Building and sustaining capital for dementia care: the dementia network initiative

Director of Education, Regional Geriatric Program of Toronto

Director, Psycho-geriatric Resource Consultation Program in Toronto

Assistant Professor and Consultant, Continuing Education and the Knowledge Translation Program, Faculty of Medicine, University of Toronto.

Dr. David Patrick Ryan, Ph.D. C.Psych.

Financial capital: Money and infrastructure

Human capital: Skills and interests

Information capital Knowledge creation and management

Social capital: Networks and collaboration

The sources of capital for effective dementia friendly communities

network as complex system

Structural holes (Burt)

Resource mobilization and connectedness (Lin)

Peripheral participation (Wenger)

Strength of weak ties (Granovetter)

Trust and strong ties (Uzzi)

Diverse ties (Wellman)

Outcome expectancies (Ancona)

Boundary management (Tjosvold)

Systems issues (Bateson)

Network dynamics

A network analysis diagram (Burt, 1999)

Adapted from Brown et al (2001) Strategic Planning in Rural Health Networks available online at www.academyhealth.org/ruralhealth/ strategicplanning.pdf

   Forming

 Evolving

 Maturing

 Growth 

Joint planning Program evaluation

Joint marketingExpanding service line

New servicesProgram integration

 Efficiency

Benchmarking Standard setting

Administrative consolidation

Shared services Service relocation

 Value  

Resource manualsPeer networks/directory

Grant writingShared investments

Common budgetingResource planning/consolidation

 

Network activities that may improve growth, efficiency and value

Network Name Focus Clinical Services

Funding Role

The Child Health Network  

population no no Plan, collaborationstandard setting

Cancer Care Ontario 

disease yes base Service, research, leadership

Ontario Family Health Networks 

population yes base A managed care network

The Cardiac Care Network  

disease Wait list mgmt only

project Monitor analyze and advise MOH

Northern Diabetes Health Network 

disease yes base Assess needs, contract services, evaluate, educate

GTA Rehab. Network  

population no no Plan, research, educate, advise

ABI Network 

population data base mgmt only

mixed Lead, advocate educate collaborate

RGP Network  

population database mgmt only

mixed Advocate educateleadership

Dementia networks

disease no startup funding

 

Several Health Care Networks in Ontario

Name that network Visitors paths at Duisberg Zoo from the gallery of social structures http://www.mpi-fg-koeln.mpg.de/~lk/netvis.html

Service map or inventory

Establish “first link”

Profile of consumer needs

Physician Newsletters

Develop a website

Develop guidelines, care-maps and algorithms

Collaborate with other networks

Establish databases

Gap identification

Public education materials/workshops

Health professional education materials/ workshops

Physician Education materials /workshops

Classes of Activities across the 30 Dementia Networks

2 network projects in toronto

Create a Web site listing more than 300 organizations that provide dementia services across the city. www.dementiatoronto.org

Conduct a series of community consultations using the in Toronto to better understand the circumstances of care and the needs that exist within our communities.

Francoise Hebert, Alzheimer Society of Toronto

Rory Fisher, Geriatrician

Eric Hong – Whitby Mental Health

Vija Mallia – Castleview Wychwood Towers

Pam Goldsilver - COTA

Marta Krywonis – Etobicoke-York CCAC

David Ryan, Regional Geriatric Program of Toronto

Dementia Network Co-chairs

dementiatoronto.org team

Community consultation task force

Rhona Phillips, MOH/LTC

Fern Terplitsky, DHC

Angela Mendes, Alzheimer Society

Francoise Hebert, Alzheimer Society

200 Agencies invited

170 accepted the invitation

92 of these participated

158 people

Managers, Social workers, RN’s, case coordinators, therapists. PSW, DOC’s, educators,

PRC’s and Alzheimer Society Educators provided facilitation

Community consultation: who was involved?

Building cases mirrors naturalistic learning

When health professionals talk about cases several things happen:

A composite case is formed during the discussion

These composites reflect practice contexts

A diversity of approaches to assessment and intervention emerge

Recognizing this diversity, a learning moment is created

Build-A-Case captures this most natural and contextual process of learning and is a distinct application of problem based learning

Problem Based Learning Build-A-Case

Socratic Dialogue Reflective Dialogue

Teacher - knowledge expert Teacher - inquiry expert

Learners declare Learners describe

“Eats Cases” Produces Cases

Expensive Inexpensive

Ubiquitous Novel

Centralized Situated

1. Introduction by the region’s PRConsultants2. Welcome from the Homes for Aged Educator or Administrator3. Introductions of participants4. Overview of the Dementia Network, the Community Consultation Steering Group, the provincial Alzheimer’s Strategies 5. Overview of the morning’s objectives and activities 6. Case building session a) Case profile b) Real intervention plan c) Ideal intervention plan d) Gaps identification7. Sharing and discussion of constructed case profiles 8. Sharing and discussion of identified gaps9. Wrap-up, “next steps” and evaluation

An outline of each consultation meeting

 

63% of the built cases were seniors whose first language was not English

Languages included Gujarati, Italian, Macedonian, French, Ukranian, Russian and Polish.

On average each case had 4 health problems in addition to dementia

Co-morbidities: Diabetes (17), behavioral problems (16) depression (11), rheumatoid and osteo-arthritis (11), vision difficulties such as macular degeneration (8) , hypertension (8), mobility difficulties (5), osteoporosis (5), hearing problems (4), heart disease (4), alcohol related problems, continence problems (3), skin ulcers, falls, paranoia/hallucinations, stroke (2), CHF, sleep disturbance and anemia (1).

Twenty-seven cases were constructed

Sixty knowledge, service & communications gaps identified

21 Knowledge gaps

19 Communication gaps

30 Service gaps

Service gaps significantly more frequent with overall higher importance ratings

No regional or service differences

  1. Family and general public knowledge of dementia services 2. Knowledge of how to plan to avoid crisis situations 3. General knowledge of how the system works 4. Public education on aging, stigmatization and dementia 5. Understanding of problems mixing young, old and demented people 6. MOH doesn’t understand the reality of care 7. Limited education on aging for younger people 8. Professional awareness of all services available in the community 9. Volunteer training .10. Family physician knowledge of resources/medications/dementia/delirium11. Knowledge of what services require extra payment 12. Knowledge of the role of case managers13. Lack of emphasis on aging in the training of health professionals14. Awareness of boundaries/catchment areas 15. Awareness of value of alcohol treatment programs. 16. Methods for the resolution of family conflict17. Information systems sometimes encourage disability not health 18. Support and Education for the PSW/home support workers19. Some organizations are not committed to developing their staff20. Misuse/misunderstanding of the purpose of respite beds21. Lack of information about the client for PSW and home support workers

 3.43.32.92.92.92.92.82.72.72.72.72.72.62.62.62.52.42.22.02.01.9

Knowledge gaps identified in the city-wide consultation process and their importance ratings (1 = not a gap in our community and 4 = a very big gap)

  1. Services for people with behavioral problems 2. Affordable, readily available and flexible transportation services 3. Provision for “adult care leave “ 4. Staffing levels are insufficient 5. The salary gap between community and facility/hospital staff 6. Translation services 7 days a week, 24 hours a day 7. Psycho-geriatrician house calls 8. Geriatrician house calls 9. Wait lists for specialized services 10. Lack of hospital beds prompts discharge to early11. Sharing of clinical data across agencies 12. Insufficient numbers of nurse practitioners with geriatric expertise13. Inconsistent services across agencies14. Individuals don’t have power to make decisions or individualize services 15. Payment schedules to encourage doctors work with seniors16. No standard of care or management protocols for people with dementia17. Geriatric Assessments in the emergency room18. Funding to renovate facilities 19. Insufficient focus on prevention and health promotion20 Access to day programs that can adjust to changing functional levels21. Cultural and linguistically sensitive services and programs 22. Extended hours for programs and services. 23. Telephone assistance services for dementia24. No continuum of housing services 25. Services just for meal preparation, housekeeping and socialization26. Bedside coaching and mentoring services for PSWs27. Availability of respite services 28. Services for sponsored immigrants 29. Family physicians who do house calls30. Not enough case coordinators

 3.63.43.23.23.23.13.13.13.13.03.13.12.92.72.92.92.92.92.92.92.92.82.82.72.72.72.32.32.32.2

Service gaps identified in the city-wide consultation process and their importance ratings (where 1 = not a gap in our community and 4 = a very big gap)

1.     Communication between doctors and community agencies 2.     Better marketing of services3.     Communications that would help physicians make referrals to other services 4. Inter-agency case conferences for common goal setting/evaluation. 5. Need for a single source information database6. Insufficient involvement of mass and local media in aging issues 7. Communication between family doctors and Emergency Departments . 8. Legal/ethical gaps re: sharing information about clients i.e. confidentiality9. Sharing information between community, acute care and LTC10. Ability to communicate with involved social groups e.g. churches. 11. Services to help seniors communicate with family members.12. Communication between family, physicians and client13. Communication between all staff on all shifts and all disciplines 14. Timeliness of interagency communication15 Need for information in plain language 16. Lack of communication between regulated and unregulated staff 17. Insufficient information on service applications forms 18. No one who seems to push “the agenda” or advocate for individual clients19. Communication between care providers and care coordinating agencies

3.13.13.03.03.02.92.92.92.82.72.72.72.62.62.42.42.42.32.3

Communication gaps identified in the city-wide consultation process and their ratings (where 1 = not a gap in our community and 4 = a very big gap)

CCAC Family Doc/Emergency Communications Better marketing of services

  3.0 3.0 

Community service agencies Communication between physicians and community agencies Communications that would help physicians make referrals Better marketing of services Need for single source information database Inter-agency case conferences for goal setting/evaluation. Sharing information between community, acute and LTC

 

3.63.33.33.23.13.0

Long Term Care Better marketing of services

Insufficient involvement of mass and local media

Need for a single source of information

Services to help seniors communicate with family

Legal/ethical gaps sharing confidential information

Communications that would help physicians make referralsInter-agency case conferences

 3.13.13.13.03.03.03.0

Communications gaps rated higher than 3 for each service sector

CCACKnowledge of how to plan to avoid crisis situationsFamily and general public knowledge of dementia services Family physician knowledgeKnowledge of the role of case managersOrganizational commitment to staff development Knowledge of services requiring extra payment

  3.6 3.3 3.3 3.3 3.0 3.0

Community Service Agencies Family Physician Knowledge of resources/meds/dementiaGeneral knowledge of how the system worksAwareness of boundaries/catchment areas Family and general public knowledge of dementia servicesLimited education on aging for younger peoplePublic education on aging, stigmatization and dementia

 3.73.33.23.23.03.0

Long Term Care Family and general public awareness of dementia services MOH doesn’t understand the reality of careUnderstanding of problems mixing young, old and demented people Knowledge of how to plan to avoid crisis situations

 3.53.43.33.3

Knowledge gaps rated higher than 3 for each service sector

No standard of care or management protocols for dementia Geriatric Assessments in the emergency room Psycho-geriatrician house calls Geriatrician house calls Services for people with behavioral problemsWait lists for specialized services Affordable, readily available and flexible transportation services No continuum of housing servicesrovision for “adult care leave “ Sharing of clinical data across agencies

Access to day programs that can adjust to changing functional levelsInsufficient numbers of nurse practitioners with geriatric expertiseServices just for meal preparation, housekeeping and socializationThe salary gap between community and facility/hospital staffFamily physicians who do house callsLack of hospital beds prompts discharge to early Not enough case coordinators Insufficient focus on prevention and health promotion Payment schedules to encourage doctors work with seniors

3.73.73.73.73.33.33.33.33.03.03.03.03.03.03.03.03.03.03.0

Service gaps rated greater than three for CCAC’s

The salary gap between community and facility/hospital staffPayment schedules to encourage doctors to work with seniorsFamily physicians who do house callsPsycho-geriatrician house callsGeriatrician house calls Translation services 7 days a week, 24 hours a dayServices for people with behavioral problemsAffordable, readily available and flexible transportation services Inconsistent services across agenciesAccess to day programs that can adjust to changing functional levelsExtended hours for programs and services Staffing levels are insufficientGeriatric Assessments in the emergency room Lack of hospital beds prompts discharge to early Insufficient focus on prevention and health promotion

3.53.33.33.33.33.33.33.23.13.03.03.03.03.03.0

Service gaps rated higher than 3 for community service agencies

Services for people with behavioral problems 3.8

Affordable, readily available and flexible transportation 3.5

Provision for “adult care leave “Staffing levels are insufficient 3.5

Funding to renovate facilities 3.4

Insufficient numbers of nurse practitioners with geriatric expertise 3.2

Translation services 7 days a week, 24 hours a day 3.2

The salary gap between community and facility/hospital staff 3.1

Lack of hospital beds prompts discharge to early 3.0

Service gaps rated higher than 3 by long-term care

Three ratings of consultation process effectiveness( Numbers in each cell indicates the number of respondents and the corresponding percentage of respondents is in parentheses)

 Rating scale 1 2 3 4 5 (where 1 = very much so and 5 = not at all)

 Productive and informative

79 (59%)

40 (30%)

8 (6%)

5 (4%)

1 (1%)

 Well organized 

91 (68%)

32 (24)

5 (4%)

4 (3%)

1 (1%)

 Influence practice  

51 (37%)

44 (33%)

25 (22%)

7 (6%)

2 (2%)

A sample of participant comments

• Very informative and enlightening. This session needs to be presented across the health care system.

• It was helpful to have an opportunity to voice concerns, ideas and to brainstorm solutions in long term care. It can sometimes feel like no one is listening outside of our facility.

• Thank you – A very informative session and a positive environment to share information. Good Job!

• Interesting session! I liked the diversity of the group members. Great to hear what other agencies do and learn about their role.

• This is a very informative networking session. Extremely well done!• Very interesting method of learning• Love the format of build-a-case• David Ryan was fantastic. I learned so much from his comments

Strong leadership/formal and informal

Structure/formal and informal

Funding

Build on what exists

Add value

Share labor and resources

Build social capital

Identify and close gaps

Communicate

Meta-communicate

Inclusiveness

Design-in sustainability

Dementia Network Sustainability Advice

Manage outcome expectancies

Manage boundary mgmt initiatives

Manage system dynamics

Manage the knowledge to practice process

Creation

TransferTranslation

Utilization

Description

Correlation

Experimentation

Met-analyses

Co-modification

Marketing

Detailing

Mediating

Education

Opinion Leadership

Simplification

Explanation

Interaction

Advocacy

Individual factors such as beliefs about self-efficacy, utility, value and expectancies

Organizational factors such as organizational readiness and support, information systems, quality management processes

Inter-organizational factors such as boundary and expectancy management

A Model for Exploring the Knowledge to Practice Process

Alzheimer Society of Ontario website on the Dementia Networks of Ontario http://alzheimerontario.org/English/dementia%20networks/default.asp?s=1

Ryan, D. & Marlow, B. (2004) Build-A-Case: A Brand New CME Technique that is Peculiarly Familiar, Accepted for publication Journal of Continuing Education in the Health Professions.

Ryan, D., Cott, C. & Robertson, D. (1996) A conceptual tool-kit for thinking about inter-teamwork in clinical gerontology. Journal of Educational Gerontology, 23, 651-668.

The Change Foundation website on networks and alliances http://www.changefoundation.com/lspace/css/css03/schedule.nsf?opendatabase&db=sc

Start learning about network theory at Barry Wellman’s Netlab online resources http://www.chass.utoronto.ca/~wellman/

Some useful resources

That’s all folks

Say goodnight Irene