Behavioural Supports Ontario

About Behavioural Supports Ontario

The Behavioural Supports Ontario (BSO) project aims to improve the lives of Ontarians with behaviours associated with complex and challenging mental health, dementia or other neurological conditions living in long-term care homes or independent living settings. This principle-based Framework for Care is designed to mitigate the strain and improve outcomes for persons with responsive behaviours, families, health providers and the healthcare system.

Framework principles

Person and caregiver-directed care is the overarching principle:

• 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 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.

Framework principles

Person and caregiver-directed care is the overarching principle:

• 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 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.

Care Navigator (CN)

Support for the client, caregiver, and staff.

The role of the CN is to provide support access and navigation to BSO services and programs. As the initial point of contact with both formal and informal referral sources, they identify the needs, and strengthen the communication and care planning linkages between care providers across the various sectors along the continuum of care. Operating with a "no wrong door policy" they ensure that the necessary supports are received when and how they are needed.

Behavioural Support Counsellor (BSC)

Support for the caregiver.

The BSC provides education, support, counselling and guidance to caregivers and family members who are caring for a loved one with responsive behaviours that may be attributed to Alzheimer’s disease and related dementias that impact the ability to provide care. To ensure continuity of care, BSCs support caregivers in both acute care and community settings. They assist in navigating the healthcare system and connect caregivers to community resources, support groups or educational workshops. Support for caregivers is provided in a location that is most convenient for the caregiver – it may be one-on-one based at home, hospital, office visit or a discussion over the phone. A BSC provides intensive support to family members/caregivers by working through issues together and providing specific care strategies to help manage the responsive behaviours that are barriers to providing care.

Community Support Worker (CSW)

Support for the client.

The primary role of the CSW is to address responsive behaviours of members within the community which includes Adult Day Programs. CSWs assist with the critical need to support the successful transition of individuals at all key transition points that include long term care, acute care and community (ADS/Home). Community support workers work closely with individuals to develop strategies to minimize responsive behaviours. Their goal is to support the successful transition of an individual from one setting to another, as well as assessing for further support or reassessment of the interventions currently being implemented. These strategies are then communicated to caregivers, day program staff, and staff within the long term care home.

Psychogeriatric Resource Consultant (PRC)

Support for the staff.

The primary role of the PRC is to provide education and developing staff / organizational capacity to provide care for seniors with responsive behaviours related to complex physical, cognitive and mental health needs. The PRCs facilitate the transfer of knowledge to practice through formal and informal on-site staff development. Through a consultative model, the PRCs build capacity throughout the system to better support the person with responsive behaviours and the caregiver. PRCs promote and work with the PIECES model and teach the PIECES program to regulated care providers and supervisors. The PRCs are also qualified as Gentle Persuasive Approach (GPA) coaches and Mental Health First Aid facilitators, delivering these programs to front-line workers, often in collaboration with other trained coaches and facilitators.

Acute Care Behavioural Consultant (ACBC)

Support for acute care partners.

The ACBC supports the acute care sector in managing the responsive behaviours which are considered to be the barrier to discharge from hospital. The ACBC works closely with the social workers, discharge planners, care coordinators and front-line staff at the hospital to identify the triggers, manage behaviours and determine the most appropriate discharge location. ACBC collaborate with community agencies and long term care homes to help transition clients to the most appropriate care setting post their acute episode. The ACBC has a key role in building capacity within the acute care sector in managing behaviours of admitted patients/clients.

Behavioural Intervention Specialist (BIS)

Support for the client.

The BIS works within the hospitals with patients with responsive behaviours. The BIS will collaborate with the patient, caregivers and hospital staff to look for triggers to behaviours and develop some interventions to help manage behaviours. The BIS will assist in developing a care plan for the patient, in collaboration with the receiving agency and caregivers to support transitions from the acute care setting. At the time of discharge the BIS will work with the staff and caregivers to support the transition and follow up as needed.