1. Legislation and Promising Practices for Reducing Restraint & Seclusion Use Restraint and Seclusion in Foster Care Presented by Lloyd Bullard, M. Ed. LB International Consulting, LLC.

2. Introduction

3. Legislation Children’s Health Act of 2000 (H.R. 4365) Signed into Law October of 2000 by President Clinton The Act contains two significant section: –Part H and; –Part I.

4. Children’s Health Act of 2000 Part H - applies to public and private general hospitals, nursing facilities, intermediate care facilities, or other health care facilities Part I – applies to public and private non-medical, community-based facilities for youth (as defined by the secretary)

5. Children’s Health Act of 2000 Part I – required physical restraints and seclusion to only be imposed in emergency circumstances and only to ensure the safe of the child, staff or others Other less restrictive interventions would have been determined to be ineffective

6. Children’s Health Act 2000 Restraints or seclusion are imposed only by an individual trained and certified by state recognized body (as defined by the secretary) Interim Procedures – Supervisory or senior staff with training in restraint and seclusion who is competent to conduct a face-to-face assessment (as defined by the secertary) Supervisor or senior staff continues to monitor the situation for the duration of the restraint or seclusion Secretary 6 months to develop standards/States 1 year to develop standards once the Federal standards are implemented

7. Foster Parents and Restraint & Seclusion Use Cornell University’s Research – Numerous focus groups with children in foster carte and foster parents Cornell has refused to train foster parents on restraint techniques. Based on children perceiving that the foster parents were attempting to hurt them Liability issues related to safety risks

8. Why So Many Restraints? Caretakers say: –It’s the clients. –They have such severe problems –They often put themselves, other clients, and staff at risk. –It’s necessary to keep everyone safe.

9. But Some Studies Suggest Otherwise Programs serving similar children have widely varying rates of restraint. Some programs serving very difficult children have low restraint rates. Many programs have significantly reduced restraint without changes in their populations.

10. What is it about us? Our belief that the problem lies with the clients Focus on management and control as opposed to support and teaching Lack of staff skills in effective de-escalation

11. Bad News or Good? Being identified as the source of the problem may sound like bad news or an indictment of caretakers. But it’s actually good news. –If it really were the clients, we’d be stuck doing thousands of restraints forever. –If it’s us, we can do something about it.

12. Successful Strategies to Reduce Restraint and Seclusion

13. The Issue Brief (NETI, 2003) Reducing the Use of Restraint and Seclusion: Promising Practices and Successful Strategies –An issue brief that annotates policies and practices that successfully reduce the use of restraint and seclusion Chapters Leadership Organizational Culture Agencies’ Policies, Procedures and Practices Staff Training and Professional Development Treatment Milieu Continuous Quality Improvement

14. The Issue Brief Information pulled from a variety of sources as outcomes and data on children is scarce Project’s own preliminary quantitative and qualitative findings Subject matter experts Focus groups findings (Federation of Families for Children’s Mental Health - FFCMH) Published research findings

15. Leadership (NETi, 2003) Supportive Executive Leadership –Identify Restraint and Seclusion as a Top Priority Sustained commitment by the executive leadership team. –Set the Tone Mission statement supports a violence- and coercion-free environment Restraint and seclusion are crisis events, treatment failures, and high-risk interventions Leaders must model the interest, time commitment, and “sell” the initiative to managers and direct care staff

16. Leadership (NETI, 2003) Supportive Executive Leadership continued: –Provide Training and Resources Emphasize training in alternatives to restraint and seclusion Ensure integration of training into practice –Establish an Oversight Committee Include executive leaders, managers, supervisors, direct care staff, family members, children, and advocates Committee empowered to implement changes

17. Leadership (NETI, 2003) Supportive Executive Leadership continued: –Take Responsibility Administrators shoulder the burden of reducing restraint and seclusion –Maintain Accountability Executive leader(s) on-call 24 hours a day to whom each incident is immediately reported

18. Leadership ( NETI, 2003) Supervisory and Managerial Involvement Set the Tone –Send a clear message –Support coercion-free environment, partnerships, choice, and proactive communication –Elimination of the unnecessary use of restraints and seclusion is paramount Model and Coach –Alternative approaches –High expectations, time commitment, training resources, 24 hour on-call support

19. Leadership (NETI, 2003) Supervisory and Managerial Involvement continued Lead Debriefing –Exercise for learning not punishment –Gather data –Discuss –Document timelines

20. Leadership (NETI, 2003) Elimination by Mandate Banning restraint use or types, eliminating of seclusion rooms, or use of prns Constant vigilance and ongoing training in de-escalation Requires emphasizing behavioral support instead of emergency intervention

21. Organizational Culture ( NETI, 2003) Relationship Building –Facilitates support of positive behavior –Helps de-escalate children in times of crisis Healthy Relationships are developed over time

22. Organizational Culture (NETI, 2003) Person-Centered Environment –Needs of the child are at the forefront of care –Use supportive language, and express an unwillingness to label children as “manipulative” or “needy” –Emphasize collaboration rather than compliance –Offer culturally and linguistically competent services

23. Organizational Culture (NETI, 2003) Staff Empowerment Youth Involvement Family and Natural Support Involvement –Treatment Planning –Programming –Participation on Review Team –Advocacy

24. Agency Policies, Procedures and Practices (NETI, 2003) Comprehensive Assessment History of aggression, and the physical, psychiatric, and emotional risks of restraint and seclusion Inform the behavior support and treatment plans –Treatment Planning Individualized and strengths-based Developed in conjunction with child and family –Individualized Behavior Support Plan Identify triggers, successful intervention strategies, and options for self-calming Communicated to all relevant staff Revisited regularly

25. Agency Policies, Procedures and Practices (NETI, 2003) Monitoring –Face-to-face, third party –Assess the physical and psychological well-being of child –Authority to stop intervention if signs of distress are evident Debriefing –Occurs with the child, witnesses, staff, and family members –Express feelings about the incident and to make a plan to avoid for incidents –Debriefing does not assign blame –Should be carefully documented Staff Designated to Implement Restraint and Seclusion

26. Staff Training and Professional Development (NETI, 2003) Training on Trauma-Sensitive Care, Prevention, and De-escalation –AT LEAST 50% of all training should focus on these three core elements Competency-Based Training Culturally and Linguistically Competent Services –Tones, gestures, and postures that may be misinterpreted by youth Frequent Refreshers to Minimize Training Drift Regular Staff Supervision, Mentoring, and Coaching

27. Treatment Milieu (NETI, 2003 ) Treatment Philosophy –Coercion-free and non-punishment based Trauma-Informed Care –Culture of empathy –Acknowledge that most children have experienced trauma –Restraint and seclusion is re-traumatizing –Staff should know signs of trauma Positive, Structured Environment –Requires active programming –Well-maintained environment Behavior Support –Give children anger and anxiety management skills. –Constant role playing.

28. Continuous Quality Improvement (CQI) (NETI, 2003) Setting Organizational Goals Collecting and Analyzing Data Reporting Results Corrective Feedback Mechanisms Celebrating Successes Program Evaluation

29. CWLA Resources

30. Best Practice Guidelines For Behavior Management Ethical & Legal Framework Administration & Leadership Continuum of Intervention Medical Issues Professional Development & Support for Caregivers.

31. Reducing the Use of Restraint & Seclusion: Promising Practices & Successful Strategies Leadership Organizational Culture Polices, Procedures & Practices Training & Professional Development Treatment Milieu Continuous Quality Improvement

32. Best Practice Guidelines for Behavior Support & Intervention Training Organizational Leadership & Culture Behavior Support & Intervention Training Programs Risk Factors Emergency Interventions Training Process

33. Supervisors Training Curriculum Changing Organizational Culture Behavior Support Plans Program Factors Family Involvement Diversity Issues Reward & Consequence Systems Supervisory Role No Blame Culture De-Briefing

34. State Regulations Definitions Criteria Monitoring Ordering Post Assessment De-Briefing Family Notification Training Documentation Reporting CQI Plans Prohibited Practices Data Collection Reduction Plans

35. Summary Restraint reduction is a 4-step process: 1.Admit it’s us who have to change 2.Look honestly at our contributions to this problem 3.Attack each of the six areas 4.Evaluate progress and don’t give up