Promising Practices for Management of Challenging

Behaviors in VISN-6Jorge Cortina, MD, DFAPA

Eleanor McConnell, PhD, RN, GCNS, BC

Innovators throughout VISN-6 Geriatrics & Extended Care

Commentary from Conference Faculty

Goals

• Highlight current practices in VISN-6 that illustrate key concepts in challenging behavior management

• Promote networking among resource people within the VISN

• Stimulate learning and ongoing program evaluation

• Stimulate strategies for implementing knowledge and skills learned at conference

In other words…

• Not enough to know what to do….– How to get it done is just as important.

• So…how do we expect you to make use of what we’ve learned here?– Build on success!– Learn from challenges!

Approach

• Describe innovative VISN-6 programs in action

• Showcase key components that illustrate conference concepts

• Share evaluation data when available or evaluation plan when not

• Invite discussion from conference participants about how this might be useful to their current efforts

Behavioral Interventions Note Overview

Antecedents

Behaviors

Consequences

BehaviorsChecklist

&

Textboxes toallow more

specific description of

behavior

Imports key information on

possible Antecedents from CPRS

&

Prompts further

documentation of common

antecedents in environment

Point of Care Decision

Support on Common

Antecedents

&

Prompts to use non-

pharmacologic interventions

before medications

BIN Note Lessons Learned

• Pilot testing is a good idea…find barriers– Key barriers to its implementation:

• Time (to train, to try out)• Work habits

– Front line staff accustomed to seeing behavior and taking action – not seeing behavior, doing more careful observation, thinking, and trying things out before calling

– Overcoming barriers:• Be prepared for slow going at first• Link use of note to orientation of new staff• Link use of note to other practices

(one-on-one or restraint competencies)

Behavioral Interventions NoteSummary

• Location: Asheville• Contact: Kathryn (Kitty) Hancock, RN, MSN, Nurse Educator• CPRS template developed by VISN-6 Challenging Behaviors

Committee – Systematic evaluation

• Goals: • Increase use of non-pharmacologic interventions• Reduce use of psychotropic medications

– Who implements: Nursing staff– When used: prior to use of PRN medications or restraints

• Notable Features– Facilitates implementation of ABC model– Intended to be used prior to requesting/using PRN medication– Developed with VISN-wide input

• Why a good idea:– Allows systematic documentation of behaviors, their antecedents, & outcomes of

interventions

Acknowledge role of Martin Cruz, PharmD, & Jan Cavanaugh, PhD from VISN Challenging Behaviors Task Force 2008

Snoezelen Room

Salisbury Community Living Center

Salisbury, NC

What is Snoezelen?

• A Multi-sensory experience that uses lighting, projected pictures, music and sounds, textures, aromatherapy, and vibration to stimulate, energize or relax

• Several VA CLC’s have implemented this program

• Salisbury opened their room Sept 2009 with a grant of $30,000

How is Snoezelen Implemented in Salisbury?

• Located on the gated Dementia Unit, the Veterans have access as part of their overall treatment plan under staff supervision

• Veterans from other units are also brought in as part of their restorative treatment plan

• Serves as an alternative to medication to reduce agitation and aggression

• Serves to calm providing rest for the wanderers

Snoezelen Summary• Location: Salisbury• Contact: BJ Nelson, RN, Nurse Manager & Julie Merrick, OTR• Description:

– Multi-sensory stimulation program, originally implemented for those with developmental disabilities

– More of the what, who implements, – Goals:

• Provide systematic, controlled stimulation to those with severe dementia

• When initiated: September, 2009• Notable Features

– Positive intervention whose cognitive function is at a low level (pearls)– Interprofessional approach– Builds on evidence-base borrowed from another population

• Why a good idea:– Addresses under-stimulation experienced by veterans with limited cognitive

function– Proactive rather than reactive

Pre-Service Education on Challenging Behaviors

• Location: Fayetteville• Contact: Jan Cavanaugh, PhD, HBPC Mental Health Provider• Description:

– Two-hour in-service on basics of managing challenging behaviors during staff nurse orientation. Development of curriculum on challenging behaviors for direct care nursing staff that is implemented during orientation

– Goals: • Highlight importance of behavior management skills• Alert new staff to resources available to nursing staff and VA approach

• When initiated: 2008• Notable Features

– Sets expectation that challenging behaviors are an important part of care– Gives specific examples of nursing role in managing challenging

behaviors• Why a good idea:

– Staff exposed to team care expectation when motivation to learn is high– Proactive rather than reactive

Overview of Session

• Introduction to basic concepts of Cultural Transformation and Community Living Center

– HATCH model

• Teach basics of Transforming Patient Care to Person-Centered approach

• Learn basics of Dementia Care– What is Dementia– Awareness/Sensitivity Training– Positive Approach– Communication/Cueing/Hand under Hand (HuH)– Levels of Dementia and Care Needs– Self Care/Centering/Breath/Relaxation– ABC Model of understanding behavior.

Lessons Learned

• Psychologists teaching nurses about behavior management– Need to negotiate – can’t be imposed

• Able to build on knowledge developed during orientation when psychologist consults on residents with challenging behaviors

Challenging Behaviors Education In Nurse Orientation Training

• Location: Fayetteville• Contact: Jan Cavanaugh, PhD, HBPC Mental Health ProviderDescription:

– Development of curriculum on challenging behaviors for direct care nursing staff that is implemented during orientation

– Goals: • Highlight importance of behavior management skills• Alert new staff to resources available to nursing staff and VA approach

• When initiated: 2008• Notable Features

– Sets expectation that challenging behaviors are an important part of care– Gives specific examples of nursing role in managing challenging behaviors

• Why a good idea:– Staff exposed to team care expectation when motivation to learn is high– Proactive rather than reactive

Special Care Unit in CLC• Location: Hampton• Contact: Martin Cruz, PharmD, , Bev Edmonds, RN

• Goals: • Expand access to behavioral health care for Veterans• Reduce use of psychotropics

• When initiated: 2007-2008

• Targeted behaviors:– Wandering– Disturbing Inappropriate vocalizations– Physical resistance to ADL care– Sexually inappropriate behavior– Hyperactivity due to delirium

Key Features:•Increased square footage per patient• Secured, keypad exit

•Increased hours per resident day•Staff competencies in management of ADL care for CLC residents with behavioral complications of dementia

•Weekly rounds by Interdisciplinary team (Medicine, Nursing, Mental Health, SW, Pharmacy)

Evaluation

FY07 – FY08 Changes in CLC• Increased behavioral care

access:– Number of veterans served– Bed-days of care

• Improved quality indicators– Antipsychotic use in the absence

of psychotic or related conditions– Cut in half from 18.5% to 8.9%

• Improved percentile: 50th to 25th

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Percent use Percentile

Prevalence of Antipsychotic Use in the Absence of Psychotic or Related Conditions

FY 07

FY09

Lessons Learned

•Environment is a powerful shaper of behavior

•Combined physical and social environmental changes

•Systematic evaluation suggests that it was effective in reducing psychotropic use.

DENs: Dementia Engagement Nooks• Location: Richmond

• Contact: Violet Oliver, RN, Nurse manager

• Description:– Painted with murals to be less hospital-like

– Vets encouraged to spend time there with each other. 

– When possible, nurses assigned just to the DEN to direct activities, engage vets in conversation, exercise, painting, reading, etc.

– Structured activities planned in advance 

DENS in Richmond

Street to Den Entrance Contains Schedule

Structured Activities from 6AM 11PM!

Lessons Learned

• Since DENS were created

– Bedfast days have dropped significantly– Falls have also decreased dramatically.   – More peer-to-peer interaction

– Lately we’ve had student volunteers in there with the vets hanging out with them and interacting.

Outpatient Dementia Care Team Clinical Demonstration

• Location: Durham• Contact:

Linda Chilton, RN, MSN, NP; Judith Davagnino, LCSW, MSW Barbara Kamholz, MD; Jack Twersky, MD,

• When initiated: 2010• Notable Features

– Behavior management protocols from successful research-based program

– Interdisciplinary approach– Intervention targeted to veterans who are living at home

• Why a good idea:– Teaches informal caregivers evidence-based behavior

management techniques– Proactive rather than reactive– Individualized intervention

Description

Interdisciplinary, evidence-based dementia care management program

Goals:

Delay institutionalizationImprove dementia care managementReduce caregiver burden Improve quality of life

Target population

Veteran living at home with caregiver 65 years old and over MMSE 20 and under 30 mile radius from Durham VA

Medical Center

INTERVENTIONS Home visits Individualized care plan Psycho-education Caregiver support Problem-solving Behavior management Reduction of anticholinergic impacts of patient

medication Case management Novel Methods: Screening for Delirium and PTSD

Examples of Protocols to be Adapted

More detailed

example

Source: Indianapolis Discovery Network for Dementiahttp://www.indydiscoverynetwork.org/(X(1)A(9heKr3V1ywEkAAAANjRkOGQ0NzQtNTJiMC00MWViLWFlYzUtMzM4Nzg4MjNhZTkzt1cVAvUv9D--EZq_OdoXSsbXx_I1)S(ilfxf1abiaickj455bld2n2d))/HABCInitiative.html

Summary

• Many programs or practices already implemented within VISN 6 that make use of principles discussed in this conference

• Speaks to feasibility of implementing non-pharmacological techniques to help in managing challenging behaviors

• Opportunity exists to build on successes of others!