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Incorpora)ngPBISIntoAdultInpa)entTreatmentToEnhanceID/MIClients’DischargeReadiness

15thInterna)onalConferenceonPosi)veBehavioralSupportMarch2018

JoNewkirk-HorneckerMA,NCC,LPCWyomingStateHospital,Evanston,Wyoming

Introduc)ons • WhoamIandwhyamIhere?• Whoareyouandwhyareyouhere?• Whatcanweexpectofthis)metogether?• Terms

•  Dualdiagnosis=ID/MI• “Hall”–areaofthehospital• “Cheyenne”=StateGovernment/Dept.ofHealth• WSH=WyomingStateHospital• Title25=WyomingStatutere:dangerousness/gravedisability

• APS–AdultPsychiatricServices(residen)alhalls)

CARF Survey Report, January 2018 excerpt, p. 7

AreasofStrength:“ThePeopleEncouragingPeopleprogram(PEP),

implementedbytheclinicaldirectorandherteam,showstheexcep)onalcommitmenttoprogramsdrivenbytheneedsofpa)ents.”

Program SeCng & Background

• WyomingStateHospitalhistory•  Statesystem•  Title25–inten)onandreality• Growingpopula)onof“stuckpeople”

•  LackofappropriateprogrammingforID/MI

WyomingStateTrainingSchool↔WyomingLifeResourceCenterLanderWyoming

•  1907–Legislatureauthorized“WyomingHomefortheFeeble-mindedandEpilep)c

•  1912–Openedas“WyomingSchoolforDefec)ves”•  1919–WyomingStateTrainingSchool•  1990’s–WyomingLifeResourceCenter(WLRC)

In105yearsithasserved2400clients,exclusivelyID.ConcernfortheduallydiagnosedclientsremandedtotheStateHospitalinspiredtheforma)onoftheir“Pathways”program,asistertoPEP.ID/MIclientswhoarestableintheirmentalillness,andwhohavenoop)onsfordischargeintothecommunity,canspend3-36monthsatWLRCimprovinganddemonstra)ngtheirdischargereadinesswhilestaffworktobridgethemtocommunityproviders.

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Why it finally happened How

•  30%ofWSHpopula)onIDorID/MIin2016

•  ExtantTXmodali)esinadequateandineffec)ve

•  Mallgroupexamples•  Purposeandexecu)onofbehaviorplans

•  SPMIvs.ID/MIstaffapproach

•  Lengthofstay•  Limitedplacementop)ons•  S)gma

•  Lengthywaitlistfor“Titled”

• MicheleFlyr&CoraKlotzbach•  Timing• Newhospitaladministrator•  EncouragementofDr.Courage• PressurefromCheyenne

•  Lengthofwaitforadmission•  Differentneedsofthepopula)on

Our implementa)on process •  August2016

•  Ini)alproposaltohospitaladministra)on•  September2016

•  Nego)a)onbeganre:staffing,loca)on,oversight•  November2016

•  Coreteamforma)on•  Expecta)ons=“4CoreValues”•  Designedtheme•  Recruitedgroupfacilitators•  Tenta)vestartdate

•  December2016•  Designedques)ons&interviewedprospec)vestaff•  Trainingofprogramandhallstaff•  Recruitmentofappropriatepar)cipants–intro.toconcepts•  Devisedschedule

•  January2017•  Ini)atedprogramming

Proposal to Administra)on

Purpose:TheWSHcurrentlyservesasresidenceandtreatmentcenterforapproximately10-12IDclientsastheywaitforwaiverfunding,availablegrouphomeplacementsand/ortheestablishmentofasignificantperiodofsafebehaviorinordertobeginplacementplanning.WhileseveralofthecurrentTreatmentMallgroupsfittheseclients’needs,manydonotnordothegroupsaddressthespecialneedsoftheseclientswithrespecttoskillsneededorappropriatelearningstylesrequired.Therefore,itisproposedthataspecializedprogrammingtrackbedevelopedandimplemented.Goal:Providesimilarprogrammingandexpecta)onsthataclientmightberequiredtopar)cipateinandmaintainwhileatagrouphomeorcommunitysenng.Thiswillallowaneasiertransi)ontosuchaplacementanddemonstratereadinessfordischarge.

Program Staff interview ques)ons 1.  Pleasedescribeadifficultsitua)onwithanID/MIclient,howyouhandled

it,theoutcomeandanychangesyouwouldhavemadeinmanagingit.2.  Thisposi)onwillinvolveeduca)onandinstruc)onregardingintensely

personalissuessuchashygiene,sexuality,vic)msandperpetratorsoffinancialemo)onalphysicalandsexualabuse,boundaries(socialphysical,emo)onal,sexual,financial,etc.)TalkaboutyourexperiencewithandcomfortleveltowardapproachingthesesubjectswithID/MIclients.

3.  Howwillyouhandlethesitua)onifaguardiancallsandexpressesconcernaboutaneventorinterac)onrelatedtobytheirward?

4.  Talkaboutmaintainingappropriateprofessionalboundarieswithclientswhileatthesame)medeliveringprogrammingwhichdependsheavilybothonstaffmodelingappropriatesocialandinterpersonalskills(socializing,playinggames,communityou)ngs,etc.)andoneduca)onanddiscussionregardingdeeplypersonalissues.

5.  Whatdoyouseeasthestrengthsyouwouldbringtothisposi)on?

Ini)al training of Program and Hall staff

• ReviewofTraumaInformedCareprinciples•  Introduc)onofPBISmodel•  Introduc)onofRSVPmodel,fromwhichPBISexpecta)onsweredrawn

• 4CoreValues;BeSafe,BeLegal,BeHonest,BeCourteous• Treatmentapproach~ID/MIvs.SPMI• Posi)veresponses,modifiedforadultpopula)on• Clubhousemodel• Programpurpose,goals,measuresofeffec)veness

Some Positive Responses to Undesirable Client Behavior “You want your responses to take the least amount of planning, the least amount of effort, the least amount of time, and the least amount of paperwork.” Fred Jones Non-verbal Responses

Positive Staff Responses Looks Like/Sounds Like 1. With-it-ness: Know what is

happening at all times in the area.

• Walk around the room. Make sure you spend time in each area.

• Scan the faces of the clients, making eye contact with as many as possible.

• Look for behaviors that can turn into problems—make eye contact, move toward client, and/or say something.

2. Signaling: eye contact and facial expressions

• Look at the client in a way that it sends the message: “I know what you are doing.”

3. Signaling: gestures • Gestures include: pointing to the rules posted in the room, holding up your hand, shaking your head, placing your index finger to your lips.

4. Proximity • Move around the room. • Stand near a client who is struggling. • Arrange seats so that you can get to any client quickly.

5. Planned Positioning • Stand or sit between two clients 6. Waiting • Stop talking. Stand quietly and wait. Wait until all

clients are doing what they are supposed to be doing.

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Kickoff Week ~ 9-13 January 2017

•  Introduc)onsofpar)cipantsandstaff• Re-namingoftheprogram• CoreValues•  Teambuilding

•  Puzzleac)vity•  Boas)ngBuddies•  Ownership

• BuildingtheMatrixusingposi)veterms• Orienta)ontoschedule• Presenta)ontoAdministra)on

P.E.P. program Expectations

(for clients & staff)

1. Be Safe 2. Be “legal” 3. Be honest 4. Be courteous

The Brainstorming Sessions The Brainstorming sessions

Be“Legal” •  Followhospitalandclubhouserules•  Followstaffrequests•  Treatothersthewayyouwanttobetreated•  Followyourtreatmentplan•  Useyourcopingskills•  Justaskonestaff•  Accept“no”forananswer•  Beon)me•  Handsoffthingsthatdon’tbelongtoyou

BeHonest •  Tellthetruth•  Admititwhenwe’vemadeamistake&askforhelp•  Treatothersthewayyouwanttobetreated•  Meanwhatyousay/saywhatyoumean•  Betruthful&Don’tmakethingsup•  Waityourturn`•  Expectthebest/preparefortherest•  Askbeforeyou“borrow”

BeCourteous •  Use“please”,“thankyou”and“excuseme”•  Respectthepersonalspaceofothers•  Respectthepropertyofothersandofthehospital•  Treatothersthewayyouwanttobetreated•  Beclean,wearcleanclothesandsmellnice•  Usea)ssue...•  Beon)me•  Shareconcernsaboutothersprivately•  Taketurns

BeSafe •  Useyourcopingskills•  Askforhelpifyouarestruggling•  Don’thurtyourselforothers•  Usetherighttoolfortherightjob•  Respectthepersonalspaceofothers•  Usekind,non-triggeringwordsandexpressions•  Treatothersthewayyouwanttobetreated•  Thinkitthroughbeforeyouact

Be“Legal” •  Followhospitalandclubhouserules•  Followstaffrequests•  Treatothersthewayyouwanttobetreated•  Followyourtreatmentplan•  Useyourcopingskills•  Justaskonestaff•  Accept“no”forananswer•  Beon)me•  Handsoffthingsthatdon’tbelongtoyou

BeHonest •  Tellthetruth•  Admititwhenwe’vemadeamistake&askforhelp•  Treatothersthewayyouwanttobetreated•  Meanwhatyousay/saywhatyoumean•  Betruthful&Don’tmakethingsup•  Waityourturn`•  Expectthebest/preparefortherest•  Askbeforeyou“borrow”

BeCourteous •  Use“please”,“thankyou”and“excuseme”•  Respectthepersonalspaceofothers•  Respectthepropertyofothersandofthehospital•  Treatothersthewayyouwanttobetreated•  Beclean,wearcleanclothesandsmellnice•  Usea)ssue...•  Beon)me•  Shareconcernsaboutothersprivately•  Taketurns

BeSafe •  Useyourcopingskills•  Askforhelpifyouarestruggling•  Don’thurtyourselforothers•  Usetherighttoolfortherightjob•  Respectthepersonalspaceofothers•  Usekind,non-triggeringwordsandexpressions•  Treatothersthewayyouwanttobetreated•  Thinkitthroughbeforeyouact

Be“Legal”Encouraging •  Followhospitalandclubhouserules•  Followstaffrequests•  Treatothersthewayyouwanttobetreated•  Followyourtreatmentplan•  Useyourcopingskills•  Justaskonestaff•  Accept“no”forananswer•  Beon)me•  Handsoffthingsthatdon’tbelongtoyou

BeHonest •  Tellthetruth•  Admititwhenwe’vemadeamistake&askforhelp•  Treatothersthewayyouwanttobetreated•  Meanwhatyousay/saywhatyoumean•  Betruthful&Don’tmakethingsup•  Waityourturn`•  Expectthebest/preparefortherest•  Askbeforeyou“borrow”

BeCourteous •  Use“please”,“thankyou”and“excuseme”•  Respectthepersonalspaceofothers•  Respectthepropertyofothersandofthehospital•  Treatothersthewayyouwanttobetreated•  Beclean,wearcleanclothesandsmellnice•  Usea)ssue...•  Beon)me•  Shareconcernsaboutothersprivately•  Taketurns

BeSafe •  Useyourcopingskills•  Askforhelpifyouarestruggling•  Don’thurtyourselforothers•  Usetherighttoolfortherightjob•  Respectthepersonalspaceofothers•  Usekind,non-triggeringwordsandexpressions•  Treatothersthewayyouwanttobetreated•  Thinkitthroughbeforeyouact

PeopleEncouragingPeopleProgram–Expecta)onMatrix,Specific

Kitchen

Dining Area

Day Room & library

Group

Bathroom

Bus / vancommunity

Sensory

room

Be

“Legal”

-Followstaffdirec)ons-Followrecipe-

-Followtherules-Onlytake“legal”thingsbacktohall

-Usefurnitureandequipmentcorrectly-Uselegallanguage

-Confiden)ality-Followarearules-Useequipmentcorrectly-Accessappropriatewebsites

-Doyourbusinessandgetbacktobusiness

-Beseatedwhilemoving-Keepyourbodyandbelongingsinsidethebus-Listentostaff-Staywiththegroup

-Leavethechairwhereitis.

BeHonest

-Waitun)lit’s)metoeat-

-Eatwhatisyours-Eatwhatyoutake

-Useyour)mewisely

-Useac)velistening-Par)cipate!

-Respecttheprivacyofothers-Askforhelpifthere’saproblem

-Focusonbecomingcalm

BeCourteous

-Waityourturn-Listenforinstruc)ons

-Usegoodmanners-Chewquietly-Quietconversa)on-Cleanupaveryourself

-Cooperate&share-Taketurns,workitout

-Taketurnstalking-Eyesonspeaker

-Flushandwash-Keepyoureyestoyourself

-Quiettalk -Returntogroupassoonasyou’recalm

BeSafe

-Usetoolscorrectly-Wipeupspills-Puttoolsaway-Washhands&tools-Payawen)on-Cleanasyougo-Wearcleanclothes-Followinstruc)ons

-Walk,don’trun-Keepfoodover)le-Wipeupspills-Waitpa)ently

-Askforhelpifneeded

-Avoidtriggeringwords,expressions,andtone.

-Keepfloordry-Walk,don’trun-Reportanyproblems-Washyourhands

-Enterandexitsafely-Stayseated-Waityourturn-Visitquietly-Letthedriverfocus

-Usethesensorytoolsasintended

PeopleEncouragingPeopleProgram–Expecta)onMatrix,Specific

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P.E.P.Week“A”Schedule(1-8-18) Monday Tuesday Wednesday Thursday Friday9:00-9:45

Choicetime Choicetime Choicetime Choicetime Choicetime

9:45-10:00

Gatherin;Previewthedayandweek,teachandpracticeweeklyskillCoraK.

Gatherin&previewthedayJo&Ashlee

Gatherin&previewthedayAshlee

Gatherin&previewthedayJo&Ashlee

RidingtheRollerCoasterCoraK

10:00-10:30

GrossMotor&CardioAshlee,Phil&Pam

LifeManagementGennifer&Ashlee

GrossMotor&CardioKelly&Ashlee

10:30-10:45 Break Break Break Break Break10:45-11:30

BrainGamesBrandon

RidingtheRollerCoasterCoraK

GroceryShopping&Plannextweek’smeal

ArttherapyRebekah

CookinggroupPam&Phil

11:30-12:30

Lunch/choicetime

Lunch/choicetime

Lunch/PublicLibrary-Michele

Lunch/Choicetime

Lunch@ClubhouseCommunityactivity–VariesReview,preview,closing-Varies

12:30-1:15

KarnGymPEPStaff

KeepingBusyGennifer&Ashlee

PetTherapyTipsy&Dr.Courage

1:15-1:30 Break Break Break1:30-2:15 Music

PhilPracticalLivingJo/Pam/Phil

YogaReaAnna

2:15–3:00 Snack,choicetime,cleanup,chores,prepareforreturntohall

P.E.P.Week“B”Schedule(1-9-18) Monday Tuesday Wednesday Thursday Friday9:00-9:45

Choicetime Choicetime Choicetime Choicetime Choicetime

9:45-10:00

Gatherin;Previewthedayandweek,teachandpracticeweeklyskillCoraK.

Gatherin&previewthedayJo&Ashlee

Gatherin&previewthedayJo&Ashlee

Gatherin&previewthedayJo&Ashlee

RidingtheRollerCoasterCoraK.10:00-

10:30GrossMotor&CardioAshlee,Pam&Phil

LifeManagementGennifer&Ashlee

GrossMotor&CardioKelly&Ashlee

10:30-10:45 Break Break Break Break Break10:45-11:30

NursingnotesToni

RidingtheRollerCoasterCoraK

GroceryShopping&Plannextweek’smeal

ArttherapyRebekah

CookinggroupPam&Phil

11:30-12:30

Lunch/choicetime

Lunch/choicetime

Lunch/PublicLibrary-Michele

Lunch/Choicetime

Lunch@ClubhouseCommunityactivity–VariesReview,preview,closing-Varies

12:30-1:15

KarnGymPEPStaff

KeepingBusyGennifer&Ashlee

PettherapyTipsy&Dr.Courage

1:15-1:30 Break Break Break1:30-2:15 Music

PhilMoneyMattersJo

Readingtime

2:15–3:00 Snack,cleanup,chores,choicetime,prepareforreturntohall

Establishing Rou)nes has been cri)cal

Star0ngtheWeek• Gather-intoconnectandreviewweekend,checkin

• Previewweeklyschedule• Previewday’sschedule,menu• Discussion&choosing“CoreValueoftheWeek”

•  Teachandprac)ceweeklyvalue• Draw“Boas)ngBuddies”fortheweek

• Coaching&examples

Star0ngeachday• Gather-intoconnectandreviewpreviousdayandevening

• Addressanyissuesbroughtforth

• Pre-viewdailyschedule,menu• Remindersre:devia)onsfromrou)ne

Our first home – the old locker room . . .

Our Clubhouse on Bighorn Hall Nottheoldest,newestorprenestbuildingoncampus,buttheadministra)onagreedtoaremodeljustforus.WemovedourdayprogramminghereonApril3rd,2017andonApril27thhadanopenhouseforallthestaffwhohelpedwithgenngournewspaceready.PEPpar)cipantsbakedcookies,bananabreadandothergoodiesandgavetourstovisi)ngstaff,tellingthemallabouttheprogram,whattheywerelearning,andtheirplansforthefuture.Agood)mewashadbyall!

People Encouraging People Clubhouse on Bighorn Hall

P.E.P. Words •  RESPONSE-ABILITY•  Vississitudes•  Consequences•  Compliment•  Dis-engage•  Quest•  Compassionate•  Charity•  Mindfulness•  Hypothesis•  Humgruffin•  Kerfuffle•  Yubi – good intentions from the heart•  Expiate•  Quinch•  Goodbye•  thewai)ngplace

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P.E.P. Clubhouse Music area and Library

“Gradua)ons” and moving on.

Whenit’s)mefordischarge,wethrowa“Gradua)onparty”,completewithdecora)ons,atreatoftheclient’schoice,and“lovelypar)nggivs.”•  PEPbackpack•  Boxwithgelpens,pencils,

markers,acalculator,astressballandotheritems

•  3-ringbinderwiththerecipesweprac)ced,“PEPwords”,12waystosaygoodbyeinotherlanguages

The unavoidable . . . Policy & Procedure

• Wewerebusilychuggingalong,buildingtheprogram,teachingskills,runninggroups,dischargingpeoplewhen...ANOFFICIALFROMCHEYENNEWANTEDTOCOMEANDSEEWHATWEWEREDOING...

• Wewereexcitedatfirst,un)ltheadministratorsaid“RememberItoldyounottoworryaboutP&P,tojustgetthingsgoing?Well,weneedpolicies.Thursday.”

•  Sowe(meaningI)gottoworkpunnganopera)onalwork-in-progressonpaper...

Policy and Procedure • Par)cipantInclusion(Admission)•  Transporta)on•  TreatmentModali)es• OffCampusAc)vi)es• Kitchenuse• GuardianCommunica)on•  Facilitytofacilitytransport• Dischargereadinesscriteria• Dailyac)vityschedule• Par)cipantsa)sfac)onsurveys• WSH/WLRCCollabora)on

People Encouraging People, so far . . . • Opera)onal14months• PersonsServed–33• Agerange-18-65yearsold• Programcomple)on-20• Withdrewfromtheprogram–4• Removedforassault–2• Currentpar)cipants–7• Returnedaverdischarge-3(+1fora“tuneup”)

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Popula)on comparison ID/MIand/orTBIClients• PersonsServed-22• Programcomple)on-16• Withdrewfromprogram–0• Removedforassault–0• Currentpar)cipants–6• Returnedaverdischarge–2(12.5%)

• Diagnoses:IDorTBIandASD,IED,PTSD,Bi-PolarII,ODD,FASD,Anxietyd/o,Polysubstanceabuse

SPMIClients• PersonsServed-11• Programcomple)on-4• Withdrewfromprogram–4• Removedforassault–2• Currentpar)cipants–1• Returnedaverdischarge–2(50%)

• Diagnoses:BPD,PTSD,MDD,Schizophrenia,Schizoaffec)ved/o,Conductd/o,Methdependence

Program assets •  SupportfromHospitalAdministra)onandCheyenne

•  Financial,organiza)onalandcultural• Mul)-disciplinarygroupleaders

•  OT&RTforcommunica)on,interpersonal,leisureandfree)meac)vi)es•  Psychologyprovidesindividualandgrouptherapies,intrapersonalskillstraining

•  Nursingteachesaboutmedica)ons,physicalhealth,dentalhealthandselfcare

•  Socialservicesstaffcueforsocialskillsandaddressspecificskilldeficits•  CNAstaffprovidesocialmodelingandteachcookingandotherhouseholdanddailylivingskills

•  Arttherapistencouragescrea)ve,non-verbalexpression•  Fullkitchenformealprep,familystyledining•  Awendanceatmovies,concerts,fes)vals,publiclibraryandmuseum,restaurants=opportuni)estoglobalizegainedskills

•  Social,interpersonal,moneymanagement,self-advocacy,appropriateself-expression

Challenges

• Establishingfidelityinanon-residen)alsenng• Dischargefacili)esapprehensivere:dualdiagnosisandWSHstay

• Riskmanagementconcernsvs.QOL&lifeskillsteaching• Pressureforinappropriatereferrals• Lackofunderstanding/resentmentofAPSstaff

• “Princesses”•  Rumoredpaydifferen)al• “Theygetawaywithmurderoverthere.”

• Fluctua)ngpar)cipantnumbers • AccessingneededreportsforPI

Take-aways • Datadrivendecisionmaking

• SPMIvs.ID/MIsuccess• Groupofferingsmirroringpar)cipants’expressedneeds

• Fidelitywithlongevity,popula)onshiv,staffchanges• Flexibility,challengingourownpreconcep)ons

• Rigidinclusion/exclusioncriterion• Learningtoask“Whyarewesayingno?”

• ResultsPIre:incidentreports• Hospital-wideimplementa)onofPBISthisspring

Wyoming State Hospital’s “People Encouraging People” Discharge Readiness Program

Thank you! Contact informa)on

JoNewkirk-HorneckerMA,NCC,LPCWyomingStateHospitalP.O.Box177Evanston,WY82931307-789-3464ext.518jo.newkirk-hornecker@wyo.gov

Be Safe, Be Legal, Be Honest, Be Courteous Carry These Values With You