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Implementation of Positive Behavioral Interventions & Supports (PBIS) in a Children’s Residential Mental Health Treatment Program Veronica P. Arellano, O&E Manager Andrew Pane, Milieu Activities Therapist Georgetown Training Institute Conference Orlando, FL July 2006 1 Context and Reasoning for Change To achieve improved outcomes Poor outcomes cited nationally for residential services High cost of services, in context of diminishing resources Effectiveness of community based services Focus on permanency and the effect foster care has had on severing family connections To implement evidence based services including PBIS, TFCBT, and Parent Management Training To utilize residential services as an intervention, not a placement To increase youth and family connections and sustainable community supports To ensure consistent implementation of a strength based, needs driven, family centered, individualized and culturally relevant philosophy in all aspects of care To partner with families and ensure family involvement in all aspects of care 2 Phases Change Process Phase 1 - Data Gathering Focus groups with families and children Staff questionnaires Customer questionnaires Reviewed 7 years of internal data Literature review of Evidence-Based Practices Benchmarking other residential programs Attendance at “Best Practices” conferences Phase 2 – Implementation Implemented PBIS Family Finding Family Inclusion Practices and Procedures Community Based Practices Switch to Mental Health Model vs. Day TX. Developed Transitional Services 3 Residential Services Description 4 RCL (Rate Classification Level) 14 cottages, capacity of up to 10 children Two units for children ages 6-12 years Two units for youth ages 12-18 years 3 are co-ed and 1 is all male Array of Services Comprehensive assessment of all life domains Family Therapy Individual Therapy Intensive case management and linkage to community activities Nursing services Psychiatric Assessment and Treatment Psycho educational and psychotherapeutic groups Academic support Family Finding Family Partner Services Medical/Dental Assessment and Linkage Recreational, Music and Art Therapy Therapeutic milieu based on PBIS principles 4 Youth Characteristics Residential Gender Male 59% Language English 95% Ethnicity African American 13% Caucasian 30% Latin American 46% Other 12% Age at Entry 13 to 18 Years Old 54% % of Out-of-Home Placements 3 or More 79% CAFAS at Entry Severe (140 and Higher) 69% 5 Youth Characteristics (cont.) Residential History of Abuse Physical Yes 64% Sexual Yes 40% Drug/Alcohol Yes 77% 6 Why PBIS? Evidence in schools that approach creates pro social positive environments Alignment with agency philosophy Goodness of fit: congruent with behavioral approach already utilized Focus on increasing quality of life, achieving broad goals and supporting portable skills Use of a proactive and educative approach to support elimination of “control based” interventions including restraints Eber, Sugai, Smith, & Scott (2002); Scott & Eber (2003 a & b) 7 PBIS Implementation Strategies PBIS Overview Training for all staff Hired a Consultant who observed each cottage to understand current operations and provided 3 8-hour trainings on Functional Behavioral Assessment and Behavior Support Plans Developed an implementation work team Developed a “Support team” Developed behavior and cottage management system Reviewed past point and level system, developed new systems based on values matrix 8 Living Situation at Exit 100% 80% 60% 40% 20% 0% Pre-EBP Post-EBP Pre-EBP Willow Post-EBP Sequoia Home Foster Family Pre-EBP Post-EBP Pre-EBP Penn East More Restrictive Post-EBP Ruth Mallery Other 9 Reason for Discharge 100% 80% 60% 40% 20% 0% Pre-EBP Post -EBP Pre-EBP Post -EBP Pre-EBP Post -EBP Pre-EBP Post -EBP Willow Sequoia Penn East Rut h Mallery P l anned Di schar ge T x Goal s Not M et Neut r al M i ssi ng I nf or mat i on 10 Avg. Number of Restraints Average Number of Restraints Per Month 14 12 10 8 6 4 2 0 12 9 8 6 3 0 1 Willow 0 Sequoia Pre-EBP Penn East Ruth Mallery Post-EBP 11 Avg. Number of Assaultive Behaviors Average Number of Assaultive Behaviors Per Month 20 16 15 11 8 10 7 5 5 3 2 0 0 Willow Sequoia Pre-EBP Penn East Ruth Mallery Post-EBP 12 Facilitative Factors Agency and PBIS philosophy alignment Sponsorship and resources from management Outcome and Evaluations Department Clearly delegating tasks to specific people with timelines PBIS Trainer/consultant became familiar with program, built relationship with staff and maintained on-going support for implementation. Data management practices Using electronic record to gather and report data Use of change methodology and quality improvement techniques Open to concerns and seeing resistance as helping to inform the change process Acknowledging staff and celebrating successes Resource binders and books Developing Program Procedures to support implementation Structuring discussions of BSP in team meetings Development of a “Support Team” and an Operations work team Building PBIS job expectations into staff evaluations 13 Challenges Implementing significant change while caring for children 24-7 Deciding what practices to discontinue to make room for new practices Development of a sustainability plan Considering multi-systemic needs and regulations, particularly in terms of documentation Maintaining focus and prioritizing PBIS implementation with multiple other demands Learning curve on how to utilize data to inform practice Establishing consistency and accountability across three shifts, 20 staff and registry Overcoming agency culture “flavor of the day” 14 References Scott, T.M. & Eber, L. (2003). Functional Assessment and Wraparound as Systemic School Processes: Primary, Secondary, and Tertiary Systems Examples. Journal of Positive Behavior Interventions, Vol 5 (3), pp 131-143. Eber, L., Sugai, G., Smith, AC.R., & Scott, T.M. (2002). Wraparound and Positive Behavioral Interventions and Supports in the Schools. Journal of Emotional and Behavioral Disorders, Vol 10 (3), pp 171-180. 15