The Science and Art of Behavior Management Kelly

The Science and Art of Behavior Management Kelly Trevino, Ph. D Clinical Psychologist VA Boston Healthcare System GRECC Audio Conference Series July 29, 2010

Acknowledgements Nurse Managers ◦ ◦ Annette Couchenour Steve Mc. Garry Connie Soule Mary Farren Nursing Director ◦ Ronald Molyneaux CLC Nursing Staff Medical Staff ◦ Dr. Juman Hijab ◦ Jack Earnshaw Psychiatrists ◦ Dr. Mohit Chopra ◦ Dr. Ronald Gurrera

Outline Background The Science The Art ◦ Learning Behavior Model ◦ Person-Environment Fit Model ◦ Need-Driven Behavior Model ◦ Staff Training ◦ Behavior Management Team (BMT) ◦ Lessons Learned Behavior Management Program Implementation

Background 5. 3 million persons in the U. S. have Alzheimer's Disease 1 11 -16 million persons in US will have AD by 20502 In 2004: 136, 174 veterans with dementia using VHA 3 ◦ 2022: 205, 781 47% of nursing home residents have dementia 1 ◦ Up to 70% have memory problems 4 ~66% of community elders and ~77% nursing home elders with dementia have disruptive behavior 5, 6 Disruptive behavior associated with negative outcomes 7 -9

Psychotropic Medications and Restraints Psychotropic Medication ◦ Limited effectiveness 10 ◦ Negative side effects 11, 12 Restraints 13 ◦ Higher rate of falls ◦ Negative psychological outcomes

THE SCIENCE

The Science: Learning Behavior Model Learned relationship between antecedents, behaviors, and consequences (ABCs of behavior management)14 ◦ A=Antecedents=Triggers ◦ B=Behaviors ◦ C=Consequences=Reinforcement or Punishment Manipulate antecedents and consequences to change behavior ◦ Provide new learning experience Comprehensive functional analysis important

The Science: Learning Behavior Model Instrumental Conditioning Principles 15 ◦ Reinforcer contiguity ◦ Response-reinforcer contingency ◦ Reinforcement Problems with punishment ◦ Negative affective reaction ◦ Focus on avoiding punishment (rather than improving behavior) ◦ Negativity can generalize to other stimuli (person, environment, time)

The Science: Learning Behavior Model Characteristics of Interventions 16 -18 ◦ Staff education Topics: Dementia, Psychiatric disorders, Behavior problems, ABCs of behavior management, communicating with persons with dementia Method: Didactic, discussion, role playing, video case vignettes, handouts ◦ ◦ ◦ Assistance with care planning On-site supervision Increasing resident participation in pleasant events Peer support Caregiver problem-solving skills Exercise program

The Science: Person-Environment Fit Dementia increases vulnerability to the environment 19 ◦ Stimuli affect people with dementia at a lower threshold People with dementia have fewer coping resources Poor fit b/w person and environment impairs functioning and increases disruptive behavior Intervention ◦ Create a familiar and comforting environment ◦ Stimulate through reliance on remote memory and positive emotions

The Science: Person-Environment Fit Characteristics of Interventions 20 -22 ◦ Simulated presence therapy ◦ Activity programming Based on mental and physical abilities Adjust for mood and behavior Incorporate periods of stimulation and rest ◦ Individualized music ◦ Environmental modifications ◦ In-home counseling

The Science: Need-Driven Behavior Normal needs + Abnormal conditions = Disruptive behavior 23 ◦ Behavior is response to unmet need Adjust environment and build on strengths/preferences of individual to meet and prevent unmet needs ◦ Consider sensory deficits Treatment Routes for Exploration of Agitation (TREA)24 ◦ Identify correlates of particular behaviors ◦ Provide suggestions for changing the correlates

General Guidelines Basic principles ◦ Specificity ◦ Individualization ◦ Consistency: Implementation and documentation Behavior may increase initially ◦ Re-examine plan after 2 -3 days Behaviors are not ◦ ◦ Voluntary or purposeful Rudeness Due to a “bad attitude” Attempt to make your job difficult

Boston VA CLC THE ART Behavior Management Team (BMT)

BMT: Creation Recognition of a problem Weekly interdisciplinary meetings ◦ Psychology, nursing, medicine Identified: ◦ Problem ◦ Goals ◦ Process ◦ Staff Training ◦ Documentation

Staff Training: BMT What is the BMT ◦ Explain why ◦ Explain how ◦ Get feedback/ideas BMT Documentation ◦ Focus on BMT Shift Note Outcome measures ◦ ◦ ◦ ◦ Frequency of behaviors Severity of behaviors Referrals to BMT Medications for behaviors Inpatient psych transfers Code greens for behaviors Staff feedback on BMT

Staff Training: Functional Analysis Prevalence of behaviors Difficulty of managing behaviors Define types of behaviors and correlates DON’T PANIC ABCs of behavior management Unmet needs Questions for describing context of behaviors

ABCs of Challenging Behavior (B) Antecedents (A) Consequences (C)

Staff Training: Creating/Implementing Behavior Plans Basic principles ◦ Specificity ◦ Individualization ◦ Consistency: Implementation and documentation Behavior may increase initially Behaviors are not ◦ Re-examine plan after 2 -3 days ◦ ◦ Voluntary or purposeful Rudeness Due to a “bad attitude” Attempt to make your job difficult Questions for identifying new ABCs

Behavior Frequency/Severity Start Behavior Plan Time

The Art: Behavior Management Team ◦ BMT Members: Psychologist Nursing staff Nurse manager MD/PA Geriatric psychiatrist consulted, as needed Identification of residents ◦ CPRS consult ◦ Direct communication from staff

The Art: Behavior Management Team Inclusion criteria ◦ Demonstrate physical and/or verbal behaviors that: Create potential harm/distress to the resident, staff, other veterans Are difficult to manage (are not re-directable) Do NOT refer residents that are an immediate safety risk Treatment implementation ◦ Functional analysis of behavior ◦ Create behavior plan Set behavioral goal ◦ Monitor over time ◦ Change as needed ◦ Discharge when goal met 2 consecutive weeks

The Art: Behavior Management Team Weekly meeting on each unit ◦ Learning circle ◦ “Rounding” ◦ Meet with floor staff and PA, then consult nurse manager Documentation ◦ BMT Management Plan ◦ BMT Shift Note ◦ BMT Weekly note

The Nursing staff Art: Behavior Management Team observe disruptive behavior BMT creates behavior management plan BMT enters “BMT Management Plan” Nurse (RN) documents behavior AND adds MD/PA as cosignor BMT conducts evaluation BMT consults with direct care staff Nurse consults with MD/PA BMT responds within one business day MD/PA decides to consult BMT MD/PA enters consult for BMT Nursing staff continues to complete “BMT Shift Note “ BMT monitors behavior and consults with treatment team weekly Staff continue to implement behavior plan Behavior goals met: Resident discharged from BMT

BMT Management Plan Primary BMT Member: Reason for Referral: Behavior 1: Goal: Frequency of behavior: Disruptiveness: Not at all A little Moderately Type of Behavior: Verbal Physical Non-aggressive Psychology: Psychiatry: Recreation Therapy: Medical: Nursing: Very much Extremely Physical Aggressive

BMT Shift Note Target Behaviors (from BMT Management Plan): 1. Frequency of behavior this shift: Disruptiveness: Not at all A little Moderately Very much Extremely Times of behavior: Locations of behavior: Antecedents (what happened before): Interventions (what action was taken): Outcomes (Resident’s response to intervention):

BMT Weekly Note Session Type: BMT Rounds Time spent discussing veteran: Review for week of: CONSULTATIONS: ********************************** Behavior: Goal: Frequency of behavior this week: Disruptiveness of behavior this week: Behavior frequency: Percent change from previous week: Disruptiveness: Description of behavior: a. Times: b. Locations: c. Antecedents (what happened before): d. Interventions (what actions were taken): e. Outcomes (resident's responses to intervention): ********************************** NEW RECOMMENDATIONS (based on today’s BMT Rounds): CONTINUED RECOMMENDATIONS (based on previous BMT assessments):

BMT Outcomes Participants Measures ◦ ◦ ◦ n=24; Residents of the VA Boston CLC Age: M=74. 75; SD=11. 39 Gender: 95. 8% Male Residential Status: LTC (54. 2%); Rehab (37. 5%); Transitional (8. 3%). Approved by the IRB of the VA Boston Healthcare System. 1. Demographic information: Age, gender, residential status 2. BMT Shift Notes a. ) Frequency of behaviors: b. ) Severity of Behaviors Method ◦ Medical record review of residents treated in the first six months of BMT implementation (July 28, 2009 -February 1, 2010)

Lessons Learned: Behavior Management Person-centered care ◦ Implement WITH the resident, not TO the resident Interdisciplinary ◦ Consider role of MD/PA Individualization Consistency Communication ◦ Team ◦ Ask/Talk to the resident Dementia-care skills

Lessons Learned: Program Implementation Identify and include relevant stakeholders ◦ Facility specific ◦ All services ◦ All levels Union ◦ Include early Intervention-setting ◦ Resources ◦ Limitations fit

Lessons Learned: Program Implementation Education ◦ First step to buy-in Hands-on demonstration ◦ Don’t be afraid to make mistakes Observe impact and make changes ◦ Be flexible Sustainability ◦ Repeat education ◦ Leadership support Policy

Questions

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