Collaborative Problem Solving - mehca.org Proble… · COLLABORATIVE PROBLEM SOLVING GUIDED BY DICE...

Maine Health Care Association E-Learning Series

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Collaborative Problem Solving:Becoming an Adaptive Dementia Care Team

Presented by: Heather McKay, PhD, OT/L, Dementia Care Specialist

Contact Heather at www.pfhnc.com

Objectives

1. Introductions

2. Understand the DICE approach to managing challenging dementia care cases

a. Connect background information

b. Justify using a standardized approach to problem solving

c. Report origins of DICE

d. List steps of DICE

3. Analyze the DICE approach in a case example

4. Identify strategies for implementation

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Poll the Audience

• What is your current role?

• Did you attend the previous session?

Understanding the DICE

Approach to Managing

Challenging Dementia Cases

• Background

• Justification for a standardized approach to problem solving

• Origins of DICE

• Steps of DICE

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Understanding the DICE Approach to Managing Challenging Dementia Cases

Background

● Challenging nature of dementia

caregiving

● Intervention approaches (outcomes, risks)

○ Pharmacological

○ Medical

○ Non-pharmacological (behavioral &

environmental)

● Why the lack of a process for analyzing

and resolving challenging cases? (Kales et al., 2014)


Need for a Standardized Approach

● Single process for analyzing and resolving challenging cases

would improve and coordinate care (Kales et al., 2014)

● Teams need opportunities to practice a generalizable process involving:

○ Recognizing challenges

○ Assessing root causes to get to the heart of the matter

○ Creating case-specific plans

○ Implementing with teamwork

○ Returning for on-going problem solving

○ Linking knowledge, skills, creativity, and willingness to try something

new together (McKay, 2019a)

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• University of Michigan Program for Positive Aging & John’s Hopkins AD Research Center and Center for Innovative Care in Aging

• Convened interdisciplinary expert panel (2011)

• Compiled evidence• Created the DICE approach

(Kales et al., 2014)

Origins of DICE


Steps of DICE (Kales et al, 2013; McKay, 2019a; Positive Approach to Care, 2018)

● Describe the challenging case

○ Contexts○ Person○ Care environment○ Rhythm of the day○ Stage of dementia○ Other health conditions○ How we help ○ The challenge/problem

● Investigate possible causes

○ Clarify the main concern○ Generate an idea about the

root cause of the problem○ Determine what improvement

would look like

● Create a plan to try something new

○ Pull from dementia care strategies learned in previous training (Maine Healthcare, 2020)

● Evaluate

○ Effectiveness, Efficiency,

Satisfaction to self and others

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Applying DICE in a Case

• Listen to one team’s story of a challenging case

• Notice how DICE guided their conversation and collaborative problem solving

• Notice similarities and differences in your team’s approach

COLLABORATIVE PROBLEM SOLVING GUIDED BY DICECase Example

Date: 10/31/18 Time:(start) 1:00pm (finish) 2:00pm

Facilitator: Heather

In Attendance

Betsy, CNA in home care (storyteller)

Christopher, transporter

Nancy, RN, home care manager

Jake, administrative assistant

Heather, consulting OT (facilitator)

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DESCRIBE

Background/ContextBetsy, experienced CNA, 16 years in home care, covers all areas (IL, AL, SNF)

Purpose of home care: Helping clients remain at home as long as possible. Giving clients a feeling of home wherever they live

Getting to know clients: Talking directly to the client, speaking with family and teammates

Sharing Info: Documentation on a tablet. “I’m prepared when I get there.” Details in the care plan. Talk with families

Notice changes by being present daily, paying attention. Helping others recognize change by talking with teammates and family members

Typical day: Starts early, greeting clients in their homes, setting up the environment before beginning tasks together. “Gotta take your time.” Enjoys laughing and socializing with clients.

Case Example

COLLABORATIVE PROBLEM SOLVING GUIDED BY DICE

The PersonMrs. Queen. Lives with her husband. Married 53 years.

Family: Two daughters. Kate lives locally and helps with frequent phone calls,

visits, and written notes. Another daughter lives out of town. The couple attends

the Lutheran church every week.

Physical description: Mrs. Queen is a petite lady. Slumped posture. Spends most

of her time in a chair. Uses a walker to move around the house.

Personal preferences: Likes to proceed slowly through the steps of an activity. Betsy takes her time and does the steps of each activity the same way every day—Mrs. Queen likes consistency. Mrs. Queen does not like to be rushed. She likes to laugh and cut up with Betsy while they work together.

The Home Environment

one-story townhouse

Case Example

Mrs. Queen


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Case Example

Rhythm of the DayCaregiver arrives early every morning.

Laugh and visit before starting an activity-make a friendly connection. Then, Mrs. Queen is willing to go to the bathroom after the social visit. Mr. Queen fixes breakfast while the ladies do personal care together. After

breakfast, the couple is on their own for the rest of the day.

Level of Dementia/Skills and AbilitiesMrs. Queen has skills/abilities typical of early stage dementia. With step-by-step set up in the bathroom, Mrs. Queen can do many tasks for herself. She can wash most of her body, brush her teeth with set up. Dressing

and moving from place to place take more physical assistance.

Other Health Conditions

• Parkinson’s disease• History of falls• Frequent pain in her heels

• Betsy has noticed that Mrs. Queen seems to need more support for balance recently


Case Example

How the Caregiver is HelpingMrs. Queen likes things done a certain way.

Likes to do the steps of the morning routine the same every day. She appears scared during the activity, so comforting words, taking her time, and giving her control over the parts of the activity that she can still do relieves

her fear.Loves to laugh and cut up, so Betsy keeps the mood light, which also helps to ease Mrs. Queen’s fear during the activities.

Family Dynamics

Mr. Queen is fiercely independent and wants to do things on his own.

He gets confused and upset at times.

Mr. Queen has Mild Cognitive Impairment and back problems.

Helping his wife can be frustrating and painful for him.

Mr. Queen sees himself as Mrs. Queen’s primary caregiver, but the couple

seems to need more assistance lately.

Daughter Kate writes notes and lists to keep the couple on track

Betsy makes things easier for Mr. Queen by helping his wife.


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Case Example

INVESTIGATE

The Challenge

The couple seems to need more help than they currently have—beyond just the

morning routine. However, Mr. Queen is resistant to change. Previous attempts at

providing more services, especially transportation, have been unsuccessful. Mr.

Queen wants to drive.

The Main Concern

Outings are risky for the couple when they travel alone. Mrs. Queen needs more

help than her husband can provide, and Mr. Queen’s diving seems unsafe. The

couple currently makes regular outings to church and doctor’s appointments.

Possible Root Causes

Mr. Queen’s feelings appear to be at the heart of the matter. Accepting more help

may feel like a loss.


Case Example

INVESTIGATE

How could we test the idea?Aim communication about transportation at Mr. Queen’s

feelings

(desire to be in control, desire to be his wife’s caregiver, desire

to feel capable) to create a positive feeling about riding in the

agency’s van.

What would indicate improvement?Initially, Mr. Queen might show more interest in the service. Even better, he would take a ride with the transporter and have a positive feeling about the experience. Ultimately, the couple would have a system of scheduling the service for routine outings.


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Case Example

CREATE

The PlanChristopher will make a visit to show Mr. Queen his new van, emphasizing positive communication in his social visit.Betsy will ask the couple about future appointments and relay information to the team.The home care manager will speak to the couple about adding additional hours of coverage in the afternoon/evening.

Implement with TeamworkAction period 10/31/18-11/6/18 focused on communication and cooperationThe team will reconvene on 11/6/18 to evaluate and plan next steps


Case Example

Evaluate

Evaluate First Attempt

Christopher’s first visit ended in a positive feeling for Mr. Queen. Christopher made a follow-up visit to share written information about transportation service. The couple agreed to ride with Christopher.

Return for Ongoing Problem SolvingKnowing the couple’s next appointment, the team scheduled the ride.

Two weeks after the initial plan, the couple took their first ride to a doctor’s appointment. The team evaluated the outcome with improvements in:

• Effectiveness

• Efficiency• Satisfaction

The team also determined that the additional hours of in-home care were not high priority at this time, and they would continue to focus on transportation for now. With the new transportation plan in place, the team

determined “case closed.”


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Poll the Audience

As you listened to the story,

• Did you notice similarities in the way your team approaches problem solving? (Think process)

• If yes, type what was the same in the chat box

Poll the Audience

As you listened to the story,

• Did you notice any differences in the way your team approaches problem solving? (Think process)

• If yes, type what was different in the chat box

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Strategies for Implementation

• Think about new and existing clients/patients

• Think about all the dementia-specific knowledge and skills your team has

• Think about how your team communicates

• Time Saving Tips

• Remember cases change, but the process is the same

• What to do first

• What other resources you might need

Strategies for Implementing DICE

Think About New and Existing Clients/Patients

● Who might identify a challenge?

○ Client/Patient

○ Frontline caregiver○ Family

○ Others

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Think About Your Team’s Knowledge and Skills for Dementia Caregiving—Tools for the Job

● This webinar series

● Dementia Care Training in your agency

● Dementia care training online

● Content experts on your team

● Local experts/community teachers

● Many years of collective experience


Think About How Your Team Communicates

● Gather information from a diverse group

● Optimize phone, email, text, face-to-face,

online communication

● Cover the logistics

● Don’t forget to plan your follow up

● Look for signs of your team’s progress

○ Cases resolved○ Process improvements

○ Teamwork ○ Satisfaction

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Think About These Time Saving Tips● Pick a scribe

● Choose one facilitator and one storyteller

o Allow the storyteller time to prepareo Allow the facilitator time to prepare

● Take notes while the team brainstorms

● Present the notes in a way that everyone can see

● Think carefully about shortening the conversation

o IF everyone is familiar, abbreviate/cut contexts surrounding the case

● Practice

o Teammates distinguish need-to-know vs. nice-to-know

o Fewer follow-up questions to get to the heart of the matter


Think About What Changes and What Stays the Same With Different Kinds of Cases

● Cases in different areas of your facility

● Cases of different types of dementia

● Cases with little or no family involvement

Remember, the process remains the same

● Describe

● Investigate

● Create

● Evaluate

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What To Do First

● Identify a challenging case

● Convene a diverse group

● Try a conversation DICE-style

What Other Resources Might You Need?

Poll the Audience

• Do you have at least one new idea to improve your dementia care team’s collaborative problem solving?

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Thank You For Join Us!

• Announcements of upcoming MHCA events

• See more of Heather’s training videos and contact her at www.pfhnc.com

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http://www.pfhnc.com/

Collaborative Problem Solving - mehca.org Proble… · COLLABORATIVE PROBLEM SOLVING GUIDED BY DICE...

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