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Behavioural Health Resource Consultants:
A bit about us
Leona Wilneff, RN, CBRC
Karine Smith, BSc, CTRS, CBRC
Natalie LeJean, RN,CBRC
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• “PIECES Lady”
• Behaviour Person
• Challenging Behaviour Resource Consultant
• Behaviour Resource Consultant
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• Nova Scotia Department of Health and Wellness
established the Challenging Behaviour Program
province-wide in 2004
• Aim is to enhance capacity in the provision of care
to older adults experiencing cognitive impairment
and associated responsive behaviours
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Recognizes client’s care needs are impacted by:
• Their health condition
• Environment
• Healthcare team that provides direct care
• Organization/facility that administers their care
• The system (resources and policies )
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• Build on strengths, knowledge and skills of
individuals and care teams
• Provide support and facilitate teams to work
together toward a common goal of client centered
care
• Promote a coordinated approach to care within and
across systems of care
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How consultants help with systems approach through
education
Education
•Workshops, including P.I E.C.E.S. Education
•Informally through coaching, resource sharing
Consultation
•Case-based consultations*
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Capacity Building
• Facilitate communication and collaboration
between partners in care ( Senior’s Mental
Health, other healthcare staff )
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Challenging Behaviour Resource Consultant Systems of Care
LLoonngg--TTeerrmm CCaarree//RRCCFF
Services offered to all facilities,
responsive behaviour team
meetings, case by case, Input
regarding utilization of 1:1
attendant care, PIECES
education- 24 hour and one day
Enabler course. Build capacity
within facility
Care Planning and
liaison, transition
from acute to LTC
Acute Care
Case by case, advice and
assistance with care
planning for transition to
Long-Term Care
CBRC
CCoommmmuunniittyy
Close work with Care Coordinators,
some liaison with SMH, GPs, Geriatrics,
case by case, educate home care
providers, team work with OT/PT/
family, education of community groups
Transitions/placement,
AP-liaison, education
Committee,
education,
transitions
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• Responsive behaviours that the team are struggling
to manage (calling out, exit seeking)
• ‘Resistance’ to Care
• Physical/verbal aggression
• Inappropriate sexual behaviour/aggression
• Assistance troubleshooting causes of behaviour
• Developing Care Plan
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NSHA Zones
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MANAGER Paul Fieldhouse [email protected]
WESTERN ZONE Karen Bennet Karen [email protected]
Karine Smith [email protected]
Marnie Oatway [email protected]
EASTERN ZONE Brenda Nicholson [email protected]
Natalie LeJean [email protected]
Leona Wilneff [email protected]
NORTHERN ZONE Ruth Slack [email protected]
MaryAnne Johnston [email protected]
Janet Aucoin [email protected]
CENTRAL ZONE Jeanne Ju [email protected]
Lynda Culley [email protected]
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Case Study:
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SMH Received The Referral. An 86
year old female with a diagnosis of
Dementia (Alzheimer’s Type) by
Geriatric Medicine Specialist in 2012.
Client No longer had capacity to make
decisions.
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We will not focus on the details of Mrs. B’s
case but on the Team’s Best Practice Approach
used in helping this resident achieve the best
quality of life.
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Full SMH assessment completed:
Presentation
Medical Hx & Medications
Social Hx
Environmental Survey
Mental Status exam
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Areas of Concern:
- Psychosis
- Verbal & Physical Aggression
- Change in physical status (was ambulatory
– now wheelchair due to hip #)
- Increased agitation
- Pain management
- Poor medication compliance
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Resident had a sitter 8hrs a day
Family very supportive and involved closely –
would sit with resident every evening
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Consult for CBRC
- DOS Started
- PIECES Template Completed
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Medical profile Reviewed with family physician
- liquid medication was trialed with some
effectiveness
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Some triggers were identified. CBRC made
recommendations upon speaking with staff.
Care plan was modified.
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PT and OT assessment completed – to
determine abilities & comfortable
wheelchair, able to be self propelled
allowing increased physical activity
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Some improvement noted but resident was
still struggling. 1:1 staff was changed from
nursing staff to recreation staff. Resident
responded to interventions and engagement
in new activities in 1:1
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SMH Psychiatrist was consulted to assess
medication profile. Meds were altered in
slow and low increments.
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CBRC continued to meet with staff and re-
evaluate triggers and responsive behaviors.
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Case with discussed at monthly SMH special
care team meetings which included
multidisciplinary staff. SMH Clinician, CBRC,
Nursing, Recreation, Dietary, Housekeeping.
Occasionally, the treating physician and
Continuing Care would attend.
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Psychiatrist kept informed of status.
Medications adjusted occasionally, with
discontinuing medication not found to be
effective. Keeping polypharmacy in mind
throughout.
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CBRC assisting staff in utilizing assessment
tools (Cohen Mansfield Agitation Inventory,
DOS) throughout to help determine if
interventions were being effective
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As changes occurred with regard to
presentation, A new PIECES Template would
be completed by trained staff with CBRC’s
ongoing support.
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Resident’s QOL has improved slowly over time
with each team members’ input.
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Over time (18 months) this resident has shown
a decline both cognitively and physically.
Her needs have changed as well as her care
plan.
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Collectively, using a team approach, we
educate and support each other and do our
best to meet the needs and improve the QOL
of our residents.
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Case Study:
Continuing Care – Home
Support – Behavioral Health
Collaboration
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Consult to Behavioral Health Consultant from Care
Coordinator and Home Support Manager
Presenting situation:
49 yr old female, living at home with Husband.
Diagnoses with advanced frontal lobe dementia.
Difficulty with communication, does not speak, no
facial expressions, flat effect, unable to carry out
previous household duties. Grabbing at home
support staff and has become physically aggressive
with husband when he is helping with personal care
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CBRC, Home Support Manager/staff, Care
coordinator meet
Home support explain presenting situation to
Care Coordinator and CBRC
CBRC completes PIECES Ax with input from
staff, manager and care coordinator
Home Support have identified a team to work
within the home to provide consistency
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Triggers identified
CBRC made recommendations with home
support staff team
Provided home support with resources on
frontal lobe dementia
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Care Coordinator updated care plan
Client offered bed in LTC and accepted.
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Case Study:
Alternate Level of Care
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ALC
Mrs. D is a 76 year old widowed woman who was living alone in
her own home. She was transferred to the local ER after a fall that
resulted in a broken arm. While in hospital she frequently tried to
exit seek and subsequently transferred to the regional hospital
“ALC” unit for safety where she awaits placement to long term
Care. The CBRC has been contacted as she continues to exit seek
and is becoming increasingly agitated.
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Case study con’t
Additionally we know that within the past year she was diagnosed
with moderate dementia of the Alzheimer type by her family
physician. Aricept was suggested however she refuses to take
medications. Over the past year family and friends have observed
a significant decline in her ability to care for herself. Family
report that she has always been a bit suspicious and paranoid.
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What Now ? Further Assessment ?
Q 1 What has changed ?
Avoid assumptions; think atypical
Q 2 What are the RISKS and possible causes
Think P.I.E.C.E.S
Q 3 What is the action ?
Intervention
Interactions
Information
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Team Work
• RN, LPN, CCA
• Family Physician
• Geriatrician
• Family and Friends
• Mrs. D
• PT/OT
• Care Coordinator
• ?
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What We Learned
As a result of a team meeting including family we learned:
• When she can’t visualize her cat she will wander in search of her
• She was a botanist and used herbs for medicinal purposes
• She and her husband experienced a home invasion in their early
marriage that left her fearful
• She took her pain medication for 1 nurse who served it in her favorite
ice cream flavour “strawberry”
• She loved classical music which often helped her relax
• She was not socially involved. Spent most of her time at home in her
gardens, with the exception of weekly church service
• Blood work and urinalysis normal
• She accepted personal care from a CCA who has a quiet demeanor
• A Cohen Mansfield assessment concluded her agitation presented the
highest risk
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Plan For 1 Week
• Family to bring photos of her cat
• Staff to remind her “kitty” is ok when observed to be “searching
• Move her to a room closer to the Nurse Station for a sense of
safety/security
• Administer pain meds in strawberry ice-cream
• Assess for atypical signs of pain
• Family to bring CD player and favourite music CD’s for relaxation
• Family to visit routinely and when possible take her out to the
hospital flower gardens
• Request pastoral visits
• OT to assess her for an arm support guard
• Repeat Cohen-Mansfield after 1 week
• Team to review plan effectiveness
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Wrap Up
• When to call the team?
• YOU are the experts
• Make your consultation
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Questions?
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Thank You
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Case Study
George is a 56 year old man who has been living in an acute year bed
for 5 years.
Five years previously George was working in Alberta. While driving his
motor cycle to work one morning he struck a bull moose and as a
result sustained a significant brain injury.
For the first 3 years in acute care he had custodial care 24 hours daily.
He was described as having “violent”
outbursts and was resistive to care. He did well with certain custodians
and caregivers and no staff member ever sustained injury as a result
of caring for George.
Hi Natalie,
Of course, you can change it back. I hadn’t
changed any of the text- I summarized
it on the slides.
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continued
During the last 2 years in acute care he has had custodians for 8-12
hours daily.
As the facility manager of a long term care facility you have been
requested to consider admitting George. You are informed that other
nursing homes in the area have declined to admit him.
George has a wife and two teenage children who live in the area.
George’s wife visits frequently and wishes he could be transferred to
LTC.
Where do you Start ??
Who is your Team ??