Guided By Excellence: Strengthening service capacity to support people living with BPSD

Carer

The aim of the Guided By Excellence Project was to investigate

and if so:

  • how they are appreciated and implemented by external stakeholders using DSA services.

Key Project Outcomes
  • DSA delivers evidence-based care recommendations that show a high degree of adherence with Clinical Practice Guidelines and Principles of Care for People with Dementia.
  • Referrers into DSA consider evidence as vital to DSA recommendations, but the level of that evidence varied widely.
  • Strong and clear communication between DSA Dementia Consultants and referrers was important in establishing a foundation of trust on the suitability and efficacy of recommendations.
  • The Guidelines are often unknown or considered impractical by staff in residential care. DSA Dementia Consultants are considered enablers in translating these guidelines into practice.
Background

It is expected that contemporary health care in Australia is based on evidence that promotes health, prevents harm and encourages best practice. However, despite decades of research and experience, translating best practice principles to supporting people with dementia who also experience behaviours and psychological symptoms of dementia (BPSD) has proven difficult.

This realisation led, in part, to two separate activities:

  1. The development of the Clinical Practice Guidelines and Principles of Care for People with Dementia: These clinical practice “Guidelines” include 109 recommendations that health care professionals can apply to support the needs of a person living with dementia and their carer/s.
  2. The establishment of Dementia Support Australia (DSA): DSA is the largest national provider of support for people living with dementia who experience behaviours and psychological symptoms of dementia. DSA provides this support through non-pharmacological and person-centred strategies and recommendations. 

Both the Guidelines and DSA have independently demonstrated positive outcomes, yet there is limited understanding of adherence and impact the Guidelines have on DSA service delivery and, if adhered to, how they are appreciated and implemented by external stakeholders using DSA services.

The Dementia Centre was commissioned by the Australian Government Department of Health to investigate this relationship through the research project “Guided by Excellence: Strengthening service capacity to support people living with BPSD”.

The project investigated these questions through two projects summarised below. 

Project 1: Reviewing DSA recommendation report adherence to Clinical Practice Guidelines

This project was designed to objectively determine the adherence of DSA recommendation reports to relevant Guidelines. A random selection of 10% of recommendation reports over a six-month period were audited against the Guidelines by four reviewers; two external to HammondCare and DSA, and two who worked on the DSA program.

The results of this audit revealed extremely high compliance of DSA recommendation reports to the Guidelines.

Of note:

  • Identification of factors contributing to BPSD (Guideline 77) was met 87% to 97% of the time (average rate of 94%).
  • People with dementia and BPSD should be offered a comprehensive assessment by a professional (Guideline 78) was met 86% to 99% of the time (average rate of 95%).
  • People with dementia and BPSD should be supported initially through non-pharmacological approaches (Guideline 79) was met 99% of the time.
  • People with dementia suspected to be in pain are provided with a pain assessment and pharmacological management of pain is considered (Guideline 81) was met 87% to 99% (average rate of 93%).
  • People with dementia who have depression, anxiety, or agitation should have interventions tailored to the person’s preferences (Guideline 84) was met 86% to 89% of the time (average rate of 87%).

Only one Guideline had a low rate of adherence by DSA recommendation reports. Specifically, Advance Care Plans (Guideline 106) were only recognised in 0.7% of recommendation reports. However, this appeared to be due to external factors outside the control of DSA Dementia Consultants, including not being available to the Consultant for viewing or the clients being at an earlier stage of dementia where an Advance Care Plan was not warranted.

Project 2: Clinical perceptions of DSA recommendation reports

In-depth interviews with 32 DSA Dementia Consultants and 25 residential aged care managers examined the perceived evidence base of the Guidelines, the perceived use of Guidelines in DSA recommendation reports, and any barriers or enablers to incorporating these recommendations into practice.

Key findings

Broadly, interviewees believed DSA recommendation reports use current best evidence and these recommendations translate to clinical improvements in DSA clients. Specifically, interviewees reported the following themes when discussing barriers and enablers of implementing DSA recommendations:

  1. Evidence is important: Evidence for DSA recommendations was considered a vital motivating factor for their implementation.
  2. Evidence can take many forms: Despite the reported significance of evidence, what constituted “evidence” varied considerably. 
  3. Evidence may not always be available: Interviewees reported that, due to the heterogeneity of people living with dementia and the idiosyncratic nature of delivering person-centred care, it was impossible to have evidence for all recommendations that may be useful.
  4. Strong relationships are needed between Dementia Consultants and referrers: A mutually respectful relationship between DSA and referrers was reported as being an important foundation of trusting the evidence and efficacy of recommendations.
  5. Recommendations need to be communicated clearly: Effective interpersonal communication and well-articulated, well-informed recommendations were associated with implementation of recommendations.
  6. Guidelines may not be known or may be considered impractical: Many staff working in aged care were unaware of the Guidelines. If Guidelines were known many staff considered Guidelines to be impractical to implement.
  7. Guidelines tell us “what” not “how”: While Guidelines detailed what was important in supporting people with dementia, generally there was a lack of supporting information on how to implement these in residential care. DSA Dementia Consultants, as knowledge translators of the Guidelines, were reported as being especially important enablers for the correct implementation of these Guidelines into practice.