The Science and Art of Behavior Management

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					                       The Science and Art
                     of Behavior Management

Kelly Trevino, PhD
                                   GRECC Audio Conference Series
Clinical Psychologist
                                                   July 29, 2010
VA Boston Healthcare System
   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
   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
   5.3 million persons in the U.S. have Alzheimer's
   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
        Psychotropic Medications and Restraints

   Psychotropic Medication
    ◦ Limited effectiveness10
    ◦ Negative side effects11,12

   Restraints13
    ◦ Higher rate of falls
    ◦ Negative psychological outcomes
        The Science: Learning Behavior
   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
    ◦ Provide new learning experience

   Comprehensive functional analysis important
        The Science: Learning Behavior
   Instrumental Conditioning Principles15
    ◦ Reinforcer contiguity
    ◦ Response-reinforcer contingency
    ◦ Reinforcement

   Problems with punishment
    ◦ Negative affective reaction
    ◦ Focus on avoiding punishment (rather than improving
    ◦ Negativity can generalize to other stimuli (person,
      environment, time)
The Science: Learning Behavior
   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,
    ◦   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
   Dementia increases vulnerability to the
    ◦ 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
   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
    ◦ 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

 ABCs of behavior management
 Unmet needs

   Questions for describing context of behaviors
ABCs of Challenging Behavior


 Antecedents              Consequences
     (A)                      (C)
      Staff Training:
      Creating/Implementing Behavior
 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

           The Art: Behavior Management
◦ 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
   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
   Weekly meeting on each unit
    ◦ Learning circle
    ◦ “Rounding”
    ◦ Meet with floor staff and PA, then consult nurse

   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:
Frequency of behavior:
Disruptiveness: Not at all A little Moderately     Very much    Extremely
Type of Behavior: Verbal Physical Non-aggressive     Physical Aggressive

Recreation Therapy:
       BMT Shift Note
Target Behaviors (from BMT Management Plan):
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:
Frequency of behavior this week:
Disruptiveness of behavior this week:
Behavior frequency:
Percent change from previous week:

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
   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
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