The Hospital Avoidance Model for Persons with Dementia who have refractory aggression project was endorsed by the Statewide Older Person’s Health Clinical Network to undertake a systematic approach for identifying Persons with Dementia (PWD) who demonstrate refractory aggressive behaviours and whose care needs are incongruent with Aged Care facility resources and community care. This will assist older persons with Behavioural Psychological Symptoms of Dementia (BPSD) gain specialist review and management within an environment that assists to reduce severity and frequency of BPSD.
Hospital avoidance model for persons with dementia who have refractory aggression
The project aims to establish a dedicated pathway for assessing and managing the extreme behaviours within an appropriate environment.
- A systematic approach for identifying persons with dementia who demonstrate refractory aggressive behaviour and whose care needs are congruent with aged care facility resources and community care.
- An appropriate assessment, management and referral guidelines.
- A dedicated environment for specialist management.
The Cognitive Care Project managed by Dr Jane McLean from Central Queensland HHS, was sponsored by the Statewide Older People Health Clinical Network (SOPHCN) in 2016-17 and then extended in 2017-18.
Stage One of the project focused on engaging key stakeholders to identify existing cognitive care practices and associated service gaps and/or knowledge and skill requirements. During the 12 month project the project team developed two clinical pathways of BPSD management (a hospital inpatient pathway and a community/RACF pathway) designed to improve the quality and safety of care provision for this client group through collaborative practice and improved communication.
In Stage two from March 2017 to June 2018 they completed the work done in Stage one by consolidating local service provider relationships and simplifying the collaborative decision pathway for supporting people experiencing BPSD and/or delirium within Rockhampton and surrounding areas. Cognitive care education needs were identified and training programs subsequently developed.
Residents with extreme aggressive behaviours have proven extremely difficult to manage in our community settings. Subsequently these patients are sent to the acute care setting as a management strategy. When hospitalised these patients become difficult to discharge, because aged care facilities recognise that the care needs outweigh facility resources. Their increased care needs are often associated with a high risk of physical harm for staff and others within the same environment and pose a serious concern for management and carers. There are also notable risks for the patient with the potential of harming themselves very real and as well with the increased use of antipsychotic medication placing them at risk of deleterious outcome.
Currently within our healthcare district we would have five residents, PWD with severe aggressive behaviour: These patients have complex care needs requiring closer observation and intensive review. The aim of our project will be to provide management strategies particular to this group’s needs so they benefit from specialist management within an appropriate environment to avoid unnecessary hospitalisation.
To facilitate new uptake of project outputs (particularly in regional and rural areas), we recommend:
• Further work be undertaken to create a common language in clinical documentation and coding for patients with cognitive impairment and older-person specific diagnostic groups. This must include consultation with consumers, and education for clinicians to facilitate practice change.
• Local Older Persons Healthy Ageing and Cognition advocacy groups be established to offer leadership in development of older persons’ health services and care environments (including people with cognitive impairment).
• The collaborative processes, decision pathway (‘BPSD, 123’) and tools are adapted according to local resources and identified needs, before being formalised in cognitive care policy.
• Innovative, multi-modal cognitive care education programs are developed or adopted for all staff (clinical and non-clinical), including experiential components to foster better understanding of the patient’s perspective.
In the CQHHS evaluation and results section of the project report Dr McLean reported the following:
The following offers a summary of the key challenges to collaborative support for people with BPSD, identified through stakeholder engagement and process review, and the chosen approaches to addressing them to meet project objectives:
1. No consistent means of assessing, managing or communicating the presentation of BPSD within or across services.
2. Lack of clarity regarding roles and responsibilities amongst services involved in providing care to people experiencing BPSD.
3. Limited opportunity or encouragement for staff to attend locally-orientated, cognition-specific training.