Outcome 5.6.1

Put in place processes* to identify and respond to complex needs.

• Put in place policies* and procedures* to make sure the older person’s rights to dignity, independence and choice are a part of processes* to identify, monitor and provide care for cognitive impairment*.
• Consider how policies*, procedures* and processes* for the clinical care* of people with cognitive impairment* can support workers and health professionals* to understand:
  • the range of possible physical, social, psychological and behaviour support needs associated with cognitive impairment*
  • the importance of learning about the person to better identify and understand their needs, and preferences. This includes their history, personality, roles in life, values, beliefs, culture.
  • their roles and responsibilities* for monitoring and mitigating clinical risks for the older person with cognitive impairment*, including increasing risk of falls*, pain*, pressure injuries*, oral deterioration*, medication errors and delirium*.
  • the range of potential contributing factors to cognitive and behaviour changes, including clinical, environmental and medication related factors. Consider that factors may be modifiable and require regular review to minimise impact.
• Put in place policies* and procedures* which explain how to identify signs of cognitive deterioration* and what to do when these are identified. This includes:
  • putting in place best practice strategies for early recognition and response to acute delirium*, such as those recommended in the Delirium Clinical Care Standard
  • identifying older people with symptoms of cognitive impairment*, including recording information about a person’s specific diagnosis and considering referring them for specialist support service
  • identifying and addressing any clinical, psychosocial or environmental issues contributing to cognitive symptoms
  • escalating observations or concerns about cognitive change to relevant health professionals*
  • screening and clinical assessment is completed in line with the older person’s needs and preferences. This is when cognitive impairment* is first identified and when there is any change in cognitive status, including delirium*.
  • identifying changing and related physical, social, psychological, communication and behaviour support needs associated with cognitive impairment*. These can then be thoroughly assessed, monitored, supported and escalated as necessary.
  • assessing, managing and monitoring clinical risks including recent and repeated falls*, pressure injuries*, dehydration and medication changes or errors
  • documenting risks, needs and strategies to support cognitive impairment* including changes behaviours in the care and services plan*. This may include strategies for identifying and supporting unmet needs, mealtime support, memory support, safe movement, and managing and preventing falls*.
  • identifying and addressing factors which can make cognitive or behaviour symptoms worse, as outlined in Action 5.6.3.
• Put in place processes* for ongoing monitoring and response to:
  • changing clinical care* needs which could include changes in behaviour, changes to medication
  • changing communication needs
  • changing daily care needs such as personal hygiene and dietary requirements.
  • need for additional care minutes from health professionals* and workers.

Monitor, review and improve processes* to identify and respond to complex needs.

• Consider how to monitor the safety and quality of the organisation’s processes* to identify and respond to complex needs. Monitoring methods could include:
  • analysing trends in National Mandatory Quality Indicator Program data against indicators for clinical risks, such as hospital admissions, restrictive practices*, falls* and pressure injuries*
  • analysing trends against relevant indicators from the Psychotropic Medicine in Cognitive Disability or Impairment Clinical Care Standard
  • themes from incident* reports related to clinical risks such as falls*, medication errors and pressure injuries*
  • feedback* from workers about their knowledge of and confidence in identifying and responding to complex needs
  • feedback* from older people with cognitive impairment*, their families and others about whether they feel that their full range of needs are understood and supported.
• Consider how to use the information collected during monitoring to identify areas for quality improvement*.
• Consider how to measure if quality has improved.
• Report the results of quality improvement* efforts to the governing body*, older people and workers.

Outcome 5.6.2

Put in place processes* to partner with older people with cognitive impairment*.

Put in place policies* and procedures* that support collaboration, effective communication and shared decision-making* between workers, health professionals* and the older person, their family and carers (Outcome 3.2).

This can include:

• developing or identifying information on care for people with cognitive impairment* that is easy to understand. Then, making this information available to the older person and their support people (where required) in several formats.
• providing workers with access to training on how to identify individual communication needs, and on methods for communicating with the older person, their family and other support people to understand:
  • the person
  • their preferences
  • interests
  • goals
  • preferred support strategies (as part of training activities specified in Action 2.9.6).
  • documenting the older person’s preferences and goals of care* in their care and services plan* and, when needed, in their behaviour support plan* (Action 5.6.3).

Monitor, review and improve processes* to partner with older people with cognitive impairment* .

• Consider how to monitor the quality of the organisation’s partnerships* with older people with cognitive impairment*. Possible ways to achieve this include:
  • feedback* from workers about their ability to partner with older people, their families and other supporters in a meaningful way
  • feedback* from older people with cognitive impairment*, their families and other supports:
    • whether they’re involved as much as they can or want to be in decisions about their care.
  • whether they feel their needs and preferences inform the strategies used to prevent and reduce the impact of distress from changed behaviours*.
• Use the information to consider where there are opportunities for quality improvement* in partnering with older people with cognitive impairment*.
• To close the feedback* loop, monitor the impact of any quality improvement* activities and report these to the governing body*, older people and workers. Closing the feedback* loop is following up with the older people, their families, representatives and workers who have provided you with feedback*.

Outcome 5.6.3

Put in place processes* to prevent and support changed behaviours*.

• Consider how to make sure that care is informed by assessment and understanding of any clinical, situational, psychosocial and environmental factors that may cause changed behaviours* for an older person. Avoid assumptions that changes are caused by cognitive impairment*.
• Identify and reduce stressors in the care environment and the day-to-day routines and processes* that can increase the risk of acute behaviour changes happening.
• Put in place non-pharmacological strategies known to be effective and acceptable to the older person, as identified in Action 5.6.2, such as:
  • access to outdoor spaces
  • engagement in meaningful activities and interests, to reduce distress or harm, and changes in well-being from changed behaviours* and to minimise use of restrictive practices* (Outcome 3.2).
• Put in place assessment processes* to respond to changed behaviours* that include:
  • making sure the immediate safety of the older person and others is maintained
  • identifying factors that could cause changes, including unmet needs, environmental, malnutrition, delirium*, pain*, eating, drinking, swallowing and medication changes
  • identifying each older person’s psychosocial and support needs
  • involving carers and family, or others who know the person (when relevant)
  • referring to behavioural support specialists/ services and allied health* professionals when needed for residential and home services, as outlined in Action 7.2.3.
• Make sure person-centred*, accessible and effective behaviour support plans* are in place (in the care and services plan*) and effectively implemented for the older person with changed behaviours*.

Monitor, review and improve processes* to prevent and manage changed behaviours*.

• Consider how to monitor the safety and quality of the organisation’s processes* to prevent and support changed behaviour* . Monitoring methods could include:
  • analysing trends in Mandatory Quality Improvement Program data against indicators for restrictive practices* and use of psychotropic medicines* for residential services
  • analysing trends against relevant indicators from the Psychotropic Medicine in Cognitive Disability or Impairment Clinical Care Standard
  • considering themes from incident* reports related to changed behaviours* and trends in incident* numbers and types
  • feedback* from workers about their knowledge of and confidence in strategies to prevent and support changed behaviour*
  • feedback* from older people with cognitive impairment*, their families and other supporters about whether they feel their needs and preferences inform the strategies used to prevent and reduce the impact of distress from changed behaviour*. You should have processes* to review and revise the BSP regularly or when there is a change in the older person’s circumstances.
• Consider how to use the information collected during monitoring to identify areas for quality improvement*.
• Consider how to measure if quality has improved.
• Report the results of quality improvement* efforts to the governing body*, older people and workers.