – Central Zone. The research project consisted of a mixed method approach that focused on collecting and analyzing quantitative and qualitative data. It is premised that the use of quantitative and qualitative approaches in combination provides a more comprehensive picture that offsets the weaknesses of separately applied quantitative and qualitative research methods (Creswell, J.W., 2003). The qualitative approach for this study consisted of six focus groups and the quantitative approach consisted of a Facility Manager Questionnaire, a Staff Questionnaire and a retrospective health record chart audit. SMHP Chart Audits: Chart audits were completed (124 discharged and 127 inpatient charts). The audits did not provide the level of consistent data that was expected and extracting of data from written progress notes proved difficult. As a result, chart information was not used as initially planned in the development of survey questionnaires and identification of issues affecting discharge. In 2010, the SMHP in conjunction with Placement Office – Central Zone, devised a Continuing Care Readiness for Discharge Checklist (Appendix 4, page 31) to ensure that discharge options were considered for all patients admitted to the SMHP and to identify reasons that discharge was not supported. Results from the checklists were used in the development of survey questionnaires and identifying barriers affecting the discharge of patients. A summary of the approaches and methods used are presented in Table 1: Research Approaches and Methods.


Table 1: Research Approach and Methods

Qualitative Approach Focus Groups

Quantitative Approach Staff Survey (Mail Questionnaire)

Facility Manager Survey (Mail Questionnaire) Continuing Care Readiness for Discharge Checklist

Study Design

Interpretive phenomenological design Cross-sectional research design

Sampling Six focus groups (N = 43) were held at various Central Zone sites involving multi-professional stakeholders that included: • Placement Officers • Seniors Outreach Nurses • Continuing Care Counselors • CCMHBI Social Workers

Staff Survey: A population of 1334 current staff members was included in the sample The response rate was 17.4% • Health Care Aides: 60.1% • Nurses: 21/5% • LPNs: 15.7% • Management: 1.3% • Other: 1.3%

Facility Manager Survey: A population of 29 current managers was included in the sample and the response rate was 72.4%

Continuing Care Readiness for Discharge Checklists: 49 checklists included (June 01, 2010 – May 30, 2011)

Measures Focus group questions were developed by the project team members from the SMHP (CCMHBI) in consultation with Seniors Health, Central Zone

The focus group questions were:

• What is working well to help address the needs of clients with a dementia or mental illness?

• What needs to be improved? • How can A&MH work together with

Seniors Health to support the ongoing needs of seniors with a dementia or mental illness?

• Other suggestions and/or comments.

The questionnaires were designed and pilot-tested by the project team members from the SMHP (CCMHBI) in consultation with Seniors Health, Central Zone and contained both closed and open-ended questions

Staff Survey: • Personal feelings & opinions of managers/staff

working with clients with a dementia and/or mental illness

• The greatest barriers to meeting the needs of these clients within the care facility

• Ability of the care facility (managers/staff) to manage challenging behaviors related to a dementia and/or mental illness

• Strategies currently used to manage these behaviors

• Resources currently available to access for support in dealing with clients with dementia and/or mental illness

• Recommendations that would help managers/staff work more effectively with a clients who have a dementia and/or mental illness

Facility Manager Survey: • Characteristics of Continuing Care facilities • Experience with SMHP service

Continuing Care Readiness for Discharge Checklist: • Data element used: Reasons for non-support of a

full application for Continuing Care placement

Continued…


Table 1: Research Approach and Methods

Qualitative Approach Focus Groups

Quantitative Approach Staff Survey (Mail Questionnaire)

Facility Manager Survey (Mail Questionnaire) Continuing Care Readiness for Discharge Checklist

Data Analysis

Focus group sessions were manually recorded by 2 or 3 observers Written transcripts were analyzed to describe emergent themes and validated by members of the project team The transcripts were then reviewed to determine the frequency of recurring themes across the different focus groups

Questionnaires were coded and data entered into analytical software SPSS (Version 18.0 for Windows) A data quality check was completed on 10% of questionnaires received Initial frequency runs were conducted on all data elements in the data set to control for duplicates and out of range variables For the open-ended questions, content analyses of the responses were conducted by members of the project team Descriptive statistics were utilized in analyzing survey results

A more detailed description of the qualitative and quantitative project designs, population involved, sampling methods, measures and data analysis is contained in Appendixes 1,2 & 3. Key Findings Services/programs that are working well for seniors with a dementia and/or mental illness:

Services identified as working well tended to be specific to each focus group and the distinctive roles of their positions/roles. This was also influenced by the services they had access to and the strong working relationships they had developed with individual service providers in communities (Appendix 1). The most common barriers regarding the discharge process for seniors with a dementia and/or mental illness were identified as follows: Staffing related issues:

• Not enough time to provide the level of care required for clients (Staff Survey – 77%) • Not enough care staff to work effectively with clients (Staff Survey – 45%; Continuing Care

Readiness for Discharge Checklist – 65%) • Focus Groups: Staff/client ratios and high staff turnover that impact staff’s ability to manage

clients Education:

• Lack of skills/expertise needed to work with clients (Staff Survey – 63%) • Need for continuous education to help staff work more effectively with clients (Staff Survey –

42%) • Focus Groups: Lack of educational resources (e.g. staff mentors or online learning that is easily

accessible, timely and maintainable) Environment:

• Physical layout of facilities does not allow for safe supervision of clients (Staff Survey – 46%) • Need for clients to be managed in a more specialized unit/facility (Staff Survey – 49% clients with

dementia and 69% for clients with mental illness) • Focus Groups: Need for specialized services/units/facilities for clients with special or challenging

needs (i.e. those under age 65, brain injury, specialized dementia care, mood/thought disorders, and clients that “fall through the cracks”)

Management of Challenging Behaviors (Behaviors most identified in Staff Surveys and by Focus Groups): • Aggressive behaviors – physical and/or verbal aggression (e.g. striking out, abusive language) • Psychiatric features (e.g. hallucinations, delusions, depression, bipolar illness) • Sexual disinhibition (e.g. verbal/physical sexual advances, intercourse/ masturbation in public)


• Safety of self/others Mental Health Support/Follow-Up (Identified in Focus Groups):

• Need for better mental health support and follow-up for patients discharged from the SMHP • Need to improve access to community Mental Health Clinics (e.g. willingness to accept those

over age 65, Outreach Services and Consumer Support Workers) for seniors living in the community

Management /Planning (Identified in Focus Groups): • Concerns regarding “not enough beds for future needs” • Issues related to rural/isolated communities (e.g. lack of services and/or easy access to mental

health services, transportation issues) • Need for A&MH and Seniors Health “to work as one, not as separate entities” • Specific concerns related to private facilities (e.g. staff/client ratios, lack of training, dilution of

nursing role and increased cost to seniors) Identified areas for improvement (as evident from project results) include:

• Review of staffing levels in Continuing Care facilities • Continuous mental health education for Continuing Care staff • Development of specialized environments (services/units/facilities) to address the needs of clients

with complex needs that don’t fit well in current facilities • Provision of/access to mental health support/follow-up for clients with a dementia and/or mental

illness • Strong, cross-boundary leadership/management between A&MH and Seniors Health for service

planning and delivery Conclusions It is evident that there are certain, “individual” programs/services that are working well to address the needs of seniors with dementia and/or mental illness.

Within Continuing Care facilities, the majority of staff members are more confident working with clients who have dementia, than those with other mental illnesses.

Areas for improvement related to the identified barriers are staffing, continuous mental health education, development of specialized environments to address the needs of clients with complex needs, provision of/access to mental health, support/follow-up and leadership/management between Mental Health and Seniors Health. These results may facilitate further dialogue between A&MH and Seniors Health and increase advocacy for advancements/improvements to patient/client care.

This research project provided an opportunity for collaboration for both A&MH and Seniors Health to begin to understand the challenges/limitations both systems face in providing services to seniors. The momentum created by this project needs to be carried on and could so, by engaging both systems in a multitask working group that would problem solve and assist in future research projects such as staffing models. IMPLICATIONS FOR POLICY OR PRACTICE Results from this project have implications for policy and practice development/enhancement. The multiagency collaboration of decision and policy makers from A&MH and Seniors Health (program planners, managers, stakeholders and front-line staff) working towards the strategy of “Aging in the Right Place”, with a focus on addressing areas related to:

• Mental health education/training requirements/programs • Development of protocols that streamline the discharge/placement process, promoting a

integrated managed care approach through stakeholder discussions and collaborative planning between A&MH and Continuing Care

• Adequate funding to support staff/client ratios responsive to the complexity of clients with a dementia and/or mental illness

• Functional environmental layouts that promote safety and security


• Coordinated service delivery within Central Zone, across area boundaries and between services • Access to and provision of mental health support and follow-up services in communities to

improve system patient flow • Engage the Alberta Ministry of Seniors in discussions regarding accommodation standards for

long term care and licensing for supportive living facilities that enhances capacity to provide care/services to seniors with complex mental health needs and to reduce unnecessary variance in practice and standardize care

DIRECTIONS FOR FURTHER RESEARCH Suggested research/evaluation projects in this area include, the exploration of:

• Models of specialized care/units for seniors with complex dementia and mental illness respectively, including approaches to care needs (psychiatric, behavioral and physical), staff/client ratios and environmental layouts that promote safety and security

• The collective-efficacy of rural/isolated communities in relation to the needs of seniors with dementia and/or mental illness and addressing these needs in their communities

• Round table discussions for further research that includes A&MH, Seniors Health and Alberta Ministry of Seniors that would assist in operationalizing the strategy Aging in the Right Place (Alberta Continuing Care)

KNOWLEDGE DISSEMINATION AND TRANSLATION ACTIVITIES

• A copy of this research project will be sent to all stakeholders involved with this initiative for discussion and follow-up

• Meetings will be organized between Continuing Care and SMHP to begin dialogue on addressing practice issues

• Presentation at conferences and submission for journal articles will be considered

PRINCIPAL APPLICANT (TEAM LEADER) Name Position Title Topics of interest Terry Zibin Care Manager, Transition Housing &

Recovery Supportive housing for persons with a mental illness, psychosocial rehabilitation, choice and recovery

PROJECT PARTNERS (TEAM MEMBERS) Name Position Title Role Shauna Prouten Unit Manager, SMHP, CCMHBI Project Chair – planning,

implementation Roy Koshy Director, Community Services, City of

Red Deer, Seniors Health Project Partner – consultation, planning

Dr. D Danyluk Zone Clinical Section Chief, SMHP, CCMHBI

Project Partner – consultation, planning

Marilyn Nakonechny Program Manager, SMHP, CCMHBI Team member – planning, implementation

Melanie Baxandall Unit Manager, SMHP, CCMHBI Team member – planning, implementation

Jean Anne Nichols Clinical Information Resource, Cross Level Services – Central Zone

Team member – planning, data collation, analysis

Neels Ehlers Clinical Information Resource, Cross Level Services – Central Zone

Team member – planning, data collation, analysis

Dora Anderson Facilitator Facilitator for Focus Group, managing of survey questionnaires


PUBLICATIONS AND PRESENTATIONS • Found in Translation Event 2012, Alberta Addiction & Mental Health Research Partnership

Program, March 8, 2012: Oral presentation • CCMHBI Program Management Committee, March 20, 2012: Oral presentation


ABOUT THE ALBERTA ADDICTION AND MENTAL HEALTH RESEARCH PARTNERSHIP PROGRAM The Alberta Addiction and Mental Health Research Partnership Program is comprised of a broad-based multi-sectoral group, representing service providers, academic researchers, policy-makers and consumer groups, working together to improve the coordination and implementation of practice-based addiction and mental health research in Alberta. The mission of the Research Partnership Program is to improve addiction and mental health outcomes for Albertans along identified research priority themes, by generating evidence and expediting its transfer into addiction and mental health promotion, prevention of mental illness, and innovative service delivery. The Research Partnership Program sets out to increase Alberta’s excellence and output of addiction and mental health research findings, and to better translate of these findings into practice improvements.


References Alberta Health and Wellness. Continuing Care Strategy Aging in the Right Place. December 2008. www.health.alberta.ca Brodaty, H., Draper, B. & Low, L. (2003). Nursing home staff attitudes towards residents with dementia: strain and satisfaction with work. Journal of Advanced Nursing, 44(6), 583-590: 583-590. Canadian Coalition for Senior’s Mental Health. (No Date). Fact Sheet: Focusing on long-term care settings. http://www.ccsmh.ca/pdf/FactSheet-LTC.pdf Canadian Study of Health and Aging. (1994). Canadian Study of Health and Aging: Study methods and prevalence of dementia. Canadian Medical Association Journal. 150(6): 899-913. Conn, D. (2002). An Overview of Common Mental Disorders Among Seniors. In Writing in Gerontology: Mental Health and Aging (18). Ottawa. National Advisory Council on Aging. http://www.naca-ccnta.ca/writing_gerontology Creswell, J. W. (2003). Research design: Qualitative, quantitative and mixed methods approaches (2nd ed.). Thousand Oaks, CA. Hebert, F., Bubois, M., Wolfson, D., Chamber, L. & Cohen, C. (2001). Factors associated with long-term institutionalization of older people with dementia: Data from the Canadian Study of Health and Aging. Journal of Gerontology. Vol 56A(11) 693-699. Hill, G., Forbes, W., Berthelot, J., Lindsay, J. & McDowell, I. (1996). Dementia among Seniors. Statistics Canada: Health Reports. 8(2): 7-10. Government of Alberta. Becoming the Best: Alberta’s 5- Year Health Action Plan, 2010-2015. Nov 2010. Shoenmakers, B., Buntinx, F., Devroey, D., Van Cansteren, V. & Delepeleire, J. (2009). The process of definitive institutionalization of community dwelling demented vs non demented elderly: data obtained from a network of sentinel general practitioners. International Journal of Geriatric Psychiatry 24: 523-531. Smith, J. A., Flowers P. and Larkin, M. Interpretative Phenomenological Analysis: Theory, Method and Research. (2009). SAGE Publications Ltd. Statistics Canada. (2005). The Daily December 15, 2005: Population projection. http://www.statcan.gc.ca/daily-quotidien/051215/dp051215b-eng.htm Woods, R., Wills, W., Higginson, I., Hobbins, J. & Whitby, M. (2003). Support in the community for people with dementia and their careers. A comparative outcome study of specialist mental health service interventions. International Journal of Geriatric Psychiatry 18: 298-307. Zibin, T. & Hodgson, S. Housing Needs Assessment Addiction and Mental Health-Central Zone (June 2009). Not published.


Appendix 1: Qualitative Approach – Focus Groups STUDY DESIGN The study design used was an interpretive phenomenological design utilizing six focus groups. SAMPLING METHOD The focus groups consisted of multi-professional stakeholders, who were involved in providing services to seniors with a dementia and/or mental illness. These included the following stakeholder groups:

• Central Zone Placement Officers • Central Zone Seniors Outreach Nurses (SONs) • Central Zone Continuing Care Counselors • Centennial Centre for Mental Health & Brian Injury (CCMHBI) Social Workers

MEASURES A framework for the focus group sessions was developed that contained the following questions to guide discussions:

• What is working well to help address the needs of clients with a dementia or mental illness? • What needs to be improved? • How can Addiction & Mental Health (A&MH) services work together with Seniors Health to

support the ongoing needs of seniors with a dementia or mental illness. • Other suggestions and/or comments

Focus group sessions were held at different venues and were approximately one-hour in length. The sessions started with an introduction (5-10 minutes) and then proceeded into the discussion, with each question being allotted about 15 minutes. The number of focus group participants ranged from 3 – 14, with an approximate total of 43 participants. Some participants arrived late or left early and did not sign the attendance records sheets. DATA ANALYSIS Focus group discussions were manually recorded by two or three observers. Written transcripts were analyzed to describe emergent themes, which were validated by members of the project team. The transcripts were then reviewed to determine the frequency of recurring themes across the focus groups. RESULTS

1. What is working well to help address the needs of clients with a dementia or mental illness? Services identified as working well tended to be specific to each focus group, relating to the distinctive nature of each focus group team and the communities they served. These services included:

• Seniors Outreach Nurse • SMHP/CCMHBI programs/resources (SMHP Intake Meeting, psychiatrists, social workers, and

CCMHBI pharmacists and other program social workers) • Rosehaven (Facility/Outreach Nurse/Follow-Up) • Assessment services through Glenrose/ Northern Alberta Regional Geriatric Program (NARG) • Community support programs (Alzheimers Society, caregiver support groups, day programs) • Community services (e.g. Independent living Skills services/workers, Family & Community

Support Services (FCSS), Home Care, Primary Care Network (PCN) Geriatrician and Mental Health Liaisons in communities where available

• Access to client information through services such as Netcare or service discharge summaries • Placement Office (increased and more consistent staffing, having Transition Coordinators from

Edmonton/Calgary visiting patients on-site at CCMHBI to assess for placement) • Development and maintenance of good working relationships with individual workers/partners • Some good Continuing Care facilities in communities


2. What needs to be improved?

• Staffing issues in Continuing Care facilities, such as low staffing rates and high staff turnover • Lack of trained staff and need for mental health education/training/support for staff in Continuing

Care and Acute Care (biggest challenges in facilities are behaviors, elopement and smoking) • Need for additional Continuing Care beds (corresponding to the projected increase in the elderly

population) • Specific concerns related to private facilities, includes: low staffing levels, lack of staff training, a

lack of interest in providing staff education (in some facilities), changes to the nursing role (e.g. cleaning toilets then serving lunch) and the additional cost for seniors to reside in private facilities

• Designing of services/facilities for special or challenging needs (i.e. those under age 65, brain injury, specialized dementia care, mood & thought disorders, those falling between SL levels 3 & 4, group homes)

• Confusion regarding the changes to the new Supportive Living criteria levels and concern the levels are not working for seniors with dementia and/or a mental illness as they focus on physical not mental health needs

• Better communication/understanding between Placement Office, Continuing Care facilities and the SMHP: o Understanding by SMHP of issues/challenges faced by Continuing Care facilities when

accepting a client from this service (e.g. different staffing ratios, less male staff) o Fear/lack of trust to accept clients from the SMHP (causes delays in discharge and the

exchange of copious amounts of information) • Stigma of mental illness and stigma associated with being admitted to SMHP/CCMHBI • Lack of mental health support/follow-up (e.g. on discharge from SMHP/CCMHBI or follow-up from

SONs regarding recommendations) • More mental health outreach and consumer/home support workers (non-existent in some areas) • No timely return, if needed, for clients discharged from the SMHP/CCMHBI (have to go back

through the referral process) • Telehealth consultation reports not always coming back in a timely manner from the SMHP • Lack of services/supports in isolated/rural communities • Issues related to the information systems used across the zone (i.e. computer systems are not

compatible – Meditech used in facilities and ARMHIS used in community) • SMHP/CCMHBI not using the Resident Assessment Instrument – Home Care (RAI-HC) for

placement applications as is the rest of the province • Issues related to community physicians (e.g. lack of trained/qualified physicians in rural

communities, physicians not following through with psychiatric recommendations) • Lodges difficult to access for placement • Lack of and/or access to the following services:

o Transportation services that are affordable and accessible o Day support programs and caregiver support groups o Respite services o Therapy and counseling services o Palliative/grief support o Recreation Therapy/Occupational Therapy (in the community and Continuing Care facilities)

• Increased awareness of available services • Increased public awareness, health promotion, early intervention services/programs • Issues related to elder abuse


3. How can A&MH work together with Seniors Health to support the ongoing needs of seniors

with a dementia and/or mental illness?

Focus group participants referred to the following actions that would support A&MH and Seniors Health working together to meet the ongoing needs of seniors with a dementia and/or mental illness:

1. Work together as one, rather than two separate governmental departments, to reduce boundaries and/or role issues between and within services (e.g. duplication of services, rigid criteria for services, hesitancy to share information)

2. Lobby together for more resources/services for seniors and their families 3. Improve communication and trust among partners (e.g. through sharing of information, listening

to one another, seeking input from front-line staff for decision-making at higher managerial levels) 4. Take action on the recommendations of this “Barriers to Discharge” project (frustration was

reported with the lack of follow-through with previous surveys/evaluations participants were involved with- no follow-up or follow-through)

5. Other suggestions and/or comments.

• Advocates for seniors and their families to reduce “falling through the cracks” (helping with navigating the system, someone that knows the available resources)

DISCUSSION

Diversity in the responses provided by focus group participants was evident. Uniqueness in responses was found related to services provided by a team(s) and/or the area/community they served within the Central Zone.

Programs and services identified as working well to help address needs of clients with a dementia and/or mental illness included those available at the SMHP/CCMHBI (Intake Meeting, access to social workers and psychiatrists). Seniors Outreach Nurses across the zone were also reported as helpful as was the services provided by Rosehaven Care Center. Caregiver support groups and day programs were also deemed to be working well in areas where they were available. There was a variety of singular services mentioned that were also viewed as working well (e.g. Home Care, Mental Health Liaisons). Access to client information (e.g. Netcare, Discharge Summaries) and having good working relationships with individual workers in other programs/services was also reported as helpful.

Areas/opportunities identified for improvement can be summarized into the following most noted needs: • Continuing Care facilities - increased staffing levels, need for staff education and training and an

increase in the number of beds to accommodate the projected increase in the elderly population • Specialized services/facilities/units to address the needs of specific individual groups that are not

currently addressed well in Continuing Care facilities (e.g. under age 65, brain injury, in need of specialized dementia care, mood & thought disorders, those falling between SL levels 3 & 4)

• Improved mental health support and follow-up along the continuum of care (e.g. discharge follow-up from SMHP/CCMHBI and Mental Health Outreach Workers and Consumer Support Workers available in the community to provide ongoing support and reduce admissions to Acute Care and SMHP/CCMHBI)

• Difficulties faced by rural/isolated communities (e.g. lack of availability and/or access to services/supports, including transportation issues)

Suggestions for ways in which A&MH and Seniors Health could work together to support the ongoing needs of seniors with a dementia and/or mental illness involved working as one, not separate entities. This included reducing boundaries and/or role issues between and within programs/services, lobbying together for more resources/services for seniors and their families, and improving communication and trust between partners and stakeholders. Participants also reported a lack of results/follow-up from their previous involvement with similar evaluation activities, and thus noted a desire to see the implementation of concrete actions based on recommendations arising from this project.


CONCLUSION/RECOMMENDATIONS

The results showed that some “individual” programs/services were working well to address the needs of seniors with dementia and/or mental illness. Recommendations for improvements were related to:

• Staffing: Need for a review of staffing levels (staff/client ratios) in Continuing Care facilities • Development of educational resources (e.g. staff mentors or online learning) that are easily

accessible, timely, maintainable, and specific to dementia and mental illnesses • A model of special services/facilities/units to be explored that would care for dementia and/or

mental illness respectively (e.g. under age 65, complex dementias, brain injured) • Mental health support and follow-up along the continuum of care (following discharge from

SMHP/CCMHBI, having access to Mental Health Outreach Workers and Consumer Support Workers)

• The collaboration of A&MH and Seniors Health: Need to work together as one entity to reduce service barriers


Focus Group Questions

Understanding Discharge Challenges for Seniors with a Mental Illness

by Understanding Systems Limitations

A joint project sponsored by Seniors Health – Central Zone & The Seniors Mental Health Program at The Centennial Center for Mental Health and Brian Injury

Within your current role, please consider the following questions for discussion:

1. What is working well to help you address the needs of clients with a dementia or mental illness?

2. What needs to be improved?

3. How can Addiction & Mental Health services work together with you to support the

ongoing needs of seniors with a dementia or mental illness.

4. Other suggestions and/or comments.


Appendix 2: Quantitative Approach – Staff Surveys STUDY DESIGN

The study design consisted of a cross-sectional research design utilizing a mail survey SAMPLING METHOD

A population of 1334 current staff members was included in the survey sample. The questionnaires with self-addressed envelopes were distributed to staff members by inter office mail and through program managers. SURVEY DEVELOPMENT

The questionnaire was compiled and pilot-tested by the project team members from Seniors Mental Health (SMHP), The Centennial Centre for Mental Health & Brain Injury (CCMHBI) in consultation with Seniors Health, Central Zone. It contained both closed and open-ended questions and took less than fifteen minutes to complete. (See page 23) MEASURES

The primary constructs measured in this evaluation were: • Personal feelings and opinions of managers/staff working with clients with a dementia and/or

mental illness • The greatest barriers to meeting the needs of these clients within the care facility • The ability of the care facility (managers/staff) to manage challenging behaviors related to a

dementia and/or mental illness. • The strategies currently used to manage these behaviors • The resources currently available for support in dealing with clients with dementia and/or mental

illness. • Recommendations that would help managers/staff work more effectively with a clients who have

a dementia and/or mental illness DATA ANALYSIS

Questionnaires were coded and data entered into analytical software SPSS (Version 18.0 for Windows). The quality of data entry was enhanced by conducting initial frequency runs on all data elements to control for duplicates and out of range variables. For the open-ended questions, content analyses of the responses were conducted by members of the project team. Descriptive statistics were utilized in analyzing survey results. RESULTS

Response Rate: 1334 questionnaires were distributed and 232 (17.4%) completed surveys were returned. The majority (60.1%) of respondents were Health Care Aides, followed by Nurses (21.5%), LPNs (15.7%), Management (1.3%) and Other (1.3%). Data Limitations: Because of the low response rate, the 5-point Likert-type scales of the Staff Questionnaire were re-coded into a three point scale, combing Somewhat Agree with Agree into “Agree” and Somewhat Disagree with Disagree into “Disagree”. This provided more useful data, as the numbers when analyzed by the separate categories were small and found not to be as valuable for the purpose of analysis.


Personal feelings and opinions of managers/staff working with clients with a dementia and/or mental illness.

• More than 87% of staff reported feeling confident working with clients with dementia and 87% of staff reported past experience working with these clients. Fifty-nine percent (59%) of staff felt confident working with clients with mental illness and 70% reported past experience working with them.

• Eighty-four percent (84%) of staff felt knowledgeable about the symptoms and behaviors associated with dementia and identified themselves as having the right skills and knowledge to work with these clients. Almost 61% reported knowing the symptoms and behaviors associated with mental illness, while52% felt prepared with the right skills and knowledge to work with these clients.

• Sixty-three percent (63%) of staff felt they could access the help they needed to work with clients with dementia, while 44% indicated the ability to obtain help working with a client with mental illness.

• Sixty-six percent (66%) of staff felt that their facility did a good job of caring for clients with dementia, while 47% of staff expressed similar sentiments for clients with mental illness.

• Forty-nine percent (49%) of staff felt that clients with dementia should be managed in a more specialized unit/facility, 69% felt that clients with mental illness should be managed in a more specialized unit/facility.

TABLE 2: Personal feelings and opinions of managers/staff working with clients with a dementia and/or mental illness

Type of Client

Disagree Neutral Agree

N % N % N %

I feel confident working with these clients Dementia 15 6.6 13 5.7 200 87.7

Mental Illness 50 22.7 40 18.2 130 59.1

I have past experience working with these clients

Dementia 14 6.2 14 6.2 199 87.7

Mental Illness 32 14.3 35 15.7 156 70.0

I feel I know the symptoms and behaviors associated with these illnesses

Dementia 13 5.7 22 9.6 194 84.7

Mental Illness 43 19.5 43 19.5 134 60.9

I feel I have the right skills and knowledge to work with these clients

Dementia 20 8.7 17 7.4 194 84.0

Mental Illness 61 27.7 44 20.0 115 52.3

I can get the help I need to work with these clients

Dementia 57 25.0 26 11.4 145 63.6

Mental Illness 85 38.5 38 17.2 98 44.3

I feel my facility (staff and management) does a good job caring for these clients

Dementia 38 16.6 40 17.5 151 65.9

Mental Illness 76 34.4 42 19.0 103 46.6

I feel these clients should be managed in a more specialized unit/facility

Dementia 63 27.8 53 23.3 111 48.9

Mental Illness 32 14.3 38 17.0 153 68.6


Greatest barriers in care facilities to meet the needs of clients with a dementia and/or mental illness.

Length of time required to provide care for clients with dementia and/or mental illness (77%) was identified as the greatest barrier to meeting the needs of these clients. This was followed by limited access to psychiatric/mental health supports (70%), inability to provide to the level of supervision these clients need (69%), disruption to care for other clients and to daily routines (67%), lack of staff skills/expertise to deal with these clients (63%), and physical layout of the facility does not allow for safe supervision of clients (46%). TABLE 3: Greatest barriers in care facilities to meet the needs of clients with a dementia and/or mental illness N = 226 %

Length of time required to provide care for these clients 175 77.4

Disruption to care for other clients and to daily routines 152 67.3

Inability to provide the level of supervision these clients need 155 68.6

Limited access to psychiatric/mental health support 158 69.9

Lack of staff skill/expertise to deal with these clients 143 63.3

Physical layout of facility does not allow for safe supervision of clients 103 45.6

Other 50 22.1 Ability of care facilities (managers/staff) to manage challenging behaviors related to a dementia and/or mental illness.

Staff reported that their facilities have good ability managing the following behaviors: safety related issues (e.g. unsafe smoking), (53%), exit seeking/elopement (45%), care issues (e.g. restraint use), (45%) and resistance to care (37%). On the other hand, staff stated that their facilities have poor ability managing physical aggression (41%), psychiatric features (34%), sexual disinhibitions (31%) and verbal aggression (30%). TABLE 4: Ability of care facilities (managers/staff) to manage challenging behaviors related to a dementia and/or mental illness Poor Average Good

N % N % N %

Physical Aggression – striking out, kicking, physical threats, etc. 94 40.7 87 37.7 50 21.6

Verbal Aggression – abusive language, verbal threats, etc. 70 30.3 89 38.5 72 31.2

Anxiousness – pacing, wandering, restless, etc. 55 23.9 92 40.0 83 36.1

Resistiveness to care provided (to daily care or redirection, etc.) 54 23.5 91 39.6 85 37.0

Vocally Disruptive – repetitive non-productive words or phrases, moaning, etc. 59 25.8 100 43.7 70 30.6

Socially Inappropriate Behavior – voiding in inappropriate places, disrobing, spitting, etc. 64 27.8 89 38.7 77 33.5

Sexual Disinhibition – verbal or physical sexual advances, sexual intercourse, masturbation in public 68 30.5 82 36.8 73 32.7

Continued…


TABLE 4: Ability of care facilities (managers/staff) to manage challenging behaviors related to a dementia and/or mental illness Poor Average Good

N % N % N %

Hoarding / Rummaging – going through, accumulating items, etc. 49 21.3 97 42.2 84 36.5

Shadowing – clinging to others, unwilling to be left alone, etc. 44 19.3 106 46.5 78 34.2

Safety-related issues – unsafe smoking, ingesting nonfood items, etc. 38 16.6 70 30.6 121 52.8

Care Issues – night time wakefulness requiring intervention, frequent PRNs, restraint use, etc. 43 18.7 84 36.5 103 44.8

Psychiatric Features – hallucinations, delusions, depression, bipolar illness, etc. 76 33.6 95 42.0 55 24.3

Strategies currently used to manage behaviors related to a dementia and/or mental illness.

It was reported that facilities use the following strategies to deal with and /or manage behaviors, having care/treatment plans to address behaviors (82%), referral procedures to a physician for assessment or medication reviews (82%), and using items such as Broda chairs and lap belts (71%).

TABLE 5: Strategies currently used to manage behaviors related to a dementia and/or mental illness N = 220 %

Development of a care/treatment plan to address behaviors 181 82.3

Referral to physician for assessment or medication review 181 82.3

Use of items such as Broda chairs, lap belts, lap trays, etc. 156 70.9

Other 29 13.2

What would help to work more effectively with clients who have behaviors related to a dementia or mental illness.

Staff indicated that continuous education (42%), increased staffing (39%), improved client care (33%) and environmental changes (29%) would help them to work more effectively with clients who have behavioral issues related to a dementia and/or mental illness. TABLE 6: What would help to work more effectively with clients who have behaviors related to a dementia or mental illness N = 198 %

More Staff 77 38.9

Continuous Education 83 41.9

Improved Client Care 65 32.8

Environmental Changes 39 19.7

Other 22 11.1


Resources currently available to access for support in dealing with clients with dementia and/or mental illness.

Continuing Care Counselors (49%) are accessed most frequently for support, followed by Rosehaven Provincial Program (47%), Seniors Outreach Nurses (33%), Home Care Nurses (27%) and Acute Care of the Elderly Team (ACE), (15%).

TABLE 7: Resources currently available to access for support in dealing with clients with dementia and/or mental illness N = 157 %

Continuing Care Counselor 77 49.0

Seniors Outreach Nurse 51 32.5

Home Care Nurse 42 26.8

Acute Care of the Elderly Team (ACE) 23 14.6

Rosehaven Provincial Program 73 46.5

Other 23 14.6

Recommendations that would help managers/staff work more effectively with clients who have a dementia and/or mental illness.

To work more effectively with clients who have a dementia and/or mental illness, staff recommend the need to increase staffing (45%), improve client care (45%), provide more education for staff (41%), and address environmental needs (23%).

TABLE 8: Recommendations that would help managers/staff work more effectively with clients who have a dementia and/or mental illness N = 198 %

More Staff 70 45.2

Continuous Education 64 41.3

Improved Client Care 69 44.5 Appropriate Environment 36 23.2 Other 24 15.5

DISCUSSION

It is evident that Continuing Care facility staff felt more confident working with clients with dementia rather than those with mental illness. They also report a better knowledge of symptoms and behaviors related to dementia (vs. mental illness) as well as skills and knowledge to work with these clients. Although 66% of staff felt that their facility did a good job of caring with clients with a dementia, 49% of staff felt that these clients should be managed in a more specialized unit/facility. Less than half of staff (47%), felt their facility did a good job of caring for clients with a mental illness, with 69% feeling these clients should be managed in a more specialized unit/facility.

Barriers to meeting the needs of clients with dementia and/or mental illness within facilities were almost equally reported. These barriers included, length of time required to provide care for these clients,


access to psychiatric/mental health supports, inability to provide to the level of supervision required and resulting disruption to care for other clients and to daily routines, along with lack of staff skill/expertise to deal with these clients and physical layout of the facility that does not allow for safe supervision of clients. According to staff, aggression (physical and/or verbal), psychiatric features and sexual disinhibition were the behaviors that facilities had the most difficulty managing. Staff members indicated that increased education and increased staffing, improved client care and environmental changes (e.g. quiet/safe areas for clients to wander without restrictions) would help them work more effectively with clients who have behavior problems related to a dementia and/or mental illness.

Staff accessed Continuing Care Counselors and the Rosehaven Provincial Program most frequently for support in dealing with clients with dementia and/or mental illness. They also accessed Seniors Outreach Nurses, Home Care Nurses and the Acute Care of the Elderly (ACE) Team for support. To work more effectively with clients who have a dementia and/or mental illness, staff recommend the need to increase staffing, improve client care, provide more education for staff and address environmental needs. CONCLUSION/RECOMMENDATIONS

It is apparent that there are different needs associated with caring for clients with dementia versus caring for clients with mental illness. The staff members within Continuing Care facilities appear to experience greater difficulty in dealing with clients with mental illness.

It may be beneficial to explore models of special units that would care for clients requiring complex care for both dementia and mental illness respectively. The need for education resources (e.g. staff mentors or online learning) particular to dementia and mental illness was a recurring theme. The need for easily accessible, timely and continuous education/training was also stressed. Another strong theme evident from survey results was the need for a review of staff/client ratios in Continuing Care facilities as this appears to be major factor affecting the ability of staff to care for clients with a dementia and/or mental illness.


The Centennial Center for Mental Health and Brain Injury Seniors Mental Health Program

Staff Questionnaire The purpose of this questionnaire is to get feedback on your experience of caring for people who have a mental illness or dementia. The information will be used to help make decisions about the care they need. We would like to let you know:

• Completing this questionnaire is voluntary – you are not required to complete it.

• Completing the questionnaire means you are agreeing to take part in this project.

• Completing the questionnaire will not affect your job in any way.

• Your answers are anonymous and your privacy is protected – do not put your name on the questionnaire.

• The only people who will see your completed questionnaire are the project team members, with the main person from this team seeing your answers being the project team member who puts your responses into a computer data base. No one else will see your questionnaire.

• Completed questionnaires will be kept in a locked cabinet in a locked area in the Seniors Mental Health Program at The Centennial Center for Mental Health and Brain Injury. Computer files will be kept on a secure service that is password protected. Questionnaires must be kept for 7 years. Both the questionnaires and computer files will be retained and destroyed as outlined in the AHS Records Retention Schedule.

If you have any questions about the questionnaire, please call Marilyn Nakonechny, Program Manager, Seniors Mental Health Program, #403-783-7642.


1. Position: □ Management □ Nurse □ LPN □ Health Care Aide

□ Other (please specify)___________________________________

2. Please rate the following questions, based on your personal feelings and opinions using the scale provided, for both clients with a dementia and/or mental illness (Circle the number that best applies):

Please note: Dementia: Refers to clients who have a diagnosis of Alzheimer’s, Vascular Dementia or other type of dementia.

Mental Illness: Refers to clients who have a diagnosis of Depression, Bipolar or Anxiety Disorder, or Schizophrenia or other psychiatric illness.

Type of Client Disagree Somewhat

Disagree Neutral Somewhat Agree Agree

I feel confident working with these clients

Dementia 1 2 3 4 5 Mental Illness 1 2 3 4 5

I have past experience working with these clients

Dementia 1 2 3 4 5

Mental Illness 1 2 3 4 5

I feel I know the symptoms and behaviors associated with these illnesses

Dementia 1 2 3 4 5


I feel I have the right skills and knowledge to work with these clients

Dementia 1 2 3 4 5


I can get the help I need to work with these clients

Dementia 1 2 3 4 5


I feel my facility (staff and management) does a good job caring for these clients

Dementia 1 2 3 4 5


I feel these clients should be managed in a more specialized unit/facility

Dementia 1 2 3 4 5

Mental Illness 1 2 3 4 5 3. What factors present the greatest barriers in your care facility to being able to meet the needs of these clients (check all that apply): □ Length of time required to provide care for these clients □ Disruption to care for other clients and to daily routines □ Inability to provide the level of supervision these clients need □ Limited access to psychiatric/mental health support □ Lack of staff skill/expertise to deal with these clients □ Physical layout of facility does not allow for safe supervision of clients □ Other (please specify):_____________________________________________________


4. Please rate the ability of your care facility (staff and managers) to manage the following behaviors. (Circle the number that best applies):

Very Poor Poor Average Good Very

Good

Physical Aggression – striking out, kicking, physical threats, etc.

1 2 3 4 5

Verbal Aggression – abusive language, verbal threats, etc. 1 2 3 4 5

Anxiousness – pacing, wandering, restless, etc. 1 2 3 4 5 Resistiveness to care provided – to daily care or to redirection, etc. 1 2 3 4 5

Vocally Disruptive – repetitive non-productive words or phrases, moaning 1 2 3 4 5

Socially Inappropriate Behavior – voiding in inappropriate places, disrobing, spitting, etc. 1 2 3 4 5

Sexual Disinhibition – verbal or physical sexual advances, sexual intercourse, masturbation in public

1 2 3 4 5

Exit-seeking / Elopement – actively trying exit doors, windows, etc. 1 2 3 4 5

Hoarding & Rummaging – going through or accumulating items, etc. 1 2 3 4 5

Shadowing – clinging to others, unwilling to be left alone, etc. 1 2 3 4 5

Safety-related issues – unsafe smoking, ingesting nonfood items, etc. 1 2 3 4 5

Care Issues – night time wakefulness requiring intervention, frequent PRNs, restraint use, etc. 1 2 3 4 5

Psychiatric Features – hallucinations, delusions, depression, bipolar illness, etc. 1 2 3 4 5

5. Please list any other behaviors not listed that your care facility (staff and managers) has difficulty managing:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________


6. Please indicate which of the following strategies your care facility currently uses to deal with and/or manage behaviors:

□ Development of a care/treatment plan to address behaviors

□ Referral to physician for assessment or medication review

□ Use of items such as Broda chairs, lap belts, lap trays, etc. If yes, please indicate what items you are using_____________________________________________________________________

_____________________________________________________________________________

□ Other (please specify)___________________________________________________________

_____________________________________________________________________________ 7. Please comment on what you feel would help you to work more effectively with clients who have

behaviors related to a dementia or mental illness: ________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

8. What resources does your care facility currently have available, or access to, if you have questions

regarding clients with dementia or mental health issues?

□ Continuing Care Counselor □ Acute Care of the Elderly Team (ACE)

□ Seniors Outreach Nurse □ Rosehaven Provincial Program

□ Home Care Nurse □ Other (please specify):____________________ 9. Please list any recommendations you have that you feel would help you work more effectively with

clients who have a dementia, mental illness, or display difficult to manage behaviors. ________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Thank you for completing this questionnaire.

Please return using the self-addressed, stamped envelope enclosed.


Appendix 3: Facility Manager Questionnaire Analysis Report STUDY DESIGN

A cross-sectional research design utilizing a mail survey. SAMPLING METHOD

A population of 29 Continuing Care facilities in Central Zone was included in the survey sample. The questionnaires with self-addressed envelopes were distributed to managers of these facilities. SURVEY DEVELOPMENT

The questionnaire was compiled by the project team members from the Seniors Mental Health Program (SMHP) at The Centennial Centre for Mental Health & Brain Injury (CCMHBI) in consultation with Seniors Health, Central Zone. It contained both closed and open-ended questions. (See page 29) MEASURES

The primary constructs measured in this evaluation were: • Characteristics of the facility including Designated Supportive Living levels of care (Levels 3, 4, 4

Dementia and/or Long Term Care), number of clients living in the facility, type of security used and type of staff, staff/patient ratios)

• History of referrals made and/or admissions to the SMHP from Continuing Care facilities • Type of building security used

DATA ANALYSIS

Questionnaires were coded and data entered into analytical software SPSS (Version 18.0 for Windows). The quality of data entry was enhanced by conducting initial frequency runs on all data elements to control for duplicates and out of range variables. For the open-ended questions, content analyses of the responses were conducted by members of the project team. Descriptive statistics were utilized in analyzing survey results. RESULTS

Response Rate: 29 questionnaires were distributed and 21 (72.4%) completed surveys were returned. Central Zone facilities responding by area were as follows:

• 6 - North Area • 8 - South Area • 6 - East Area • 1 - Red Deer Area

Data Limitations: Responses to some questions in the surveys did not allow for reliable analysis because participants did not respond to the question as indicated.

For example, Question 9: “What is your average staffing ratio (staff to client) on the following shifts of Days, Evenings and Nights”. Some responses indicated only a single number and it was not clear if this number related to staff or clients and some did not indicate the ratio according to shift.


Characteristics of the facility (designation levels - DSL3, 4 and/or LTC, number of clients living in the facility, type of security used and type of staff, staff/patient ratios) Designation levels of facilities reported as:

• DSL3 (4%), DSL 4 (4%), LTC (83%) and Other (8%)

Private/Shared Rooms: • 605 private rooms (range: 7 – 112 private rooms) • Shared rooms (range: 0 – 70 shared rooms)

Number of clients living in facilities • 1090 clients (range: 13 – 112 clients)

Number of staff working at these facilities • 174 nurses (range: 0 – 24 nurses) • 120 LPNs (range: 0 – 15 LPNs) • 752 aides (range: 1 – 123 aides) • Other professions – unable to accurately report due to inconsistent recording, however it

appears that 20 facilities have some level of access to Recreation Therapy, 19 to Occupational Therapy and 13 to Physical Therapy

Staff/client ratios at facilities • Unable to report accurate staffing ratios due to inconsistent recording (e.g. some reported

staffing by actual numbers, others by FTEs)

Type of restraints currently used in facilities • Side rails – 81% • Restraint belts on chairs, toilet or commodes – 57% • Chair/table restraint – 55% • Hand/arm board – 17% • T-belt restraint – 15% • Other (foot/hand restraint, hand control mitt, jumpsuits) – 5% respectively

Main reasons for use of restraints: Safety, prevention of falls and positioning

History of referrals made and/or admissions to the SMHP from Continuing Care facilities

• Facilities that have referred clients for assessment and treatment at the SMHP Yes – 85% No – 10% Unsure – 5%

• Facilities has clients that have been treated as an inpatient at the SMHP Yes – 80% No – 10% Unsure – 10%

Type of building security used

• Wanderguard – 52% • Coded/Key Punch Door – 41% • Other – 7%

CONCLUSION/RECOMMENDATIONS

Results provide an overview of the characteristics of Continuing Care facilities in Central Zone.

It may be of value to further investigate staff/client ratios as results were inconstantly reported and did not provide useful information.


Centennial Centre for Mental Health and Brain Injury Seniors Mental Health Program

Facility Manager Questionnaire To: Facility Manager or Designate

Thank you for completing the following questions. The information you provide will assist us in gaining a better understanding of your facility and difficulties you may have in providing services to clients having a dementia or mental illness. If you have any questions about the questionnaire, please call Marilyn Nakonechny, Program Manager, Seniors Mental Health Program, #403 783-7642.

1. Name of your facility_______________________________________________________________ 2. Designation of facility (please check all that apply)

□ DSL 3 □ DSL 4 □ LTC

□ Other (please specify)_____________________________________________________________ 3. Have you referred any clients from your facility assessment to the Seniors Mental Health Program for

inpatient treatment and assessment?

□ Yes □ No □ Unsure 4. Has any client from your facility been treated as an inpatient at the Seniors Mental Health Program?

□ Yes □ No □ Unsure 5. Type of security used in your facility:

□ None □ Wanderguard □ Coded / Key Punch Door

□ Environmental Design (please describe)______________________________________________

________________________________________________________________________________

□ Other (please specify)_____________________________________________________________ 6. Number of beds/rooms in your facility that are:

Private Rooms_____________ Shared Rooms_________________

Other (please specify)_______________________________________________________________ 7. Number of clients living in your facility.__________________________________________________


8. Please list type and number of staff at your facility

Type of staff Number of staff Nurses LPNs Aides Recreation Therapist Occupational Therapist Other (Please List)

9. What is your average staffing ratio (staff to client) on the following shifts: Days_________________ Evenings_______________ Nights_________________ 10. Does your facility currently use any of the following type of restraints?

Yes No If yes, for what reason Restraint belts on chairs, toilet or commodes

Chair table restraint T-belt restraint Hand/arm board Foot/hand restraint Hand control mitt Soft ties Side rails Jumpsuits

11. Please indicate any other comments you wish to make:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Thank you for completing this questionnaire.

Please return using the self-addressed stamped envelope.


Appendix 4: SMHP Continuing Care Readiness for Discharge Checklist

Continuing Care Readiness for Discharge Checklist (June 1, 2010 – May 31, 2011)

*Includes only those reasons over 10%

67% 65%

53%

37%

24% 24% 24%

12% 12%

Aggression Staff Resources in LTC

Safety (Self/Others)

Behavior Management

Resistiveness (Care/Meds)

Agitation Restraints Used Refusing Medications

Disruptive

Reasons for "Non-Support" of a Formal Application to Continuing Care(n=49)


Seniors Mental Health Program Continuing Care Readiness for Discharge Checklist

Please indicate how often the patient/client has had any of the following behaviors, safety‐related issues, care issues, psychiatric features and/or mood difficulties in the past four weeks, by circling the number of the category that best describes the frequency of occurrence.

Never

Less than

once a week

Once or several times a week

Once or several times a

day

A few times an hour or continuous

for ½ hour or more

Aggression – Physical • Physical threats • Attempts to, or actual striking out • Grabbing, kicking, pushing, biting, scratching or

spitting. • Throwing objects at others • Ramming others with walker/wheelchair

0 1 2 3 4

Aggression –Verbal • Verbal threats • Abusive language (swearing, yelling, name calling,

racial slurs)

0 1 2 3 4

Agitation – Psychomotor • Non-directable disruptive activities (e.g. moving

furniture) • Restlessness, pacing, wandering, rocking or tapping• Intrusive with co-patients • Reaching out and latching on to others • Inability to sit during meals • Throwing, tearing or damaging things

0 1 2 3 4

Agitation – Verbal • Repetitive requests, sentences, or questions 0 1 2 3 4

Resistive • Difficult to provide basic ADL care • Difficult when being moved to another area, when

getting out of bed, when taking nutrition or medications and when being redirected

0 1 2 3 4

Sexual Disinhibition • Making verbal or physical sexual advances • Fondling, sexual intercourse, masturbation in public,

removing clothing from others

0 1 2 3 4


How often has the patient/client had any of the following behaviors in the last few weeks: Circle the number that best applies: Never

Less than

once a week



day

A few times an hour or continuous

for ½ hour or more

Vocally Disruptive • Repetitive non-productive words or phrases,

moaning • Strange noises (e.g. howling)

0 1 2 3 4

Socially Inappropriate Behavior • Voiding anywhere other than in toilet/urinal in a

bathroom (e.g. in public areas, garbage cans, on the floor etc.)

• Disrobing – Removing of clothing at inappropriate times or places

• Feces smearing, rectal digging • Spitting behavior

0 1 2 3 4

Exit-Seeking / Elopement • Actively trying exit doors or windows • Scaling fences

0 1 2 3 4

Hoarding & Rummaging • Accumulating of any items belonging to others • Going though own or others belongings and leaving

them in significant disarray • Hiding things

0 1 2 3 4

Shadowing • Clinging onto others, usually a caregiver • Unwilling to be left alone • Difficult to redirect or reassure

0 1 2 3 4

Safety-Related Issues • Unsafe smoking habits • Spitting of tobacco in inappropriate places • Substance abuse or seeking of same • Stuffing toilets with Attends or other items • Ingesting nonfood items • Sleeping in other’s beds (empty or occupied) • Placing self on floor, climbing on tables, lying on

countertops

0 1 2 3 4


How often has the patient/client had any of the following behaviors in the last few weeks:

Circle the number that best applies: Never

Less than

once a week



day

A few times an hour or continuous for ½ hour

or more Care Issues • Night time wakefulness requiring frequent

intervention by staff • Frequent PRNs • Ingesting food to the point of choking • Requiring treatment/rehabilitation for an acute

medical illness or condition (e.g. UTI, pneumonia, hip fracture)

• Restraint use (e.g. lap belts, Broda chairs, bed side rails, wheelchairs with back-fastening belt)

• Receiving Hypodermoclysis

0 1 2 3 4

Psychiatric Features • Hallucinations, delusions and/or suspiciousness

that are distressing for the patient or others 0 1 2 3 4

Mood • Frequent interventions to address symptoms of

anxiety, depression or mania 0 1 2 3 4

Risk Management (Check those that currently apply):

□ Q15 Observation Level □ Constant Observation Level □ Formal Status

Comments:__________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________


Seniors Mental Health Program (CCMHBI)

Readiness for Continuing Care Placement Checklist

Continuing Care Placement Office Decision

□ Recommend an application for Continuing Care placement be completed

□ Do not recommend an application for Continuing Care placement be completed for the following

reasons:__________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Other Comments / Follow-Up Suggestions:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

collaborative research grant initiative: mental …...directions for further research include...

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