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

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)

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: ] Staff : 200+ in four sites

Why Change? It looked bad and felt bad 1998 – restraints, 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

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

Restraint Reduction YearRestraintsYouth Injuries Requiring Medical Attention Staff Injuries Due to Physical Management (% of overall) (71%) (66%) (27%) (34%) (49%) (31%)

Restraint Reduction

Positive Change and Success: Seclusion Reduction Seclusion Reduction YearSeclusions [1 st Q = nd Q = 35]

Seclusion Reduction

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

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

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

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

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

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

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)

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

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

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

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

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

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

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