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

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.

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 2017. 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

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

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

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

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

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

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

Questions?

Contact Information Courtney Downing, MA, BCBA Behavior Support Specialist Welcome House, Inc. cdowning@welcomehouseinc.org Phone: 440-356-2330, x262 Tony Thomas LISW-S, ACSW Executive Director tthomas@welcomehouseinc.org Phone: 440-356-2330, x226