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

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

National Perspective Six Core Strategies for the Reduction of Seclusion /Restraint - National Technical Assistance Center/National Executive Training Institute 2/25/2005  Leadership toward Organizational Change  Use of Data to Inform Practice  Workforce Development  Use of Restraint Reduction Tools  Consumer Roles  Debriefing Techniques

National Perspective Assumption  Restraints keep patients safe.  Restraints keep staff safe. Reality  Each year, 50 – 100 deaths occur nationally due to seclusion and restraint.  For every 100 mental health aides, 26 injuries were reported in three – survey 1996

National Perspective Assumption  Restraints are used only when absolutely necessary and for safety reasons.  Restraints are not used as, or meant to be punishment Reality  Patients are restrained for such trivial “offenses” as refusing to move to another dining room table.  People who have been secluded or restrained typically experience a sense of punishment.

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

History Positive Approaches Subcommittee Positive Approaches Local Networking Groups Restrictive Procedure Workgroup OMHSAS & OMR Dual Diagnosis Forums

History Trainings for families, direct support professional and other support staff Mental Health Support Process subcommittee Statewide Positive Practices Committee Positive Practices Resource Team (Pilot)

Everyday Lives Values AccountabilityChoiceCollaboration Community Inclusion Contributing to the Community ControlFreedom IndividualityMentoringQualityRelationshipsSafetyStabilitySuccess

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

Positive Approaches Paradigm Positive Approaches asks us to always look at the context in which we frame our work. Positive Approaches is grounded in two basic assumptions: –People always have good reasons for what they are doing. –People always do the best they can with what they know in that context and at that point in time.

Positive Approaches CommunicationAssessmentEnvironment Hanging in there

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

Elimination of Restraints through Positive Practices MR Bulletin Effective May 1, 2006

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

Elimination of Restraints through Positive Practices Philosophy of Care Continuous Risk Management and Quality Efforts Reducing Restraints and Restrictive Procedures

Philosophy of Care The individual is the central focus of the planning team. Creating a safe and supportive person centered environment. Use and inclusion in the ISP of positive practices that are known to be effective in helping the individual.

Philosophy of Care Prevention and early detection are critical. Creating a culture of respect and insuring training for staff that focuses on all forms of positive practices.

Continuous Risk Management Training Recommendations Environmental design, social, physiological and cultural motivators for behavior, including information on individuals who have experienced trauma. Positive behavioral and support methods that include techniques to deescalate behavior. Information on methods for interacting with individuals who have a dual diagnosis of mental retardation and a mental illness.

Continuous Risk Management Training Recommendations Person centered alternatives to the utilization of restraint, including the integration of effective behavioral supports and individual teaching strategies. Basic training in body mechanics. Definitions, policies and the risks associated with the application of restraint.

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

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

Continuous Risk Management Administrative Review OMR Recommends  The County Mental Health/Mental (MH/MR) Retardation Program or Administrative Entity should review each provider’s policies on behavior supports, restrictive procedures and restraint.  OMR Licensing Representatives and the Department Health Representatives, as part of their annual surveys and program monitoring, will review provider policies on restrictive procedures and restraint use.

Reducing Restraints and Restrictive Procedures Restraint is not treatment or a substitute for treatment. Physical restraint is used only as a last resort safety measure when there is a threat to the health and safety of the individual and/or others And only when less intrusive methods have been ineffective.

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

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

Reducing Restraints and Restrictive Procedures Individual Plan Recommendations A review of “sentinel events” to learn and communicate what has worked well in avoiding the restraint. The type of procedure to be used with an individual whose restraint reduction plan incorporates the possible use of emergency restraint in order to protect the individual’s health and safety.

We are already on our way…

OMR Plan to Eliminate the Need for Restraint May 2006

OMR Plan to Eliminate the Need for Restraint Developed to complement and correspond with the principles of the Department of Public Welfare ACT Initiative Establishes the requirement for Regional Positive Practice Committees to review restraint reduction plans specific to the region in concert with Regional Risk Management Committees Charges the Statewide Positive Practices Committee with the responsibility of reviewing regional plans

OMR Plan to Eliminate the Need for Restraint Sets a goal of twenty percent reduction in each of the four regions using data from the Home and Community Information Systems (HCSIS) during FY  Expectation that there will be a 20% reduction in the number of physical restraints thereafter  At the end of the fiscal year the restraint elimination plan will be reviewed with adjustments in expectations and strategies as appropriate

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

Regional Positive Practices Committee (PPC) Promote and expand interest/leadership within the County MH/MR Program/Administrative Entities to build capacity to serve people with challenging behavior Develop Regional Restraint Elimination Plans In partnership with the local stakeholders, plan and facilitate local Positive Practice Committee Meetings

Regional Positive Practices Committee (PPC) Identify existing resources and gaps within the local PPC area Identify steps to address gaps Identify the regional structure to support the Positive Practices Resource Teams (Pilot)

Statewide Positive Practices Committee Review statewide restraint data Review Regional Positive Practices Committee Plans Make recommendations regarding Regional Restraint Elimination plans

OMR and OMHSAS Partnership Positive Practices Resource Team (Pilot)  Purpose is to identify and develop system resources that will be dedicated to address issues pertaining to a person’s behavioral support needs.  The criteria for referral is the person must be demonstrating escalating at risk behavioral challenges and may be at risk for needing enhanced levels of support not readily available to the provider  Piloted in Central Region with resources from OMR Regional Office, OMHSAS Field Office, Selinsgrove Center, Danville State Hospital, Wernersville State Hospital

OMR Bulletins Supporting the Plan OMR Elimination of Restraints through Positive Practices OMR Positive Approaches OMR Principles for the Mental Retardation System OMHSAS, OMR Coordination of treatment and support for people with a diagnosis of serious mental illness who also have a diagnosis of mental retardation OMHSAS, OMR Guidelines for Identifying Persons with Mental Retardation and Mental Illness for State Mental Health Hospital Discharge

Next Steps OMR will integrate the Positive Practice goals with the Quality Management Framework to ensure learning, sustainability and connection to other OMR initiatives Implement three month pilot of Positive Practice Resource Team Regions to complete Restraint Elimination Plans Next Positive Practices State Wide Committee to review Regional plans and provide input into plans

OMR Contacts Western RegionNortheast Region Sharon LipscombMichele O’Toole 300 Liberty Avenue100 Lackawanna Ave. Pittsburgh, PA 15222Scranton, PA Central RegionSoutheast Region William BruawKathleen Gerrity 430 Willow Oak Bldg.1400 Spring Garden St. Harrisburg, PA 17105Philadelphia, PA