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January 18, 2021

A new virtual pilot program to assess and treat people with challenging behaviours caused by dementia and related cognitive disorders is helping acute care hospitals, long-term care homes and family caregivers better care for people living with dementia and improve their quality of life.

Launched in April 2020, the Virtual Behavioural Medicine (VBM) Program is a collaboration between the Sam and Ida Ross Memory Clinic at Baycrest and the Toronto Central Behavioural Support for Seniors Program (TC-BSSP), which sees patients through virtual visits over the secure Ontario Telemedicine Network rather than in person.

Program reducing pressure on acute care beds
In just a few months, the program has helped to reduce the pressure on acute care hospital beds because patients with challenging responsive behaviours, such as physical and verbal aggression, agitation, hallucinations and paranoia, receive pharmacological and non-pharmacological interventions to mitigate their behaviours and allow them to be transferred back to the community or to long-term care homes.

“The VBM Program has assisted greatly in helping to manage some of the most challenging behaviours of our patients,” says Dr. Sandra Black, Clinician Scientist at Sunnybrook Health Sciences Centre and Professor of Medicine (Neurology), University of Toronto. “This has improved not only their quality of life, but that of their caregivers and family.”

Virtual visits reduce wait times for assessment and treatment
The same results have been experienced in long-term care, according to Shitu Wang, the Behavioural Supports Resources Team Lead in the Apotex Centre, Jewish Home for the Aged. “In April we had a new admission with behavioural symptoms of extreme aggression, both verbal and physical. We needed security and extra staff 24 hours a day.”

A referral was made to Dr. Morris Freedman, Baycrest Behavioural Neurologist in the Sam and Ida Ross Memory Clinic, who explained that he could assess the resident without seeing her in person through the new VBM Program. There was no need to transfer her to an in-patient Behavioural Neurology unit for assessment and treatment, which can have wait times of up to one year. Based on the data from the VBM program to date, it is anticipated that the need to admit patients to the Behavioural Neurology Unit at Baycrest can be reduced by approximately 65 to 80 per cent.

Behaviours improve with two-pronged intervention approach “Dr. Freedman came on board along with the Long-Term Care Behavioural Support Outreach Team,” says Wang. “It took two months of sustained work with our team using medications and non-pharmacological interventions identified by the Behaviour Support Team, and the result was amazing. The resident went from having no quality of life whatsoever, to being a completely changed person. She was pleasant and able to have a conversation and take part in activities. And it was all done virtually.”

The ability to see Dr. Freedman virtually on a daily basis removed the separation that is typically experienced between a care team and a specialist and allowed them to collaborate on the resident’s care.

When the Downsview Long-Term Care Centre in Toronto referred a resident with physical aggression to the VBM Program, they too were impressed with how quickly the resident was assessed and how the program worked collaboratively with their interdisciplinary team to develop and implement effective strategies to stabilize her condition. “The resident is now stable and no longer requires one-to-one monitoring,” says Roland Madrona, RPN and Behavioural Supports Ontario (BSO) Lead at the centre. “I highly recommend the program.”

Specialists and care teams co-develop care plans
Among the benefits of the VBM Program is that its team of specialists – including nurses, social workers, pharmacists, mental health professionals and the BSO team – can provide a rapid response where and when they are needed. They work with care teams in acute care hospitals and long-term care homes and with family members in the community to help them develop and implement care plans, access behavioural and social supports and provide follow-up. 

“It’s like having a virtual Behavioural Neurology in-patient unit in each location,” says Dr. Freedman. “And just like on an in-patient unit, we have weekly rounds to talk about each patient as a team.”

The VBM Program has also implemented bi-weekly case review rounds involving the whole team to look at each case and ensure that any gaps are filled, all available resources are optimized and a transitional plan and supports are in place for a person’s discharge from the program.

“The program brings together for the first time, both specialists and Behaviour Support clinicians to work shoulder-to-shoulder as one team, and address responsive behaviours, using both pharmacological and non-pharmacological interventions, allowing a comprehensive approach to behaviour management,” says Einat Danieli, Clinical Manager, TC-LHIN, BSSP.

Increase in referrals signals demand for program
Since the VBM Program began, there has been a steady increase in referrals from acute care, long-term care and the community. There were 150 referrals between April and November 2020 and none have been refused. Most were from the Greater Toronto Area, but patients have also been seen around Ontario in places such as London, Orillia and Brampton.

“These figures demonstrate the need for this program and a growing awareness of what it has to offer,” says Fidelma Serediuk, Clinical Manager of Baycrest Ambulatory Medical Clinics and the Sam and Ida Ross Memory Clinic. “The concept for a virtual program was developed prior to the COVID-19 pandemic, but the pandemic has been an accelerator that has highlighted a need that was always there.”

Family caregivers receive support at home
For Josh and his 80-year-old mother, Margaret, the VBM Program is helping him manage her progressive neurological symptoms so she can remain living with him at home. Her symptoms include depression, not wanting to get out of bed and a delusion that she is falling, which causes her to shake and awaken at night from fear.

“My mom’s health went downhill quite quickly after my father’s death,” says Josh. “Taking care of her has been very challenging and stressful. When she was referred to the VBM Program, I was willing to take any opportunity for support.”

Josh and his mother were connected with Cara Macanuel, a Behaviour Support clinician from the Community Behavioural Support Outreach Team at Baycrest, who met with them regularly over a two-month period. “She provided resources for me to read and practical advice on how to engage with my mom, how to establish routines, how the room should be set up and what foods to avoid in her diet,” says Josh. “She definitely provided me with lots of useful information to help keep my mom comfortable and always followed up our sessions with an email about the things we discussed. I found it very comforting to talk with her.” His mother was also assessed by Dr. Freedman, and they are trying different medications to ease her symptoms. “I talk to a doctor every two weeks,” says Josh. “There is some improvement with her fear of falling, and she is not shaking like she used to, but she’s still clenching the bed rail and wakes up at night. Hopefully, we’ll see more improvements in the coming months.”

Program is integrated across three care sectors
Although he doesn’t want his mother to move into a nursing home, particularly during a pandemic, one of the objectives of the VBM Program is to help patients transition to long-term care when needed and to follow up with them through their care teams.

“The VBM Program is nimble, responsive and integrated across the whole spectrum of care – community, acute care and long-term care,” says Serediuk. “Patients can move from one sector to the other during their involvement with the program.”

Support available seven days a week
A physician referral is necessary to access the VBM Program. Referrals are processed through the TC-LHIN Behaviour Support Hotline at Baycrest. The wait time for an assessment is currently two to three weeks. Healthcare practitioners requiring support can contact the BSO Hotline seven days a week, from 8:30 a.m. to 4:30 p.m., including weekends and holidays, to be connected to support as well as to the VBM Program as needed.

Additionally, for patients actively managed in the VBM Program, Nurse Clinician Mindy Halper is available by phone on a day-to-day basis to provide advice and emotional support to families.

The VBM Program pilot runs until the end of March 2021. It is hoped that a reinvestment of funds by the Toronto Central Local Health Integration Network (TC-LHIN) will allow the program to continue and expand to meet the growing demand.

To refer a patient to the VBM Program, please contact:
Behaviour Supports Coordinating Office

416-785-2500, ext. 2005 or toll-free at 1-844-785-2500
Fax: 647-788-4883
Email: behaviouralsupport@baycrest.org
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