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BSO: Framework for Mental Healthcare Cheat Sheet (DRAFT) by [deleted]

This is a draft cheat sheet. It is a work in progress and is not finished yet.


Older people with cognitive impair­ments due to mental health problems, addict­ions, dementia, or other neurol­ogical conditions often exhibit responsive or challe­nging behaviours such as aggres­sion, wandering, physical resistance and agitation. These behavi­ours, which occur whether the person is living at home, in acute care or in long-term care are a major source of distress to the person with the behaviour, family caregivers and others providing support.

We call this behaviour “respo­nsive,” because it is not unpred­ict­able, meanin­gless aggression or agitation, but is due to circum­stances related to the person’s condition or a situation in his or her enviro­nment. Although people with responsive behaviours and their caregivers need high levels of support, sadly it is often inadequate or even non-ex­istent. The number of people with cognitive impairment is growing, which places further strain on indivi­duals and the entire healthcare system.

Framework Principles

• Everyone is treated with respect and accepted “as one is”
• Person and caregi­ver­/fa­mil­y/s­ocial supports are the driving partners in care decisions
• Respect and trust charac­terize relati­onships between staff and clients and care providers.

Supporting principles bring these concepts to life for those making daily decisions about care:
1. Behaviour is commun­ica­tion: Behaviours are an attempt to express distress, solve problems or commun­icate unmet needs. They can be minimized through interv­entions based on unders­tanding the person and adapting the enviro­nment or care to satisfy the indivi­dual’s needs.
2. Diversity: Practices value the language, ethnicity, race, religion, gender, belief­s/t­rad­itions, and life experi­ences.
3. Collab­orative care: Access­ible, compre­hensive assess­men­t/i­nte­rve­ntions include shared interd­isc­ipl­inary plans of care that rely on input and direction from the client and family members.
4. Safety: A culture of safety and well-being is promoted where older adults and families live and visit and where staff work.
5. System coordi­nation and integr­ation: Systems are built upon existing resources and initia­tives. Partners to enable access to the range of needed, integrated services and supports.
6. Accoun­tab­ility and sustai­nab­ility: The accoun­tab­ility of the system, health and social service providers and funders to each other is defined and ensured

The Framework for Care

Pillar 1 - System Coordi­nation and Management

Coordi­nated, cross-­agency, cross-­sec­toral collab­oration and/or partne­rships based on clearly defined roles and processes are required to facilitate seamless care.
Establish system management through a coordi­nated network of service providers and regional coordi­nators with accoun­tab­ility to Local Health Integr­ation Networks (LHINs)
Initiate integr­ated, collab­orative intake, transi­tions and referrals.

Pillar 2 - Integrated Service Delivery

Integrated Service Delivery: Inters­ectoral & Interd­isc­ipl­inary
Outreach and cross-­sector interd­isc­ipl­inary transi­tional teams across the continuum enable equitable and timely access and transi­tions to the right provider for the right service
Introduces collab­ora­tiv­e/s­hared care service delivery through mobile interd­isc­ipl­inary cross-­sector and system support teams, case management and inters­ectoral frameworks and commun­ication vehicles
Value the least restri­ctive / intrusive approach: enhanced approaches and services that promote early detection and health promotion; specia­lized reside­ntial treatment.

Pillar 3: Knowle­dgeable Care Team & Capacity

Knowle­dgeable Care Team & Capacity Building
Education and training strengthen the capacity of family caregivers and profes­sio­nals. The goal is person­-di­rected care, prevention and early detection; implem­ent­ation of standa­rdized best practices in behavi­oural health; and continuous quality improv­ement.
Help families make informed choices
Create supportive learning infras­tru­ctures and foster collab­oration between indivi­duals, teams, organi­zat­ions, systems
Nurture cutting edge research and apply new techno­logies
Support efficient, effective use of human resources and eviden­ce-­based decisions.