The NDB model, originally developed for nursing home residents, views behavioral problems as the patient’s expression of unmet needs, because the patient with dementia is cognitively impaired and may be unable to effectively communicate. The NDB model assesses the patient’s personal preferences and disabilities (cognitive deficits, heat preferences, taste, comfort, pain, etc) in an effort to mitigate those factors that may account for the patient’s behavior. The NDB model encourages the use of behavior logs to assess for temporal relationship of behavioral problems (eg, sundowning, preprandial/postprandial) for the purposes of anticipating future behaviors or uncovering root causes.
The model is structured to address delirium and any physiological or medical conditions that may be contributing to the patient’s behavior. The NDB model takes into account safety to determine which interventions will be the most effective for the patient’s behavior while taking into account the safety of other patients and staff. The model promotes investigating social and environmental factors that can be addressed with nonpharmacological interventions as first-line therapy (eg, music therapy, light therapy, recreational therapy).16
The PLST model is based on the concept that as a person ages, he or she is less able to accommodate various kinds of stress. When the stress exceeds the ability to manage the stress, behavioral problems ensue. The PLST model uses all staff members to incorporate the following 6 tenets14,15:
• Maximize safe function by supporting all real and perceived losses by providing care in a calm and consistent manner for the patient
• Provide unconditional positive regard
• Use behaviors to gauge activity and stimulation levels
• Teach caregivers to interpret behaviors
• Modify the environment to support losses and enhance safety
• Provide ongoing assistance, education, and training to all caregivers
The NDB and PLST models provide a framework for goals from which interdisciplinary team members can identify and address areas of improvement that transcends their specific health care niche.
Setting up a collaborative model
Establishing a practical cohesive plan from theory is a daunting but achievable task. Kaiser Permanente, the Veterans Administration, and the Group Health Collaborative have established functional models to show that collaborative care can be used in both the public and private sectors.17 Although precedent has been set, the task of establishing a system of collaborative care is not without challenges. The single most important obstacle to efficient and effective care is the designation of a single point of contact responsible for coordinating all care. Other collaborative barriers include the following18:
• Territoriality and self-protective behaviors
• Lack of insight into primary health care
• Undervalued nursing care
Zwarenstein and colleagues19 highlighted the confusion of interprofessional responsibility and differences in the providers’ approach to patient care as hurdles to collaborative success. The article discusses the lack of clinical and administrative information, poor financial incentive, and poor or absent behavior management education and training as specific challenges to collaborative implementation.
Providers in multidisciplinary group practices are able to provide better care than their colleagues in solo private practices. The chasms between outpatient, inpatient, and extended-care facilities frustrate attempts at seamless and safe transfer of care.17 One of the last obstacles to integrated services is payment. Unfortunately, financial payment systems that encourage individual effort perpetuate the difficulty of establishing a team approach. In the United States, the current financial system rewards the individual and creates a piecemeal and fragmented approach to patient care. A prepaid or group payment schedule for collective services has been shown to encourage collaboration and improve quality of care.17
Fortunately, there are promising ways to overcome obstacles to collaborative efforts. First of all, it has been suggested that in order to break rigid territorial lines of responsibility, it may be necessary to teach the theory and practical execution of collaborative models during early clinical training (eg, medical and nursing schools) before territorial attitudes develop.18
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