COORDINATION PBS TEAM Orientation Guide

What is PBS It is a philosophy and a set of tools ► A way of thinking and doing ► Positive behavior support offers a proactive process for  addressing interfering behaviors,  teaching adaptive skills, and  improving quality of life. ► Positive means we are focusing on increasing adaptive skills, not decreasing interfering behaviors.

What is the PBS Network An inter-agency coalition promoting positive support to enhance the quality of life for persons with disabilities. 3

Polk County PBS Mission & Values ► We are an inter-agency coalition promoting positive support to enhance the quality of life for persons with disabilities. ► We make decisions based on:  Dignity & respect  Long-term commitment  System consistency  Person-centered  Empowerment through training, support, & education  Reducing the need for rights restrictions  Promoting full citizenship and the exercise of choice 4

PBS Provider Agencies ► Candeo ► Case Management ► ChildServe ► Community Support Advocates ► Crest Services ► Easter Seals ► Eyerly-Ball Residential ► ISA/FACT ► Link Associates ► Lutheran Services in Iowa ► Mainstream Living 5

PBS Provider Agencies ► Mosaic ► Optimae LifeServices ► Polk County Health Services ► Progress Industries 6

Coordination PBS Team ► Comprised of representatives from each of the case management/service coordination/IHH agencies in Polk County. ► Overall Goal: Embed the PBS Culture into the coordination service delivery system.

What Does Positive Behavior Supports Look Like in Case Management/Care Coordination? ► Used to assist consumers and their support systems in  Identifying interfering behaviors which are not working for them  Understand the triggers, antecedents, and consequences of the behavior  Identify and learn to utilize other behaviors that are healthy. IDENTIFY. UNDERSTAND. LEARN IDENTIFY. UNDERSTAND. LEARN 8

PBS Catalyst ► The role of the Case Manager/Service Coordinator/Care Coordinator in PBS is to be a catalyst for moving PBS throughout all services provided to the individuals we support by:  Educating support systems  Setting the tone of services: Recovery and Growth  Supporting implementation through Crucial Conversations with providers and team members. Conversations with providers and team members.  Asking the right questions 9

Questions to Ask ► What about doing an assessment? ► What is the unmet need? ► What is the person communicating? ► What does the person do well? ► What behavior would be more desirable? What can you live with that isn’t bad? ► What is the positive behavior with which we want to replace the interfering behavior? 10

Questions to Ask ► What changes in routines have you noticed? In what routine? - Who, what when, where, how? ► What tools could be used to help define what is happening and lead us to what we might be able to do? ► What is the setting event, antecedent and interfering behavior? ► How are people responding when the behavior occurs (staff and other people around the consumer)? ► What works? ► What has been tried before? Why didn’t it work? ► How can we reengineer the environment? 11

Defining Characteristics of PBS ► Person Centered ► Collaborative on-going process ► Data-driven decision making ► Prevention, positive, proactive strategies ► Meaningful outcomes 12

Five Essential Goals of Person Centered Planning ► Expressing preferences and making choices in everyday life ► Gaining and maintaining satisfying relationships ► Having opportunities to fulfill respected roles and live in dignity ► Being present and participating in community life ► Continuing to grow 13

Characteristics of Person-Centered Planning ► Includes and focuses on the individual ► Respects the individual and their dreams and choices ► Emphasizes strengths, abilities, and capacities  Strengths-Based Training principles ► Individualized supports ► Empowers the consumer and team 14

Person Centered Planning Collaboration and Teaming ► Effective collaboration and teaming helps: - reach consensus on top priorities with the person, the family and other team members. - conduct a functional assessment and develop a hypothesis that explains the reason for the individual’s interfering behavior. 15

Respect – Fundamental to PBS ► A personal quality that is non-contingent, provided without judgment, and given equally to all persons. ► People should not have to earn your respect they should be the recipient of your respect without condition. 16

IS NOT IS NOT ► Simple ► Short Term ► Just Decrease Behavior ► Reactive ► Aversive (punish) ► Observable Behavior ► Experts Decide IS IS ► Comprehensive ► Long term ► Teach Useful Skills ► Proactive ► Positive (reinforce) ► Function (message behind the behavior) ► Involve Individual 17 Person Centered Planning

End of Part One

Part 2: Philosophy of PBS 19

The Purpose of Life is a Life of Purpose How you see me….. How I want to be seen…. 20

Universal Enhancements ► Pomeranz/Recovery philosophy-get folks into roles-create things of value. ► Identify the life the people we support want and coach them into it. ► If someone has nothing of value, what difference does it make if you take it away? 21

Universal Enhancement Strategies Things of Value INTERFERING BEHAVIOR Spontaneity Positive rituals Dining out Exercising Day at the spa Dancing Sex Friends Voting Having a will Family Fishing Movies Vacationing Good Health Grilling out Music Volunteering Work Pets Hiking Religion Gardening 22

GEM ► G ood E nough for M e –Tom Pomerantz 23

I have come to the frightening conclusion that I am the decisive element in my environment. It is my personal approach, which creates the climate. My daily mood makes the weather. I possess tremendous power to make a person’s life miserable or joyous. I can be a tool of torture or an instrument of inspiration. I can humiliate or humor, hurt or heal. In all situations, it is MY response that decides whether a crisis will be escalated or de-escalated and a person humanized or dehumanized. (Adapted- Halm Ginott)

Life We must provide an environment that is healthy enough for a life to happen. Dan Berkowitz 25

Effective Behavioral Support..requires the design of an environment that makes problem behaviors: 26

What is a “Behavior”? ► Any action or skill that a person does to accomplish something: ► Examples:  Self-inflicted injuries  Manipulation  Balancing a checkbook  Completing homework  Attending work 27

Behavior is method of: communication both verbally & physically of hopes, dreams, fears, anxieties, preferences, intentions and priorities Behavior is also a method to: cope with or respond to demands from others control and impulses, conform to generally accepted social conduct, and or influences of the environment Behavior is the result of complex neurological and sensory process. 28

Why do people display challenging behaviors? Biological/Medical Reasons: Biological/Medical Reasons: Drugs/medicine Drugs/medicine Seizure activity Seizure activity Allergies/hormonal changes Allergies/hormonal changes To mask pain or discomfort To mask pain or discomfort Self-Regulation Self-Regulation To maintain a level of arousal To maintain a level of arousal Reaction to a change in sensory input Reaction to a change in sensory input 29

Reinforcement: Reinforcement: Internal-it feels good Internal-it feels good External-to serve a purpose in one’s environment External-to serve a purpose in one’s environment Absence of Alternative Skill Absence of Alternative Skill Most behaviors have the goal to communicate Most behaviors have the goal to communicate Messages are sent through behavior Messages are sent through behavior Control is the key word Control is the key word 30

How to Define a Target Behavior ► Definition of behavior needs to be clear, concise, and specific ► A description of what you will see when the behavior occurs. ► Written so that everyone can agree when the behavior occurs. 31

Specific Target Behaviors Examples ► high-pitched scream ► Kicks chair over ► Hits others/self ► Completes tasks Non-Examples ► Poor impulse control ► Angry, frustrated ► Aggressive ► Pay attention 32

Lack of Understanding To call someone lazy, uncooperative or stubborn is to admit we don’t understand them. She’s just plain stubborn. She refused to take her meds again! 33

Reframing: ► Pejorative Label  Obnoxious  Rude, arrogant  Resistant  Lazy, un-invested  Manipulative  Just looking for attention  Close-mouthed  Different, odd  Stubborn, defiant  Tantrum, fit, outburst ► Positive, Hope- Based  Good at pushing people away  Good at affecting people  Cautious  Good at preventing more hurts  Good at getting needs met  Good at caring about yourself  Loyal to family and friends  Under-appreciated  Good at standing up for yourself  Big message 34

Prove It! Prove that: treating people with dignity and respect meeting unmet needs bonding decreases the frequency and intensity of challenging behavior. Does it Matter?! 35

If an individual doesn’t know how to read, we teach. If an individual doesn’t know how to swim, we teach. If an individual doesn’t know how to multiply, we teach. If an individual doesn’t know how to drive, we teach. If an individual doesn’t know how to behave, we…………………teach? punish? Why can’t we finish the last sentence as automatically as we do the others? Tom Herner (NASDE President, Counterpoint 1998, p.2) 36

End of Part 2

Part 3: Tools How we get to a Life! 38

Tools for PBS implementation ► Detailed functional assessment completed annually. ► Behavior Analysis Form completed on identified behavior ► WRAP (Wellness Recovery Action Planning) ► Journaling and self-tracking ► Crisis Planning **PBS tools are used by providers and encouraged by Case Managers/Coordinators 39

Four Steps The Provider Uses When Designing an Effective Behavior Support Plan Step One Step Two Step Three Step Four Gather Information Develop a Hypothesis Build a Support Plan Evaluate effectiveness and modify support plan as needed 40

Step 1: Gather Information Step 1: Gather Information Functional Assessment 41

What is Functional Assessment ► A functional assessment is a process for identifying clear, predictive relationships between events in a person’s environment and occurrences of a challenging behavior.  Not a data collection form  Not an event * To be created and completed by provider. Each provider has a variety of assessments to choose from. Our role is to identify when one is needed and request one be done. ** 42

The ABC’s of a Functional Behavioral Assessment ► Setting Event the state a person is in, e.g., the person is tired, or hungry; a state that predisposes a person to behave in a certain way given a particular antecedent. ► Antecedents any stimulus which precedes a behavior occurrence ► Behaviors any observable act of an individual; the activity one performs in the presence of a particular stimulus ► Consequences the events which occurred following behavior 43

Practice the ABC’s Which is the Antecedent, Behavior and the Consequence in each of these examples.  1. During dinnertime, Ben watches the staff pass the tea pitcher to a peer. Ben then passes the water pitcher to the staff, who says “ Thank you” to Ben.  2. Betty repeatedly teases Samantha. Following the teasing remark, Samantha throws a magazine at Betty. The staff tells Samantha not to throw things.  3. A staff person tells Natasha that a visitor will be visiting her in a few minutes. Natasha puts on a new dress. The visitor tells Natasha how nice she looks 44

Practice the ABC’s ► Setting Event: Person grew up in a home in which he wasn’t getting the attention he needed or deserved. ► Antecedent: His girlfriend broke up with him. ► Behavior: He threatened suicide. ► Consequence: He went to the hospital where he got the attention he needed. 45

Alternative Behaviors ► What is the best way to decrease a behavior that is a barrier to getting a life? ► Find an alternative behavior that serves the same function or purpose – gets the same results. 46

Take what you can get; closest to what you want! Reinforce even small improvement or steps to reaching the objective 47

Step 2: Develop a Hypothesis 48

Hypothesis Formula ► When this occurs (what is the setting event/antecedent)…. ► The individual does (behavior) ► To access or avoid (consequences or functions) 49

Step 3 : Build a Support Plan 50

What is a Behavior Support Plan ► A written document that summarizes strategies that assist in preventing challenging behavior from occurring and helps the consumer learn new skills ► The plan should:  develop and maintain skills  enhance opportunities for learning and self-fulfillment  Focus on positive rather than negative techniques 51

Behavior Support Plans ► Developed by Integrated Service/Provider staff ► Completed in conjunction with the consumer and their support team Develop a plan that assists in preventing interfering behavior from occurring and helps the consumer learn new skills.Develop a plan that assists in preventing interfering behavior from occurring and helps the consumer learn new skills. Should be a living document. It was made to be changed as a person grows and changes.Should be a living document. It was made to be changed as a person grows and changes. ► Evaluate effectiveness and modify support plan as needed. 52

Step 4: Evaluate effectiveness and modify support plan as needed 53

Is the plan working? ► Are there improvements in challenging behavior? ► Are there increases in skill development? ► Are there improvements in quality of life?  Increased participation  Increases choice/decision making  Inclusion ► Are there improvements in satisfaction?  Consumer and family  Staff and others ► Are there improvements in health or well-being? 54

Remember, PBS is all about ► Determining the function of challenging behavior and then:  Changing environments  Teaching new skills  Addressing quality of life issues  Changing our patterns of interaction 55

Point of View “When you change the way in which you see things-the things you see will change.” 56

Final Thoughts ► There is no such thing as a bad person, just bad luck and bad choices. ► Every person is unique ► People do not have limits on what they can learn, but how and what we teach them is what is limited. 57

Treat everyone as though they are who they wish they could be. (Ghandi) 58

Comments/Questions 59

60