The Science and Art of Behavior Management Kelly Trevino, PhD GRECC Audio Conference Series Clinical Psychologist July 29, 2010 VA Boston Healthcare System Acknowledgements Nurse Managers Medical Staff ◦ Annette Couchenour ◦ Dr. Juman Hijab ◦ Steve McGarry ◦ Jack Earnshaw ◦ Connie Soule ◦ Mary Farren Psychiatrists ◦ Dr. Mohit Chopra Nursing Director ◦ Dr. Ronald Gurrera ◦ Ronald Molyneaux CLC Nursing Staff Outline Background The Science ◦ Learning Behavior Model ◦ Person-Environment Fit Model ◦ Need-Driven Behavior Model The Art ◦ Staff Training ◦ Behavior Management Team (BMT) ◦ Lessons Learned Behavior Management Program Implementation Background 5.3 million persons in the U.S. have Alzheimer's Disease1 11-16 million persons in US will have AD by 20502 In 2004: 136,174 veterans with dementia using VHA3 ◦ 2022: 205,781 47% of nursing home residents have dementia1 ◦ Up to 70% have memory problems4 ~66% of community elders and ~77% nursing home elders with dementia have disruptive behavior5,6 Disruptive behavior associated with negative outcomes7-9 Psychotropic Medications and Restraints Psychotropic Medication ◦ Limited effectiveness10 ◦ Negative side effects11,12 Restraints13 ◦ 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 Principles15 ◦ 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 Interventions16-18 ◦ 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 environment19 ◦ 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 Interventions20-22 ◦ 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 behavior23 ◦ 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 Outcome measures ◦ Explain why ◦ Frequency of behaviors ◦ Explain how ◦ Severity of behaviors ◦ Get feedback/ideas ◦ Referrals to BMT ◦ Medications for behaviors BMT Documentation ◦ Inpatient psych transfers ◦ Focus on BMT Shift Note ◦ 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 Behavior (B) Antecedents Consequences (A) (C) Staff Training: Creating/Implementing Behavior Plans 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 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 Art: Behavior Management Team BMT Management Plan Primary BMT Member: Reason for Referral: Behavior 1: Goal: Frequency of behavior: Disruptiveness: Not at all A little Moderately Very much Extremely Type of Behavior: Verbal Physical Non-aggressive Physical Aggressive Psychology: Psychiatry: Recreation Therapy: Medical: Nursing: 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 ◦ 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. Measures 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 fit ◦ Resources ◦ Limitations 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 References 1. Alzheimer’s Association (2010). 2010 Alzheimer’s Disease Facts and Figures (2010). 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