Health Quality Ontario Narrative
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Health Quality Ontario Narrative
2018/2019
Overview
Wellington Terrace is a 176 bed long term care home operated by the County of Wellington. Wellington Terrace's Mission Statement is "together our team is committed to providing compassionate care honouring the unique needs of each resident."
Wellington Terrace is divided into 6 resident neighbourhoods with 28-30 residents living on each area. We believe that resident and family satisfaction is higher when residents are grouped together with other residents of similar care needs. As such, we have three neighborhoods with a dementia care focus, two neighborhoods that serve residents with more complex, heavy care and one that is lighter care serving those who are more mobile with less cognitive impairment. Currently, over 91% of our residents have a dementia diagnosis.
Our home is committed to ensuring that we follow best practice guidelines in geriatric care. As such, we have a strong focus on falls prevention, skin and wound management, dementia support, continence care and infection control. Each of these programmes is led by an RN champion who guides the team in setting goals and implementing best practices. We are continually auditing our practices and using other homes in our LHIN and across the province as a benchmark for quality activities.
Organizations QI achievement in the last year
What we have learned in our work over the years is that quality improvement is an ongoing process. Our achievements are rooted in an interdisciplinary approach where teams build on the work from the previous year by reviewing outcomes, trialing potential solutions, and collaborating across the home to ensure that staff embraces the change ideas. These efforts prepare us to advance our quality outcomes annually.
Our Professional Health Care Committee meets 6 times a year to review and discuss updates with our Quality Improvement Monitoring Groups and collaborative approaches taken to improve the delivery of care and services to our residents.
In addition the Clinical Practice team which is comprised of the Medical Director, Pharmacist, Dietitian, Physiotherapist and the nursing leadership team meets to review and evaluate policies and procedures relating to the medical care that the residents receive and recommend best practices for implementation in the home.
Wellington Terrace has maintained a restraint free philosophy that respects the autonomy, quality of life and preservation of dignity for all residents. Our falls rate is higher than the provincial average in large part because we do not use restraints in our home. We employ many strategies to reduce falls or decrease falls with serious injury but we know that all falls cannot be prevented. Our journey to reduce the number of falls has been driven by a committed 'Falls Prevention Team' and builds on efforts of each year to strive for quality improvement. In 2016 we implemented several initiatives to assist us in reducing our overall falls and in particular our falls with serious injury. We initiated hourly purposeful rounds for all residents. Using the acronym “cares”, direct care staff addresses the following areas when observing the resident: Comfort, anticipating needs, repositioning, elimination and safety and sensitivity. In addition a post fall huddle was initiated in order to provide a structure for the interdisciplinary team to do a root cause analysis of a fall and develop a plan to prevent further falls in the future. In 2017, we added to our preventative strategies, implementing a bed height initiative to ensure when residents were not in bed, the height of the bed was left at an appropriate height for the resident occupying the room following the completion of care or when remaking the bed. Ensuring the bed is set at an appropriate height will reduce the number of falls when a resident wishes to lie or sit down. We also initiated a bed pendant strategy which ensures that only residents capable of safely operating bed controls have access to the pendants in order to reduce the hazard of compromised bed positions. In 2018 we will review protective products that will mitigate injuries from falls for implementation.
Residents in long term care are at high risk for weight loss and dehydration due to their complex medical issues and frailty. In 2016 Wellington Terrace had success with a program called ‘Sweet Social’ supported by an interdisciplinary team for two resident home areas. Those residents identified at high risk were encouraged to attend an afternoon social where music, dance and beverages such as smoothies and other nutritional drinks and snacks are offered. It was proven to be very successful in the two targeted neighbourhoods where the residents are at high risk due to frailty. We noted improvement in the fluid intake, weight gain, improved skin condition and increased social contact. The time this program is held also coincides with time of day when residents are seeking out social contact. In 2017, this program was implemented throughout the home. Teams have embraced this collaboration and families are joining in on the fun as another structured program where they are welcome to join in. In 2018, we will continue to support this program and continue to encourage opportunities for ongoing joint efforts to support resident care.
Residents with a dementia often struggle with the traditional method of meal service experienced in LTC Homes over the years. In 2014 Wellington Terrace introduced a ‘Flexible Meal Program’ to the home and continues to enhance the program to best meet the needs of residents struggling with eating routines due to their dementia. The program focuses on increasing the time required by residents to adequately enjoy their meal. This also facilitates the schedule of residents who wake very early or later. By ensuring nutritious snacks and meals are available to our residents and increasing their ability to be awake and engaged in the dining experience. In 2016, we implemented this approach in another 2 neighbourhoods, making enhancements based on our learning during the pilot and adjusting to meet the care levels of each area.
In 2017, to further support our efforts during meal times, we adjusted the duties of our staff; the hours they work; and centralized some of the tasks to release staff time to support the increased needs of our residents. In 2018, we will continue to see the positive effects of the department re-organization; residents will benefit from increased support. In addition, we are moving towards the implementation of the “IDDSI” (International Dysphagia Diet Standardization Initiative). This provides a new standardized language and description for food and fluid textures to better meet the increasing nutritional needs of our residents.
Five years ago the Ministry of Health and long term care provided funding for homes to have dedicated staff to participate in the behaviour support program. The purpose of this program is to provide coaching and support to our teams on best practice care strategies to most appropriately respond to residents with responsive behaviours. We have a dedicated Personal Support Worker and Registered Practical Nurse who are committed to ensuring this program serves all residents of Wellington Terrace. Their role is to assist residents in their transition to the home, identify Montessori based activities that the resident may be interested in to give them a sense of purpose and meaning as well as educate staff and build capacity in the way of skills, strategies and approaches to support the resident. To ensure a consistent level of knowledge for all staff, Wellington Terrace has identified Gentle Persuasion Approaches (GPA) training in our education plan over the past 6 years. Today 99% of our workforce is trained. This education is conducted by in house trainers and teaches staff how to use a person-centred, compassionate, gentle persuasive approach and to respond respectfully with confidence and skill to challenging behaviours associated with dementia. We believe this investment in our staff produces a consistent approach to care and compliance with best practices. The cost to LTC Homes to provide staff with required education is significant. We advocate through our association, for continued funding to ensure all staff are given the tools to provide the highest level of care.
In 2017, we introduced the GPA Refresher to ensure our team's skill level remains current and offered the full day session to new employees. The BSO team facilitated 57 education opportunities related to responsive behaviours and a total of 719 staff participated in these sessions. We believe the spirit of investing time and efforts in building capacity of all staff is the hallmark to quality care. In 2018, we will invest in training a new GPA trainer to replace a member of our team who retired.
Wellington Terrace has put strategies in place for those residents who have responsive behaviours when receiving personal care. These behaviours may include verbal or physical interactions or sexual disinhibition. We use the term responsive behaviors because we believe that the resident is responding to something in their environment that is causing the behaviour. As such, our care staff becomes detectives by trying to determine what is causing the behaviour. It could be that the resident is in pain, is too warm, hungry, has an infection or there is too much noise in the environment. The staff develops an understanding of what triggers the resident’s behaviour and what strategies can be put in place to mitigate the behaviour. We recognize that the resident is not able to change their response so we must alter the environment, approach or care strategies. In 2017 we educated staff on the ‘stop and go’ approach as guided by Gentle Persuasion Approaches, where staff begin care but if the resident is distressed the staff member will return again to complete the task. This strategy of completing care in waves is effective in helping residents to feel more relaxed and maintain calm as well as attempt to reduce the amount of staff injuries; however it does take longer to complete care.
In 2017 we became a 'Music and Memory' certified home. Music and Memory helps people living with a wide range of cognitive and physical challenges to find renewed joy through musical favorites. Music can transport an individual to another place and time often unlocking fond memories from our youth or special events in our lives. Personalized playlists are created in consultation with the resident or their family and the resident is provided with an ipod. There is no cost for the resident to participate in the program as donations cover the cost. In 2018, our 'Music and Memory' initiative continues and our goal is to extend the program to 45 residents by the end of the year.
Through collaboration with pharmacy, nursing, behaviour supports, life enrichment and our physician we were able to successfully reduce antipsychotic use in 2016 to below provincial average. We recognize that there are instances where antipsychotic medication is required in order to manage risk or maintain the resident’s dignity due to the distressing responsive behaviour they have as a result of cognitive impairment. We have a formal review of this medication at least quarterly by the physician, pharmacist and Behaviour Supports team with the goal of reducing or eliminating this medication when possible.
Resident, Patient, Client Engagement
Members of our management team are invited to attend both family and resident council to share organizational and quality improvement goals, as well as updates on the delivery of care and services. Wellington Terrace has been proactive in our approach to ensure the information shared at these forums is as meaningful as possible. With an increased number of residents identified with a dementia (91.1% in 2017 CIHI data) long term care homes are challenged in keeping our residents informed about details regarding their care delivery and opportunities for sharing their concerns. In 2016 suggestion boxes were installed in each neighbourhood in an attempt to get their feedback in the moment. In the area of Nutrition Services, staff will share verbal feedback they receive on the resident's satisfaction with food and meal service so we can proactively make improvements around food preferences and service. Since the implementation of this initiative, it has been noted that residents appreciate that the concern was proactively addressed by the time it reaches the Residents' Council meeting. In 2017 in support of the Ontario Resident Council Association's new initiatives in promoting resident rights, Wellington Terrace now offers a presentation at meetings on describing how we are committed to the day to day examples of ensuring resident rights are acknowledged and then communicated throughout the team. The feedback from the residents on this effort has been appreciated as it helps to initiate increased dialogue at their meetings. Any effort to contribute to the content of the meeting is helpful as leadership within the resident group is limited at this time due to resident frailty and cognitive impairment.
Our Family Council meets with the Administrator quarterly. The Administrator is invited to discuss and seek input on policies, legislation, challenges and quality improvement successes and challenges. Our family council hosts an annual education event inviting families and members of the community for a presentation on a topic of interest. The topic of Dementia has been featured 2016 and 2017. This initiative affords us the opportunity to engage with community members while educating them on the issues facing seniors. The focus of this education in 2018 is care for the caregiver.
Families and residents are provided with regular updates on our quality improvements efforts through newsletters, displays and presentations at resident and family council meetings. We are very mindful of limiting the technical jargon and often provide the information in the form of an example or story especially for resident council.
Wellington Terrace conducts a preadmission interview with resident or care giver to establish a smooth transition in the home by clearly understanding preferences and strategies to successfully provide care. This has reduced the stress for both resident and their family member. Since this implementation, we have shared our resources with other members in our association including at the annual conference. In our post admission questionnaire in 2017, 96% of admission satisfaction survey respondents said that the preadmission interview was excellent and 96% of respondents said that the emotional support that they received on admission day was excellent.
We seek feedback from families after the death of their loved one. Surveys have helped us to enhance our palliative care program throughout the years. In 2017, 100% of respondents shared that they felt staff were compassionate and caring. In addition 100% of respondents felt that their loved ones comfort was maintained throughout the palliative care journey.
We also ask our families and residents to provide us with feedback following the initial and annual care conference. We appreciate the feedback on the extent and clarity of information we provide at the conference. We believe it sets the stage for their ability to respond accurately to the annual satisfaction survey by clarifying aspects of the resident's care. Families shared that 99% of families felt that wishes and important issues were dealt with effectively during the care conference. 99% of families felt that the care conference summary (mailed to them after the care conference) was helpful.
The annual resident survey was conducted in March 2017 and we are pleased that in 2017, 85 residents and families took the time to provide us with their feedback. In 2017 98% of residents who responded positively to the statement: “I can express my opinion without fear of consequences"; 98% of our residents and families said that they feel safe in the home. 98% stated that the home provides an environment that promotes client safety. 99% said that they would recommend Wellington Terrace to friends and family.
Resident's length of stay has reduced in past several years. Residents being admitted have a shorter length of stay. In 2008 15% of those who died had lived here for less than a year, in 2017, 41 % were here less than a year before they passed away. 77 residents passed away at the Terrace in 2017.
Wellington Terrace takes a proactive approach when supporting families struggling with admission or who find it difficult to cope based on their own medical challenges. By meeting and communicating regularly, we have a greater chance in establishing a care giver support in a timely way. Our social worker supports a number of families struggling with admission as well as offers a spousal support group.
In 2017, Wellington Terrace responded to the Health Quality Ontario document, “A Guide to Improving Complaints Processes in Long Term Care Homes”. The document echoes our approach to maintaining an open and collaborative relationship with families. The document prompted us to clarify the many ways a resident or family member can bring forward their concerns. We revised our handbook so it reinforced this approach. We post our QIP and Annual Inspection results on our website and provide displays of our Quality Improvement initiatives throughout the year. Resident and Family concerns is a standing item on our management team agenda so that we all are aware and collectively respond to the concerns. In 2018, we are providing training for all staff in helping respond to family concerns in a supportive and empathetic way.