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PIE - Positive Interactive Engagement

Canterbury Close, Elizabeth East, SA

Residential - Metropolitan, 80 + beds 

Award descriptors:
Health and wellbeing, Enablement, Social participation

About the program
The Alzheimer’s Association identifies that people with dementia may become more confused, restless or insecure in late afternoon or early evening, and often seek reassurance or connection at this time. 

Within residential facilities, activities that promote connection are regularly held earlier in the business day, and often outside of these times, staffing is reduced. Camp (2010) identifies that people with dementia need structure and order in their environment and activities, and therefore the development of Positive Interactive Engagement (PIE) evolved to provide connection, stimulation, routine and positive triggers for residents with a diagnosis of dementia.

PIE is a structured after hours activity program that offers a range of activities and triggers for individuals with dementia and aims to create a positive environment; to increase interaction and engagement with our residents; and to reduce unsettled behaviour in the evenings and times of reduced activities. The ultimate aim is to improve individual quality of life. 

PIE has a defined program with set activities that trigger connection as well as a variety of stimulating programs to ensure that residents stay interested. This innovative program has been developed to meet the needs of residents within the memory support unit and has been driven by resident, family and staff feedback. The aim is to be proactive rather than reactive to unsettled behaviours, while encouraging a calm engaging and safe environment for all. PIE is based on research and Montessori principles that have been founded on an evidenced based commitment to an individually focused approach.

What we did 
PIE was developed after review of research, feedback, training, and internal analysis, and was founded on research and evaluation methodology. The program was developed with a continuous improvement approach where the focus was to move from service to resident focused model. Challenging traditional approaches with an aim to embed an innovative and empowering culture and ultimately improve resident wellbeing is the defined emphasis. 

PIE is offered to all residents within a 30 bed memory support unit and was developed to optimise their daily experience and quality of life.

Galik (2014), supports other research which identifies that behavioural symptoms may be managed with person centred care, sensory stimulation and music strategies. PIE is a person centred approach with Montessori ideals, and aims to reduce restlessness and changed behaviours through a range of connection, sensory and stimulation activities. A structured activity format is offered from 3.30 until 8.00pm every day.

The model has a specific and clear structure to optimise resident comfort. Prior to the evening meal, stimulation of the senses aim to promote appetite. A range of sensory activities are offered from 3.30pm and immediately prior to the evening meal, warmed scented sensory towels are presented to residents and provide a trigger that meals are ready to be served and also stimulates appetite.

After the evening meal, high intensity interactive activities are offered to optimise engagement and stimulation for individuals within a group environment. Connections and sense of community are fostered through activities that promote physical activity and gross motor skills. The environment is familiar, calm and unstressed to optimise individual outcomes as recommended within literature from the Alzheimer’s Association.  

The model moves to low intensity approach in the early evening and a range of sensory and reminiscing activities are offered. All activities follow the methodology described within Montessori methods and are repetitive with a high probability of success and engagement (Camp, 2010).

The evening concludes with relaxation activities in a calm and relaxing environment, while also emulating normal evening activity that may be observed within most family homes. The evening program is brought to a conclusion with the serving of supper. 

PIE provides a structured ordered model for residents with dementia which Camp (2010) suggests to optimise comfort.

PIE has been developed through a multifaceted methodology and the redesign of the workforce model was essential to provide the resources to achieve the defined aims.  

PIE is constructed of a range of activities with many influences and determinants. A range of approaches and problem solving attitude have been utilised as traditional approaches were changed and the model embedded. 

Prior to implementation of PIE, objectives, goals and measures were identified and are fundamental to the model design, providing an ability to assess individual outcomes and embed a continuous improvement approach. This evidence informed methodology is ongoing and provides both qualitative and quantitative data. A research, best practice approach has provided accountability and rigor to PIE as we aim to improve the quality of life for our residents.

Why we did it
People with dementia often display increased restlessness, agitation and confusion in the late afternoons which is often referred to as sundowning (Alzheimer’s Association). Staff reviewed research as they explored ways to improve the daily experience for our residents, and also sought suggestions from residents, families and staff. A review of internal evidence including incidents and an observational analysis within the memory support unit provided an opportunity for reviewing the engagement activity program as we explored how to optimise positive interaction and engagement for residents with dementia.

It was apparent that there was potential for improvement within the lifestyle programs if the residents’ quality of life was the primary focus and we made a commitment to move from a service driven to resident focused approach. A restructure to include an evening and weekend staffed program was designed to optimise engagement at times of potential restlessness and previous minimum staffing. Within these hours, Montessori activities which provide socialization, meaningful activities and diversion would form the foundation. Van der Ploeg (2010) identifies how this approach can easily be adapted to meet the interests and skills of people with dementia, and Camp (2010) concludes that Montessori  programming not only produces positive affects for the individual but it also assists with the creation of communities where the person with dementia lives.

PIE was developed to improve the daily experience for residents with dementia and that success with the program would reduce restlessness, agitation and incidents, improving the quality of life for residents and our community.

Who worked with us
The primary stakeholders of the PIE program are the residents. They provide valuable feedback and input through their engagement, feedback and documented outcomes regarding the models of care and interaction. The memory unit resident families were informed and involved with the program development and review. Families who have provided feedback regarding the care and services across the site have also worked with us to continually seek improvements to services. Their support and feedback is ongoing and has been instrumental in the review of services, including the development and implementation of PIE.

Staff are a valuable resource and source of feedback and the objectives of PIE have been achieved through a collaborative site commitment. The project has been driven by the management team with input and support from all site staff. Staff work closely together to ensure full engagement and successful outcomes are achieved. The Lifestyle Enhancer is a key resource for the program, while the Site Manager undertook the research and coordinated the implementation of PIE, empowering staff to embrace change and the new approach.

Within the aged care arena, it is essential to work with tight budgets. The organisations finance team were pivotal in the roster review and justification of the staffing redesign that ultimately allowed PIE to commence. Corporate support is valued and required with extensive service model changes.

External support was resourced from key agencies including Alzheimer’s Australia and Montessori Ageing Support Services. This support was pivotal to the program and was accessed via the internet.

What we learned
The implementation of PIE has demonstrated that through sound evidenced based approaches, resident focused models can be realised. This change process was founded on current research and ideals from academics and dementia specialists, and was made possible through sound internal continuous improvement practices. This rigor and evidence has provided the foundation for a successful and positive outcome and has reinforced that this methodology is essential in the aged care sector if we are to achieve ongoing improvements to industry service models.

PIE was implemented within a 30 bed memory support unit, and the interactive program was offered to all residents. To provide in-depth data analysis, 20% of the residents were randomly selected and their individual outcomes were more intensely recorded, tracked and evaluated. This group has been identified as the cohort and included a random selection of individuals with complex medical conditions, indigenous or CALD backgrounds, and one had a history of homelessness. This group provides an accurate snap shot of the residents within the unit.

A range of qualitative data has been captured and evaluated to assess individual and group outcomes. Data has been collated over the period of PIE implementation and compared with data from the previous year. PIE aimed to reduce restlessness and agitated behaviour which is often reported with residents who have a diagnosis of dementia (Galik, 2015). Data analysis of reported incidents of ‘Challenging /resistive behaviours’ per month have been compared. 

The cohort group demonstrates a 22.5% rate of challenging/resistive behaviour incidents for the pre PIE period, and this reduced to 5% with the implementation of PIE, and a further reduction to 0% is trending. As the level of engagement increased, the rate of incidents has declined.

A general measure of wellbeing is body weight. Eating difficulties and weight loss are common in residential facilities (Stone, 2014), and data analysis demonstrates that 75% of the cohort group have maintained or gained weight. Reported weight loss was related to critical health episodes. Critical health episodes are a trigger point and have a major impact on individual wellness and this is reflected in interaction and participation rates.
Case studies illustrate the individual impact for residents. For example, one resident was previously isolated and did not interact with staff or residents. PIE provided the structure and timely activities that met her individual interests and needs and the steady increase in participation is testament to her personal connection.  

A review of the data also demonstrates a drop in participation during November 2015 following a critical health incident. Participation reduced for a short period as would be anticipated, however the previous pattern of isolation did not return and reengagement was achieved, supporting evidence of positive outcomes for residents participating in PIE. 

Data is collected on a daily basis. Individual behaviours and responses including whether any restlessness is displayed as well as the level of participation during each activity group are recorded. Assessment of residents for agitation, wandering, verbal participation or disruptive behaviour, physically disruptive or participation is documented. Declining activities is also noted. This daily report has provided the data that assists with ongoing review and evaluation for both individuals and group. Staff also note any resident, family or staff comments and feedback. This subjective and qualitative data has assisted in the evaluation and trending of individual outcomes from PIE participation. This data is collated and reported monthly and is analysed by the Site Manager and key staff.

The qualitative and quantitative data has provided evidence of the successful outcomes of the program as well as the justification for its continuation. The data has also provided further support to research that non pharmacological interventions for changed and restless behaviour can be achieved with fewer risks (Van Der Ploeg, 2010), while also improving the quality of life for individuals with dementia.

PIE has been successfully implemented and is transferrable to other environments as it is based on research and evidence based practice and it is resident focused. The model aligns with the organisational values and therefore has a solid organisational foundation. As the residents within the unit demonstrated greater engagement, so have the staff. Staff engagement is fostered with ongoing reinforcement and in-house training and this is the key to sustainability of PIE. PIE has seen rewards for residents and staff; now is time for all of us to enjoy a piece of the PIE!

More information on this program: 
Stephanie Brown, , or phone (08) 8256 2100

Friday, 21 December 2018 - 6:44am