Legislation and Promising Practices for Reducing Restraint

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Legislation and Promising Practices for Reducing
Restraint Seclusion Use

• Restraint and Seclusion in Foster Care
• Presented by Lloyd Bullard, M. Ed.
• LB International Consulting, LLC.

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Introduction
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Legislation

• Childrens Health Act of 2000 (H.R. 4365)
• Signed into Law October of 2000 by President
  Clinton
• The Act contains two significant section
• Part H and
• Part I.

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Childrens Health Act of 2000

• Part H - applies to public and private general
  hospitals, nursing facilities, intermediate care
  facilities, or other health care facilities
• Part I applies to public and private
  non-medical, community-based facilities for youth
  (as defined by the secretary)

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Childrens Health Act of 2000

• Part I required physical restraints and
  seclusion to only be imposed in emergency
  circumstances and only to ensure the safe of the
  child, staff or others
• Other less restrictive interventions would have
  been determined to be ineffective

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Childrens Health Act 2000

• Restraints or seclusion are imposed only by an
  individual trained and certified by state
  recognized body (as defined by the secretary)
• Interim Procedures Supervisory or senior staff
  with training in restraint and seclusion who is
  competent to conduct a face-to-face assessment
  (as defined by the secertary)
• Supervisor or senior staff continues to monitor
  the situation for the duration of the restraint
  or seclusion
• Secretary 6 months to develop standards/States 1
  year to develop standards once the Federal
  standards are implemented

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Foster Parents and Restraint Seclusion Use

• Cornell Universitys Research Numerous focus
  groups with children in foster carte and foster
  parents
• Cornell has refused to train foster parents on
  restraint techniques.
• Based on children perceiving that the foster
  parents were attempting to hurt them
• Liability issues related to safety risks

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Why So Many Restraints?

• Caretakers say
• Its the clients.
• They have such severe problems
• They often put themselves, other clients, and
  staff at risk.
• Its necessary to keep everyone safe.

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But Some Studies Suggest Otherwise

• Programs serving similar children have widely
  varying rates of restraint.
• Some programs serving very difficult children
  have low restraint rates.
• Many programs have significantly reduced
  restraint without changes in their populations.

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What is it about us?

• Our belief that the problem lies with the clients
• Focus on management and control as opposed to
  support and teaching
• Lack of staff skills in effective de-escalation

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Bad News or Good?

• Being identified as the source of the problem may
  sound like bad news or an indictment of
  caretakers.
• But its actually good news.
• If it really were the clients, wed be stuck
  doing thousands of restraints forever.
• If its us, we can do something about it.

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Successful Strategies to Reduce Restraint and
Seclusion
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The Issue Brief(NETI, 2003)

• Reducing the Use of Restraint and Seclusion
  Promising Practices and Successful Strategies
• An issue brief that annotates policies and
  practices that successfully reduce the use of
  restraint and seclusion
• Chapters
• Leadership
• Organizational Culture
• Agencies Policies, Procedures and Practices
• Staff Training and Professional Development
• Treatment Milieu
• Continuous Quality Improvement

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The Issue Brief

• Information pulled from a variety of sources as
  outcomes and data on children is scarce
• Projects own preliminary quantitative and
  qualitative findings
• Subject matter experts
• Focus groups findings (Federation of Families for
  Childrens Mental Health - FFCMH)
• Published research findings

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Leadership(NETi, 2003)

• Supportive Executive Leadership
• Identify Restraint and Seclusion as a Top
  Priority
• Sustained commitment by the executive leadership
  team.
• Set the Tone
• Mission statement supports a violence- and
  coercion-free environment
• Restraint and seclusion are crisis events,
  treatment failures, and high-risk interventions
• Leaders must model the interest, time commitment,
  and sell the initiative to managers and direct
  care staff

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Leadership(NETI, 2003)

• Supportive Executive Leadership continued
• Provide Training and Resources
• Emphasize training in alternatives to restraint
  and seclusion
• Ensure integration of training into practice
• Establish an Oversight Committee
• Include executive leaders, managers, supervisors,
  direct care staff, family members, children, and
  advocates
• Committee empowered to implement changes

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Leadership(NETI, 2003)

• Supportive Executive Leadership continued
• Take Responsibility
• Administrators shoulder the burden of reducing
  restraint and seclusion
• Maintain Accountability
• Executive leader(s) on-call 24 hours a day to
  whom each incident is immediately reported

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Leadership(NETI, 2003)

• Supervisory and Managerial Involvement
• Set the Tone
• Send a clear message
• Support coercion-free environment, partnerships,
  choice, and proactive communication
• Elimination of the unnecessary use of restraints
  and seclusion is paramount
• Model and Coach
• Alternative approaches
• High expectations, time commitment, training
  resources, 24 hour on-call support

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Leadership(NETI, 2003)

• Supervisory and Managerial Involvement continued
• Lead Debriefing
• Exercise for learning not punishment
• Gather data
• Discuss
• Document timelines

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Leadership(NETI, 2003)

• Elimination by Mandate
• Banning restraint use or types, eliminating of
  seclusion rooms, or use of prns
• Constant vigilance and ongoing training in
  de-escalation
• Requires emphasizing behavioral support instead
  of emergency intervention

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Organizational Culture(NETI, 2003)

• Relationship Building
• Facilitates support of positive behavior
• Helps de-escalate children in times of crisis
• Healthy Relationships are developed over time

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Organizational Culture(NETI, 2003)

• Person-Centered Environment
• Needs of the child are at the forefront of care
• Use supportive language, and express an
  unwillingness to label children as manipulative
  or needy
• Emphasize collaboration rather than compliance
• Offer culturally and linguistically competent
  services

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Organizational Culture(NETI, 2003)

• Staff Empowerment
• Youth Involvement
• Family and Natural Support Involvement
• Treatment Planning
• Programming
• Participation on Review Team
• Advocacy

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Agency Policies, Procedures and Practices(NETI,
2003)

• Comprehensive Assessment
• History of aggression, and the physical,
  psychiatric, and emotional risks of restraint and
  seclusion
• Inform the behavior support and treatment plans
• Treatment Planning
• Individualized and strengths-based
• Developed in conjunction with child and family
• Individualized Behavior Support Plan
• Identify triggers, successful intervention
  strategies, and options for self-calming
• Communicated to all relevant staff
• Revisited regularly

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Agency Policies, Procedures and Practices(NETI,
2003)

• Monitoring
• Face-to-face, third party
• Assess the physical and psychological well-being
  of child
• Authority to stop intervention if signs of
  distress are evident
• Debriefing
• Occurs with the child, witnesses, staff, and
  family members
• Express feelings about the incident and to make a
  plan to avoid for incidents
• Debriefing does not assign blame
• Should be carefully documented
• Staff Designated to Implement Restraint and
  Seclusion

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Staff Training and Professional
Development(NETI, 2003)

• Training on Trauma-Sensitive Care, Prevention,
  and De-escalation
• AT LEAST 50 of all training should focus on
  these three core elements
• Competency-Based Training
• Culturally and Linguistically Competent Services
• Tones, gestures, and postures that may be
  misinterpreted by youth
• Frequent Refreshers to Minimize Training Drift
• Regular Staff Supervision, Mentoring, and Coaching

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Treatment Milieu(NETI, 2003)

• Treatment Philosophy
• Coercion-free and non-punishment based
• Trauma-Informed Care
• Culture of empathy
• Acknowledge that most children have experienced
  trauma
• Restraint and seclusion is re-traumatizing
• Staff should know signs of trauma
• Positive, Structured Environment
• Requires active programming
• Well-maintained environment
• Behavior Support
• Give children anger and anxiety management
  skills.
• Constant role playing.

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Continuous Quality Improvement (CQI)(NETI, 2003)

• Setting Organizational Goals
• Collecting and Analyzing Data
• Reporting Results
• Corrective Feedback Mechanisms
• Celebrating Successes
• Program Evaluation

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CWLA Resources
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Best Practice Guidelines For Behavior Management

• Ethical Legal Framework
• Administration Leadership
• Continuum of Intervention
• Medical Issues
• Professional Development Support for Caregivers.

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Reducing the Use of Restraint Seclusion
Promising Practices Successful Strategies

• Leadership
• Organizational Culture
• Polices, Procedures Practices
• Training Professional Development
• Treatment Milieu
• Continuous Quality Improvement

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Best Practice Guidelines for Behavior Support
Intervention Training

• Organizational Leadership Culture
• Behavior Support Intervention Training Programs
• Risk Factors
• Emergency Interventions
• Training Process

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Supervisors Training Curriculum

• Changing Organizational Culture
• Behavior Support Plans
• Program Factors
• Family Involvement
• Diversity Issues
• Reward Consequence Systems
• Supervisory Role
• No Blame Culture
• De-Briefing

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State Regulations

• Definitions
• Criteria
• Monitoring
• Ordering
• Post Assessment
• De-Briefing
• Family Notification

• Training
• Documentation
• Reporting
• CQI Plans
• Prohibited Practices
• Data Collection
• Reduction Plans

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Summary

• Restraint reduction is a 4-step process
• Admit its us who have to change
• Look honestly at our contributions to this
  problem
• Attack each of the six areas
• Evaluate progress and dont give up