The Office of Mental The Office of Mental Retardation’s Plan to Support Retardation’s Plan to Support Elimination of Restraint Elimination of Restraint through Positive Practices - through Positive Practices - Chapter 1Chapter 1

National PerspectiveNational Perspective

Elimination and reduction of restraint is a national trend. Elimination and reduction of restraint is a national trend.

“…“…It is now a priority for SAMSA to work with States…to It is now a priority for SAMSA to work with States…to ultimately eliminate the use of seclusion and ultimately eliminate the use of seclusion and restraint…There is a wealth of research that physical restraint…There is a wealth of research that physical force, bodily immobilization and isolation inherent in force, bodily immobilization and isolation inherent in the practices of seclusion and restraint are the practices of seclusion and restraint are dehumanizing…” Substance Abuse & Mental Health dehumanizing…” Substance Abuse & Mental Health Services Administration. Administrator Charles CurieServices Administration. Administrator Charles Curie

National PerspectiveNational Perspective

Six Core Strategies for the Reduction of Six Core Strategies for the Reduction of Seclusion /Restraint - National Technical Seclusion /Restraint - National Technical Assistance Center/National Executive Training Assistance Center/National Executive Training Institute 2/25/2005Institute 2/25/2005

Leadership toward Organizational ChangeLeadership toward Organizational Change Use of Data to Inform PracticeUse of Data to Inform Practice Workforce DevelopmentWorkforce Development Use of Restraint Reduction ToolsUse of Restraint Reduction Tools Consumer RolesConsumer Roles Debriefing TechniquesDebriefing Techniques

National PerspectiveNational Perspective

AssumptionAssumption

Restraints keep Restraints keep patients safe.patients safe.

Restraints keep staff Restraints keep staff safe.safe.

RealityReality

Each year, 50 – 100 Each year, 50 – 100 deaths occur nationally deaths occur nationally due to seclusion and due to seclusion and restraint.restraint.

For every 100 mental For every 100 mental health aides, 26 health aides, 26 injuries were reported injuries were reported in three – survey 1996in three – survey 1996

National PerspectiveNational Perspective

AssumptionAssumption

Restraints are used only Restraints are used only when absolutely when absolutely necessary and for safety necessary and for safety reasons.reasons.

Restraints are not used Restraints are not used as, or meant to be as, or meant to be punishmentpunishment

RealityReality

Patients are restrained for Patients are restrained for such trivial “offenses” as such trivial “offenses” as refusing to move to refusing to move to another dining room another dining room table.table.

People who have been People who have been secluded or restrained secluded or restrained typically experience a typically experience a sense of punishment.sense of punishment.

Department of Public Welfare InitiativeDepartment of Public Welfare Initiative

Alternative to Coercive Techniques Initiative Alternative to Coercive Techniques Initiative (ACT) – Initial goal of eliminating unnecessary (ACT) – Initial goal of eliminating unnecessary restraints in the children’s service system, and restraints in the children’s service system, and an ultimate goal of having all Department of an ultimate goal of having all Department of Public Welfare serving systems be restraint free. Public Welfare serving systems be restraint free. Office of Children Youth and Families (OCYF)Office of Children Youth and Families (OCYF) Office of Mental Health and Substance Abuse Office of Mental Health and Substance Abuse

Services (OMHSAS)Services (OMHSAS) Office of Medical Assistance Programs (OMAP)Office of Medical Assistance Programs (OMAP) Office of Mental Retardation (OMR)Office of Mental Retardation (OMR)

HistoryHistory

Positive Approaches SubcommitteePositive Approaches Subcommittee

Positive Approaches Local Networking Positive Approaches Local Networking GroupsGroups

Restrictive Procedure WorkgroupRestrictive Procedure Workgroup

OMHSAS & OMR Dual Diagnosis ForumsOMHSAS & OMR Dual Diagnosis Forums

HistoryHistory

Trainings for families, direct support Trainings for families, direct support professional and other support staffprofessional and other support staff

Mental Health Support Process Mental Health Support Process subcommittee subcommittee

Statewide Positive Practices CommitteeStatewide Positive Practices Committee

Positive Practices Resource Team (Pilot)Positive Practices Resource Team (Pilot)

Everyday Lives ValuesEveryday Lives Values

AccountabilityAccountabilityChoiceChoiceCollaborationCollaborationCommunity InclusionCommunity InclusionContributing to the Contributing to the CommunityCommunityControlControlFreedomFreedom

IndividualityIndividualityMentoringMentoringQualityQualityRelationshipsRelationshipsSafetySafetyStabilityStabilitySuccessSuccess

Positive Approaches ParadigmPositive Approaches Paradigm

Positive Approaches is a worldview in which all Positive Approaches is a worldview in which all individuals are treated with dignity and respect, individuals are treated with dignity and respect, and all are entitled to “Everyday Lives”.and all are entitled to “Everyday Lives”.Positive Approaches recognizes that an Positive Approaches recognizes that an “Everyday Life” means being able to make “Everyday Life” means being able to make choices, face challenges, succeed, and choices, face challenges, succeed, and sometimes fail. sometimes fail. Positive Approaches is a characterized by an Positive Approaches is a characterized by an integration of values, philosophies and integration of values, philosophies and technologies.technologies.

Positive Approaches ParadigmPositive Approaches Paradigm

Positive Approaches asks us to always look at Positive Approaches asks us to always look at the context in which we frame our work.the context in which we frame our work.

Positive Approaches is grounded in two basic Positive Approaches is grounded in two basic assumptions:assumptions:– People always have good reasons for what People always have good reasons for what

they are doing.they are doing.– People always do the best they can with what People always do the best they can with what

they know in that context and at that point in they know in that context and at that point in time.time.

Positive ApproachesPositive Approaches

CommunicationCommunication

AssessmentAssessment

EnvironmentEnvironment

Hanging in thereHanging in there

Positive ApproachesPositive Approaches

Environment - An individual's perception of their Environment - An individual's perception of their environment, and how that environment will environment, and how that environment will meet their needs may influence their behavior.meet their needs may influence their behavior.Communication - An individual may use a Communication - An individual may use a variety of means to communicate inclusive of variety of means to communicate inclusive of challenging behavior.challenging behavior.Assessment - Formal assessment tools, in Assessment - Formal assessment tools, in addition to developing a holistic view of the addition to developing a holistic view of the persons life.persons life.Hanging in there – Staying with the person, and Hanging in there – Staying with the person, and of critical importance, supporting the team to be of critical importance, supporting the team to be able to stay with person.able to stay with person.

Elimination of Restraints Elimination of Restraints through Positive Practicesthrough Positive Practices

MR Bulletin 00-06-09 MR Bulletin 00-06-09

Effective May 1, 2006Effective May 1, 2006

Elimination of Restraints through Elimination of Restraints through Positive PracticesPositive Practices

Although the intent of this Bulletin is to guide Although the intent of this Bulletin is to guide activities toward the eventual elimination of activities toward the eventual elimination of restraints throughout the entire MR Service restraints throughout the entire MR Service system, the bulletin does not prohibit their use. system, the bulletin does not prohibit their use. Restraint is to be considered only as a last resort Restraint is to be considered only as a last resort and in situations where any person’s immediate and in situations where any person’s immediate health and safety are in jeopardy. This bulletin health and safety are in jeopardy. This bulletin offers best practice suggestions that are part of offers best practice suggestions that are part of an OMR plan to incrementally reduce the an OMR plan to incrementally reduce the incidents of restraint.incidents of restraint.

Elimination of Restraints through Elimination of Restraints through Positive PracticesPositive Practices

Philosophy of CarePhilosophy of Care

Continuous Risk Management and Quality Continuous Risk Management and Quality EffortsEfforts

Reducing Restraints and Restrictive ProceduresReducing Restraints and Restrictive Procedures

Philosophy of CarePhilosophy of Care

The individual is the central focus of the planning The individual is the central focus of the planning team.team.

Creating a safe and supportive person centered Creating a safe and supportive person centered environment.environment.

Use and inclusion in the ISP of positive practices Use and inclusion in the ISP of positive practices that are known to be effective in helping the that are known to be effective in helping the individual. individual.

Philosophy of CarePhilosophy of Care

Prevention and early detection are critical.Prevention and early detection are critical.

Creating a culture of respect and insuring Creating a culture of respect and insuring training for staff that focuses on all forms of training for staff that focuses on all forms of positive practices.positive practices.

Continuous Risk Management Training Continuous Risk Management Training RecommendationsRecommendations

Environmental design, social, physiological and Environmental design, social, physiological and cultural motivators for behavior, including cultural motivators for behavior, including information on individuals who have experienced information on individuals who have experienced trauma.trauma.

Positive behavioral and support methods that Positive behavioral and support methods that include techniques to deescalate behavior.include techniques to deescalate behavior.

Information on methods for interacting with Information on methods for interacting with individuals who have a dual diagnosis of mental individuals who have a dual diagnosis of mental retardation and a mental illness. retardation and a mental illness.

Continuous Risk Management Training Continuous Risk Management Training RecommendationsRecommendations

Person centered alternatives to the utilization of Person centered alternatives to the utilization of restraint, including the integration of effective restraint, including the integration of effective behavioral supports and individual teaching behavioral supports and individual teaching strategies.strategies.

Basic training in body mechanics.Basic training in body mechanics.

Definitions, policies and the risks associated with Definitions, policies and the risks associated with the application of restraint.the application of restraint.

Provider Risk Management Process Provider Risk Management Process RecommendationsRecommendations

Ongoing quality improvement directed at Ongoing quality improvement directed at reducing and eliminating restraint. reducing and eliminating restraint. Policies and procedure for insuring the safety of Policies and procedure for insuring the safety of individuals in crisis in a restraint free agency.individuals in crisis in a restraint free agency.Procedure for post review of restraints with staff Procedure for post review of restraints with staff involved in the implementation of restraints.involved in the implementation of restraints.

Provider Risk Management Process Provider Risk Management Process RecommendationsRecommendations

Procedure for debriefing with the individual, post Procedure for debriefing with the individual, post restraint, that provides for processing the event.restraint, that provides for processing the event.Internal review committees responsible for post Internal review committees responsible for post restraint follow up and the outcomes based on restraint follow up and the outcomes based on the review.the review.Policies of risk management consistent with MR Policies of risk management consistent with MR Bulletin 6000-04-01 entitled “Incident Bulletin 6000-04-01 entitled “Incident Management”Management”

Continuous Risk Management Continuous Risk Management Administrative ReviewAdministrative Review

OMR RecommendsOMR Recommends The County Mental Health/Mental (MH/MR) The County Mental Health/Mental (MH/MR)

Retardation Program or Administrative Entity Retardation Program or Administrative Entity should review each provider’s policies on should review each provider’s policies on behavior supports, restrictive procedures and behavior supports, restrictive procedures and restraint.restraint.

OMR Licensing Representatives and the OMR Licensing Representatives and the Department Health Representatives, as part Department Health Representatives, as part of their annual surveys and program of their annual surveys and program monitoring, will review provider policies on monitoring, will review provider policies on restrictive procedures and restraint userestrictive procedures and restraint use ..

Reducing Restraints and Reducing Restraints and Restrictive Procedures Restrictive Procedures

Restraint is not treatment or a substitute for Restraint is not treatment or a substitute for treatment.treatment.

Physical restraint is used only as a last resort Physical restraint is used only as a last resort safety measure when there is a threat to the safety measure when there is a threat to the health and safety of the individual and/or others health and safety of the individual and/or others And only when less intrusive methods have And only when less intrusive methods have been ineffective.been ineffective.

Reducing Restraints and Restrictive Reducing Restraints and Restrictive ProceduresProcedures

Individual Plan RecommendationsIndividual Plan Recommendations

OMR Recommends Providers develop OMR Recommends Providers develop procedures that outline specific steps to be procedures that outline specific steps to be taken for the elimination of restraint taken for the elimination of restraint components in any individual’s plan and components in any individual’s plan and approval of individual specific plans that approval of individual specific plans that contain the following positive components:contain the following positive components:

Reducing Restraints and Restrictive Reducing Restraints and Restrictive Procedures Procedures

Individual Plan RecommendationsIndividual Plan Recommendations

Information about the occurrence of the problem Information about the occurrence of the problem behavior and what specific positive practices behavior and what specific positive practices that can be used to prevent future occurrences that can be used to prevent future occurrences Justification that the proposed plan contains the Justification that the proposed plan contains the most effective methods of helping the individual most effective methods of helping the individual deal with the problem behavior while promoting deal with the problem behavior while promoting the safety of the individual and others.the safety of the individual and others.Information about what procedures did not work Information about what procedures did not work in the past as well as alternatives if the current in the past as well as alternatives if the current procedures prove ineffective.procedures prove ineffective.

Reducing Restraints and Restrictive Reducing Restraints and Restrictive ProceduresProcedures

Individual Plan Recommendations Individual Plan Recommendations

A review of “sentinel events” to learn and A review of “sentinel events” to learn and communicate what has worked well in avoiding communicate what has worked well in avoiding the restraint.the restraint.

The type of procedure to be used with an The type of procedure to be used with an individual whose restraint reduction plan individual whose restraint reduction plan incorporates the possible use of emergency incorporates the possible use of emergency restraint in order to protect the individual’s health restraint in order to protect the individual’s health and safetyand safety..

We are already on our way…We are already on our way…

0

100

200

300

400

500

600

700

July Aug Sept Oct Nov Dec Jan Feb March April May June

Statewide Restraint Data Fiscal Year and Month

FY 2004/05 Total Restraints N=7,048

FY 2005/06 Total Restraints N=5,355 (year to date 4/30/06)

FootnotePurpose: For review by the PPC Date Data Pulled: 4/17/06 and 5/18/06

Data Source: HCSIS Impromptu*These data are intended for the Positive Practices Committee (PPC) . They are not to be distributed or shared without knowledge of the

chairperson.

72,538 73,486

7,048 5,355

828 699

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Total People Served Total Number of Restraints Total Number of Unique IndividualsRestrained

Restraint Fiscal Year 04/05 and 05/06 (year to date 4/30/2006)

FY 2004-05 FY 2005-06 (year to date 4/30/06)

FootnotePurpose: For review by the PPC Date Data Pulled: 4/17/06 and 5/18/06

Data Source: HCSIS ImpromptuCensus Data from the Gov. Ex Budget 2006-2007

*These data are intended for the Positive Practices Committee (PPC) . They are not to be distributed or shared without knowledge of the chairperson.

9.7% 1.1%

7.3% 1.0%

OMR Plan to Eliminate the OMR Plan to Eliminate the Need for RestraintNeed for Restraint

May 2006May 2006

OMR Plan to Eliminate the Need OMR Plan to Eliminate the Need for Restraintfor Restraint

Developed to complement and correspond with Developed to complement and correspond with the principles of the Department of Public the principles of the Department of Public Welfare ACT InitiativeWelfare ACT InitiativeEstablishes the requirement for Regional Establishes the requirement for Regional Positive Practice Committees to review restraint Positive Practice Committees to review restraint reduction plans specific to the region in concert reduction plans specific to the region in concert with Regional Risk Management Committeeswith Regional Risk Management CommitteesCharges the Statewide Positive Practices Charges the Statewide Positive Practices Committee with the responsibility of reviewing Committee with the responsibility of reviewing regional plans regional plans

OMR Plan to Eliminate the Need OMR Plan to Eliminate the Need for Restraintfor Restraint

Sets a goal of twenty percent reduction in Sets a goal of twenty percent reduction in each of the four regions using data from each of the four regions using data from the Home and Community Information the Home and Community Information Systems (HCSIS) during FY 2006 -2007Systems (HCSIS) during FY 2006 -2007 Expectation that there will be a 20% reduction Expectation that there will be a 20% reduction

in the number of physical restraints thereafterin the number of physical restraints thereafter At the end of the fiscal year the restraint At the end of the fiscal year the restraint

elimination plan will be reviewed with elimination plan will be reviewed with adjustments in expectations and strategies as adjustments in expectations and strategies as appropriateappropriate

Resources to Support Plan to Resources to Support Plan to Eliminate the Need for Restraint & Eliminate the Need for Restraint &

OMR BulletinOMR Bulletin

Regional Positive Practices Regional Positive Practices Committee (PPC)Committee (PPC)

Promote and expand interest/leadership within Promote and expand interest/leadership within the County MH/MR Program/Administrative the County MH/MR Program/Administrative Entities to build capacity to serve people with Entities to build capacity to serve people with challenging behaviorchallenging behaviorDevelop Regional Restraint Elimination PlansDevelop Regional Restraint Elimination PlansIn partnership with the local stakeholders, plan In partnership with the local stakeholders, plan and facilitate local Positive Practice Committee and facilitate local Positive Practice Committee MeetingsMeetings

Regional Positive Practices Committee Regional Positive Practices Committee (PPC)(PPC)

Identify existing resources and gaps within the Identify existing resources and gaps within the local PPC arealocal PPC area

Identify steps to address gapsIdentify steps to address gaps

Identify the regional structure to support the Identify the regional structure to support the Positive Practices Resource Teams (Pilot)Positive Practices Resource Teams (Pilot)

Statewide Statewide PositivePositive Practices Practices CommitteeCommittee

Review statewide restraint dataReview statewide restraint data

Review Regional Positive Practices Committee Review Regional Positive Practices Committee PlansPlans

Make recommendations regarding Regional Make recommendations regarding Regional Restraint Elimination plansRestraint Elimination plans

OMR and OMHSAS PartnershipOMR and OMHSAS PartnershipPositive Practices Resource Team (Pilot)Positive Practices Resource Team (Pilot) Purpose is to identify and develop system resources Purpose is to identify and develop system resources

that will be dedicated to address issues pertaining to that will be dedicated to address issues pertaining to a person’s behavioral support needs.a person’s behavioral support needs.

The criteria for referral is the person must be The criteria for referral is the person must be demonstrating escalating at risk behavioral demonstrating escalating at risk behavioral challenges and may be at risk for needing enhanced challenges and may be at risk for needing enhanced levels of support not readily available to the providerlevels of support not readily available to the provider

Piloted in Central Region with resources from OMR Piloted in Central Region with resources from OMR Regional Office, OMHSAS Field Office, Selinsgrove Regional Office, OMHSAS Field Office, Selinsgrove Center, Danville State Hospital, Wernersville State Center, Danville State Hospital, Wernersville State HospitalHospital

OMR Bulletins OMR Bulletins

Supporting the PlanSupporting the Plan 00-06-09 OMR Elimination of Restraints through Positive Practices

00-04-05 OMR Positive Approaches

00-03-0500-03-05 OMR Principles for the Mental Retardation System

00-02-1600-02-16 OMHSAS, OMR Coordination of treatment and support for people with a diagnosis of serious mental illness who also have a diagnosis of mental retardation

00-00-0400-00-04 OMHSAS, OMR Guidelines for Identifying Persons with Mental Retardation and Mental Illness for State Mental Health Hospital Discharge

Next StepsNext Steps

OMR will integrate the Positive Practice goals OMR will integrate the Positive Practice goals with the Quality Management Framework to with the Quality Management Framework to ensure learning, sustainability and connection to ensure learning, sustainability and connection to other OMR initiativesother OMR initiativesImplement three month pilot of Positive Practice Implement three month pilot of Positive Practice Resource TeamResource TeamRegions to complete Restraint Elimination PlansRegions to complete Restraint Elimination PlansNext Positive Practices State Wide Committee to Next Positive Practices State Wide Committee to review Regional plans and provide input into review Regional plans and provide input into plans plans

OMR ContactsOMR ContactsWestern RegionWestern Region Northeast RegionNortheast RegionSharon LipscombSharon Lipscomb Michele O’TooleMichele O’Toole300 Liberty Avenue300 Liberty Avenue 100 Lackawanna Ave.100 Lackawanna Ave.Pittsburgh, PA 15222Pittsburgh, PA 15222 Scranton, PA 18503Scranton, PA 18503412-565-3688412-565-3688 570-963-3212570-963-3212

Central RegionCentral Region Southeast RegionSoutheast RegionWilliam BruawWilliam Bruaw Kathleen GerrityKathleen Gerrity430 Willow Oak Bldg.430 Willow Oak Bldg. 1400 Spring Garden St.1400 Spring Garden St.Harrisburg, PA 17105Harrisburg, PA 17105 Philadelphia, PA 19130Philadelphia, PA 19130717-705-8266717-705-8266 215-560-2247215-560-2247