Transcript Massachusetts - Hogg Foundation for Mental Health

Real Reduction Experiences
Commonwealth of Massachusetts
Department of Mental Health
Janice LeBel, Ph.D.
Director of Program Mgmt., Child & Adol. Division
Nan Stromberg, MSN, APRN,BC
Director of Nursing – Licensing Division
1
Massachusetts DMH Specifics
o State Mental Health Authority
• Licensing oversight of acute care system
• Contract monitoring of continuing care/state system
o Emphasis of SMHA
• Setting standard of low/no R/S utilization
• Promoting change
o Statewide Restraint Reduction Initiative
• All Child & Adolescent Inpatient Providers (33)
• Both acute & continuing care
(500 + beds)
2
How did we know we
had a problem?
The Quantitative Perspective
3
A Review of the Data
150
Episodes per 100
Admissions
o Restraint use with
kids increasing
each year
Restraint Episodes per 100
Admissions (Licensed Facilities)
Pre-Initiative
125
100
75
50
25
0
1998
1999
2000
Years
o Children/Adolescents
using more S/R
o Systemic
discrepancies
Child (L)
Adult (L)
Adolescent (L)
Mix CA (L)
Acute Care Hospital Comparison - 2000
Rate per
1000 Patientdays
100
66.5
High Utilization
6.9
Low Utilization
0
Hospitals A and B
4
How else did we know
we had a problem?
The Qualitative Perspective
5
Overburdened with R/S Forms
from across the State
We knew there was too much restraint & seclusion when the
forms were practically up over our heads.
6
A Painful Pattern &
Restraint Recipe
Challenging behavior by kid → limits set by
staff → kid escalated → staff more restrictive
→ kid lost control → R/S took place
•
•
•
•
•
Over-reactivity – focus on control
Safety means containment
Lack of early intervention and support
Lack of crisis planning
Staff blamed the kids because they lacked training
and skills
7
Clinical Review: Trauma & Behavioral
Distress Underappreciated
o We assumed high rates of trauma but we
didn’t know how much….
o 84% of inpatient children and adolescents had
histories of trauma (point in time medical record
review)
o Out-of-control (distressed) behavior reflected
prior abuse by adults & lack of trust
o Capacity to self-control & self-soothe
severely disrupted
o Kids lacked skills
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Children were Hurt in Restraint
Physical injuries

Broken legs

Broken arms

Broken teeth

Bruises

Cuts

Rug burns & abrasions
9
What Were we Doing?
Hippocrates’ Dictum:
“First, do no harm”
Federal Law:
Diagnosis & treatment
NASMHPD:
R/S are not therapeutic
& reflect treatment failure
State Law:
The child who has been
hurt is always the victim
The Kids:
“It’s not right to grab me.
It hurts. Be nice!”
(Kenny, 9)
10
The Disgraceful Reality
11
Back to the Literature

Data and literature review
found no evidence base
to support R/S use

Cochrane Review
 2,155 articles but no controlled studies
 R/S efficacy not established
 Harm and trauma cited
12
Strength-Based Care:
Essential Features Identified
o Prevention orientation
o Nurturing treatment: individualized,
age-appropriate, active, skill focused
o Teaching, supporting thru crises & skill
development
o Staff = teacher & coach
13
The Search for Better Practice
Where
to start?
14
The Search for Better Practice
o Researched and visited programs
successful in reducing/eliminating R/S
o Identified key promising practices elements
(prevention, relationship building, staff & child skill
development, leadership & commitment)
o Brought MA hospital staff to NY programs
for full cultural immersion – got R/S
reduction religion
o Initiated peer-to-peer roundtable
discussions
15
Pediatric Unit: Post-Visit Restraints
(07/00–08/02)
120
NY
100
80
Visit
60
40
Jul-02
Apr-02
Jan-02
Oct-01
Jul-01
Apr-01
Jan-01
Oct-00
0
Jul-00
20
Adolescent Unit: Post-Visit Restraints
(07/00-08/02)
600
NY
Visit
500
400
300
200
Jul-02
Apr-02
Jan-02
Oct-01
Jul-01
Apr-01
Jan-01
Oct-00
0
Jul-00
100
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Changing the Paradigm:
Sorting Myth from Reality
Does not require
Does require

More money

Using resources flexibly

More staff

Core staff

New staff


Micro-management of
staff
New staff attitude & open
to change

Valuing & empowering
staff

Enhanced training:
coaching, modeling,
mentoring & supervision

Traditional training
17
Changing the Paradigm:
Sorting Myth from Reality
Does not require
Does require

State of the Art
Environment of Care

Flexibility with the
Environment

Control

Collaboration

Confrontation/Limitsetting
Reacting to the
Negative

Negotiation/Dialogue

Rewarding the
Positive
Strict Data Collection

Active use of Data


18
Multi-Year Planning
Fundamental Plan





Create a R/S Reduction Team
Consumer & Family Involvement
Best Practice Conference Kick-Off & Provider
Strategic Planning
Quarterly Statewide Grand Rounds
Annual Provider Presentation Forums
The Goal
To change culture, practice & “root” the Initiative by:

Communicating & educating

Continually reviewing & planning

Regulating
19
Re-wrote the DMH Regulations,
Effective April 2006, DMH Regulation 104 CMR 27.12
Focus on prevention – not just ‘safe
application”
o Prevention requirements:
o Crisis Prevention Plans
o Assessment of Trauma and potential for retraumatization
o Program Quality Improvement Plans
o New Policies and Procedures
o Increased Education for Staff
o Sensory Resources
o Active use of Data
20
Re-wrote the DMH Regulations,
Effective April 2006, DMH Regulation 104 CMR 27.12
o Restrictions if Used
o
o
o
o
Shortened renewal time for orders (2 hours)
Prohibition of prone restraint
Clarified and tightened seclusion definition
Prohibition of mechanical restraint for children
under 13
o Intensive “real-time” review of long restraints
by facility director and medical director
o Debriefing Requirements
Consumer
Staff
Administrative Review
21
For some … a bit of reluctance
22
Broadening the Perspective:
Improving Care for Children
o Models of Care
o CPS, PEM, DBT, PBS, Holistic, Resiliency,
Relational, Trauma Systems
o Child, Adolescent & Family Perspective
o Public Health Approach
o Crisis Planning
o Understanding Trauma
o Sensory Approaches
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Coming to our Senses
o Sensory Assessment: What’s your diet?
o Sensory Intervention: A universal experience
o Giving children and staff greater array of
alternative tools
o Broad Application:


Treatment, early intervention & crisis planning
Touch: Renewed consideration
o Touch Assessment


Supported by the literature
Arm & hand massages, weighted items, pressure
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Providers “Model” Success
o Metro West
- 98%
Holistic Approach
o Cambridge Hospital
- 100%
Collaborative Problem-Solving
Model
o Westwood Lodge SCU - 86%
Resiliency Model
o Boston University IRTP - 100%
Trauma Systems Model
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9/
1/
0
12 0
/1/
00
3/
1/
0
6/ 1
1/
01
9/
1/
0
12 1
/1/
01
3/
1/
0
6/ 2
1/
02
9/
1/
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12 2
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0
3/ 2
1/
03
6/
1/
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9/
1/
12 03
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1/
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6/
1/
04
9/
1/
12 04
/1/
04
3/
1/
05
6/
1/
05
# Episodes per 1000 Patient Days
Hunt Center
Total RS Episodes per 1000 Patient Days
200
175
Hunt Mixed C/A
150
Unit Type Average
125
100
75
50
25
0
Significant Periods
26
80
Boston University
Intensive Residential Treatment Program
Total Restraint & Injury Episodes
09/00 - 01/05
B U IRTP
70
Kid Injury
Restraint & Injury Episodes
60
Staff Injury
50
40
30
20
10
Se
pD 00
ec
-0
M 0
ar
-0
Ju 1
nS e 01
pD 01
ec
M 01
ar
-0
Ju 2
nS e 02
pD 02
ec
M 02
ar
-0
Ju 3
nS e 03
pD 03
ec
M 03
ar
-0
Ju 4
nS e 04
pD 04
ec
-0
M 4
ar
-0
Ju 5
n05
0
Significant Periods
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Top Tips from Providers




Encourage flexible “out of the box”
thinking. It is not win or lose.
Needs to be a forum for staff to openly
express feelings so they don’t act these
out on clients
Instill hope and optimism no matter what
If client doesn’t succeed 80% of time

Break expectations into smaller steps until
they have achieved goals
28
Top Tips from Providers




Praise staff & clients for good work. –
“Caught in the Act” documents the specific
positive behaviors & promotes everyone’s
strengths
Keep goals brief and focused
Utilize humor
Use complementary therapies – massage,
Reiki, yoga, relaxation, visualization,
positive affirmations, spiritual needs
29
Top Tips from Providers
Offer support during difficult transitions
 “Reframe” behavioral description to be
more strength-based

“Wandering” halls is now “grazing for
sensory input”
 “Needy” is now “understandably in need of
staff attention”

30
What Have we Learned?
o Without leadership, it does not happen!
o Plan for incremental advancement &
change
o Systematize the effort and make it part of
the organizational fabric
o You must celebrate, reward/award &
appreciate hard work
o Culture change takes years – this is
marathon work
31
S/R Hours
Decreased – 49%
C/A DMH Licensed and State Facilities
Total RS Hours per Episode
2.50
Pre-Intervention
2.18
# Hours per Episode
2.00
Post-Intervention
Child
1.50
Adolescent
Mixed C/A
1.00
0.59
0.55
0.52
0.50
0.38
0.34
0.00
11/1/99 - 10/31/00
4/1/05 - 3-31-06
Significant Periods
32
S/R Episodes
Decreased – 72%
C/A DMH Acute and Continuing Care Facilities
Total R/S Episodes per 1000 Patient Days
Pre-Intervention
100
# Episodes per 1000 Patient Days
90
80
84.0
72.2
73.4
70
Post-Intervention
60
Child
Adolescent
50
Mixed C/A
40
27.57
30
20.87
20
14.51
10
0
11/1/99 - 10/31/00
4/1/05 - 3/31/06
Significant Periods
33
Medication Restraint
Decreased -86%
C/A DMH Acute and Continuing Care Facilities
Involuntary Administration of Medication
Episodes per 1000 Patient Days
# Episodes per 1000
Patient Days
Pre-Intervention
40
30
20
32.5
Child
21.3
Adolescent
15.9
Post-Intervention
Mixed C/A
6.3
10
1.9
0.1
0
11/1/99 - 10/31/00
4/1/05 - 3/31/06
Significant Periods
34
“Good ideas are not adopted
automatically. They must be
driven into practice with
courageous patience.”
Hyman G. Rickover
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Massachusetts DMH
Contact Information
Janice LeBel, Ph.D.
Nan Stromberg, MSN, APRN, BC
25 Staniford Street
Boston, Massachusetts 02114
(617) 626-8119 & (617) 626-8085
[email protected]
[email protected]
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