American Public Health Association, Washington D.C., November 6, 2007 Creating safer mental health treatment settings: The Movement in Texas to Reduce Seclusion and Restraint Use Melissa Cook, J.D., LMSW, & Lynda Frost, Ph.D., J.D. Hogg Foundation for Mental Health, The University of Texas at Austin Kevin Ann Huckshorn, RN, MSN, ICADA National Coordinating Center for Seclusion and Restraint Reduction Statement of the Problem Approach Intervention Utilized Implications for Policy & Practice Widespread and unnecessary use of seclusion and restraint presents serious risk of physical and psychological harm to consumers and staff. This reality is true across many treatment environments including juvenile detention centers, state hospitals, private hospitals, residential treatment centers, and schools. The Hogg Foundation for Mental Health employed several strategies to encourage safer and more effective treatment practices for mental health consumers in Texas. Through a collaboration between the Foundation and Kevin Ann Huckshorn of the National Association of State Mental Health Program Directors, provider organizations received comprehensive training and technical assistance to change their cultures of care and increase consumer involvement. Texas-based agencies developed reduction plans using NASMHPD curriculum “Creating Violence Free and Coercion Free Mental Health Treatment Environments for the Reduction of Seclusion and Restraint.” (NASMHPD, 2006) Over the past three years, the Foundation has identified several elements that are essential to successfully reducing seclusion and restraint use in Texas-based agencies: 1. While at first agencies resist a cross-agency approach, over time they recognize the value added by comparing ideas and successes across treatment environments. 2. Successful reduction statewide requires work at many levels, including consultation at the facility level to address idiosyncratic issues around implementing a reduction plan, training within specific systems such as juvenile justice or child welfare, and policy work at the state level to improve data collection, uniformity in service delivery throughout multiple settings, and rapid introduction of best practices. 3. Consumers and family members play a critical and central role in improving treatment environments and changing agency culture. 4. Recruitment, training, and retention of mental health workers are significant challenges to creating and maintaining a positive treatment environment, given severe workforce shortages in the state. SIX CORE STRATEGIES TO REDUCE THE USE OF SECLUSION & RESTRAINT PLANNING TOOL © 142 deaths related to seclusion and restraint use from 1988 to 1998 (Hartford Courant, 1998) STRATEGY 1: LEADERSHIP TOWARDS ORGANIZATIONAL CHANGE STRATEGY 2: USING DATA TO INFORM PRACTICE STRATEGY 3: WORKFORCE DEVELOPMENT STRATEGY 4: USE OF S/R REDUCTION TOOLS STRATEGY 5: CONSUMER ROLES IN INPATIENT SETTINGS STRATEGY 6: DEBRIEFING TECHNIQUES KEY EVENTS -Hogg Foundation highlights Seclusion and Restraint Reduction at the 13th RLS Conference (December 2004) -Hogg Foundation releases Safe and Appropriate Behavioral Interventions publication and CD (2005) -79th Texas Legislature passes SB 325 which mandates human services agencies in Texas to promulgate regulations that, among other things, include new definitions for emergency and seclusion, prohibit restraints that obstruct airways, and restricts use of prone and supine holds. (May 2005) -Cross-agency Behavior Management Task Force mandated by SB 325 completes report with recommendations on best practices in a variety of settings (2006) -Hogg Foundation hosts Seclusion and Restraint Reduction Training Institute for over 300 participants representing 29 facilities, state agencies, and policy makers. Participating organizations send leadership teams of up to 14 staff members to develop a seclusion and restraint reduction plan for their facility. (September 2006) -Hogg Foundation convenes a cross-agency Leadership Group representing consumers, family members, advocates, state agencies, and private providers to establish leadership support for changing the culture of care in Texas agencies (February 2007) -Leadership Group assists Texas’ Health and Human Services Commission in applying for a SAMHSA grant (Spring 2007) -Hogg Foundation sponsors a follow-up conference for participants of the 2006 Training Institute to provide advanced training in workforce development, trauma- informed care, and roles of consumers and family members. (June 2007) -State of Texas Alternatives to Restraint & Seclusion (STARS) Project is funded by SAMHSA in full— $213,817 each year for three years (September 2007) 50 to 150 deaths occur nationally each year due to seclusion and restraints estimated by the Harvard Center for Risk Analysis (NAMI, 2003) Outcomes 26 injuries occur for every 100 mental health aides. The injury rate was higher than what was found among workers in lumber, construction, and mining industries (Weiss et al.,1998) A number of facilities reported a significant drop in seclusion and restraint use. 23 of the 29 Texas-based agencies that developed Seclusion and Restraint Reduction plans report success in reducing rates of seclusion and restraint use by implementing several successful strategies in the areas of staff training, facility environment modifications, data collection and analysis, and consumer involvement. All Health and Human Services Agencies in Texas are engaged in rule revisions in accordance with best practice recommendations of the SB 325 Report. References Purpose For a complete reference list, see www.hogg.utexas.edu/programs_S&R.html This project aims to reduce seclusion and restraint use by supporting Texas-based agencies serving people with mental illness in changing their cultures of care from control to collaboration, increasing consumer voice, and preventing power struggles. Effective cross-agency leadership is essential to promote and support the culture change needed for seclusion and restraint reduction. One children’s residential treatment center converted two seclusion rooms into soothing rooms and report over 50% reduction in seclusion and restraint incidents. National Alliance for the Mentally Ill. (2003, January 11). A summary of reports of restraints & seclusion abuse received since the October 1998 investigation by The Hartford Courant. Retrieved January 11, 2003 from www.nami.org/update/hartford.html National Association of State Mental Health Program Directors (NASMHPD). (2006). Training curriculum for the reduction of seclusion and restraint: Creating violence free and coercion free service environments. Alexandria, VA: National Technical Assistance Center for State Mental health planning (NTAC) Weiss, E. M., Altimari, D., Blint, D.F. et al. (October 1998). Deadly restraints. The Hartford Courant. A juvenile probation department reports a 60% reduction in seclusion and restraint use in the first quarter of 2007 when compared to the first quarter of 2006. Leadership in Texas To further support the gains made by Texas agencies, the Hogg Foundation launched the cross-agency Seclusion and Restraint Reduction Leadership Group in February of 2007. Composed of mental health consumers, family members, advocates, and representatives of private and public agencies, the group serves as a resource in the state, providing leadership to support and guide culture change in Texas agencies. Since attending the September 2006 training institute, one private psychiatric hospital realized a 61% reduction in seclusion and restraint use campus-wide. Grant funding provided by SAMHSA allows Texas to continue seclusion and restraint reduction efforts in state hospitals. The anticipated benefits and lessons learned will be distributed across agencies through the guidance of the Leadership Group. The SAMHSA-funded STARS Project will include a rigorous evaluation of outcomes over the next three years. What We Know About Seclusion and Restraint Harm from seclusion and restraints is well documented; the positives are not substantiated Seclusion and restraints are not evidence- based practices Significant culture change is needed Contact Lynda Frost, Ph.D., J.D. Associate Director Hogg Foundation for Mental Health Lynda.Frost@austin.utexas.edu www.hogg.utexas.edu Kevin Ann Huckshorn, RN, MSN Director, National Technical Assistance Center National Association of State Mental Health Program Directors Kevin.huckshorn@nasmhpd.org www.nasmhpd.org American Public Health Association, Washington D.C., November 6, 2007