About the Toolkit

Promoting Positive Behavioral Health:
A Non-pharmacologic Toolkit for Senior Living Communities


This Toolkit was prepared for the Commonwealth Fund in collaboration with the Hartford Foundation. Ann Kolanowski, RN, Ph.D., and Kimberly Van Haitsma, Ph.D., served as the coordinators of the expert panel who compiled much of the information contained in the toolkit.

Electronic Access and Copies of Toolkit

This toolkit may be downloaded free of charge from: nursing.psu.edu/hartford/toolkit

Recommended Citation

Kolanowski, A., & Van Haitsma, K. (2013). Promoting positive behavioral health: A nonpharmacologic toolkit for senior living communities.

Toolkit Overview

This Toolkit-Promoting positive behavioral health: A nonpharmacologic toolkit for senior living communities-contains resources to help staff in senior living communities promote nonpharmacologic behavioral health strategies to address behavioral and psychological symptoms of dementia (BPSD) behaviors that frequently occur in long-term care residential settings, especially among residents with dementia.

Many terms may be used to describe BPSD, such as agitation, aggression, behavioral expressions of dementia etc. Further, numerous terms may be used to describe nonpharmacological approaches for responding to these symptoms such as treatment, intervention, approach. The language that describes symptoms and approaches reflects differences in how symptoms and approaches are conceptualized. This Toolkit uses the terms BPSD and nonpharmacological approaches because these terms have wide acceptance, are person-centered, and are understood by most nursing home staff.

What is the goal of the Toolkit?

Non-pharmacological approaches (NPA) are a first priority for responding to the behavioral and psychological symptoms of dementia (BPSD) due to the high risks and limited effectiveness of antipsychotic medications for treating BPSD1. As a result, there is an urgent need to equip nursing home providers with readily accessible tools for identifying and implementing NPA.

Based on this critical need, the goal of our project was to convene a national, interdisciplinary group of geriatric behavioral experts who would collaborate on the development of a behavioral health toolbox for staff. This toolbox was conceptualized as a compendium of peer-reviewed/expert-endorsed existing resources that would assist staff in the implementation of non-pharmacological strategies for BPSD. Further, the toolbox would be readily accessible and include: staff educational programs for non-pharmacological approaches; methods for assessing behaviors; person-centered interventions; and system-wide methods for integrating interventions into the culture of care.

Who is the Toolkit for?

The Toolkit contains resources relevant to any type of senior living community, including nursing homes, assisted living facilities, and continuing care retirement communities. There is information targeted to professional and paraprofessional staff in all departments, including the executive director, administrators, department supervisors; nurses, physicians, mental health professionals, social workers, and recreational therapists.

What is in the Toolkit?

The Toolkit uses a comprehensive framework that consists of explicating a person-centered philosophical stance, and an overview of evidence-based resources addressing the following major areas:

  • Person-Centered Philosophy
  • This resource provides a rationale for approaching BPSD behaviors through the lens of person-centered care, including a summary of what types of behaviors are included in the definition of BPSD.
  • Systems Integration issues
  • A review of systems-level considerations that should be examined prior to initiating any new initiative.
  • Evidence-based leadership and direct care giver education programs
  • Available education programs that have demonstrated effectiveness in training leaders and direct caregivers on topics relevant to approaching BPSD.
  • Behavior Assessment tools
  • Available measures to ensure that staff appropriately identifies BPSD.
  • Clinical decision-making algorithms
  • Strategies ensuring that staff members comprehensively examine the causes of BPSD.
  • Evidence-based approaches to ameliorate or prevent BPSD
  • Approaches that have been proven to be effective in rigorously designed research studies.
  • Crisis response approaches
  • Procedures for appropriate responses to acute and emergent behaviors that put the senior or others at risk.

How do you use the Toolkit?

We suggest long-term care providers use the toolkit in the following sequence:

1. Community leaders should designate a "champion" for leading this initiative.

2. The designated "champion" should share the overview of the Toolkit with the interdisciplinary team members.

3. Read the Philosophy section first to ensure that the team is all on the same page in overall approach to care.

4. Read the section on Systems Integration to ensure that organizational issues are addressed first.
  • Address issues that emerge from this review.

5. Read the overview on Leadership and Staff Educationprograms to determine if your community would benefit from enhancing their knowledge about BPSD approaches.
  • Select and implement educational programs based on your community's needs.

6. Read the overview on Assessment Tools to ensure that your community is using the measurement tool that best matches your population's needs.
  • Select and implement an assessment tool based on your community's needs.

7. Read the overview of Clinical Decision-making Algorithms to ensure that team members are comprehensively examining the causes of BPSD.
  • Select and implement an algorithm based on your community's needs.

8. Read the overview of Evidence-based approaches to ameliorate or prevent BPSD to ensure that the approaches you select have some solid research evidence to back them up.
  • Select and implement an approach based on the needs of the residents experiencing BPSD in your community.

9. If needed, examine the section on Crisis Response Approaches for tips on handling acute and emergent behaviors that put the senior or others at risk.
  • Select and implement a crisis approach based on the needs of the residents experiencing BPSD in your community.

Principal Investigators and Experts

Principal Investigators

Ann Kolanowski, Ph.D., R.N., F.A.A.N.
School of Nursing
106 Health & Human Development East
Penn State
University Park, Pa. 16802
TEL: Eight One Four - Eight Six Three - Nine Nine Zero One
Mail: amk20 at psu dot edu

Kimberly S. Van Haitsma Ph.D.
Polisher Research Institute
1425 Horsham Road
North Wales, Pa. 19454
TEL: Two One Five - Three Seven One - One Eight Nine Five
Mail: kvanhaitsma at abramsoncenter dot org

Expert Panel
(List in Alphabetical Order)


Karen Love, BA
Founder, CCAL-Advancing Person-Centered Living

Jackie Pinkowitz, M.Ed.
Chair, CCAL-Advancing Person-Centered Living

Education & Leadership

Cornelia Beck, RN, PhD, FAAN
Department of Geriatrics
College of Medicine
University of Arkansas for Medical Sciences
Little Rock, Arkansas

Ann Bossen, PhD, RN
University of Iowa College of Nursing

Brenda Cleary, PhD,RN,FAAN
Healthcare Consultant: Improving Eldercare through Policy, Education/Workforce and Evidence-Based Practice
State Lead, Organizing for Action Health Care Team

Judith A. Lucas Ed.D., R.N., GCNS-BC
Associate Professor
Department of Behavioral and Community Health
College of Nursing
Seton Hall University


Laura N. Gitlin, Ph.D.
Department of Community Public Health
School of Nursing
Joint Appointments, Department of Psychiatry, Division of Geriatrics and Gerontology, School of Medicine
Director, Center for Innovative Care in Aging
Johns Hopkins University

Bryan R. Hansen, MSN, RN, FNE-A
PhD Student
School of Nursing
Johns Hopkins University
National Hartford Centers of Gerontological Nursing Excellence Patricia G. Archbold Scholar, 2013-2015

Christine R. Kovach, PhD, RN, FAAN, FGSA
College of Nursing
University of Wisconsin-Milwaukee

Katherine A. Marx, Ph.D., MPH
Sr. Research Program Supervisor
School of Nursing
Center for Innovative Care in Aging
Johns Hopkins University


Natalie Baker, DNP, ANP-BC, GNP-BC
Assistant Professor
Primary Adult/Gero Nurse Practitioner Track Coordinator
School of Nursing
The University of Alabama at Birmingham

Ann Bossen, PhD, RN
University of Iowa College of Nursing

Lois K. Evans, PhD, RN, FAAN
van Ameringen Professor in Nursing Excellence, Emerita
University of Pennsylvania School of Nursing

Andrea L. Gilmore-Bykovskyi, MS, RN
John A. Hartford Foundation BAGNC Predoctoral Scholar
University of Wisconsin-Madison School of Nursing

Rita A. Jablonski, PhD, CRNP
Associate Professor
School of Nursing
The University of Alabama at Birmingham

Darina Molkina Petrovsky RN, MN
Doctoral Student
University of Pennsylvania

Sharon Nichols, CTRS/L
Northeast Division Therapeutic Recreation Specialist
Genesis HealthCare Corporation

System Integration

Marie Boltz PhD, CRNP
Assistant Professor and Associate Director for Research
NICHE (Nurses Improving Care for Healthsystem Elders)
College of Nursing
New York University

Carmen Bowman MHS
Author, Consultant
Edu-Catering: Catering Education for Compliance and Culture Change

Patricia A. Parmelee, PhD
Director, Center for Mental Health and Aging
Department of Psychology
The University of Alabama

Dissemination Plan

Barbara Resnick, PHD,CRNP, FAAN, FAANP
Professor and Sonya Ziporkin Gershowitz Chair in Gerontology
University of Maryland

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