innovation fund handbook - neshw · the innovation fund handbook since its inception in 2013,...

Innovation Fund Handbook

The Innovation Fund HandbookSince its inception in 2013, Covenant’s Network of Excellence in Seniors’ Health and Wellness (the Network) has focused on creating capacity and expertise for better and more sustainable models of seniors care in Alberta. In order to design, evaluate and share ideas that enable seniors to live fully, as active and connected members of their communities, the Network has partnered with seniors, families, experts, and a wide range of other stakeholders.

Over the years, the Network has invested in 18 research projects through its Innovation Fund Program. The goal of this program was to generate new knowledge and incent innovation. Projects were run in a wide range of settings including independent living, supportive living, seniors’ activity centres, home care, community service organizations, acute and long term care, and primary care networks.

This handbook provides a synopsis of the Innovation Fund projects, how these projects tackled a variety of issues and resulted in valuable new products, services and practice changes across the continuum of care.

We hope you will find it useful! Please contact the Network if you have questions about any of the projects and let us know if you would like to be part of the spread and scale of the knowledge gained through these projects.

Table of Contents

6 Coaching for Older Adults (with OA) for Community Health (Coach Study)Project Lead: Dr. Allyson Jones

8 Navigation Partnerships: Connecting, Accessing, Resourcing and Engaging Older Persons, Families and Communities (Nav-CARE)Project Lead: Dr. Wendy Duggleby

10 Supporting Healthy Aging by Peer Education and Support (SHAPES)Project Leads: Dr. Adrian Wagg and Dr. Saima Rajabali

12 Collaborative Case Management (CCM)Project Lead: Beth Whalley

14 Seniors Helping Seniors: Promoting and Empowering Peer Support for Seniors’ Health and WellnessProject Lead: Dr. Haidong Liang

16 Seniors’ Community HubPro ject Lead: Dr. Marjan Abbasi and Dr. Sheny Khera

18 Integrated Home Care: Data-Driven Decision-Making for Quality ImprovementProject Leads: Dr. Erika Goble and Laura Milligan

20 Camrose PCN Fall Prevention ProgramProject Lead: Stacey Strilchuk

22 Innovating to Improve Seniors’ Care in Kalyna CountryProject Lead: Brian Match

24 Northern Home Care Knowledge to Action Strategies that Support Persons with Dementia (PWD) and their Family Caregivers (CGS)Project Lead: Dr. Dorothy Forbes

26 Examining Aged Care Transitions (EXACT)Project Leads: Dr. Greta Cummings and Dr. Jude Spiers

28 Implementing a Responsive Leadership Intervention in Long Term Care Facilities: A Pilot Study

Project Lead: Dr. Sienna Caspar

30 From Cooperative Learning Strategies to Quality Continuing Care WorkplacesProject Lead: Dr. Sharla King

32 Skills-Based Video Training on the Care of the Orthopaedic Client for Frontline Workers in Long Term Care Facilities

Project Leads: Dr. Erika Goble and Laura Milligan

34 Spreading and Sustaining the Decision-Making Capacity Assessment (DMCA) Model: Development and Evaluation of the DMCA Model Implementation and Sustainability Framework

Project Lead: Dr. Suzette Bremault-Phillips

36 Managing Responsive Aggressive Behaviours: Implementing and Evaluating a Capacity Building Process in Acute Care, Supportive Living and Long-Term Care

Project Lead: Dr. Suzette Bremault-Phillips

38 Evaluation of the GEM-ED (Geriatric Evaluation and Management in the ED) Service Project Lead: Dr. Jed Shimizu

40 TransitionsinCare–EarlyIdentificationandSupportforTransitionsinCareforComplex Older Adult Populations

Project Leads: Lisa Jensen and Dr. Lesley Charles

6

Coaching for Older Adults (with OA) for Community Health (COACH Study)Problem statement and novelty Older adults living in rural communities often find it challenging to be physically active both before and after knee replacement surgery due to limited availability of rehabilitation services. The COACH program addresses this problem, and is novel because it is an approach to follow patients in rural communities during the long-term recovery after total knee replacement. This pilot is being delivered by distance to rural patients in Camrose and the surrounding area.

The project: a short description This project is assessing the effectiveness of a physiotherapist-led coaching intervention to promote self-management of physical activity after a joint replacement. It breaks down the silo of the hospital to allow the same physiotherapist to follow a patient into the community.

Technically, the COACH study is examining the feasibility of implementing theory-based behavioural coaching intervention delivered by distance to older patients before and after receiving total knee arthroplasty (TKA). By offering coaching with a physiotherapist by distance, the team will determine if this is an effective and practical method to encourage physical activity for rural Albertans. A quantitative follow-up study design has begun, and a pragmatic qualitative assessment has also been started to look at feasibility.

Overall, the project delivered1) A summary document of barriers/enablers to promoting physical activity

to seniors in rural communities2) A toolkit for implementing physiotherapist coaching techniques for

seniors in rural communities after joint replacement3) Feasibility assessment of the intervention

Project Lead: Dr. Allyson Jones, Faculty of Rehabilitation Medicine, University of Alberta

7

Potential impactOsteoarthritis is a chronic condition that is debilitating and causes pain. When pain relief is attained with knee replacement, evidence shows that patients are still not physically active. Older adults residing in rural communities may have less resources to become physically active. We feel that having a physiotherapist ‘coach’ patients to become more physically active within their community will help patients during their long term recovery.

Ultimate successWe are currently completing recruitment and will complete data collection in 2019. Based on general feedback from physiotherapists and participants, not everyone benefits from using the technology (fitbit and sensewear armband) to be coached by physiotherapists. A successful journey is to identify patients who would benefit from this coaching and implement this service within AHS to offer patients during their long-term recovery after total knee replacements.

DR. ALLYSON JONES, Professor, Faculty of Rehabilitation Medicine, University of Alberta

THIS PROJECT CAN CHANGE…

POLICY PRACTICE BEHAVIOURS

SERVICES QUALITY OF LIFE

8

Navigation Partnerships: Connecting, Accessing, Resourcing and Engaging Older Persons, Families and Communities (Nav-CARE)Problem statement and novelty The quality of life of older rural persons living at home with advanced chronic illness is often limited. These adults often have many symptoms and poor quality of life in part because they are unable to connect with the resources they need. The Nav-CARE approach is novel because experienced volunteers are specifically trained to help older adults with chronic illness to connect and access the resources they need, and to help them re-engage with their communities.

The project: a short description The goal of the Nav-CARE program is to help older adults with chronic illnesses live a better life. With Nav-CARE, specially trained volunteer navigators conduct regular visits with clients in their home. Navigation services were provided by specially trained volunteer navigators, trained to specifically help older adults find resources in the community.

Volunteer navigators were able to advocate and facilitate community connections to make a difference in how older adults lived their experience with chronic illness. Navigators learned to help older persons access services and resources, and worked to promote active engagement of older adults with their community.

Overall, the project delivered1) A resource guide for health provider and volunteer navigators specific to

their local community (Camrose and Killam)2) Trained healthcare provider and volunteer navigators in the communities

of Killam and Camrose

3) An implementation toolkit with specific strategies for implementation ofNav-CARE in a new community

Project Lead: Dr. Wendy Duggleby, Faculty of Nursing, University of Alberta

9

Potential impact Older adults identified multiple factors affecting their quality of life including physical health and symptom management, activities of daily living and instrumental activities of daily living. To address older adults’ quality of life concerns volunteer navigators connected them to community resources including CNIB, homecare, transportation services, information on personal directives, respite and day programs, and home support services such as prepared meal services.

Aside from making community connections, one of the most significant contributions navigation provided to older adults was relieving isolation and loneliness through companionship and emotional support. The Nav-CARE implementation toolkit will be used to guide other communities who wish to implement the Nav-CARE program.

Ultimate successThe ultimate success of this journey would be to have Nav-CARE implemented through Hospice Societies across Alberta.

Thank you to older persons and volunteers who participated, as well to the project team: Duggleby, W., Pesut, B., Warner, G., Fassbender, K., Nekolaichuk, C., Holroyd-Leduc, J., Ghosh, S., Hallstrom, L., MacLeod, R., Murphy, S., Klein, L., Antymniuk, C., Clark, G., Peterson Fraser, M., Woytkiw, T., McDonald, K., Jackman, D., Strilchuk, S., and Mckinstry, C.

DR. WENDY DUGGLEBY,Associate Dean, Research / Professor, Faculty of Nursing, University of Alberta




10

Supporting Healthy Aging by Peer Education and Support (SHAPES)Problem statement and novelty In Canada, the proportion of seniors (people aged ≥65 years) is estimated to rise to 23−25% by 2036. Many in our society age with long term chronic medical conditions; the management of which is partly responsible for the increasing consumption of health care resources in later life.

There is evidence that self-management and an increase in health literacy leads to an increased sense of empowerment and an improvement in health related quality of life for seniors. This study therefore proposes an innovative partnership between seniors’ community organizations and clinical faculty at the University of Alberta to provide peer delivered education and support for seniors living in the community.

The project: a short descriptionThis study explores the use of health coaches, drawn from community dwelling seniors, in educating and supporting their peers in healthy ageing behaviours and self-management of chronic disease. Three Edmonton Senior’s Centres serve as clusters, and health coaches were drawn from their membership. The health coaches then commit to the health information training, deliver the workshop and facilitate discussion groups.

The intervention consists of three education modules in the areas of healthy brain, bones and heart; each having areas in common such as exercise, diet and nutrition, social interaction and activity. Each module consists of a one-hour workshop followed by three facilitated weekly discussion sessions. Participants are encouraged to take up healthy ageing behaviours, undertake self-management techniques or, should they recognize a need, seek formal assistance.

Overall, the project delivered1) Education modules on heart, brain and bone health (interactive health

modules)2) A participant handbook and a health coach handbook3) Fitbit training guide for participants4) An interactive presentation skills session, in collaboration with the

Student Success Centre, for the health coaches

Project Leads: Dr. Adrian Wagg and Saima Rajabali, University of Alberta

11

Potential impact Seniors will see a positive change in their own health literacy and behaviours. They will have a greater involvement in their health and greater confidence in talking about and managing their health. This will also benefit clinician- patient interaction and thereby lead to better overall health. In addition, this program will successfully engage and empower older people to deliver sustainable health education

Ultimate successIf this intervention proves effective, we will have established a reliable and feasible intervention that results in a positive change in senior’s health literacy and behaviours. The project has been designed to embed peer educators within the senior’s organizations, with a view to longer term sustainability and spread by adoption of a “train the trainer” approach.

The results from this study will be fed back to senior’s organizations throughout Edmonton, regardless of their participation in this project, in relevant formats (a multi-media approach). The goal is to enhance uptake of the program and through traditional knowledge transfer routes in the professional and lay press, and via academic publications and presentations.

SAIMA RAJABALI,PhD student, Research Manager, Geriatric Medicine, University of Alberta

DR. ADRIAN WAGG,Professor of Healthy Aging Division Director, Geriatric Medicine, University of Alberta




12

Collaborative Case Management (CCM)Problem statement and novelty More than one in four seniors in Edmonton live alone in the community and fall into a low income bracket. Most of these individuals are considered “at-risk” for poor health and loss of independence. This project aimed to improve the referral and collaboration processes used by AHS Home Living Case Managers (HLCM) and community-based, senior serving/ outreach support workers (SOSW) to meet the needs of seniors (60+) living in the community. This CCM approach was unique compared to other projects because our tangible outcome was handouts. The outcome was change management: the opportunity to meet face to face and build relationships to increase awareness and engagement of people.

The project: a short description This project made it simpler for seniors living in the community to know who was coming to their homes to provide services and for what. Collaborative Case Management, or CCM, is a practice support process in senior serving/ outreach support workers (SOSW) to meet together to meet the needs of vulnerable seniors who live in the community.

Overall, the project delivered1) A process for referrals between Home Care and Community Outreach

programs2) Appropriate and unique roles of each – reference sheets3) A Memorandum of Understanding satisfactory to all parties involved4) Plan for continual evaluation of shared involvement

5) Practice Support Tools: Client Information Sheets, Referral DecisionTree, Quick Reference Sheets for HLCM and SOSW, and a ReferralTracking Sheet

Project Lead: Beth Whalley, Edmonton Zone Home Living, Alberta Health Services

13

Potential impactCollaboration between HLCM and SOSW increases vulnerable seniors’ access to services and supports and can have a positive impact on their ability to live in the community in the setting of their choice. Moreover, Seniors/Outreach Support Workers (SOSW) and Home Living Case Managers (HLCM) have found that basic relationship building and awareness of one another and role definition has led to more comprehensive and supportive care for seniors. For example:

• CCM has the potential to reduce gaps and duplication in services, whileat the same time providing a more comprehensive continuum of servicesto seniors.

• Collaboration with SOSW allows HLCM to allocate time with clientsmore efficiently.

• Seniors have increased access to a continuum of services, whichcontributes to greater confidence and comfort in their ability to live inthe community.

Ultimate successUltimate success would include a collaborative system of health and community supports that view each other as a team. We found through this project that simply meeting face to face led to stronger relationships and better communication for client care. Opportunities for more partnership engagement between SOSW, HLCM and key stakeholders will support this collaborative vision.

BETH WHALLEYManager, Practice Development Team, Edmonton Zone Home Living, Alberta Health Services




14

Seniors Helping Seniors: Promoting and Empowering Peer Support for Seniors’ Health and WellnessProblem statement and noveltyAccording to the scientific statements of 2011 Canadian Physical Activity Guidelines for Older Adults 65 Years & Older, older adults are encouraged to participate in a variety of physical activities that are enjoyable and safe. A program was needed to not only raise seniors’ awareness of the benefits of fitness training, but also ensure the quality, safety and effectiveness and exercise adherence.

This was a novel approach because it addresses the challenge that many senior serving organizations are facing – the difficulty in resourcing their programs with enough fitness experts to provide individualized client support. The Seniors Helping Seniors (SHS) program increases professional fitness staff resources with specially trained Peer Leaders, making it cost effective and sustainable.

The project: a short descriptionSenior “peer leaders” were coached, trained and supported in implementing their plans for healthy living. These seniors were then offered the chance to work with other seniors to motivate and support them in attaining a healthy lifestyle – including a pre-set exercise program and stretch routine, as well as nutritional lessons, designed by a nutritionist during the project.

Overall, the project delivered1) A cohort of healthy living senior peer leaders.2) An online toolkit focused on a tailored physical activity program for

adoption at seniors activity centres and potentially other seniors servingfacilities such as seniors homes.

Project Lead: Dr. HaiDong Liang, Westend Seniors Activity Centre

15

Potential impact• This program follows the Canadian Physical Activity Guidelines for Older

Adults 65 years & older, which indicates that added physical activity willhelp seniors achieve health benefits and improve functional abilities.The 8-week program is easy to follow, requires minimum equipment andtherefore is easy to replicate.

• Peer Leaders themselves benefit from learning how to lead a healthylifestyle and then inspire and motivate their peers to follow the samehealth and wellness path. Success in this program can mean thedifference between independence and a life spent relying on others.

Ultimate successThe prevention of health problems and illness is more important than treatment and medicine. Therefore, the ultimate success of this journey is that three levels of Government will work together to initiate and fund a National Fitness Program for older adults, just like the ParticiACTION initiative. This SHS program could serve as a resource guide for those seniors serving organizations and facilities willing to embrace the National Fitness Program concept.

The SHS Program is intended for professionals to use to develop or enhance their seniors’ programming. How many fitness experts actually understand how to provide fitness program training to seniors? Have they received proper training in working with the senior population? Ultimately, faculties such as the Faculty of Kinesiology, Sport and Recreation at the University of Alberta should shift its research and class focus to the seniors’ population.

Westend Seniors Activity Centre (WSAC) continues promoting the SHS program through its Communication Platform. Our next step is to potentially promote this program in seniors’ retirement homes.

DR. HAIDONG LIANG, Executive Director, West End Seniors Activity Centre




16

1) Development of a structured care process for seniors living with frailty inprimary care.

2) SCH training workshops for primary health care nurses, family physiciansand allied health members working in PCN clinics.

3) Implementation of the SCH program in the Edmonton Oliver PCN.

Project Leads: Dr. Marjan Abbasi and Dr. Sheny Khera, Misericordia Hospital

Seniors’ Community HubProblem statement and novelty The Seniors’ Community Hub (SCH) model of care arose in response to frustrations with the current state of seniors’ health including: late presentation of frailty to the acute care setting, unaddressed polypharmacy, challenges navigating the system, rising number of complex older adults presenting to primary care, long wait times for referrals, and suboptimal use of primary care network (PCN) resources. The SCH model of capacity building in primary care clinics also aligned with Alberta priorities to improve care for vulnerable seniors given the projected rise in this population over the next two decades, and seniors with frailty (noted among top 5% users of healthcare).

The SCH model is novel because it proactively addresses older adults’ health needs from fitness to frailty in the primary care setting.

The project: a short descriptionThe Seniors’ Community Hub (SCH) model of care builds a “hub” within each primary care practice to deliver person-centred, evidence-informed, coordinated and integrated care services to older adults living with frailty.

The SCH is designed to maintain and enhance seniors’ health and wellness. It will build integrated primary health care, centred on the needs and priorities of older adults living with frailty, and allows effective information sharing between patients, care providers and settings. The SCH will provide community-based support to family caregivers to prevent or alleviate caregiver burden.

This approach mobilizes available resources of the primary care networks (PCNs) and community partnerships to deliver this care using a team based approach within the patients’ medical home. The key elements of the SCH are related to 1) Structured Process of Care; 2) Education of Healthcare Workforce Patient and Caregiver Empowerment; and 3) Partnership in Care.

Overall, the project delivered

17

Potential impact Our evaluation is ongoing, however we have seen improvement in patient-oriented outcomes such as an improvement in gait speed, functional status, and caregiver burden. There are also positive changes in the level of frailty, and quality of life, with noticed improvement in the domains of usual activities, pain/discomfort, anxiety/depression, and mobility. Medication reviews significantly decreased the number of inappropriately prescribed medications.

Patients reported that the SCH has been helpful in providing knowledge, facilitating planning, and managing chronic diseases while feeling listened to and with consideration of their goals, priorities and opinions. Providers reported improved efficiency and quality of care, as well as improved team communication and collaboration.

Ultimate successThe SCH is a grassroots initiative highlighting a path towards integration and value based care. Success would be every primary care practice becoming a “hub” inspiring healthy aging, and optimally supporting those living with frailty.

DR. SHENY KHERA, Site Director, Misericordia Family Medicine Centre




DR. MARJAN ABBASI, Site Lead, Geriatric Program Misericordia Hospital

18

Integrated Home Care: Data-Driven Decision-Making for Quality ImprovementProblem statement and noveltyHome Care (HC) nursing and allied health staff are highly trained professionals that play an essential role in the quality and safety of care delivered to clients. However, mechanisms for HC staff involvement in quality improvement work were limited. This innovation project tested the ability of these staff members to actively participate in formalized quality improvement initiatives. Specific evaluation questions included: can HC staff members successfully lead QI initiatives; will staff be engaged in a QI role; and what supports and barriers will they encounter?

Although the use of QI is widespread in healthcare, involving frontline staff in all steps in the QI process from project identification to spread was novel for the Integrated Home Care program.

The project: a short description The project designed and piloted a quality improvement process to enable Home Care staff members to use information generated from data to inform short quality improvement (QI) projects. Six AHS Home Care Teams participated. Based on the evaluation, a framework was developed to build sustainability for frontline involvement in quality improvement within Integrated Home Care.

Overall, the project deliveredEleven recommendations were identified, based on the results of the evaluation. These were used to inform a process within Integrated Home Care for ongoing involvement of staff in quality improvement. A more generalizable ‘Quality Improvement at the Frontline’ toolkit was also created to support the development of a similar approach within other Continuing Care contexts.

Project Lead: Abram Gutscher, Integrated Home Care, Alberta Health Services

19

Potential impactThe results of the project clearly indicate that staff members can and want to successfully participate in QI work. The 6 pilot projects primarily had an impact on new clinical and administrative practices to improve efficiency and or effectiveness. However, QI projects could be initiated to create improvement in policy, practice, behaviours, services and quality of life.

Ultimate successThe major mechanism for sustainability is the implementation of the process within Integrated Home Care for ongoing involvement of staff in quality improvement. This process has been endorsed by the leadership in Integrated Home Care and the program has and continues to take steps towards frontline staff involvement in quality improvement.

ABRAM GUTSCHER,Program Manager, Integrated Home Care Alberta Health Services




20

Camrose PCN Fall Prevention ProgramProblem statement and novelty As people age, the risk of falling and becoming injured in those falls greatly increases. Fall risk statistics for seniors aged 65 years and older confirm this fact and are worth noting. Hospital admissions related to falls increase with age, and of those seniors who fall, 50% have a fall more than once.

In addressing this problem, the Camrose PCN Fall Prevention Program was novel because it addressed the health needs of the community and population through strong partnerships established within the client’s identified health home/neighborhood.

The project: a short description This project provided a combined falls prevention and intervention strategy, including a fall awareness campaign, and treatment options for seniors living in the Camrose community. The falls prevention strategy involved pre-assessments, participation in an 8-week Balance & Mobility exercise class and post assessment. Telephone follow up initiated at 3, 6 and 12 months.

Overall, the project delivered1) Fall Risk Management Pathway2) Fall Prevention Care Map3) An evaluation of participants, completed the fall prevention program

March 20174) The implementation of an ongoing fall prevention program at the

Camrose PCN

Potential impact Camrose PCN administration’s desire to coordinate, integrate and partner with appropriate healthcare and community providers to offer holistic fall prevention programming has resulted in a cost effective program that has a high probability of cost savings to the entire healthcare system over time. Specifically as it relates to emergency department visits, acute care admissions, readmissions and length of stay. In addition to this, there is evidence to support a positive impact on an individual’s quality of life.

Project Lead: Stacey Strilchuk, Camrose Primary Care Network

21

Ultimate successThis project was developed on the premise of evidence-based fall prevention practice(s). The increased awareness and education regarding fall prevention to the various participating communities and population has resulted in further education opportunities and awareness regarding the importance of prevention, chronic disease self-management and a multi-disciplinary team based care approach in the primary care setting.

Realizing that a fall prevention program can have such a positive impact on quality of life, overall health and savings to the healthcare system illustrates there is the obvious potential for spread and scale across the province however sustainable funding is required.

STACEY STRILCHUK,Executive Director, Camrose Primary Care Network

DR. VALERIE SMITH,Physician Lead, Geriatrics Priority Initiative, Camrose PCN

COLLEEN MCKINSTRY,Clinical Director, Camrose PCN




22

Innovating to Improve Seniors’ Care in Kalyna CountryProblem statement and novelty At the Kalyna Country Primary Care Network (PCN), a comprehensive evaluation of the Care of the Elderly Geriatric Assessment Program (GAP) model was needed to understand how these resource intensive assessments were impacting seniors and their health.

The goal was to create inter-professional teams to work directly with seniors in each community to provide health education, happiness basics classes, blood pressure and foot clinics.

The project: a short description Kalyna Country is located in east central Alberta, including Vegreville, Vermillion, Viking, Killam, and Tofield. First, a full report on the evaluation of the GAP program was completed. Secondly, Collaborative Teams were developed from within the PCN.

For each Collaborative Team, a project manager was hired to survey professionals providing senior services and to work closely with Community Development in each of the different communities in Kalyna Country. Working directly with seniors, where seniors meet is proving to be effective. Workshops were conducted throughout the funding on topics such as “understanding dementia”, and “compassion fatigue”.

Overall, the project delivered1) GAP Evaluation report 2) An online seniors directory; a great local resource and template for

other PCNs: http://kalynaseniorsdirectory.ca.3) Collaborative Team products: action plans, Successes and Challenges

charts, Professional Education (eg. Understanding Dementia, and Compassion Fatique workshops)

Project Lead: Brian Match, Kalyna Country PCN

23

Potential impact The collaborative teams developed in Vegreville and Viking have increased the efficiency and effectiveness of care for seniors. Service providers are familiar with each other and coordinate care more effectively. This model could be spread beyond Kalyna Country, potentially throughout the province.

Ultimate success The Compassion Fatigue workshops were extremely successful in part because they were chosen and planned for with Health Professionals and seniors themselves. For small rural communities the attendance was high (Viking a population of 800 had over 150 people attend). Virtually everyone in a community is caring for someone.

Ideally, these Compassion Fatigue workshops would spread beyond this region, in addition to continuing in these communities. Since these workshops were held originally, the need for caregiver support was identified. Fortunately, Caregivers Alberta has been accommodating in providing their COMPASS support program as requested. The health of caregivers helps to support our seniors.

The GAP analysis helped improve the Geriatric Assessment Program at the Kalyna Country PCN to better fit the needs of Family Practitioners and seniors. Collaborative teams have enabled all services to work together and succeed in improving services such as the Senior’s Directory, Education to Health Professionals, knowing each other and working together. For future vision, we are now looking at bringing the teams in the various communities within Kalyna Country together to support each other and decrease the referrals for Geriatric Assessments. How can we become more of a community of support to seniors? A Community Coordinator has been hired by the PCN whose role will be to work with these teams to help us reach this goal.

BRIAN MATCH, Executive Director, Kalyna Country PCN




24

Northern Home Care Knowledge to Action Strategies that Support Persons with Dementia (PWD) and their Family Caregivers (CGs)Problem statement and novelty In Canada, the increased prevalence of dementia and a shift from institutional to community-based care will result in an increase in persons living with dementia (PWD) in their own homes and substantially increase community care and caregiver burden, especially in rural areas.

There is a need to build capacity in dementia care knowledge brokering. The aim of this project was to improve the quality of care and life for PWD and their care partners in Alberta Health Services North Zone through integrated knowledge translation (iKT) strategies that facilitate the exchange and use of best available dementia care knowledge by healthcare providers (HCPs), PWD, and their family caregivers.

The project: a short descriptionFor this research project, two care centres located in Barrhead and Westlock, Alberta, were selected as study sites. Thirty-six individuals were recruited and interviewed three times during the project. At the outset, staff identified small, incremental improvement projects they felt were feasible with their current resources to facilitate home care providers’ access and use of best available dementia care evidence.

The team at Barrhead proceeded with three projects: 1. Developing an information package for families; 2. Creating a dementia care toolkit of websites for nurses; and 3. Hosting a presentation to senior management about available dementia services. The team in Westlock focused on offering online educational opportunities for health care aides (HCAs), including the Supportive Pathways and the Me and U-First! online modules.

An end-of grant workshop allowed for participants to share how they worked to improve their own access, assessment, adaptation and application of evidence regarding dementia care in practice. The research team met biweekly to review themes and codes emerging from transcripts; qualitative analysis of the interviews was also conducted.

Project Lead: Dr. Dorothy Forbes, Faculty of Nursing, University of Alberta

25

Overall, the project deliveredThis research contributes to our understanding of: 1) the role of the knowledge broker in facilitating the development, implementation, and sustainability of the iKT strategies; 2) the knowledge and skills required to do knowledge brokering; 3) how the strategies facilitate access to evidence-based dementia care and promote KT among and between HCPs, PWD and their caregivers; and 4) the perceived impact on PWD and their caregivers, HCPs’ level of confidence in providing quality and safe dementia care, and the ability of the home care centres to sustain a culture of brokering knowledge.

Potential impact The results of the demonstration projects would have a great impact on seniors health if they were spread to community Care offices and health care practitioners. This could include physicians in primary care clinics and acute care, pharmacists, and mental health workers. All could benefit from learning about the results (e.g. information packages for informal/family caregivers of dementia patients, a dementia care webpage for nurses.)

Ultimate successIdeally, these project would improve linkages between quality improvement initiatives and the home care setting through education, knowledge exchange and the development of community-specific information products.

Improving and supporting the home care team through the establishment of evidence-based processes, and enabling communication across roles was a high priority. The goal is to also keep in alignment with the priorities of the Alberta Health Services North Zone, and to spread the learnings as broadly as possible throughout the zone.

DR. DOROTHY FORBES, Faculty of Nursing, University of Alberta




26

Examining Aged Care Transitions (EXACT)Problem statement and novelty Around 20% of transfers of residents from long-term care (LTC) to acute care via 911 – are considered avoidable. Avoidable transfers are those that do not result in investigations or treatment in hospital. The problem with transferring unnecessarily is that residents waiting for assessment in emergency departments are at increased risk of infection, disorientation, and lack adequate Activities of Daily Living care.

The purpose of the Examining Aged Care Transitions - Decision Making Guide (EXACT DMG) study was to pilot test a fast decision-making guide for nurses in the context of potentially avoidable transfers. This decision-making guide consists of two parts, a 5 minute assessment to determine the urgency of the residents change in condition, and an algorithm that encourages the nurse to consider all pertinent factors and weigh the risks and benefits of a transfer.

The project: short description This project can potentially help frontline healthcare providers identify avoidable transfer - from LTC to the Executive Director. It provides prompts to improve decision-making in ambiguous cases, giving greater confidence in deciding whether or not to transfer residents to the emergency department. The Decision-Making Guide (DMG) consists of a 5-minute clinical assessment to determine the level of decompensation/urgency of the change in condition, and a number of steps to consider around 1) the goals of care designation, 2) family input regarding transferring or not, 3) interactions with physicians, or 4) determination of the capacity for the long-term care facility to care for the problem. These steps could all help the nurse systematically gather information to determine if a transfer is in the residents’ best interests.

The DMG may help decrease unnecessary and costly transfers - which are often detrimental to the resident’s quality of care or quality of life. The DMG guide has been implemented in three units and mid-term interviews have been conducted to ascertain nurses and managers views of the feasibility and usefulness of the guide.

Overall, the project delivered1) The Decision-Making Guide (DMG) consists of a 5-minute clinical assessment2) An animated video to guide this process (product of the larger overall

study that overarches EXACT - Older Persons’ Transitions in Care (OPTIC)).

Project Leads: Dr. Greta Cummings and Dr. Jude Spiers, Faculty of Nursing, University of Alberta

27

DR. GRETA CUMMINGS, Dean/Professor, Faculty of Nursing, University of Alberta

DR. JUDE SPIERS, Associate Professor, Faculty of Nursing, University of Alberta

Potential impact During the EXACT OPTIC study, the research team was asked to develop this decision making guide (DMG). However, in piloting the guide, nurses clearly indicated they felt the guide was duplication of documentation and unnecessary for those who were clinically experienced. Several underlying issues need to be addressed in the DMG, including, 1) the authority of nurses to provide clinical recommendations around management of change of conditions, 2) nurses’ ability to work and communicate effectively with families who demand transfers and 3) ability to collaborate with physicians who, if unfamiliar with the resident, may default to transfer. Furthermore it must be noted that confusion around the role of ‘Goals of Care Designation’ plays a major influence in a transfer decision.

Ultimate successAvoidable transfers is a major concern. Reducing the number of transfers can have a major effect on the wellbeing of LTC residents. Our research team is currently working with the College of Licensed Practical Nurses of Alberta to develop a communication workshop to enhance LPNS confidence and skills in working with families during transfers decisions, this kind of work needs to be expanded to all nurses working in LTC. A next logical step in this program is an exploration of the interactions with EMS and development of a strategy to improve transfer interactions.




28

Implementing a Responsive Leadership Intervention in Long-term Care Facilities: A Pilot Study.Problem statement and novelty Health care aides provide almost all direct care to long term care residents, but they often lack access to documented resident care information and to a formal process for transferring their knowledge to the rest of the health care team. The Responsive Leadership Intervention is novel because it simultaneously aims to improve quality of care and quality of work-life in residential care settings.

The project: a short description In this project, team leaders at Bethany Care and Capital Care sites received responsive leadership training and then introduced daily care-team huddles onto their practice routines to improve communication and collaborative decision making with health care aides (HCAs). The aim of this project was to: 1) increase supportive leadership practices by team leaders, 2) increase HCAs’ self-determination, and 3) increase HCAs’ perceived ability to provide person-centred care.

Overall, the project deliveredAs a result of the responsive leadership intervention (RLI) and the implementation of daily care team huddles, team leaders improved their supportive leadership practices, which resulted in increased collaborative decision making with the HCAs regarding resident care issues and concerns. This was associated with increases in staffs’ perceptions of their ability to provide person-centred care, and ultimately, in their ability to achieve greater outcomes for residents.

Deliverables were:

1) Huddle process and guidelines2) A Responsive Leadership Intervention workshop for Covenant staff.

Project Lead: Dr. Sienna Caspar, Therapeutic Recreation, University of Lethbridge (Formerly of Bethany Care Society)

29

Potential impact The RLI resulted in improvements in resident-care information exchange, collaboration, team work, and feedback between team leaders and HCAs. Each of these are essential to the health and wellness of seniors living in residential care homes.

Ultimate successThe ultimate success of this journey would be that all team leaders receive responsive leadership training and that daily care-team huddles are implemented as a standard care practice in residential care settings.

DR SIENNA CASPAR,Assistant Professor, Therapeutic Recreation, University of Lethbridge




30

From Cooperative Learning Strategies to Quality Continuing Care WorkplacesProblem statement and novelty Continuing Care (CC) environments reflect growing complexity when balancing the needs of those requiring care with the capacity of those delivering care services. This complexity highlights both the opportunity and challenge in supporting staff with effective continuing learning strategies.

The project: a short description This project focused on supporting staff through the use of Learning Circles (LCs), a form of collaborative learning that brings practitioners together in workplace learning groups to identify and address practice priorities. This project established and evaluated Learning Circles that support clinical practice changes and effective workplace learning for direct care providers in continuing care.

The findings were that LCs were a venue for frontline care providers to engage in self-directed reflection on practice and structured experiential learning. LCs were considered complementary to traditional education and provided a more formal valuing of frontline staffs’ knowledge and perspectives, as well as a better integration of these perspectives into practice.

Overall, the project deliveredA Learning Circle Toolkit for facilitators, site administration, management and frontline staff to ensure the systematic documentation of required knowledge, structures and resources for planning, implementing, evaluating and sustaining learning circles, both for single discipline and inter-professional learning circles.

Project Lead: Dr. Sharla King, Health Sciences Education and Research Commons, University of Alberta

31

Potential impact Increasing the provision of person-centred care is essential to both the quality of care and the quality of life. At the core of person-centred care is providing individualized care based on the recipient’s unique needs and preferences. This type of care can only be provided if frontline staff and other caregivers have access to individualized information.

Learning Circles can serve as a key process and systematic structure to share this information and additional care strategies. Developing ‘in situ’ educational structures and processes for caregivers are critical to support seniors’ health and wellness in any environment.

Ultimate success Workplace learning opportunities are often limited due to multiple challenges, yet can be so impactful for frontline staff, especially healthcare aides. Collaborating to develop strategies and approaches to effective workplace learning is critical to optimize seniors’ health and wellness.

DR. SHARLA KING,Director, Health Sciences Education and Research CommonsAssociate Professor, Faculty of Education, University of Alberta




32

Skills-based Video Training on the Care of the Orthopaedic Client for Frontline Workers in Long Term Care FacilitiesProblem statement and novelty Seniors with an orthopaedic injury may not receive adequate care if staff in long term care infrequently use their skills for this purpose. Easily accessible and simple refreshers are lacking on a number of topics to do with common orthopaedic injuries and their treatments.

This project was novel because there has not been a consistent best practice series specific on the management of an orthopaedic client for rural and long term staff.

The project: a short description This project will provide training for frontline workers (health care aides, licensed practical nurses, registered nurses) in the care of orthopaedic clients residing in long-term care (LTC) facilities. The focus will be to increase the knowledge and skills of frontline workers in the observation, assessment and management of older adult’s care after an orthopaedic injury or surgery.

Overall, the project deliveredTwelve videos: five to ten minute tutorials that provide basic skill-based training in frequently encountered orthopaedic conditions in long term care. Results of the training on skill acquisition was presented as a poster. Covenant Health has access to the videos and guidelines on their internal website for their staff.

Potential impact Better observations, reporting and management of clients with orthopaedic injuries increases recovery and decreases complications.

Project Leads: Dr. Erika Goble and Laura Milligan, NorQuest College

33

Ultimate success To continue to have the videos available to all Covenant employees and perhaps make it a part of all new orientations to sites.

CINDY BOUCHER,Senior Research Advisor, NorQuest College

LAURA MILLIGAN, Manager, ResearchAcademic Research & Development, NorQuest College

DR. ERIKA GOBLE, Manager, ResearchAcademic Research & Development, NorQuest College

CINDY BOUCHER,Senior Research Advisor, NorQuest College




34

Spreading and Sustaining the Decision-Making Capacity Assessment (DMCA) Model: Development and Evaluation of the DMCA Model Implementation and Sustainability FrameworkProblem statement and novelty As the life expectancy of Canadians and prevalence of complex chronic health conditions continues to rise, assessment of independent decision making capacity emerges as an issue of increasing importance. The Decision-Making Capacity Assessment (DMCA) Model was developed to facilitate a process by which the least restrictive and intrusive means of support can be determined and offered to persons whose decision-making has come into question.

The creation of a framework to support the spread and sustainability of the model was novel because no prior explicit, systematic and intentional implementation framework existed that would enable sites unfamiliar with the model to more easily adopt it.

The project: a short description This project developed a DMCA Model Implementation and Sustainability Framework. The National Implementation Research Network (NIRN) framework most appropriately served as the backbone for this work and template upon which the stages of implementation were framed. Once determined, the team engaged senior leaders regarding the alignment of the framework with the DMCA Model and its utility for implementing, spreading and sustaining it.

Overall, the project delivered1) A NIRN-informed implementation framework for the DMCA Model 2) A practical, evidence-informed toolkit that offers information and

resources related to the DMCA Model (including this framework)3) A DMCA education training and support inventory (DETSI)

Project Lead: Dr. Suzette Bremault-Phillips, Faculty of Rehabilitation - Occupational Therapy, University of Alberta

35

DR. ASHLEY PIKE,Post Doctoral Fellow, Faculty of Rehabilitation Medicine, University of Alberta

Potential impact The implementation framework will enhance delivery of person and family-centred care, clarify the DMCA process, support the DMCA Model’s widespread implementation and spread, create greater consistency of use of the Model across the province and by various healthcare professionals, encourage fidelity regarding DMCAs and use of the Model, and enhance the likelihood of sustainability.

Ultimate successUltimate success would be the widespread use of standardized DMCAs offered equitably to all Albertans, and adoption of the DMCA model across organizations and endorsed at the provincial level. NESHW can continue to advocate at the provincial level for the DMCA Model’s widespread use, integration of the DMCA processes into Connect Care, influence policy and decision-makers, and provide further resources for testing of the DMCAs with various populations and effectiveness of the implementation framework and toolkit.

DR. SUZETTE BREMAULT-PHILLIPS,Associate Professor, Faculty of Rehabilitation - Occupational Therapy, University of Alberta




36

Managing Responsive Aggressive Behaviours: Implementing and Evaluating a Capacity Building Process in Acute Care, Supportive Living and Long-term CareProblem statement and noveltyThe management of Responsive Behaviours (RBs) is a challenging social problem. Solutions are difficult as it is multifactorial and interconnected with other problems, involves a number of people with different opinions and knowledge levels and has an economic burden. An estimated 60-90% of residents exhibit at least one behavior and, according to a CIHI 2010 report, 58% of seniors in care with dementia exhibited RBs. Resistance to care, physically abusive behaviour, having a psychiatric diagnosis and being on a psychotropic medication are precipitating factors for transferring seniors with dementia to continuing care.

This project introduced a novel process for implementing strategies to enhance the capacity of front-line staff to manage RBs within continuing and acute care sites using a novel framework to implement and sustain best-practices at the front-line.

The project: a short descriptionThis project was designed to implement a capacity-building process to address the growing need for managing RBs. These behaviours often occur in response to something in an individual’s personal, social or physical environment and are particularly concerning for healthcare professionals who may lack the knowledge or capacity to manage them. In this project, acute care, supportive living and long-term care sites used capacity building strategies and processes for staff to help them better manage RBs and improve outcomes for residents. A framework for implementation, sustainability and spread of the best-practice was also explored.

Project Lead: Dr. Suzette Bremault-Phillips, Faculty of Rehabilitation Medicine, University of Alberta

37

Overall, the project delivered1) Implementation of P.I.E.C.E.S.™ and learning strategies (huddles and

learning circles) to enhance staff capacity to manage aggressive RBs at Bethany Care Society, Misericordia Community Hospital, Wing Kei Care Centre, Excel Society, and CapitalCare.

2) Continued building of Behavioural Support Alberta (BSA) 3) A framework for implementation, spread, sustainability of best-practices

to manage RBs. 4) A capacity-building toolkit, website and booklet for staff and

organizations to manage aggressive RBs.

Potential impact Enhancing the capacity of staff to better manage RBs promotes delivery of person and family centred care, enhances client and service provider quality of life, facilitates staff confidence and ability to manage RBs, and improves interdisciplinary collaboration. Use of an implementation framework supports adoption of best-practices, standardizes the use of best-practices and the approach to service delivery, supports transition of care, and enhances the likelihood of sustained use of best-practices as a standard of care.

Ultimate successUltimate success would be the widespread interdisciplinary use of standardized best-practices to manage aggressive RBs across Alberta. The Network can continue to advocate at the provincial level for use of evidence-based practices, integration of these processes into Connect Care, use of the implementation framework and toolkit, and support of BSA. It can also support testing best-practices and learning strategies across the continuum of care, and evaluating the effectiveness of the RB implementation framework and toolkit.




38

Evaluation of the GEM-ED (Geriatric Evaluation and Management in the ED) ServiceProblem statement and novelty Older adults are more complicated to manage in the emergency department (ED). They often have multiple existing comorbidities, increasing frailty (and decreased reserve), and are on multiple medications. In addition, they may present atypically. Older adults are more prone to associated cognitive or functional decline and may suffer from depression, anxiety and social factors. Older adults are:

• More likely to consume ED time and resources• More likely to get hospitalized• At risk of functional decline and poor outcomes

Older adults with potential geriatric issues requiring management, often first present to an ED; this is therefore an opportune time for the geriatric program at the hospital to become involved in their care. In 2013 the Misercordia Community Hospital (MCH) started a program to identify older adults with unmet geriatric needs and ensuring that the community supports required to meet these needs were in place when they were discharged home. This is essential to ensure continued recovery in the community and prevent relapse and deterioration of health and wellness.

This project was to evaluate the successes of the GEM-ED service at the MCH.

The project: a short description This innovation fund reviewed and evaluated the GEM-ED service at the MCH by conducting a quality assessment of the service through:

• Chart reviews to identify patients to track through the service• Patient, ED staff surveys

Overall, the project deliveredAn evaluation of the novel GEM-ED model of care.

Project Lead: Dr. Jed Shimizu, Covenant Health and Alberta Health Services

39

Potential impact The evaluation of the GEM-ED project showed patients were highly satisfied with their care and felt that the service:

• Addressed their needs• Was a valuable part of their ED stay• Made them more aware of the resources and supports available to them

Similarly, staff surveyed understood the role of the service and felt that it:

• Improved the attitude of staff and culture in the ED• Addressed the specialized, geriatric needs of patients • Educated staff to recognize the unique challenges in managing frail

older adults

Ultimate successThe ultimate success would be if other facilities were able to apply the learnings from this project and the GEM-ED service to improve the outcomes of older adults when they are discharged back into the community.

The Network is creating a toolkit from the learnings from this project and the GEM-ED service model to help spread the concepts and knowledge gained. This will hopefully help other hospitals and organizations be able to take the concepts and adapt them to their settings to help improve the care of older adults in the ED, and linkages to community, resulting in improved function and quality of life.

DR. JED SHIMIZU,Care of the Elderly Physician, Alberta Health Services




40

Transitions in Care – Early Identification and Support for Transitions in Care for Complex Older Adult PopulationsProblem statement and noveltyThis project’s primary purpose is to support smooth transitions from acute care to the community setting of complex patients at risk for readmission. This is accomplished by the development of an intervention for early identification of complex patients at risk for readmission and intentional connections to community supports to promote patient centric discharge planning thus improving patient transitions across care sectors.

With an increasing population, longer life expectancy and chronic conditions and advancing medical care, the healthcare system is becoming increasingly difficult to navigate, especially for seniors. They often have more complex medical problems, longer lengths of stay, and higher acute care use which may result in readmission if the discharge is not well supported.

Various seniors’ representatives, advocates, and partnerships were involved in the design and development of the project. These include Edmonton Zone Continuing Care, Covenant Health, and Edmonton Zone Primary Care Network. They were intentionally invited to promote partnerships within seniors’ care.

The project: a short descriptionThe innovation’s objective is to improve patient transitions across care sectors to create seamless care transitions connecting the patient journey from home to hospital to home. The development of an effective tool for identification of complexity and risk for readmission to hospital, and the development and implementation of post discharge follow up are part of the process of reaching the objective. Ultimately, we hoped to prevent hospital readmissions by supporting these complex patients safely and as independent as possible in the community.

Overall, the project deliveredA sustainable and effective intervention for complex, high-risk discharges, at-risk for readmission. The intervention implementation at the Grey Nuns Community Hospital included 1) use of the LACE tool for screening of high-risk patients at admission; 2) implementation of the post discharge phone call; and 3) notification of primary care providers and follow up appointment booking prior to discharge.

Project Leads: Lisa Jensen and Dr. Lesley Charles, Covenant Health

41

DR. LESLEY CHARLES,Physician and Care of the Elderly Program Director at the Grey Nuns Community Hospital

Potential for impact1) Having LACE on chart highlights complexity of patients to interdisciplinary

team and has decreased length of stay by an average of 4 days. Discharge planning should start on day 1 of admission helping teams identify that more planning may be required on a multi sector basis to support the complex older adult to successfully transition into community.

2) Despite the decrease length of stay, short term ED revisits and readmissions were not increased.

3) In the short term the phone call did not seem to have an impact on readmission, but in the long term the phone call may have. Connection with supports from community (during the phone call) may have created more sustainable and effective partnerships with community providers and primary care on a longer term basis leading to enhanced health maintenance.

4) The phone call identified that there is a problem with patients picking up equipment that wouldn’t have been identified otherwise. This is a bigger systems issue within EDM Zone and was clearly highlighted in the results (phone call).

Ultimate successThe project resulted in an effective intervention for complex, high risk discharges to prevent their readmission to hospital. Evaluation demonstrates that this intervention has been successful in decreasing acute care utilization, which may also be correlated to seniors being better supported in the community.

LISA JENSEN, RD, MBACorporate Director, Integrated Access, Acute Care Services, Covenant Health




Should you require more information about any of these projects, feel free to contact the Network.

[email protected] seniorsnetworkcovenant.ca

innovation fund handbook - neshw · the innovation fund handbook since its inception in 2013,...

Documents