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Reducing Restraints and Eliminating Seclusion: Struggles and Strategies presented by: Keith a. Bailey, Ph.D.

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Title: A Journey to Change Author: Loyal User Last modified by: Laura Mandel Created Date: 11/5/2005 1:17:48 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Reducing Restraints and Eliminating Seclusion: Struggles and Strategies presented by: Keith a. Bailey, Ph.D.


1
Reducing Restraints and Eliminating Seclusion
Struggles and Strategies presented by Keith
a. Bailey, Ph.D.
  • keith_at_keithbaileyconsulting.com
  • www.keithbaileyconsulting.com

2
A National Movement in the U.S.
  • 1996 -- Pennsylvania State Mental Health
    Hospitals begin reduction initiative
  • 1997 -- American Academy of Pediatrics position
    paper on
  • Therapeutic Holding vs.
    mechanical/chemical restraints
  • 1998 -- Hartford Courant investigative report
  • 2000 -- Childrens Health Act defines standards
    for
  • restraint and seclusion
  • 2001 -- CMS writes more stringent standards for
    youth
  • services
  • 2001 -- SAMHSA funds study with 7 youth programs
  • 2003 -- Presidents New Freedom Commission on
    Mental
  • Health report comments on
    restraint and seclusion
  • 2003 -- CWLA and NTAC begin nationwide
  • training events
  • 2004/2007 -- SAMHSA funds grants for 8 states for
    reduction efforts
  • 2004 -- State of Tennessee requires more
    stringent
  • standards for use of restraint
    and seclusion
  • 2009 -- State of Tennessee enacts laws regarding
    use of restraints and
  • seclusions with Special Education
    students

3
International Concern and Action
  • Canada
  • 2001 Patient Restraints Minimization Act
  • 2003 Implementation of The Six-Point Action
    Plan for
  • youth residential facilities
    licensed under CFSA
  • 2006 Review suggested addressing restraint
    usage in
  • amendments to the Safe School Act
    (2000)
  • Great Britain
  • Australia
  • Israel

4
New Developments
  • Prohibiting use of prone (face down) restraints
    by some licensing bodies in U.S.

5
The Personal Side
  • There is a risk of serious injury or
  • death each and every time we attempt to
    restrain or seclude a child!

6
  • True and Tragic Accounts

7
  • Edith Campos
  • 15 years old

8
  • Chris Campbell
  • 13 years old

9
  • Angellika Arndt
  • 7 years old

10
Stories of Success
  • Buckeye Ranch Ohio
  • Klingburg Family Centers Connecticut
  • Brewer-Porch Childrens Center Alabama
  • Cambridge Hospital Child Assessment Unit
    Massachusetts
  • Holston Home - Tennessee

11
Agency Restraints Seclusions
Buckeye Ranch 5 year period 99 reduction 46 reduction
Klingburg 2000-2004 500 to 100 per year 300 to 50 per year
Brewer-Porch 2002-2004 25 0 per month 18 1 to 2 per month
Cambridge CAU 2000 - Present From 140 R/S events per 1000 client days to 0 From 140 R/S events per 1000 client days to 0
12
Holston Home
  • Started as an orphanage in 1895
  • Multi-program agency
  • Continuum of Care Model
  • Foster Care (100 youth)
  • medically fragile, low intensity, therapeutic
  • In-Home Services (20-30)
  • Adoptions (60 placements in 2005-2006 FY)
  • special needs, domestic, international
  • Child Day Care (100, infant 5 yrs. old)

13
Holston Home
  • Day Treatment School (75 youth, K-12)
  • Residential Group Care Treatment (84)
  • Assessment (8)
  • Boys Treatment (40 Lv. 2 Lv. 3)
  • Girls Treatment (8)
  • Girls Developmental Home (8)
  • Boys Group Home (8)
  • Preparation for Adult Living (12)
  • Juvenile Justice and Social Services Youth
  • 2007 Residential Numbers 50
  • Staff 175 in four sites
  • Budget 10 M

14
Why Change?
  • It looked bad and felt bad
  • 1998 1400 restraints, 2600 seclusions
  • High number of disruptions, bouncebacks, and
    runaways
  • Staff were not given enough skills to
    appropriately deal with negative behavior
  • Some staff began to raise concerns about the
    therapeutic quality of our treatment approach

15
Culture Analysis Crisis Creators
  • High staff turnover
  • Inexperienced staff
  • Poor training
  • Shorter ALOS of youth
  • Higher numbers of more difficult youth
  • Older youth
  • Leadership turnover
  • poor leadership in various positions
  • Perceived lack of support from administrative
    staff
  • Control-oriented culture of care
  • Fear
  • (With Gayle Mrock)

16
Beginning the Change
  • Decision by leadership
  • Move to new crisis intervention model (1997)
  • CWLA Consultant
  • Change in Behavior Management Plans
  • More strengths based approach
  • Youth requested time-outs
  • Create a culture where restraints are viewed
    negatively by both staff and youth
  • Researched/explored what others were doing

17
Beginning the Change
  • Setting goals for reduction
  • Tracking through CQI process
  • More responsibility on directors and supervisors
    to hold staff accountable
  • More training in de-escalation techniques and
    more instructors
  • Changes in Behavior Management Plans
  • Restraint review process put in place

18
Restraint Reduction
Year Restraints Youth Injuries Requiring Medical Attention Staff Injuries Due to Physical Management (Workers Comp)
1998 1447 6 36
1999 660 2 27
2000 169 0 4
2001 93 3 12
2002 169 0 17
2003 116 0 11
2004 151 1 5
2005 77 0 3
2006 67 1 3
19
Restraint Reduction
  • Ratio - restraints 1,000 client days
  • Residential treatment, day treatment, group
    care
  • 1998 - _at_ 40 1,000 (1447 restraints)
  • 2005-2006 - 3.2 1,000 (70 restraints)

20
Seclusion Reduction
Year Seclusions
1998 2642
1999 2114
2000 1259
2001 940
2002 607
2003 386
2004 (Jan-Jun) 201 1st Q 166 2nd Q 35
July 2004 Stopped Seclusion
21
  • 2003
  • 80 of restraints were associated with the use of
    seclusion
  • 2004 January May
  • 8 staff injuries due to seclusion
  • 4 staff injuries due to restraint

22
Mistakes Successes
  • Mistakes
  • Went cold turkey
  • Didnt give other tools early on
  • Some hired-in directors didnt buy in
  • Held on to some staff who didnt buy in
  • Successes
  • Support from leadership
  • Data and goal-setting
  • Training on staff resistance
  • Training, Training, Training
  • Celebration
  • Consistent review process

23
Restraint Review Committee Attendees
  • Administrator of Residential Services (Chair)
  • Administrator of Best Practices
  • TCI Instructor
  • Residential Directors
  • Therapist
  • Staff from outside of residential treatment
  • Other staff as needed (e.g. direct care,
    supervisor)

24
Restraint Review Committee Purpose
  • Tracking through data gathering
  • Emphasis on detail of report writing
  • Identifying trends
  • Sending a message of importance
  • Giving feedback to staff
  • Learn from mistakes and successes

25
Restraint Review Committee Agenda
  • Follow-up items from previous meeting
  • New restraints presented (narrative read)
  • Critique/Questions/Discussion/Suggestions
  • Corrective action assigned (via director)
  • Minutes typed and distributed

26
Review Serious Incident Report
  • Includes
  • Childs name
  • Program
  • Date of incident
  • Time of incident
  • Contract information
  • Precipitating behavior (including any children or
    staff involved)
  • Alternatives offered/de-escalation techniques
  • WHAT IS THE SAFETY ISSUE JUSTIFYING THE
    RESTRAINT?
  • Restraint technique used
  • Positioning of staff
  • Length of restraint
  • Processing/debriefing completed, and by whom
  • Accident and injury report

27
Post Restraint / Seclusion Debriefing
  • With youth involved
  • With youth who witness the event
  • With staff involved
  • To reduce the impact of trauma
  • To learn from the event

28
Seclusion
  • Not as much attention given to seclusion
  • Sometimes addressed alongside restraints, but
    few, if any unique strategies given for reduction
  • Often used as a behavior modification technique
    to extinguish behavior vs. a safety technique
  • Like restraints, should only be used for safety
  • Can give implicit negative messages and be
    traumatizing

29
PRN Medication
  • Can be overused as a way to avoid physically
    intrusive interventions
  • Can become a substitute for teaching coping
    strategies
  • Can set up a dependency on the drug and/or the
    system to supply the drug

30
Sustaining Success
  • Cannot focus on restraint and seclusion alone
  • Requires a culture change !

31
Holston Homes Changes in Culture
  • Holston Home
  • Treatment Model Task Force - 1999
  • Training in Mediation 2001
  • Expanded Staff Training Addition of Staff
    Development Training Coordinator - 2001
  • Best Practices Department Created - 2003
  • A move away from points and levels and to a
    relational model of care using natural and
    logical consequences, refocusing, making amends
  • From controlling to connecting

32
From controlling to connecting A Move Away
from Behavior Modification
  • Behavior Mod
  • External control
  • Short-term benefits
  • Can be punitive
  • Relationships
  • Shares control
  • Long-term benefits
  • Communicates caring and teaches by using natural
    and logical consequences

33
What We Learned
  • It gets worse before it gets better
  • When you take away a tool, you have to put
    another one in its place
  • Plan thoroughly and prepare staff
  • Orientation and ongoing training is essential !!!
  • Power struggles must be recognized and redirected
  • Staff have to be supported and empowered
  • Involve youth listen and learn

34
What We Learned
  • Training Training Training
  • Data collection is key show them the numbers!
  • Review process is critically important
  • It is a process
  • Expect resistance and address it!
  • You must address all aspects of the agency
    culture

35
  • SUCCESS in beginning and maintaining restraint
    and seclusion reduction efforts requires nothing
    less than
  • a change in the
  • culture mindset of care

36
Changing the Culture of Care
  • Treatment
  • Understanding childrens behavior and where it
    comes from
  • Understanding treatment
  • Treatment statements
  • More than a mission values statements
  • Understandable and applicable by all staff and
    youth
  • Including the family and community

37
Sample Treatment Statement
  • Cognitive Behavioral approach
  • The Agency uses a treatment approach that
    emphasizes positive thinking skills, emotional
    coping skills, and appropriate choices for
    behavior in an environment that is safe and
    supportive to all youth and staff.

38
Changing the Culture of Care
  • Guiding Principles related to use of restraint
    and seclusion
  • Restraints and seclusions are not therapeutic
    techniques.
  • They can, in fact, further traumatize youth
  • Restraints should only be used as a last resort,
    when all other interventions have failed, and
    only when there is an imminent risk of harm to
    the youth or others if a restraint is not
    properly used.

39
Changing the Culture of Care
  • Infrastructure that supports treatment
  • Staff
  • Hiring Firing Credentials Scheduling
    Training
  • Supervision and Support
  • Physical environment
  • Space Décor Upkeep
  • Policies and Procedures
  • Forms - documentation

40
Changing the Culture of Care
  • Training
  • Child Development and Childrens Mental Health
  • Trauma Informed Care
  • Bruce Perry, MD, Ph.D. impact on brain and
    development
  • Sandra Bloom, M.D. Sanctuary Model
  • Goals of Behavior/Behavioral Support
  • Parenting
  • Treatment Techniques
  • Communication and Mediation Skills
  • De-escalation Techniques Skills
  • Processing Skills

41
Changing the Culture of Care
  • Supervision and Accountability
  • Training skill development
  • A style that promotes a parallel process of
    support and growth between direct care staff and
    youth
  • A Balance
  • Administration
  • Accountability of staff
  • Coaching Support

42
Commitment to Culture Change - Schein
  • Converting staff
  • 20 / 50 / 30
  • Rule
  • 5-15 years to change a culture

43
Resources
  • Organizational Change
  • Leaf. S. (1995). The journey from control to
    connection. Journal of Child and
  • Youth Care 10 (1), 15-21.
  • Organizational Culture
  • Schein, E. (1992). Organizational culture and
    leadership. 2nd edition.
  • San Francisco Jossey Bass Publishers.
  • Restraint and Seclusion Reduction
  • Child Welfare League of America. (2002). CWLA
    best practice guidelines for behavior management.
    Washington, DC CWLA.
  • Child Welfare League of America. (2003).
    Reducing the use of restraint and seclusion
    Promising practices and successful strategies.
    Washington, DC CWLA.

44
Resources
  • Trauma Informed Care
  • Bloom, S. (In print). Creating sanctuary for
    kids Helping children to heal from violence.
    The International Journal for Therapeutic and
    Supportive Organizations.
  • ww.magnasystems.com/c-5-childhood-trauma.aspx
    (DVDs -Dr. Bruce Perry)
  • www.childtrauma.org (on-line trainings - Dr.
    Bruce Perry)
  • www.nctsnet.org/nccts/nav.do?pidctr_cwtool
    (fully developed curriculum tutorial)

45
Resources
  • NTAC-NASMHPD Six Core Strategies
  • for reducing and eliminating restraints and
    seclusions
  • Role of Leadership toward Organizational
    Culture Change
  • Analysis of Data to Inform Practice
  • Staff Development and Training
  • Debriefing Techniques
  • Use of Restraint Reduction Tools
  • Youth and Family Input
  • National Technical Assistance Center - National
    Association of State Mental Health Program
    Directors
  • Training Curriculum for the Reduction of
    Seclusion and Restraint, 2004)
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