Transcript 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.

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 LeBel
MA Department of Mental Health
617-626-8085
[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 Seclusion
Are Not Treatment
In 1999, the NASMHPD Medical Directors
Council debated the challenge of R/S
reduction/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)
2004-2010
Previous 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
applications
This data are currently being analyzed by HSRI
and a group of consumer expert researchers
Data available in next few months
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Brief Historical Overview
National S/R Reduction Initiative(s)
2004-2010
New SIG Project
2007-10: 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 evidencebased 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
Reports
The 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 Transformation
System Goal = Recovery for everyone
Services/supports are consumer-centered
Focus of care must increase consumers’ ability to
self manage illness and build resiliency
Individualized Plans of Care critical
Consumers 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 nondiscriminatory”
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 change
We have come to believe that this work is a
fundamental cornerstone in transforming our
systems of care
Effective Leadership is critical
New staff knowledge and practice changes will set
a foundation
Changes 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 Literature
Qualitative Reports emerged from personal
experiences (self and colleagues) with direct
experiences in successful reduction projects
across the country
Qualitative 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 change
The Public Health Prevention approach
Use of Recovery/Resiliency Principles
Valuing Consumer/Staff Self Reports
Trauma Knowledge operationalized
Staying 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 Model
Tertiary
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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, prosocial behaviors or trust
(New Freedom Commission, 2003; Onken et al, 2002)
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Trauma-Informed Care
Emerging 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 avoided
Universal precautions required (NETI, 2005)
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Consumer/Staff self-reports
“The first time that I helped with a restraint, a fourpoint 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 #1
Leadership in Organizational Change
The 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 priority
To assure for an organized Plan
To reduce/eliminate organizational barriers
To provide or re-allocate the necessary
resources
To hold people accountable for their actions
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Core Strategy #1
Leadership in Organizational Change
Create A Vision
Live Key Values
Develop your Human Technology
Monitor Staff Performance
Elevate Oversight of Untoward Events
Assure Violence/S/R Prevention Plan
Development (Anthony, 2004; Huckshorn, 2004)
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Core Strategy #2
Using 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
use
Gather historical data by event/hours (6 months
to 1 year) to use as baseline
Set realistic goals or 100% reduction
Post reports on units monthly
Mandate data collection on S/R events,
hours, stat meds, and consumer and staff
injuries
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Core Strategy #2
Using 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 # 2
Using 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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Core Strategy #3
Workforce Development
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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Core Strategy #3
Workforce Development
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 #4
Use 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 #4
Use Violence/S/R Prevention Tools
Use of comfort rooms
Implement sensory rooms and sensory
interventions
Incorporate Person First Language
Monitor Training Guidelines (Deescalation 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 peers
Director of Drop-in Center
Director of Consumer Affairs Office
Mental health technician
Recovery specialist
Debriefing specialist
Treatment Team Advocate
Staff in QI Department
Trainer
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Core Strategy #6
Make 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 Specifics
Develop 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
inconclusive
More 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 multifactorial. “Human behavior does not occur in a
vacuum…” (p. 9).
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Promoting Risk Interventions by
Situational Management (Johnstone & Cooke, 2007)
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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Promoting Risk Interventions by
Situational Management (Johnstone & Cooke, 2007)
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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Promoting Risk Interventions by
Situational Management (Johnstone & Cooke, 2007)
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 Facilities
Salem Hospital
No. VA MH Institute
Worcester State Hospital
Western State Hospital
-100%
- 99%
- 98%
- 79%
Child & Adolescent Facilities
Cambridge Child Assmnt Unit
Boston Medical Center IRTP
Holston United Methodist Home
Natchaug Hospital
-100%
-100%
- 95%
- 93%
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Variety of Types of Programs
Intellectual & DD Facilities
Millcreek in MS (225 beds)
Siffrin in OH (300 beds)
Lutheran in WI (1,000 beds)
LifeShare in NH, ME & FL
- 100%
- 100%
- 100%
- 100%
(Ohio, 2005)
Forensic Facilities
Taylor 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 Facilities
Total R/S Episodes per 1000 Patient Days
Pre -Inte rv e ntion
100
90
84.0
# Episodes per 1000 Patient Days
80
72.2
73.4
70
Post-Inte rv e ntion
60
Child
Adolescent
Mixed C/A
50
40
27.98
30
29.04
24.33
20
10
0
11/1/99 - 10/31/00
9/1/01 - 12/31/04
Significant Periods
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MA R/S Hours Also
Reduced
Child
- 30.5%
Adolescent - 58.3%
Mixed C/A -19.2%
C/A DMH Licensed and State Facilities
Total RS Hours per Episode
Pre-Intervention
2.50
2.18
# Hours per Episode
2.00
Child
1.50
Adolescent
Post-Intervention
0.91
1.00
0.59
0.52
0.42
0.41
0.50
Mixed C/A
0.00
11/1/99 - 10/31/00
9/1/01 - 6/30/04
Significant Periods
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Child
- 49.5%
Adolescent - 28.6%
Mixed C/A - 77.4%
MA Medication
Restraint Dropped
C/A DMH Acute and Continuing Care Facilities
Involuntary Administration of Medication
Episodes per 1000 Patient Days
Pre-Intervention
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# Episodes per 1000 Patient Days
32.5
30
Child
Adolescent
21.3
Mixed C/A
Post-Intervention
20
15.9
10.75
11.35
10
7.34
0
11/1/99 - 10/31/00
9/1/01 - 12/31/04
Significant Periods
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Massachusetts Results
Examples of Most Successful Units
-100%
-100%
Collaborative Problem-Solving
Approach, close supervision,
elevating the role of MHW
Trauma System Treatment Model
-
99%
Holistic Health Approach
-
91%
Fostering Resilience in Children
- 86%
- 78%
Strength Based Approach, threw
out mechanical restraints
Conversion to Relationship Model
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80
Boston Medical Center
Intensive Residential Treatment Program
Total Seclusion, Restraint & Injury Episodes
09/00 - 05/07
SR Episodes
60
Kid Injury
50
Staff Injury
40
St
30
20
10
May-07
Jan-07
Sep-06
May-06
Jan-06
Sep-05
May-05
Jan-05
Sep-04
May-04
Jan-04
Sep-03
May-03
Jan-03
Sep-02
May-02
Jan-02
Sep-01
May-01
Jan-01
0
Sep-00
SR & Injury Episodes
70
Significant Periods
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Seclusion and Restraint Orders and
Patient Related Employee Injuries
Worcester State Hospital
Q4 FY '00 - Q1 FY '05
1200
50
1000
40
35
30
600
25
20
400
15
10
200
# S/R Orders
# Patient
Related
Employee
Injuries
5
05
04
Q
1
FY
04
Q
4
FY
04
Q
3
FY
04
Q
2
FY
03
Q
1
FY
03
Q
4
FY
03
Q
3
FY
03
Q
2
FY
02
Q
1
FY
02
Q
4
FY
02
Q
3
FY
02
Q
2
FY
01
Q
1
FY
01
Q
4
FY
01
FY
Q
3
FY
Q
2
FY
Q
1
FY
01
0
00
0
Q
4
S/R Orders
800
Patient Related Employee Injuries
45
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Strategies MA/Oregon Programs
Began to Address
Strength-based Approach (e.g.,
strengthbased assessments, daily focus on
strengths, environment plastered with
strengths, 5 or 8-1 use of praise,
respectful interactions, both children and
families)
Family Partnerships
Self-Esteem Building Activities
Sensitive Listening and Questioning
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Strategies MA/Oregon Programs
Began to Address
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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Strategies MA/Oregon Programs
Began to Address
Trauma Informed Care
Identifying 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 Bel
MA Department of Mental Health
617-626-8085
[email protected]
Kevin Ann Huckshorn or Sarah Callahan
National Association of State
Mental Health Program Directors
(703) 739-9333
[email protected]
[email protected]
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