1. Real Reduction Experiences Holston United Methodist Home for Children Greeneville, TN

2. Holston Home Started as an orphanage in 1895 Multi-program agency Foster Care (120 youth) medically fragile, low intensity, therapeutic In-Home Services Adoptions (49 placements in 2003) special needs, domestic, international Child Day Care (100, infant – 5 yrs. old)

3. Holston Home Day Treatment School (75 youth, K-12) Residential Group Care & Treatment (84) Assessment (8) Boy’s Treatment (40 – Lv. 2 & Lv. 3) Girl’s Group Home (8) Girl’s Developmental Home (8) Boy’s Group Home (8) Preparation for Adult Living (12) [2004 Residential Numbers: 50 - 60] Staff : 200+ in four sites

4. Why Change? It looked bad and felt bad 1998 – 1400+ restraints, 2600+ seclusions High number of disruptions, “bouncebacks,” and runaways Some staff began to raise concerns about the therapeutic quality of our “treatment” approach Staff were not given enough skills to appropriately deal with negative behavior

5. Culture Analysis – Crisis Creators High staff turnover Inexperienced staff Poor training Shorter ALOS of youth Higher numbers of more difficult youth Older youth Leadership turnover poor leadership in various positions Perceived lack of support from administrative staff Control-oriented culture of care Fear

6. Restraint Reduction YearRestraintsYouth Injuries Requiring Medical Attention Staff Injuries Due to Physical Management (% of overall) 19981447636 (71%) 1999660227 (66%) 20001690 4 (27%) 200193312 (34%) 2002169017 (49%) 2003116011 (31%)

7. Restraint Reduction

8. Positive Change and Success: Seclusion Reduction Seclusion Reduction YearSeclusions 19982642 19992114 20001259 2001940 2002607 2003386 2004201 [1 st Q = 166 2 nd Q = 35]

9. Seclusion Reduction

10. Relationship of Restraint Reduction to Seclusion Reduction Relationship between restraint reduction and seclusion reduction: r =.91 (p=.01)

11. Leadership Towards Organizational Change Senior leadership decision to reduce restraints Money and staff resources put into exploring/implementing change CWLA consultant brought in Researching what others were doing Buy-in of middle management and direct care supervisors More responsibility on directors and supervisors to hold staff accountable

12. Using Data to Inform Practice CQI Tracking of Restraints and Seclusion Setting % reduction goals Collecting data in a more sophisticated manner via Restraint Review Committee

13. Using Data to Inform Practice: Show them the #’s! 2004 HH Injuries to Staff (Jan. – June) 4 during Restraints 8 during Physical Guidance* *Not all may be related to Seclusion Seclusions are linked to restraints 2003: 80% of restraints due to indication of seclusion Stopped the use of seclusion July 1, ‘04

14. Workforce Development Increased staff training: From 2-4 days orientation to 2 weeks From 1 day of “restraint training” to 4 days of de-escalation and restraint techniques (2 ½ days of de-escalation techniques) Supervisory training increased Added full-time Staff Development Coordinator position

15. Reduction Tools Recently implemented tools: Individual Crisis Management Plans Behavior Support Plans

16. Consumer Roles in Inpatient Settings 14 youth participated in Treatment Model Task Force focus groups on “building relationships” 4 family members participated in Treatment Model Task Force focus groups on “building relationships” Youth input on Individual Crisis Management Plan (ICMP)

17. Debriefing Techniques After each restraint, the primary staff involved conducts a Life Space Interview (LSI) with the youth. LSI documented as a part of Serious Incident Report Informal debriefing for staff involved conducted by supervisor

18. Concurrent Changes Change of treatment culture – 1999 Treatment model task force Move to a relational model of care: “connecting” vs. “controlling” Training in Mediation – 2001 YearGrievancesFounded 200031120 200117024 2002588 2003230

19. Mistakes & Successes Mistakes Went cold turkey Didn’t give other “tools” early on Some hired-in directors didn’t buy in Held on to some staff who didn’t buy in Successes Support from leadership Data and goal- setting Training on staff resistance Training, Training, Training Celebration

20. What We Have Learned It gets worse before it gets better When you take away a tool, you have to put another one in its place Plan thoroughly and prepare staff Power struggles must be recognized and redirected Staff have to be supported and empowered Involve youth – listen and learn

21. What We Have Learned Data collection is key – show them the numbers! Review process is critically important

22. Restraint Review Committee: Purpose Tracking through data gathering Emphasis on detail of report writing Identifying trends Sending a message of importance Giving feedback to staff Learn from mistakes and successes Meeting Standards -now mandated by TN DCS

23. What We Have Learned Model for culture change – Edgar Schein It is a process Expect resistance It takes time to change a culture 5 - 15 years