1. Improving Restraint Policy in Home and Community Based Settings
Leslie McNamara
Developed for The Hilltop Institute

2. Health Coverage of Non-Elderly Adults with Disabilities, 2015
MaryBeth Musumeci and Julie Foutz, Medicaid Restructuring Under the American Health Care Act and Nonelderly Adults with Disabilities. The Kaiser Family Foundation, March 2017.

3. Demographics of non-elderly adults w/Disabilities on Medicaid, 2015

4. Percentage of 1915 ( C ) Waivers, 2013

5. Background on Restraints
Used to prevent self-injury or harm to self or others
Types:
Physical or Manuel
Mechanical
Chemical
Situations:
Emergency
Behavioral Treatment Plan

6. Problems with Restraint
Can cause injury to patient and staff
Economic
Legal Consequences
May act as positive reinforcer of challenging behavior
Unpopular procedure for providers

7. Initiative to Limit and Eliminate Restraint
Media reports of Injury and Death to Patients
Advocacy Organizations
Substance Abuse and Mental Health Administration (SAMHSA)

8. Research Question
What guidance should providers be given when and if appropriate to use restraints?

9. Methodology State Selection Reviewed CMS’s Guidelines
State Regulations
Scholarship on Restraints for Individuals with Intellectual and Developmental Disabilities
Position Statements of Advocacy Organizations and Trade Associations

10. CMS’s Guidelines Alternatives to Avoid Using Restraints
Monitoring Unauthorized Use of Restraint
Procedures of Utilizing Restraints
Documenting Restraints
Education and Training of Providers Responsible for Implementing Restraints
Source: Center for Medicare and Medicaid Services, Application for a 1915 C Home and Community Based Waiver: Instructions, Technical Guidance, and Criteria, January 2015, pg

11. Scholars on Eliminating Restraint
Not in Best Interest of Patient
Some Instances Necessary to Use Restraint
Complete Elimination Can Misguide Staff
Efforts to Limiting Restraint Should Focus on Behavior
Restraint Policy Should be Based on Professional Practices

12. Physical Restraint STATE EMERGENCY BEHAVIORAL ALASKA X MARYLAND MISS.
NEW YORK
UTAH
VIRGINIA

13. Mechanical Restraint STATE PROHIBITED EMERGENCY
BEHAVIORAL TREATMENT PLAN
ALASKA X
MARYLAND
MISS.
NEW YORK
UTAH
VIRGINIA

14. Chemical Restraint STATE PROHIBITED EMERGENCY BEHAVIORAL ALASKA X
MARYLAND
MISS
NEW YORK
UTAH
VIRGINIA

15. Scholarship on Restraints
Justified if it reduces and eliminates behavior
Used after less restrictive interventions have proven to be ineffective
Based on Data
Consulted by professionals trained in behavioral analysis
Mechanical and Physical can be implemented safely in both planned and emergency
Mixed on chemical restraints and psychotropic meds
Lack of data
Difficult to distinguish b/w behavioral problems and psychiatric conditions

16. Scholarship Staff should be trained in proper techniques
Rule out medical and health factors that pose greater risk of injury to patient
Assess antecedent conditions that lead to behavior
Fixed-release criteria

17. Behavioral Treatment Plan
STATE
Professional trained in Behavioral Analysis
Behavioral Assessment
Antecedent Conditions
Reviewed and Approved by Committee
ALASKA X
MARYLAND
MISS.
NEW YORK
UTAH
VIRGINIA

18. Advocacy Groups THE ARC SUPPORTS:
Physical restraint in a last resort scenario
Analysis in Crafting Behavioral Treatment Plan
ALLIANCE TO PREVENT RESTRAINT AND SECLUSION:
Opposes Usage of Restraint in Non-Emergency Situations
Supports Brief Physical Intervention

19. Professional Trade Association
Association of Behavior Analysis International (ABAI):
Opposes Inappropriate/Unnecessary Use of Restraints
Can be used in a a behavior treatment plan and emergency situations
Consent of individual
Data

20. Recommendations
Restraints in both emergency and Behavioral Treatment Plan
Behavioral Treatment Plan
Assessment of individual’s behavior
Antecedent factors
Every usage of restraint should be documented
Individuals should be assessed or consulted by Professionals trained in Behavioral Analysis
Staff should be properly trained in applying restraints

21. Limitations Lack of data on usage of restraints Generalizability
Further Research Needed
Generalizability

22. Sources
Center for Medicare and Medicaid Services, Application for a 1915 C Home and Community Based Waiver: Instructions, Technical Guidance, and Criteria, January 2015.
Musumeci, MaryBeth and Julie Foutz. Medicaid Restructuring Under the American Health Care Act and Nonelderly Adults With Disabilities, The Kaiser Family Foundation, March
Ng, Terence, Charlene Harrington, MaryBeth Musumeci, and Petry Ubri. Medicaid Home and Community-Based Services Programs: 2013 Data Update. The Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. October