1. 1 NYS OMH Learning Collaborative Preventing the Need for Restraint & Seclusion Summation of Key Results of SAMHSA’s National Initiative November 30, 2010 Beth Caldwell, MS Caldwell Management Associates; Faculty, Office of Technical Assistance, National Association of State Mental Health Program Directors

2. 2 Brief Historical Overview National S/R Reduction Initiative (2000-2010) Charles Curie “will eliminate R/S” (PA, 1996) Hartford Courant Series “Deadly Restraint” (1998) GAO Report for Congress (1999) NASMHPD MD S/R Reports (1999-01) CMS Rule changes (1999, 2000) NASMHPD Training Curriculum (created 2002)

3. 3 Brief Historical Overview National S/R Reduction Initiative (2000-2010) NASMHPD OTA Training starts (2003 to present) New Freedom Commission Report – Transformation (2003) Independent projects support core strategies identified (2003 on) First CMHS 8 state SIG project (2004) CMS Final Hospital Rules (2006) Second CMHS 8 state SIG project (2007) SAMHSA Recognition Awards (2010) (NAPHS Success Stories 2003; Colton, 2004; Murphy/Davis, 2005; CWLA; 2003)

4. 4 Brief Historical Overview National S/R Reduction Initiative (2004-2007) Brief Historical Overview National S/R Reduction Initiative (2004-2007) CMHS SR SIG Projects –2004: 8 State Incentive Grants to identify alternatives to reduce use (HI, IL, KY, LA, MA, MD, MO, WA) –3 year grant on best practice applications –Lead consultant assigned to each State, utilizing Six Core Strategies© to conduct 2/3X annual on-site assessments –Lessons learned: all about executive leadership –Outcomes indicate that the Six Core Strategies© meet criteria to be considered as Evidence-based.

5. 5 Brief Historical Overview National S/R Reduction Initiatives: 2007-2010 Second CMHS S/R SIG Project –2007-10: 2nd round of grants, 8 states (CT, IN, NJ, NY, OK, TX, VA, VT) –Monies for consultation & on-site assessments significantly reduced –Lessons learned – all about executive Leadership

6. 6 We now know what works to prevent violence and reduce S/R We know that the prevention of conflict and reduction of S/R is possible in all mental health settings We know that facilities throughout the U.S. have reduced use considerably without additional resources We know that this effort takes tremendous leadership, commitment, motivation, and persistence

7. 7 First step in prevention? Develop a Plan! TO START: Facility leaders must develop a S/R Prevention/Reduction Action Plan Action Plan Framework Prevention-Based Approach Continuous Quality Improvement Principles Individualized for the Facility or Agency Adopt/adapt Six Core Strategies ©

8. 8 The Six Core Strategies© to Prevent Violence and S/R 1)Leadership Toward Organizational Change 2)Use Data To Inform Practices 3)Develop Your Workforce 4)Implement S/R Prevention Tools 5)Actively recruit and include service users and families in all activities 6)Make Debriefing rigorous

9. 9 Core Strategy #1 Leadership in Organizational Change The most important component in successful prevention and culture change projects. Only Leadership has the authority to make the changes that are necessary for success: –To make violence prevention a high priority –To assure for Reduction Plan Development –To reduce/eliminate organizational barriers –To provide or re-allocate the necessary resources, and –To hold people accountable for their actions

10. 10 Core Strategy #1 Principles of Effective Leadership Create the Vision Live Key Values Develop your Human Technology Monitor Staff Performance Elevate Oversight of Untoward Events Assure Violence/S/R Prevention Plan Development (Anthony & Huckshorn, 2008: read their book: Principled Leadership)

11. 11 Real Reduction Experiences What Worked? Examples of Individual Success Stories beginning prior to NETI Training Program on Six Core Strategies Preventing Violence, Trauma, and the Use of Seclusion and Restraint in Mental Health Settings

12. 12 South Florida State Hospital Adult/350 Beds LEADERSHIP: –Full support/oversight by CEO/COO/CNO –Strong policy statement/revised S/R policies and procedures –Kick-off of initiative that included staff, residents and families, state office, Florida legislators, advocates, & the local community mental health centers –Led use of data, graphed and posted, for unit comparisons every month/all units –Project placed on every meeting agenda –Designed ‘town center’ treatment mall

13. 13 South Florida State Hospital Essential Components LEADERSHIP: –Debriefing including root cause analysis and daily reports to Executive Management Group; non-punitive environment. Change in staff roles in crisis response (security, nursing, direct care staff) –Leadership responding to every incident; on call MG member involved for oversight 24/7 –Leadership hired persons-served/consumer and gave them meaningful roles throughout project (e.g., interview residents and staff post-event; make recommendations; o develop comfort rooms; develop treatment activities) –Leadership co-led with consumers staff appreciation/recognition

14. 14 SECLUSION AND RESTRAINT RESULTS January 1999 - March 2004

15. 15 Andrus Children’s Center (Residential and School) Yonkers, New York 1999 - 2008 LEADERSHIP: –Total commitment (Note: leadership turnover in school directly correlated to > in restraints at 2 points in time) –Involved in debriefing after every incident –Decided to truly use data to inform practice –Put a strong focus on Workforce Development: staff training/staff empowerment –Decided to move to a Trauma model

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17. 17 Worcester State Hospital 156 beds/Civil (NETI training 2003 ) LEADERSHIP: –Set up taskforce, developed formal plan –Developed new policies –Held kick-off –Increased staff training –Implemented 24-7 response by CEO, COO, CNO –Decided to use data (distributed to staff) –Began to hold regular meetings - all staff & unions; focused on performance recognition –Developed roles for consumers

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22. 22 Elgin Mental Health Services, Chicago Adult Hospital: Civil & Forensic NETI Training 2003; SIG 6/05 LEADERSHIP: –Developed a formal plan and rewrote polices –Embraced value of ‘Trauma-informed care’ & engaged in hard tasks to implement (i.e. revision of unit rules) –Embraced value of ‘consumer-driven care’ (e.g., created meaningful consumer council; > consumer involvement in multiple hospital activities) –Held a facility kick-off and followed-up with training for all staff (where staff voice could be heard) –Shared and posted data

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28. 28 SAMSHA FUNDED SIG Alternatives to R/S 8 States funded 10/2004 thru 9/2007 Largest Reductions in 2 States: MA & IL NETI Training Programs offered 2005 On-site consultations began 2005

29. 29 IL DMH LESSON LEARNED Leadership responsible for culture change; in some hospitals with weak and/or non- committed leadership, especially when combined with serious, long-term cultures of control, there were serious and ongoing challenges to reduction efforts

30. 30 Madden Mental Health Center, IL Madden is an acute care state operated facility with 38 budgeted beds/increased to 150; ALOS: 11 days. In FY08, 4,133 admissions. LEADERSHIP: –Executive team, after returning from NETI training, met with all staff on all units on all shifts to share excitement about reducing R/S –Used Witnessing after EVERY event –Used data in a deep way (e.g., security guards; safety plans & psychologists)

31. 31 Madden Mental Health Center Rates of Hours, Patients and Episodes of Restraint* Anita Hour Rate Combined Hour Rate Baseline Witnessing initiated Witnessing cont’d R&S10/01/03- 10/01/04- 10/01/05- 7/01/06- 7/01/07- 9/30/04 9/30/05 10/1/06 6/30/07 6/30/08 Episodes *Per 1000 pt days 10 5.66 4.51 3.88 2.79 Patients *undup pts restrained /pts served) 7% 6.1% 3.95% 2.92%3.4% Hours *Per 1000 pt hours.82.43.23.16.11

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33. 33 MA DMH LESSONS LEARNED Leadership responsible for culture change Two hospitals receiving SIG consultant on- site reviews reduced significantly more than the others – other hospitals needed this type of support;

34. 34 MA DMH: The two state hospitals that received NASMHPD/OTA Site Visits Taunton State Hospital 10 adult units, 1 adolescent unit (highest value to lowest value ) 28.63 (February 2005) to 1.75 (February 2008) = 93.5% Reduction results: Westborough State Hospital 5 adult units, 2 adolescent unit (highest value to lowest value ) 23.47 (April 2005) to 0.73 (January 2008) = 96.9% Reduction results:

35. 35 Alegent Mental Health Services, Hospital Units in Nebraska & Iowa; Residential Program in NE NETI Training 2004 for executives – leaders went back and developed a plan: –All staff trained in TIC throughout 2005 –Phased in implementation of six core strategies from 2005 to present –On-site consultation visits 2006 (child residential program eliminated restraints) –Ongoing phone consultation throughout 2007/2008

36. 36 Acute Geriatric 7% Acute C/A Residential Partial/School 33% Acute Adult Special Care 60% Alegent Health Mental Health Services Omaha NE & Council Bluffs IA Over 6,300 patients served in the 2008 Fiscal Year  In the first quarter of 2001 (January through March), there were 167 Seclusion/Restraint events. In the last quarter of 2007 (October through December), there were only 42 events  The Alegent Health Mental Health has experienced a 56.23% reduction in the number of Seclusion/Restraint events since presenting Trauma Informed Care to staff throughout the service line in July 2005

37. SAMHSA’S Alternatives to Seclusion and Restraint Recognition Program Over 60 applications Of those the committee ranked in top 22, Beth knew 16 of the executive leaders (and worked with leaders ranked as the top 6); each leader: –Had deep passion/commitment to a set of core values that were inconsistent with R/S (e.g., recovery; consumer-driven care) –Developed a strategic plan that incorporated the Six Core Strategies©, with kick-off and regular updates/ celebrations –Focused on staff appreciation/empowerment –Used data to inform practice 37

38. 38 Remember what Margaret Mead shared: “Never doubt that a small group of committed citizens can change the world. Indeed, it is the only thing that ever has.”

39. Contact Information Beth Caldwell Caldwell Management Associates 413-644-9319 bethcaldwell@roadrunner.com 39