1. Preparing your Organization for Challenging Clients
Courtney Downing, MA, BCBA
Tony Thomas, LISW-S, ACSW
Welcome House, Inc.

2. Objectives
Attendees of this presentation will gain an understanding of how their organization can structure a clinical review team.
Attendees will gain understanding of how a clinical review team can interact with local physicians and psychiatrists who treat individuals who are dually diagnosed.
Attendees will gain an understanding of how to effectively utilize information gained from their clinical review team and how it can result in more comprehensive, person-focused care for clients using case examples.
Attendees of this presentation will be provided recommendations on how to develop a behavior support program at their organization and best practices for staff training.

3. Welcome House, Inc. History of organization (1972, 1981, 1999, 2018)
Recognizing the need to make changes to accommodate challenging clients
Conducted a new strategic plan in Four major areas of focus: Utilizing Data, Building Infrastructure, Defining Growth, and Innovate our Service and Supports
Younger adults with ASD were coming into County Board emergency system, needed respite, time away from families, post hospitalization treatment, high intensity coordination of care
Agency was serving primarily a “first generation” of persons with IDD

4. Welcome House, Inc.
FIRST GENERATION VS SECOND GENERATION (what does it mean??)
TRENDS OF SERVICE DELIVERY (need more behavior support)
AUTISM AND ASD INCREASING (pushing the system in different directions)
OLDER ADULTS WITH IDD NEED SPECIALIZED CARE (sedentary and quiet environments)
YOUNGER PERSONS WITH ASD NEED SPECIALIZED CARE (safe and secure environments)
MENTAL HEALTH NEEDS ARE HIGHER (more clients with ASD means higher episodes of mental health diagnoses combined with behavior support)
AGENCY NEEDED TO CHANGE, BUT HOW??
AGENCY CREATED A CLINICAL REVIEW TEAM

5. Behavior Support Overview of services
One-on-one behavior support, creation of person-centered behavior support plans and client goals, staff training
New Assessment Process
Interviews with staff
Functional Behavior Assessment created
Creation of individualized data sheets for baseline data
Multiple, direct observations completed by Behavior Support Specialist

6. Assessment Process-Behavior Support
Rule out all potential medical reasons
Complete records review of previous interventions/history
Interviews with family members, staff (both home and work)
Functional Behavior Assessment completed
Staff trained to take descriptive data
Direct observations and one-on-one meetings with client
Plan creation begins

9. Changes in New Staff Training
Staff are identified who are assigned to high-behavior homes
Orientation is modified based on where staff is assigned
Follow up and support is provided/offered to staff
New staff orientation now includes:
Overview of Applied Behavior Analysis strategies
Overview of functions of behavior
Preventative strategies
Overview of dual-diagnosis, autism, and psychiatric conditions
Data collection procedure

10. Date and Initials Time, Location Setting Event Antecedent Behavior
What happened right before the behavior?
Behavior
Consequence
What happened after the behavior?

11. Understanding Behavior
Setting Event: Lack of sleep, medication change, change in schedule, health issues, etc.
Antecedent: What sets off the behavior? Placing a demand on the client, transitions, waiting, other clients receiving attention, etc.
Behavior: What does the behavior look like?
Consequences: What is reinforcing the behavior?

12. Behavior Support Creation of Behavior Support Strategies
First, all factors are considered
Health factors
Environmental factors
Trauma
Are all proper supports in place (social work, group support groups, etc.)?
Staff input
Direct data
Specific and measurable goals created for client (with input from Site Supervisor and DSPs)
Training document with support strategies

13. Creation of New Training Process
First, site supervisor is trained on the plan and data collection
Initial group staff meeting to learn more about the individual and review strategies
Direct and personalized training in the home (1-3 times per week)
Provided on varying shifts
Feedback is provided to site supervisor and staff directly
One-on-one staff training provided, if necessary
Data is provided on a weekly on the current strategies and interventions
Revisions are made, as needed

14. Case Study
31 year old, female, with Autism Spectrum Disorder, Borderline Intellectual Disability, Major Depressive Disorder
Loves writing, reading, music, art
History of trauma, neglect as a child
Challenges: Elopement, physical/verbal aggression
Assessment findings: Lack of effective coping skills, inability to recognize her own triggers, lack of staff training on autism, need for an updated plan

15. Case Study One-on-one sessions began in September 2016
Developed new coping skills with client, roleplay with client, social stories to identify feelings/other’s feelings/appropriate reactions
New assessment completed
Staff training completed
Self-monitoring
Data collection
Worked directly with client’s counselor

16. September 2018 Effectively uses coping skills independently
Able to identify personal triggers and appropriate responses
Staff reinforces use of positive skills
Staff trained and actively implementing behavior support plan
Previously would not attend annual meetings, now requesting meetings to discuss issues

17. Clinical Review Team What is it? Who does it consist of? Benefits?
Use of HRST

18. Clinical Review Members
Program Director
Officer of Residential Operations
Associate Executive Director
Director of Social Work
Director of Quality Assurance
Director of Nursing
Registered Nurse
Behavior Support Specialist
Two psychiatrists

19. Meeting Structure Bi-weekly meetings
Highest need clients are evaluated and assessed
Based on:
Unusual incident reports
Illness and injury
Behavioral incidents
Frequency of incidents
Health Risk Screening Tools (HRST) scores

20. Health Risk Screening Tool (HRST)
Generates a health risk score based on:
Functional status
Behavior
Physiology
Safety
Frequency of services
Medical Care Coordinators complete assessments
Provides a comprehensive look at a person’s care that is easily accessible

21. Therap Documentation Clinical Review Team reviews: Daily shift notes
Individual Data: Medical, Behavior, etc.
Medical appointment schedules and reports

22. Developing Connections with Psychiatrists
Monthly conference call with Community Psychiatric Team
Prior to discussion with psychiatrists, clients have been evaluated medically
Observations completed by Behavior Specialist
Staff observations reviewed and discussed
Medication changes reviewed-changes made by psychiatrists, follow ups scheduled

23. Back to Case Study
January 2018-Psychiatric medication change (due to 40+ pound weight gain)
Seroquel removed, Abilify added
Client reports heart beating fast, feeling anxious, not being able to sleep, mood swings
Increased anxiety PRN use from 0-2x per month to 14 times
January 17th, 2018-Client discussed at clinical review with psychiatrist, medication moved from night to morning
February 7th, 2018-Updates given to psychiatrist, challenges continue, appointment made for the following week
Medication changes at appointment, Abilify discontinued
Client begins to stabilize at the end of February 2018

24. Benefits of Clinical Review
Allows for regular updates to psychiatrists, less wait time for medication changes and psychiatric guidance
Comprehensive approach to care
Regular updates on client progress
Improves communication between departments and residential sites
Finding gaps in medical care and appointments

25. Questions?

26. Contact Information
Courtney Downing, MA, BCBA
Behavior Support Specialist
Welcome House, Inc.
Phone: , x262
Tony Thomas LISW-S, ACSW
Executive Director
Phone: , x226