1. 1 MONITORING RESTRAINT USE to IDENTIFY BEST PRACTICES Roderick Shaner, M.D. rshaner@dmh.lacounty.gov Alysa Solomon, Ph.D. asolomon@dmh.lacounty.gov Los Angeles County Department of Mental Health and The Saks Institute for Mental Health Law at University of Southern California Policy and Ethics April 22, 2011

2. 2 SAMHSA National Action Plan on Seclusion and Restraint Revised and Adopted May 2003 The use of seclusion and restraint on persons with mental health and/or addictive disorders has resulted in deaths and serious physical injury and psychological trauma. In 1998, the Harvard Center for Risk Analysis estimated deaths due to such practices at 150 per annum across the nation. The use of seclusion and restraint on persons with mental health and/or addictive disorders has resulted in deaths and serious physical injury and psychological trauma. In 1998, the Harvard Center for Risk Analysis estimated deaths due to such practices at 150 per annum across the nation. SAMHSA has set forth a vision to reduce and ultimately eliminate the use of seclusion and restraint practices for all age groups in behavioral health care settings both institutional and community-based. The agency recognizes that these are to be used solely as safety interventions designed to protect consumer and staff safety. The focus is on identifying and encouraging the application of alternatives to prevent such use. SAMHSA has set forth a vision to reduce and ultimately eliminate the use of seclusion and restraint practices for all age groups in behavioral health care settings both institutional and community-based. The agency recognizes that these are to be used solely as safety interventions designed to protect consumer and staff safety. The focus is on identifying and encouraging the application of alternatives to prevent such use.

3. 3 SAMHSA National Action Plan on Seclusion and Restraint: 5 Domains Data Collection Data Collection Evidence-Based Practices and Guidelines Evidence-Based Practices and Guidelines Training and Technical Assistance Training and Technical Assistance Leadership and Partnership Development Leadership and Partnership Development Rights Protection Rights Protection

4. 4 April 02, 2010 - For immediate release: Massachusetts Sweeps First-Ever National Award for Reducing and Eliminating Restraint and Seclusion BOSTON — Massachusetts swept the first-ever awards given by the U.S. Substance Abuse Mental Health Services Administration (SAMHSA), recognizing sustained restraint and seclusion reduction and prevention work. Five of the ten awards were given to Massachusetts' facilities, including Taunton State Hospital and the nine child/adolescent statewide programs operated by the Department of Mental Health (DMH). BOSTON — Massachusetts swept the first-ever awards given by the U.S. Substance Abuse Mental Health Services Administration (SAMHSA), recognizing sustained restraint and seclusion reduction and prevention work. Five of the ten awards were given to Massachusetts' facilities, including Taunton State Hospital and the nine child/adolescent statewide programs operated by the Department of Mental Health (DMH).

5. 5 SB 130 (Chesbro) 2003 Legislative findings (a) The use of seclusion and behavioral restraints is not treatment, and their use does not alleviate human suffering or positively change behavior. (a) The use of seclusion and behavioral restraints is not treatment, and their use does not alleviate human suffering or positively change behavior. (b) Good milieu programs, interesting activities, and attention to every person's need for sufficient space all contribute to an environment in which the use of seclusion and behavioral restraints can be minimized. (b) Good milieu programs, interesting activities, and attention to every person's need for sufficient space all contribute to an environment in which the use of seclusion and behavioral restraints can be minimized. (g) It is the intent of the Legislature in enacting this act to achieve a reduction in the use of seclusion and behavioral restraints in facilities in California. (g) It is the intent of the Legislature in enacting this act to achieve a reduction in the use of seclusion and behavioral restraints in facilities in California.

6. 6 SB 130 (Chesbro) 2003 (became CA Health and Safety Code1180.3) (a) This section shall apply to psychiatric units of general acute care hospitals, acute psychiatric hospitals, psychiatric health facilities, crisis stabilization units, community treatment facilities, group homes, skilled nursing facilities, intermediate care facilities, community care facilities, and mental health rehabilitation centers. (a) This section shall apply to psychiatric units of general acute care hospitals, acute psychiatric hospitals, psychiatric health facilities, crisis stabilization units, community treatment facilities, group homes, skilled nursing facilities, intermediate care facilities, community care facilities, and mental health rehabilitation centers. c) (1) The secretary or his or her designee shall take steps to establish a system of mandatory, consistent, timely, and publicly accessible data collection regarding the use of seclusion and behavioral restraints in all facilities described in subdivision (a) that utilize seclusion and behavioral restraints. c) (1) The secretary or his or her designee shall take steps to establish a system of mandatory, consistent, timely, and publicly accessible data collection regarding the use of seclusion and behavioral restraints in all facilities described in subdivision (a) that utilize seclusion and behavioral restraints. It is the intent of the Legislature that data be compiled in a manner that allows for standard statistical comparison and be maintained for each facility subject to reporting requirements for the use of seclusion and behavioral restraints. It is the intent of the Legislature that data be compiled in a manner that allows for standard statistical comparison and be maintained for each facility subject to reporting requirements for the use of seclusion and behavioral restraints.

7. 7 SB 130 (Chesbro) 2003 1180.4 (k) A person in a facility described in subdivision (a) of Section 1180.2 and subdivision (a) of Section 1180.3 has the right to be free from the use of seclusion and behavioral restraints of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. (k) A person in a facility described in subdivision (a) of Section 1180.2 and subdivision (a) of Section 1180.3 has the right to be free from the use of seclusion and behavioral restraints of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. This right includes, but is not limited to, the right to be free from the use of a drug used in order to control behavior or to restrict the person's freedom of movement, if that drug is not a standard treatment for the person's medical or psychiatric condition. This right includes, but is not limited to, the right to be free from the use of a drug used in order to control behavior or to restrict the person's freedom of movement, if that drug is not a standard treatment for the person's medical or psychiatric condition.

8. 8 California Psychiatric Association Revised position statement 2011 Seclusion and restraints are not treatment. Seclusion and restraints are not treatment. Properly designed mental health facilities, with adequate staffing with trained mental health personnel, should be used to make the use of seclusions and restraints unnecessary in almost all behavioral emergencies. Properly designed mental health facilities, with adequate staffing with trained mental health personnel, should be used to make the use of seclusions and restraints unnecessary in almost all behavioral emergencies. In the absence of proper design and staffing, however, preventing responsible physicians from ordering seclusion and restraint during serious behavioral emergencies is a misguided practice that exposes patients, staff, and the community to grave risks. In the absence of proper design and staffing, however, preventing responsible physicians from ordering seclusion and restraint during serious behavioral emergencies is a misguided practice that exposes patients, staff, and the community to grave risks.

9. 9 Changing S&R use at DMH The expressed concerns Environmental safety Environmental safety Liability Liability Patient safety Patient safety Personal/moral responsibility for fellow man. Personal/moral responsibility for fellow man. Therapeutic effects Therapeutic effects

10. 10 Ending DMH MHC S&R (1) POLICY 2-3.1 Aggressive client behavior: Forceful actions directly expressed physically or verbally by a client that have caused or may indicate the potential for causing bodily injury in LAC-DMH outpatient clinics and programs should be clinically managed in a manner that maximizes safety for everyone, respect for the client, and recognition of the therapeutic mission of our services. 3.2 LAC-DMH staff may not use mechanical restraint or involuntary seclusion to clinically manage aggressive client behavior. 3.2.1 In situations in which there is immediate risk to life, staff may intervene as necessary in order to mitigate that risk, including calling 911 for emergency assistance. 3.3 While the following procedures apply to adults, those under the age of 18 should also be managed without seclusion and restraints, but in accordance with recognized responsibilities to act in specific situations in order to protect children from harm. ttp://dmhhqportal1/Document%20Library/IIPP.pdf ttp://dmhhqportal1/Document%20Library/IIPP.pdf

11. 11 Ending DMH MHC S&R (2) In a situation in which a client or individual wishes to leave the clinic, staff shall not attempt to physically detain that person or physically impede the way to the exit. Rather, staff shall attempt to safely and respectfully convince the client to stay, discussing the reasons for staying, alternatives and possible repercussions. In a situation in which a client or individual wishes to leave the clinic, staff shall not attempt to physically detain that person or physically impede the way to the exit. Rather, staff shall attempt to safely and respectfully convince the client to stay, discussing the reasons for staying, alternatives and possible repercussions.

12. 12 Ending DMH MHC S&R (3) In situations in which the client placed on an involuntary hold wishes to leave the clinic: Every attempt shall be made to convince the patient to stay. Every attempt shall be made to convince the patient to stay. In situations in which the patient is likely to leave, notify the program head or designee, and request assistance from law enforcement when indicated. In situations in which the patient is likely to leave, notify the program head or designee, and request assistance from law enforcement when indicated. In situations in which there is immediate risk to life, staff may, but shall not be required to, intervene as necessary in order to mitigate that risk, including calling 911 for emergency assistance. In situations in which there is immediate risk to life, staff may, but shall not be required to, intervene as necessary in order to mitigate that risk, including calling 911 for emergency assistance.

13. 13 The rationale for LAC DMH review of inpatient S&R DMH has statutory responsibility for reporting S&R in LPS designated facilities DMH has statutory responsibility for reporting S&R in LPS designated facilities California Welfare & Institutions Code (WIC): 5326.1 California Welfare & Institutions Code (WIC): 5326.1 DMH considers quality of care in LPS facility designation and re-designation DMH considers quality of care in LPS facility designation and re-designation DMH will monitor restraint use in LPS designated facilities to determine quality of care issues DMH will monitor restraint use in LPS designated facilities to determine quality of care issues

14. 14 The challenge for LAC DMH review of inpatient S&R Collect useful data Collect useful data Define comparison methodology among diverse hospitals Define comparison methodology among diverse hospitals Determine outliers Determine outliers Determine opportunities for improvement Determine opportunities for improvement Determine interventions Determine interventions

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18. 18 Incident Rate by LPS Hospital FY 2009

19. 19 LACDMH’s Progress (con’t) Revision of Denial of Rights form Revision of Denial of Rights form New data collection/reporting process New data collection/reporting process Consult with National Association of State Mental Health Program Directors (NASMHPD), National Research Institute, Inc (NRI) Consult with National Association of State Mental Health Program Directors (NASMHPD), National Research Institute, Inc (NRI) www.nri-inc.orgwww.nri-inc.org Begin with LPS Designated settings Begin with LPS Designated settings

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22. 22 Formulas for Calculating Comparison Rates The choice of formulas depended on the assumption of the underlying distribution and assumes that non-normal distributions are used for fair comparison. These formulas include statistical adjustments used to approximate a normal distribution. These formulas are taken from Joint Commission requirements for calculating comparison rates. Please email us for a copy of the formulas. The choice of formulas depended on the assumption of the underlying distribution and assumes that non-normal distributions are used for fair comparison. These formulas include statistical adjustments used to approximate a normal distribution. These formulas are taken from Joint Commission requirements for calculating comparison rates. Please email us for a copy of the formulas.

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24. 24 Joint Commissions Joint Commission along with NASMHPD is now requiring all accredited psych hospitals via the ORYX system to report hours of Seclusion and Restraint use as part of their core measures: Joint Commission along with NASMHPD is now requiring all accredited psych hospitals via the ORYX system to report hours of Seclusion and Restraint use as part of their core measures: http://www.jointcommission.org/accreditati onprograms/hospitals/oryx/ http://www.jointcommission.org/accreditati onprograms/hospitals/oryx/

25. 25 Roadmap to Seclusion and Restraint Reduction SAMHSA’s Roadmap to Seclusion and Restraint Free Mental Health Services: SAMHSA’s Roadmap to Seclusion and Restraint Free Mental Health Services: http://www.samhsa.gov/samhsa_news/VolumeXI V_4/article13.htm http://www.samhsa.gov/samhsa_news/VolumeXI V_4/article13.htm UK’s National Institute for Clinical Excellence (NICE) Guidelines: UK’s National Institute for Clinical Excellence (NICE) Guidelines: http://www.nice.org.uk/niceMedia/pdf/2005_003_ NICE_launches_clinical_guideline_disturbed_viol ent_behaviour.pdf http://www.nice.org.uk/niceMedia/pdf/2005_003_ NICE_launches_clinical_guideline_disturbed_viol ent_behaviour.pdf

26. 26 Health Reform Notes Eligibility = Enrollment Eligibility = Enrollment LAC/DMH holds responsibilities for California laws Health & Safety Code 1180 & 11.80.6 which address the imposition of behavioral restraints and the right to be free from the use of a drug used in order to control behavior for individuals with psychiatric conditions during enrollments. LAC/DMH holds responsibilities for California laws Health & Safety Code 1180 & 11.80.6 which address the imposition of behavioral restraints and the right to be free from the use of a drug used in order to control behavior for individuals with psychiatric conditions during enrollments. Debrief Debrief This will extend to individuals with substance abuse issues without psychiatric conditions. This will extend to individuals with substance abuse issues without psychiatric conditions. This will be explicit on LA County’s 1115 Waiver. This will be explicit on LA County’s 1115 Waiver.

27. 27 Health Reform Notes (con’t) Patient will have the ability to choose their health care provider. Patient will have the ability to choose their health care provider. Health providers will no longer cover billing for those held in mechanical restraint over 10 minutes and in psychiatric crisis; providers will have to know how to de- escalate individuals who are presenting. Health providers will no longer cover billing for those held in mechanical restraint over 10 minutes and in psychiatric crisis; providers will have to know how to de- escalate individuals who are presenting.

28. 28 Additional Websites Center for Medicare and Medicaid Services Final Interim Rule Available: Center for Medicare and Medicaid Services Final Interim Rule Available: http://www.cms.gov/CFCsAndCoPs/downloads/finalpatientrightsrule. pdf http://www.cms.gov/CFCsAndCoPs/downloads/finalpatientrightsrule. pdf Restraint and Seclusion – A Risk Management Guide: Restraint and Seclusion – A Risk Management Guide: http://www.nasmhpd.org/general_files/publications/ntac_pubs/R- S%20RISK%20MGMT%2010-10-06.pdf http://www.nasmhpd.org/general_files/publications/ntac_pubs/R- S%20RISK%20MGMT%2010-10-06.pdf Crisis Prevention Institute: Crisis Prevention Institute: http://www.crisisprevention.com/ Therapeutic Crisis Intervention: Therapeutic Crisis Intervention: http://rccp.cornell.edu/TCIpage1.htmhttp://rccp.cornell.edu/TCIpage1.htm Hartford Courant articles : Hartford Courant articles :http://articles.courant.com/1998-10- 17/news/9810170180_1_mental-retardation-psychiatric-restraintshttp://articles.courant.com/1998-10- 17/news/9810170180_1_mental-retardation-psychiatric-restraints