1 real reduction experiences commonwealth of massachusetts department of mental health janice lebel,...
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Real Reduction ExperiencesReal Reduction Experiences
Commonwealth of MassachusettsCommonwealth of MassachusettsDepartment of Mental HealthDepartment of Mental Health
Janice LeBel, Ph.D.Janice LeBel, Ph.D.Director of Program Mgmt., Child & Adol. DivisionDirector of Program Mgmt., Child & Adol. Division
Nan Stromberg, MSN, APRN,BCNan Stromberg, MSN, APRN,BC
Director of Nursing – Licensing DivisionDirector of Nursing – Licensing Division
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Massachusetts DMH SpecificsMassachusetts 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)
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How did we know we had a problem?
The Quantitative Perspective
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A Review of the DataA Review of the Data
o Restraint use withkids increasingeach year
o Children/Adolescents using more S/R
o Systemicdiscrepancies
66.5
6.9
0
100Rate per
1000 Patient-days
Hospitals A and B
Acute Care Hospital Comparison - 2000
High Utilization
Low Utilization
Restraint Episodes per 100 Admissions (Licensed Facilities)
Pre-Initiative
0
25
50
75
100
125
150
1998 1999 2000
Years
Ep
iso
des p
er
100
Ad
mis
sio
ns
Child (L) Adult (L) Adolescent (L) Mix CA (L)
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How else did we know we had a problem?
The Qualitative Perspective
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Overburdened with R/S Forms Overburdened with R/S Forms from across the Statefrom across the State
We knew there was too much restraint & seclusion when the We knew there was too much restraint & seclusion when the forms were practically upforms were practically up over over our heads.our heads.
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A Painful Pattern & A Painful Pattern & Restraint RecipeRestraint 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
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Clinical Review: Clinical Review: Trauma & Behavioral Trauma & Behavioral Distress UnderappreciatedDistress 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 disruptedo Kids lacked skills
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Children were Hurt in RestraintChildren were Hurt in Restraint
Physical injuriesBroken legs
Broken arms
Broken teeth
Bruises
Cuts
Rug burns & abrasions
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What Were we Doing?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 beenhurt is always the victim
The Kids: “It’s not right to grab me. It hurts. Be nice!”
(Kenny, 9)
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The Disgraceful RealityThe Disgraceful Reality
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Back to the LiteratureBack to the Literature
Data and literature review
found no evidence base
to support R/S use
Cochrane Review2,155 articles but no controlled studiesR/S efficacy not establishedHarm and trauma cited
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Strength-Based Care:Strength-Based Care:Essential Features IdentifiedEssential 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
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The Search for Better PracticeThe Search for Better Practice
Where Where to start?to start?
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The Search for Better PracticeThe 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
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Pediatric Unit: Post-Visit RestraintsPediatric Unit: Post-Visit Restraints (07/00–08/02)(07/00–08/02)
0
20
40
60
80
100
120
Jul-00
Oct-00
Jan-01
Apr-01
Jul-01
Oct-01
Jan-02
Apr-02
Jul-02
NYNY
VisitVisit
Adolescent Unit: Post-Visit Restraints Adolescent Unit: Post-Visit Restraints (07/00-08/02)(07/00-08/02)
0
100
200
300
400
500
600
Jul-00
Oct-00
Jan-01
Apr-01
Jul-01
Oct-01
Jan-02
Apr-02
Jul-02
NYNY VisitVisit
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Changing the Paradigm: Changing the Paradigm: Sorting Myth from RealitySorting Myth from Reality
More money More staff New staff Micro-management of
staff Traditional training
Using resources flexibly Core staff New staff attitude & open
to change Valuing & empowering
staff Enhanced training:
coaching, modeling, mentoring & supervision
Does notnot require DoesDoes require
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Changing the Paradigm: Changing the Paradigm: Sorting Myth from RealitySorting Myth from Reality
Flexibility with the Environment
Collaboration
Negotiation/Dialogue
Rewarding the Positive
Active use of Data
State of the Art Environment of Care
Control
Confrontation/Limit-setting
Reacting to the Negative
Strict Data Collection
Does notnot require DoesDoes require
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Multi-Year PlanningMulti-Year Planning
Fundamental Plan Create a R/S Reduction TeamR/S Reduction Team Consumer & Family Involvement Best Practice Conference Kick-Off & Provider
Strategic Planning Quarterly Statewide Grand Rounds Annual Provider Presentation Forums
The GoalTo change culture, practice & “root” the Initiative by: Communicating & educating Continually reviewing & planning Regulating
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Re-wrote the DMH Regulations, Re-wrote the DMH Regulations, Effective April 2006, DMH Regulation 104 CMR 27.12Effective April 2006, DMH Regulation 104 CMR 27.12
Focus on prevention – not just ‘safe application”
o Prevention requirements: o Crisis Prevention Planso Assessment of Trauma and potential for re-
traumatizationo Program Quality Improvement Planso New Policies and Procedureso Increased Education for Staff o Sensory Resourceso Active use of Data
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Re-wrote the DMH Regulations, Re-wrote the DMH Regulations, Effective April 2006, DMH Regulation 104 CMR 27.12Effective April 2006, DMH Regulation 104 CMR 27.12
o Restrictions if Used o Shortened renewal time for orders (2 hours)o Prohibition of prone restrainto Clarified and tightened seclusion definitiono Prohibition of mechanical restraint for children
under 13o Intensive “real-time” review of long restraints
by facility director and medical directoro Debriefing Requirements
ConsumerStaffAdministrative Review
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For some … For some … a bit of reluctancea bit of reluctance
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Broadening the Perspective: Broadening the Perspective: Improving Care for ChildrenImproving 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 SensesComing to our Senses
o Sensory Assessment: What’s your diet?What’s your diet?o Sensory Intervention: A universal experienceo Giving children and staff greater array of Giving children and staff greater array of
alternative toolsalternative toolso 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 Providers “Model”“Model” Success Success
o Metro WestMetro West - 98%- 98%Holistic Approach
o Cambridge Hospital Cambridge Hospital - 100%- 100%Collaborative Problem-Solving Model
o Westwood Lodge SCU Westwood Lodge SCU - 86%- 86%Resiliency Model
o Boston University IRTPBoston University IRTP - 100%- 100%Trauma Systems Model
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Hunt CenterTotal RS Episodes per 1000 Patient Days
0
25
50
75
100
125
150
175
200
Significant Periods
# Ep
isod
es p
er 1
000
Patie
nt D
ays
Hunt Mixed C/A
Unit Type Average
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Boston University Intensive Residential Treatment Program
Total Restraint & Injury Episodes09/00 - 01/05
0
10
20
30
40
50
60
70
80
Significant Periods
Restr
ain
t &
In
jury
Ep
iso
des
B U IRTP
Kid Injury
Staff Injury
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Top Tips from Providers 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
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Top Tips from Providers 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
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Top Tips from Providers 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”
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What Have we Learned?What Have we Learned?
o Without leadership, it does not happen!o Plan for incremental advancement &
changeo Systematize the effort and make it part of
the organizational fabrico You must celebrate, reward/award &
appreciate hard worko Culture change takes years – this is
marathon work
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S/R Hours Decreased – 49%
C/A DMH Licensed and State FacilitiesTotal RS Hours per Episode
0.59
0.38
2.18
0.550.52
0.34
0.00
0.50
1.00
1.50
2.00
2.50
11/1/99 - 10/31/00 4/1/05 - 3-31-06
Significant Periods
# H
ou
rs p
er
Ep
iso
de
Child
Adolescent
Mixed C/A
Pre-Intervention
Post-Intervention
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S/R EpisodesS/R Episodes Decreased – Decreased – 72%72%
C/A DMH Acute and Continuing Care FacilitiesTotal R/S Episodes per 1000 Patient Days
84.0
14.51
72.2
20.87
73.4
27.57
0
10
20
30
40
50
60
70
80
90
100
11/1/99 - 10/31/00 4/1/05 - 3/31/06
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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Medication RestraintDecreased -86%
C/A DMH Acute and Continuing Care FacilitiesInvoluntary Administration of Medication
Episodes per 1000 Patient Days
21.3
6.3
15.9
1.9
32.5
0.10
10
20
30
40
11/1/99 - 10/31/00 4/1/05 - 3/31/06
Significant Periods
# Ep
isod
es p
er 1
000
Patie
nt D
ays
Child
Adolescent
Mixed C/A
Pre-Intervention
Post-Intervention
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“Good ideas are not adoptedautomatically. They must be
driven into practice withcourageous patience.”
Hyman G. RickoverHyman G. Rickover
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Massachusetts DMH Massachusetts DMH Contact InformationContact Information
Janice LeBel, Ph.DJanice LeBel, Ph.D..
Nan Stromberg, MSN, APRN, BCNan Stromberg, MSN, APRN, BC
25 Staniford Street
Boston, Massachusetts 02114
(617) 626-8119 & (617) 626-8085