1 Creating Trauma Informed Systems of Care Overview of National Initiative to Promote Recovery,...

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Creating Trauma Informed Systems of Care

Overview of National Initiative to Promote

Recovery, Resiliency & Trauma Informed Care

Developed by Kevin Huckshorn, Director, NASMHPD Office of Technical Assistance, 2007

Adapted by Beth Caldwell for January 2008 Training Program

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INTRODUCE YOURSELF TO SOMEONE YOU DO NOT KNOW

SHARE

Your Name

What You Do

A Strength You Have in Working with Children

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ACKNOWLEDGEMENTS

Kevin Ann Huckshorn National Association of State

Mental Health Program Directors (703) 739-9333

[email protected]

Dr. Janice LeBelMA Department of Mental Health

[email protected]

Funded by the Substance Abuse and Mental Health Services Administration

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Brief Historical Overview National S/R Reduction Initiative

1998: Hartford Courant Series

1999: GAO Report (Congress) - NASMHPD MD S/R Report

- CMS Rule changes

2001: CMS Rule Changes (one-hour)

2002: NASMHPD Training Curriculum

created

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Restraint and SeclusionAre Not Treatment

In 1999, the NASMHPD Medical DirectorsCouncil debated the challenge of R/Sreduction/elimination.

They determined and declared:

Restraint and seclusion are not therapeutic and reflect a failure in treatment.

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Brief Historical Overview National S/R Reduction Initiative

2003: - NTAC Training starts

- New Freedom Commission Report –

Transformation

- Independent projects support core strategies identified

2006: CMS Final Rules (disappointing)

(NAPHS Success Stories 2003; Colton, 2004; Murphy/Davis, 2005; CWLA; 2003)

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Brief Historical Overview National S/R Reduction Initiative(s)

2004-2010Previous S/R CMHS SIG Activities

2004: 8 State Incentive Grants to identify alternatives to reduce use (HI, IL, KY, LA, MA, MD, MO, WA)Three year grants included large scale evaluation project with research center in Cambridge (HSRI) and best practice applicationsThis data are currently being analyzed by HSRI and a group of consumer expert researchersData available in next few months

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Brief Historical Overview National S/R Reduction Initiative(s)

2004-2010

New SIG Project2007-10: New round of grants, 8 states (CT, IN NJ, NY, OK, TX, VA, VT)

NTAC remains the S/R SIG Coordinating Center under auspices of CMHS and NASMHPD

Using lessons learned we are proposing a comprehensive training on S/R reduction strategies ‘early on’ and a consultant visit model that includes peers, over the next 3 years.

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What We Know at this Point:

Started with adult hospital programs

Moved to child mental health, child welfare and juvenile justice residential programs

Significant + outcomes related to reduction in staff & child injuries; child, family & staff satisfaction; agency functioning

Still evolving and young initiative - yet constructs & strategies resonate with best and evidence-based practices

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We (NTAC & faculty) know what helps to reduce S/R…, at this point…

We know that the reduction of S/R is possible in all mental health settings

We know that facilities throughout the U.S. have reduced use considerably without additional resources

We know that this effort takes tremendous leadership, commitment, and motivation

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Framing the Issue

The reduction of seclusion, restraint and coercive practices requires a CULTURE CHANGE in our mental health treatment settings that results in far more than just prevention S/R (Huckshorn, 2006).

This ‘Culture Change’ must be congruent with recovery and transformation principles

Best practice core strategies have been identified

However, practice and system change is slow and difficult… for many reasons…

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Needed Healthcare System Changes? …not just about mental health or reducing

violence….

Healthcare systems including Behavioral Health continue to be fragmented

Not customer friendly or person-centered

Not outcome-oriented

Waste resources

Poor communication between providers

Practices not based on evidence(USDHHS, 1999; IOM, 2001)

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Facilitating Culture Change in U.S. Healthcare Organizations: The IOM

ReportsThe U.S. Institute of Medicine described new rules to transition the redesign and improvement in health care (IOM, 2001, 2005)

Continuous healing relationships

Customized to individual needs/values

Consumer is source of control

Free flow of information/transparency

Use of Best Practices

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Facilitating Culture Change in Mental Health: The U.S MH New

Freedom Commission Report

A Call for System TransformationSystem Goal = Recovery for everyoneServices/supports are consumer-centeredFocus of care must increase consumers’ ability to self manage illness and build resiliencyIndividualized Plans of Care criticalConsumers and Families are full partners

(New Freedom Commission, 2003)

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A Vision of Mental Health:The Future in the U.S…?

Service users are employed in every setting, up to 30-50% of staff

Treatment planning is directed by the consumer, and family, whenever possible

Language used is “person-centered and non-discriminatory”

Evidence-based practices (EBP) are the norm, including non-coercion, effective use of meds, family education, and a treatment focus on illness self- management

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Preventing violence, coercion, seclusion and restraint (S/R) fits these calls for

action and changeWe have come to believe that this work is a fundamental cornerstone in transforming our systems of careEffective Leadership is criticalNew staff knowledge and practice changes will set a foundationChanges include using evidence-based practices, including meds; creating treatment activities that teach illness management; person-directed planning; workforce development; and preventing coercion and discrimination

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Development of the Curriculum to Reduce the Use of S/R

Ongoing Review of LiteratureQualitative Reports emerged from personal experiences (self and colleagues) with direct experiences in successful reduction projects across the countryQualitative Reports emerged from service users and staff (ongoing)Core strategies emerged in themes over time Expert Meeting(s) held in DC in 2001, 2002, 2003, and 2007 to refine

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What are the Main Change Constructs in Preventing Conflict, Violence and S/R use?

Leadership Principles in effective changeThe Public Health Prevention approachUse of Recovery/Resiliency PrinciplesValuing Consumer/Staff Self ReportsTrauma Knowledge operationalizedStaying true to CQI Principles (the ability to take risks to assure individualized treatment occurs)

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The Public Health Prevention Model

The Public Health approach is a model of disease prevention and health promotion and is a logical fit with a practice issue such as S/R

This approach identifies contributing factors and creates remedies to prevent, minimize and/or mitigate the problem if it occurs

It refocused us on prevention while maintaining safe use

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Public Health Prevention ModelPublic Health Prevention Model

Tertiary

Primary

Seco

ndar

y

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The Public Health Prevention Model applied to S/R Reduction

Primary Prevention (Universal Precautions)Early interventions designed to prevent conflict from occurring at all by anticipating risk factors & addressing

Secondary Prevention (Selective Interventions)Early interventions to minimize and resolve conflicts when they occur to prevent S/R use

Tertiary Prevention (Indicated Interventions)Post S/R interventions designed to mitigate effects, analyze events, take corrective actions, and avoid reoccurrences.

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Recovery/Resiliency Principles

New Freedom Commission Goal: Build Resiliency

Facilitate Recovery

The use of S/R is counter-intuitive

Coercive or traumatizing settings do NOT foster hope, healthy relationships, pro-social behaviors or trust

(New Freedom Commission, 2003; Onken et al, 2002)

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Trauma-Informed CareEmerging science based on high prevalence of traumatic life experiences in people we serve - up to 98% (Muesar et al, 1998)

Says that traumatic life experiences cause mental health or other problems or seriously complicate these, including treatment resistance

(NETI, 2005; Felitti et al, 1998)

Systems of care that are trauma informed recognize that coercive or violent interventions cause trauma and are to be avoidedUniversal precautions required (NETI, 2005)

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Consumer/Staff self-reports

“The first time that I helped with a restraint, a four-point restraint, I walked out of the room in tears because it was one of the most horrible things I

had ever seen.” (female direct care staff)

"The seclusion made me feel even more angry because it hurt me and made me worse. I would like staff to respond in a different way such as

give you more options during the step before they act too quickly."

(Samantha Jones, age 41)

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First Steps? Develop a Written Facility Plan!

TO START: Leaders Must Develop a S/R Reduction Action Plan that is specific to their settings

Action Plan Framework Prevention-Based Approach Continuous Quality Improvement Principles Individualized for the Facility or Agency Adopt/adapt Six Core Strategies ©

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The Six Core Strategies© to Prevent Violence and S/R

1) Leadership Toward Organizational Change

2) Use Data To Inform Practices

3) Develop Your Workforce

4) Implement S/R Prevention Tools

5) Actively recruit and include service users and families in all activities

6) Make Debriefing rigorous

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Core Strategy #1Leadership in Organizational ChangeThe most important component in successful prevention and culture change projects.

Only Leadership has the authority to make the changes that are necessary for success:

To make violence prevention a high priorityTo assure for an organized Plan To reduce/eliminate organizational barriersTo provide or re-allocate the necessary resourcesTo hold people accountable for their actions

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Core Strategy #1Leadership in Organizational Change

Create A Vision

Live Key Values

Develop your Human Technology

Monitor Staff Performance

Elevate Oversight of Untoward EventsAssure Violence/S/R Prevention Plan Development (Anthony, 2004; Huckshorn, 2004)

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Core Strategy #2Using Data to Inform Practice

Leaders and staff must use information to drive change; to start:

Identify your definitions of violent events, S/R, imminent danger, reportable injuries, stat med useGather historical data by event/hours (6 months to 1 year) to use as baselineSet realistic goals or 100% reductionPost reports on units monthlyMandate data collection on S/R events, hours, stat meds, and consumer and staff injuries

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Core Strategy #2Using Data to Inform Practice

Use Data To Identify &Analyze Events:Unit/Day/Shift/Time of day

Age/Gender/Race

Date of admission/Diagnosis

Attending Physician

Pattern of staff involved in events

Number of Grievances

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Core Strategy # 2Using Data to Inform Practice

Use Data To:

Monitor Progress

Discover new best practices

Identify emerging staff champions

Target certain units/staff for training

Create healthy competition

Assure that everyone knows what is going on

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Core Strategy #3 Workforce Development

Integrate S/R Reduction & Violence

Prevention in Human Resource & Staff Development Activities

In New Hire procedures

In revising Job Descriptions and Competencies

In doing Performance Evaluations

In New Employee Orientation

In Annual Reviews

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Leadership and staff will require education on key concepts, including:

The Public Health Prevention Approach

Common Assumptions about S/R

Experiences of staff and adults/kids with S/R

The Neurobiological/psychological effects of Trauma

Roles of Consumers, Families and Advocates

Negotiation and Problem-solving skills

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Creating Trauma-Informed Systems and Services

Principles of Recovery/Building Resiliency

Matching Interventions with Behaviors

Use of Prevention Tools (violence, death/injury, trauma, de-escalation, safety plans, environmental changes, language)

Roles in rigorous debriefing

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Core Strategy #4Use Violence/S/R Prevention Tools

Choose and Implement Violence and S/R Prevention Tools

Assess risk factors for violence and S/R use

Assess risk factors for death and injury

Implement Universal Trauma Assessment

Use Safety Plans/Crisis Plans/Advance Directives to identify triggers/preferences

(NETI, 2005)

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Core Strategy #4Use Violence/S/R Prevention Tools

Use of comfort rooms Implement sensory rooms and sensory interventionsIncorporate Person First LanguageMonitor Training Guidelines (De-escalation models)Effective Treatment Activities Manage overcrowding

(NETI, 2005)

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Core Strategy #5 Full Customer/Advocate Inclusion

Hire peers in recovery, family members/community advocates as staff members, use volunteers

Make information available

Use to interview service user post-event

Attend meetings - all levels

Empower and support participation

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Core Strategy #5 Full Customer/Advocate Inclusion

Common roles for adult peersDirector of Drop-in CenterDirector of Consumer Affairs OfficeMental health technicianRecovery specialistDebriefing specialistTreatment Team AdvocateStaff in QI DepartmentTrainer

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Core Strategy #6Make Debriefing Rigorous

Definition of Debriefing

A stepwise tool designed to:rigorously analyze a critical event,

examine what occurred and

facilitate an improved outcome next time (manage events better or avoid event)

(Scholtes et al, 1998)

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Debriefing Goals

To prevent the future use of seclusion and restraint

(Cook et al, 2002; Hardenstine, 2001)

To minimize the negative effects of the use of seclusion and restraint

(Massachusetts DMH, 2001; Huckshorn, 2001; Cook et al, 2002; Hardenstine, 2001; Goetz, 2000)

To address organizational issues and make appropriate changes.

(Huckshorn, 2007; Duxbury, 2002; Richter & Whittington, 2006)

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Debriefing SpecificsDevelop or revise your policy

Implement two types of Debriefing Activities Acute - immediate post event response

to gather info, manage milieu, assure safety

Formal - rigorous problem solving event with treatment team and consumer input, usually 24 hours later

R

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New Research on Violence Causality and Role of the Environment

Violence in mental health settings has been blamed on the “patient” for years

Hundreds of studies done on patient demographics and characteristics

Findings are completely variable and inconclusiveMore recently, studies have looked at the role of the environment in violence, including staff (Richter & Whittington, 2006; Johnstone & Cooke, 2007)

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Promoting Risk Interventions by Situational Management (Johnstone & Cooke, 2007)

Past research has focused on evaluation the ‘patient’ for risk factors due to mental illness and criminogenic factors (p. 8)

However, this focus has been judged to be severely limited as it ignored environmental factors. Conflict and violence in inpatient MH settings is believed to be complicated and multi-factorial. “Human behavior does not occur in a vacuum…” (p. 9).

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Situational factors refer to features or characteristics of the environment in which they occur.

These can include the physical setting, personal comfort, staff issues and attitudes, physical space, privacy, noise levels, unit activity levels, individual needs for freedom & other issues

This is not a new concept, just one that has been ignored for years and may be a function of discrimination and its most ugly consequences.

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Exercise

1) Please think for two minutes about what is important for you to do when you get home from work. Do you make phone calls, take a shower, turn on the news, get something to eat, go work out, walk? Write this activity down on paper.

2) How would you handle being told that you could not do this as the rules do not permit it; that your request is “not allowed” and unavailable to you? And not for one day but for many days? And perhaps while you see others being able to do your requested activity?

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Your over-arching goal here is to manage the risk of conflict and violence, as without that, neither seclusion or restraint are likely to occur.

As leaders in this effort it is going to be your challenge to investigate these issues and come up with strategies to help your staff to do this prevention work.

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Our role (NTAC& faculty) is simply to help you. We will be hosting a training, supported by CMHS, to train your facilities leaders in this work. Your “role” is to identify and involve your CEO’s, Directors, Nurse leaders, Medical Directors, QI Directors, staff trainers, and any other staff that have the formal and informal power to make these changes in your facilities unfold.

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SUCCESSFUL OUTCOMES

Yes – in a variety of settings

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Variety of Types of Programs

Adult FacilitiesSalem Hospital -100%No. VA MH Institute - 99%Worcester State Hospital - 98%Western State Hospital - 79%

Child & Adolescent FacilitiesCambridge Child Assmnt Unit -100%Boston Medical Center IRTP -100%

Holston United Methodist Home - 95%

Natchaug Hospital - 93%

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Variety of Types of Programs

Intellectual & DD FacilitiesMillcreek in MS (225 beds) - 100%Siffrin in OH (300 beds) - 100%Lutheran in WI (1,000 beds) - 100%LifeShare in NH, ME & FL - 100%

(Ohio, 2005)

Forensic FacilitiesTaylor Hardin Secure Medical Ctr. - 99%North Texas State Hospital - 50%+Treasure Coast Forensic Tx Center

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NTAC S/R Training Pre/Post Data(NRI, 2003)

The data showed that S/R hours were reduced by as much as 79%, the proportion of consumers in S/R was reduced by as much as 62%, and the incidents of S/R events in a month were reduced by as much as 68%.

(HSRI Fast Facts, 2004)

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EXAMPLES OF OUTCOMES FROM CHILD PROGRAMS THAT HAVE

REDUCED S/R

Southern Oregon Adolescent Study & Treatment Center (R/S < 85% in 18 months: Avg CAFAS score at discharge from 40 to 78; < staff turnover; < runaways)

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MA R/S Episodes Decreased Dramatically

Child - 79.7%Adolescent - 59.8%Mixed C/A - 81.5%

C/A DMH Acute and Continuing Care FacilitiesTotal R/S Episodes per 1000 Patient Days

84.0

27.98

72.2

29.04

73.4

24.33

0

10

20

30

40

50

60

70

80

90

100

11/1/99 - 10/31/00 9/1/01 - 12/31/04

Significant Periods

# E

pis

od

es p

er

1000 P

ati

en

t D

ays

Child

Adolescent

Mixed C/A

Pre-Intervention

Post-Intervention

5454

MA R/S Hours Also Reduced

ChildChild - 30.5%- 30.5%AdolescentAdolescent - 58.3%- 58.3%

Mixed C/AMixed C/A -19.2%-19.2%

C/A DMH Licensed and State FacilitiesTotal RS Hours per Episode

0.59

0.41

2.18

0.91

0.520.42

0.00

0.50

1.00

1.50

2.00

2.50

11/1/99 - 10/31/00 9/1/01 - 6/30/04

Significant Periods

# H

ou

rs p

er E

pis

od

e

Child

Adolescent

Mixed C/A

Pre-Intervention

Post-Intervention

5555

MA MedicationRestraint Dropped

ChildChild - 49.5%- 49.5%AdolescentAdolescent - 28.6%- 28.6%Mixed C/AMixed C/A - 77.4%- 77.4%

C/A DMH Acute and Continuing Care FacilitiesInvoluntary Administration of Medication

Episodes per 1000 Patient Days

21.3

10.75

15.9

11.35

32.5

7.34

0

10

20

30

40

11/1/99 - 10/31/00 9/1/01 - 12/31/04

Significant Periods

# E

pis

od

es p

er

1000 P

ati

en

t D

ays

Child

Adolescent

Mixed C/A

Pre-Intervention

Post-Intervention

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Massachusetts ResultsExamples of Most Successful Units-100% Collaborative Problem-Solving

Approach, close supervision, elevating the role of MHW

-100% Trauma System Treatment Model- 99% Holistic Health Approach

- 91% Fostering Resilience in Children

- 86% Strength Based Approach, threw out mechanical restraints

- 78% Conversion to Relationship Model

5757

Boston Medical Center Intensive Residential Treatment Program

Total Seclusion, Restraint & Injury Episodes09/00 - 05/07

0

10

20

30

40

50

60

70

80S

ep

-00

Jan

-01

Ma

y-0

1

Se

p-0

1

Jan

-02

Ma

y-0

2

Se

p-0

2

Jan

-03

Ma

y-0

3

Se

p-0

3

Jan

-04

Ma

y-0

4

Se

p-0

4

Jan

-05

Ma

y-0

5

Se

p-0

5

Jan

-06

Ma

y-0

6

Se

p-0

6

Jan

-07

Ma

y-0

7

Significant Periods

SR

& I

nju

ry E

pis

od

es

SR Episodes

Kid Injury

Staff Injury

St

5858

Seclusion and Restraint Orders and

Patient Related Employee Injuries

Worcester State Hospital

Q4 FY '00 - Q1 FY '05

0

200

400

600

800

1000

1200

Q4 FY00

Q1 FY01

Q2 FY01

Q3 FY01

Q4 FY01

Q1 FY02

Q2 FY02

Q3 FY02

Q4 FY02

Q1 FY03

Q2 FY03

Q3 FY03

Q4 FY03

Q1 FY04

Q2 FY04

Q3 FY04

Q4 FY04

Q1 FY05

S/R

Ord

ers

0

5

10

15

20

25

30

35

40

45

50

Pat

ien

t R

elat

ed E

mp

loye

e In

juri

es # S/R Orders

# PatientRelatedEmployeeInjuries

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Strategies MA/Oregon Programs Began to Address

Strength-based Approach (e.g., strength-based assessments, daily focus on strengths, environment plastered with strengths, 5 or 8-1 use of praise, respectful interactions, both children and families)

Family PartnershipsSelf-Esteem Building Activities Sensitive Listening and Questioning

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Child/Parent Identifying and Learning to Recognize/Use Triggers, Warning Signs Coping Strategies & Regular Updates /Reviews (i.e., risk assessments, use of safety plans)

Skill Building Focus Staff Expertise in a Range of Negotiation

& De-escalation Techniques

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Trauma Informed CareIdentifying and Implementing Distinct

Models of Care Eliminating/Revamping Motivation

Systems Involving and Empowering Staff (i.e.

communication, sharing of data, not constricted by ‘rules’)

Letting Go of Control Issues/Choices

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Strategies MA/Oregon Programs Employed

Warmth of Décor Proactive/Varied Activity Schedule Focus on Holistic Activities (e.g., yoga, dog

therapy) Interviewing for, Hiring, Evaluating for:

Caring & Compassionate Staff Use of Touch Sensory/Calming Rooms Variety of Sensory Tools

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Final Thought to Ponder…

Martin Luther King JR. said that:

“Violence is the language of the unheard”

Seems to be a particularly germane statement regarding our settings.

Let’s give these findings the attention they

deserve, for our children and adolescents, their families and our staff …

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Contact Information

Beth Caldwell Caldwell Management Associates

413-644-9319 [email protected]

Dr. Janice Le BelMA Department of Mental Health

[email protected]

Kevin Ann Huckshorn or Sarah CallahanNational Association of State

Mental Health Program Directors (703) 739-9333

[email protected] [email protected]

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