What Makes Our Special Care Unit Special

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What Makes Our Special Care Unit Special ?

• Deer Lodge Centre
• Dementia Care Unit
• Maureen Chouinard, Manager of Resident Care
• Arlis Decorte, Clinical Resource Nurse
• Nancy Fiebelkorn, Social Worker

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SCU Tower, SCU-West

• 47 beds on two units
• Tower opened in 1988, West opened in 2006
• Higher staff to resident ratio
• Units address behaviours, care needs
• Male or female veterans or community
  applications

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Philosophy of Care

• Equal, individualized, respectful and safe care
• A persons individuality is unique and does not
  change because of cognitive impairment
• Staff are advocates
• A specialized environment is required for
  dementia care
• Families have the right to be informed

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Philosophy of Care (continued)

• Specialized skills and abilities are essential
• Interdisciplinary team approach
• End of life care
• Upholding Residents Bill of Rights
• Effective and efficient use of available resources

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SCU Admission Criteria

• Age
• Primary and secondary diagnoses
• Environment
• Behaviours
• Risks

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How to Access the Special Care Unit at DLC

• WRHA Behavioral Panel
• Contact the panel secretary at 940-3600
• Access Office is at 490 Hargrave St.
• Application should include an A/A form, a
  Dependency Assessment Supplement and the
  Behavioral Assessment Supplement.
• A brief summary of the resident/client will be
  submitted along with behavior maps, recent
  progress notes, consults and lab work.

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Behavioural Panel Purpose

• To facilitate the management of individuals with
  challenging behaviors in the most appropriate
  care setting.

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Behavioural Panel Guiding Principles

• Behaviors are not being managed in their current
  environments
• Existing resources already accessed
• Information meets panel criteria and standards
• Panel meets monthly
• Additional problem-solving may be required to
  ensure placement in proper environment

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Behavioural PanelWho Sits on the Panel?

• Medical Director of the Rehab/Geriatrics Program
• Director of the LTC Access Centre or designate
• A representative from a PCH
• A representative from the Geriatric Mental
  Health Team
• A CNS for the WRHA long term care program
• Access Coordinators
• Health care professionals/family who have been
  integral to managing the individuals care needs

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Preadmission Visits

• Purpose
• Confirm the information provided by panel
• Meet needs of the applicant?
• Plan for any special needs or equipment
• Meet the applicant and family
• Completed by the Social Worker and Unit Manager
  once accepted by Behaviour Panel
• Visit usually within one week, at applicants
  current residence

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The Interdisciplinary Approach

• The SCU at Deer Lodge Centre utilizes an
  interdisciplinary approach to care.
• Weekly meetings
• Goal is to review each resident on a quarterly
  basis.
• Post-admission and Annual conferences
• All members of the team are available to family
• Contact information provided

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The Interdisciplinary Team Consists of

• The Resident and Family
• Attending Physician and Consultant Psychiatrist
• Manager of Resident Care
• Clinical Resource Nurse
• The Nursing Team-RNs, RPNs, HCAs

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The Interdisciplinary Team Consists of
(continued)

• Social Worker
• Pharmacist
• Physiotherapist
• Occupational Therapist
• Dietician
• Recreation Facilitators
• Spiritual Care

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What Gives Us a Sense of Well-being? -The
Bradford Dementia Group
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Well-Being (continued)

• What do we need to maintain a sense of
  well-being?
• A sense of control
• A sense of who we are
• A feeling of safety and security
• The ability to communicate with others
• The feeling that we are socially included

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Well-Being (continued)

• Having meaningful things to do
• Being taken seriously- do others respect and
  recognize when we feel frustrated, angry, sad,
  anxious, tired/exhausted, confused, lonely,
  frightened?

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Reactive Behaviours

• Reactive Behaviour- the way in which a person
  responds to a specific set of conditions.
• P.I.E.C.E.S. program
• All residents on the Special Care Unit have a
  behavioural history which has made residing in a
  regular personal care home setting difficult or
  impossible.

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Reactive Behaviours (continued)

• Reactive behaviours may include
• Restlessness Calling out
• Wandering Hoarding
• Resistance to Care Agitation
• Anxiety Aggression
• Withdrawal
• Inappropriate Sexual Behaviour

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Reactive Behaviours (continued)

• Staff are encouraged and trained to monitor and
  document reactive behaviour
• Antecedents (Triggers)
• Behaviours
• Interventions
• Consequences

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Reactive Behaviours (continued)
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Reactive Behaviours (continued)
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Key Elements of CareAlzheimers Australia, 2003

• Assessment
• Individualized Care
• Interdisciplinary Team Approach
• Programming
• Relationships

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Key Elements of Care (continued)
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Key Elements of Care (continued)

• Communication Skills
• Physical Environment
• Flexibility in Routines and Practices
• Staff Training and Education

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Communication

• Communication with persons who are cognitively
  impaired may be difficult and frustrating at
  times for both you and them
• Remember that behaviour is a form of
  communication for residents that have impaired
  expressive ability

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Communication Areas to focus on include

• Approach in a gentle manner and identify yourself
  by name
• Maintain eye contact
• Provide gentle direction
• Do not make an issue of a mistake, they happen
• Avoid asking facts

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Communication Areas to focus on include
(continued)

• Reduction of distractions and background noise
• Reorientation may not work
• Appropriate touch
• Items and illustrations to convey messages

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Visiting

• May be difficult for families/caregivers We, by
  nature, need something from our visits
• Love
• Reassurance
• Support returned to us
• Ease of guilt
• Confirmation of our decisions
• To feel that a connection remains

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Visiting (continued)

• Goals of Visiting
• Who should Visit
• When to Visit
• Where to Visit
• What to do when you Visit
• Why Visiting may be difficult
• Saying goodbye after your Visit
• When younger family members Visit

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Caregiver Support Group

• Informal group for families/friends that meet
  once a month
• Connections for them, connections for us
• Share questions and information about SCU
• Supportive and safe environment
• Luncheons

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Case Study

• 79 year-old gentleman residing on a general
  medical hospital ward.
• dx of Alzheimers/Parkinsons disease.
• hx of resistance and aggression during care,
  occasionally towards co-residents.
• Poor response to psychotropics -
  oversedation-minimal effect on behaviour.

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Case Study Care Plan in General Hospital Setting

• 6 staff to provide care
• Resident to be restrained on bed utilizing 4
  staff, 2 staff to prepare and provide care.
• Broda with lap table for meals and rest periods.
• Current Rx
• Carbamazepine 200mg bid
• Trazodone 75 mg od 1800

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Case Study Care Plan on SCU - Goals

• Gain the residents trust.
• Create a resident-friendly care plan.
• Involve resident and family in care
  planning-create an environment where resident and
  family have decision-making authority.
• Ensure Consistency/reliability.

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Case Study Care Plan on SCU - Interventions

• ADL Care
• Broda chair and table for meals.
• Bath-in-a-bag products - no tub baths, no
  showers
• Incontinent product-pullup/brief/overnight
• Monitoring behaviour on unit
• Plan all care - Scheduled..CONSISTENT

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Case Study Care Plan on SCU (continued)

• Initially provide 4 staff for care and safety
• Normalized care, bathroom routine
• When resident requires care, approach and be
  with resident
• Reapproach after a break period, invite him to
  attend his room with you, or simply walk to room
  with him.
• If care required more urgently, need to be more
  matter of fact

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Case Study Care Plan on SCU (continued)

• Adjustment to medication following admission
• Trazodone Rx on revised care plan
• 0700 - 25 mg.
• 1200 - 50 mg.
• 1700 - 50 mg.

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Case Study Care Plan on SCU - Outcomes

• 2-3 staff to provide care, dependant on mood -
  (do not provide care alone)
• Aggression with co-residents
• Broda chair/table for meals
• ADL/Bathing
• Ongoing staff education
• The challenge of CONSISTENCY

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End of Life Care

• Advance Care Plan/Health Care Directive
• Care planning around a progressive illness
• What is Comfort Care and its focus?
• Pain
• Difficulty Swallowing
• Lack of Appetite
• Labored Breathing
• Skin Breakdown
• Loving Presence

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When the Resident No Longer Requires SCU

• Resident no longer requires the specialized
  programs of our unit.
• Social Worker prepares the family
• Move to another unit in DLC or another facility

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Barriers to Discharge

• Long Wait Lists
• History of reactive behavior
• Families reluctance to move
• Concerns of receiving facility
• Small unit vs large unit
• Treatment unit vs long-term care unit

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ConclusionWhat Have We Learned?

• The value of the unit staff
• Admissions need to try new things
• Environmental challenges
• Closed-in vs. open spaces, Wall protection,
  Decoration
• Low stimulus is a great idea but
• Require a balance between environment and
  pharmacological treatment