Toolbox::Systems Integration

System Integration of Non-pharmacological Approaches

This section of the toolkit is focused on system-wide implementation of non-pharmacological approaches (NPA). The National Institutes of Health defines implementation as "the use of strategies to adopt and integrate evidence-based health approaches and change practice patterns within specific settings."1 Accordingly, this section addresses the techniques and resources that have been found to affect a positive influence upon the quality of care and quality of life of the nursing home resident, and uptake of alternatives to anti-psychotic use.

Nursing homes are complex systems comprised of people (residents, families, administrators and staff), who learn and relate to each other and the environment in a nonlinear way.2 Providing creative and individualized care for nursing home residents requires an organizational commitment to "looking at the whole picture," i.e., all the factors that influence how the resident feels, functions, and responds to care. These factors include intrapersonal characteristics (e.g., resident's health and cognitive status); interpersonal influences (e.g., resident's relationship with staff, degree of family engagement, staff knowledge and attitudes); physical and social environment (comfort, functionality, and capacity to "cue" the person with cognitive impairment); and policies (e.g., those related to staffing, communication, care evaluation, and decision-making).3-5

The organizational leadership (Administrator, Director of Nursing, Medical Director) plays a critical role in supporting resident well-being and quality-of-life, which includes clinically appropriate, responsible, and humane use of anti-psychotic medication. To that end, their initial steps in catalyzing change to a new paradigm of care include:

  • Articulating the vision of resident-centered care and incorporating the vision into strategic planning;
  • Identifying one or more champions; and
  • Facilitating the development of a quality team that will steer the initiative. 5 Members ideally include representatives from all disciplines/all levels of staff (including direct care staff), residents, and families.

Table 1 contains a blueprint for organizational strategies. These strategies are organized to address the "social-ecological"3 factors that influence the resident's well-being, and offer examples and resources to support the goal of providing safe and effective alternatives to antipsychotic use for Behavioral and Psychological Symptoms of Dementia (BPSD).


Table 1. Blueprint for Organizational Strategies

Step

Rationale

Resources/Approaches

I. Assessment of the environment (social and physical) The first action step includes an environmental assessment in order to identify areas for improvement to support resident well-being. Baseline and ongoing data can be used to track improvement. Environmental Assessment Tools:
  • Long-term Care Improvement Guide Self-assessment Tool (Planetree) 6
    • Click to access tools

    This tool is used to evaluate readiness or progress toward culture change (vision statement, human resources, communication, empowerment, work design, staff recognition, quality improvement, individual and community life, culinary experience, activities, physical environment, transitions of care, community connections)

  • TESS 2+ (Therapeutic Environment Screening Survey 2+) 7
    • Click to access tools

    A 37-item checklist consists of a range of environmental domains (safety /security, orientation, privacy/control), as well as staff interaction, resident involvement in activities, and physical environmental atmosphere.

  • The Environment and Communication Assessment Tool (ECAT)8
    • Click to access information

    The ECAT is designed to assist staff in long-term care to recognize what physical and social changes will help improve functioning, communication, and quality of life for residents with dementia. There is a charge for this toolkit.

  • Person-directed care measure 9
    • Click to access tool

    The tool consists of 50 items covering eight domains of person-centered care and is divided into two dimensions: person-directed care (PDC) and person-directed environment (personhood, autonomy/ choice, knowing the person, comfort, nurturing relationships, physical and organizational environment).

  • Person-centered care assessment tool (P-CAT) 10
    • Click to access tool

    evaluates personalization of care, organizational support, and environmental accessibility.10
II. Education of all members of the health care team The second action step is the provision of education associated with current evidence for use of specific pharmacological and nonpharmacological approaches. Staff Education

Go to Educational Programs and Leadership Development document for more information on specific educational programs.
(NB: No easily accessible methods were identified for assessing staff educational needs.)

  • Use of an evidence-based educational program
    • STAR-Staff Training in Assisted-living Residences 11
    • P.I.E.C.E.S.-Human resource development and project management tools to support changes in practice. 12 Click to access tool

  • Practices that support integration
    • Mandatory inservices, scheduled as part of routine work time
    • Incentives to participate (such as a meal) facilitate reach 13
    • Ongoing educational opportunities at the bedside 14
Resident /family education
  • Orientation to include philosophy, policy, and alternatives
  • Revisit as needed at care planning.
III. Policy development 1. Clinical protocol, monitored by champion (s) Clinical Protocol to Address:
  • Assessment of:
  • A plan for:16
    • family involvement as desired
    • a structured routine (24-hour) that reflects resident preference and capability; includes enriching activity and physical activity
    • therapeutic communication

  • Management of medical and psychiatric disorders such as depression, delusions, hallucinations, anxiety disorders, etc. If antipsychotics are used demonstrate that dose reductions have been tried and start with the lowest dose possible.17

  • Formulate and maintain an individualized plan of care to avoid situations and experiences that exacerbate behaviors for each resident and a plan of care to manage acute behavioral episodes should they arise.

    See: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309. See especially p. 35 for decision tree.

  • Respond to acute behavioral episodes with appropriate assessment and management plan (to rule out delirium, plan for safety, environmental modification, individualized approaches)

    • Go to Non-pharmacological Approaches document for more information on approaches for behaviors.
2. Interdisciplinary care planning processes 2. Assessment and care planning that: includes the resident and in the process and provides the family with a copy of care plan; includes CNAs in care planning and provides them a copy of the care plan.
IV. Sustain the improvement Quality assurance/ improvement activity

Use of evidence-based measures

  • Pharmacist audit of psychoactive use (outcome measure) with feedback to staff 18-19;
  • Steering committee to develop process measures that reflect protocol. Include assessment of congruence to resident preference20
  • Track increased use of appropriate NPA (outcome measure) with feedback to staff.

Evidence-based approach to continuous performance improvement

  • Include all levels of staff in QA/QI activity. Share results in staff meeting.21
  • Advancing Excellence (Ohio)22 Click to access

References

  1. National Institutes of Health Fogarty International Center.
    2. http://www.fic.nih.gov/News/Events/implementation-science/Pages/faqs.aspx
  2. Anderson RA, McDaniel R. Taking complexity science seriously: New research, new methods. In: Lindberg C, Nash S, Lindberg C, editors. On the Edge: Nursing in the Age of Complexity. Bordentown, NJ: Plexus Press; 2008. pp. 73-95.
  3. Stokols D. Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist 1992; 47: 6-22.
  4. M Smith, LA Gerdner, GR Hall, Buckwalter K. History, development, and future of the progressively lowered stress threshold: a conceptual model for dementia care JAGS 2004; 52 (10) 1755-1760.
  5. Berta, G.F. Teare, E. Gilbart et al. Spanning the know-do gap: Understanding knowledge application and capacity in long-term care homes Soc Sci Med 2010;70:1326-1334.
  6. Planetree Long-Term Care Improvement Guide website
    7. http://www.residentcenteredcare.org/Pages/About%20the%20guide.html
  7. Sloane PD, Mitchell M, Priesser JS et al. Environmental correlates of resident agitation in Alzheimer's disease special care units. J Am Geriatr Soc 1998;46:862-869.
  8. Calkins MP,Weisman GD. Models for environmental assessment. In: Schwarz B, Brent R, eds. Aging, Autonomy and Architecture. Baltimore, MD: Johns Hopkins University Press, 1999, pp 130-142.
  9. White DL, Newton-Curtis L, Lyons KS. Development and initial testing of a measure of person-directed care. The Gerontologist, 2008; 48: 114-123.
  10. Edvardsson, D., Sandman, P. O., & Rasmussen, B. Construction and psychometric evaluation of the Swedish language person-centred climate questionnaire-staff version. Journal of Nursing Management 2009; 17:790-795.
  11. Teri L, McKenzie GL, LaFazia D, Farran CJ, Beck C, Huda P, van Leynseele J, Pike JC. Improving Dementia Care in Assisted Living Residences: Addressing Staff Reactions to Training. Geriatric Nursing 2009; 30 (3), 153-163.
  12. Putting the P.I.E.C.E.S. Together website. http://www.piecescanada.com/
  13. Resnick B. Cayo J. Galik E. Pretzer-Aboff I. Implementation of the 6-week educational component in the Res-Care intervention: process and outcomes. Journal of Continuing Education in Nursing 2009; 40(8):353-60.
  14. Rodwell J, Noblet A, Demir D, Steane P. Supervisors are central to work characteristics affecting nurse outcomes J Nurs Scholarsh 2009; 41:310-319.
  15. Van Haitsma, K. The assessment and integration of preferences into care practices for persons with dementia residing in the nursing home. In Rubinstein R., Moss M., and Kleban M. (Eds). 2000. The Many Dimensions of Aging. New York: Springer.
  16. Pioneer Network website http://www.pioneernetwork.net/AboutUs/


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