Building Unified Service SystemsBuilding Unified Service Systems

If Not Now, When?If Not Now, When?

Yakima, WAYakima, WA

September 18, 2006September 18, 2006

Chris Heimerl11200 Carmel Ave NEAlbuquerque, NM 87122chrisheimerl@msn.com505-796-0442

It’s About Relationships

-State/provider collaboration

-Provider consortiums

It’s About Change-Capacity building-Confidence building

It’s About Action-Prevention-Intervention

Our MissionOur Mission

• We prevent crises from occurring, if one does, we help end it.

So much of our thought, time and energy are devoted to people’s extraordinary needs-arising due to impairment and disability-that we neglect or overlook people’s ordinary needs-those things we all want in our lives that are sometimes extraordinarilyhard to get.

The Short CourseThe Short Course

The BasicsThe Basics

You’ve got to have something to eat and a little love in your life before you can hold still for anybody’s sermon on how to behave.

Billie Holiday

Certainty is the sin of bigots, terrorists, and Pharisees.

Compassion makes me think I could be wrong.

Anthony DeMelloThe Wellspring of Life

DisclaimerDisclaimer

New MexicoNew Mexico

• 5th largest state geographically• Only 1.9 million people: Over half live

around Albuquerque• Low income: <$22K overall, <$17 in rural

areas• Culturally diverse: 43% white; 40%

Hispanic; 16% Native American representing 19 pueblos, 3 reservations; 1% other.

Individuals ServedIndividuals Served

• 3800 individuals receiving services through the Home and Community Based Waiver

• 3800 individuals on the Central Registry awaiting services

• Over half receive support for mental health/behavioral issues

ProvidersProviders

• ResidentialHome base: 36Assisted living: 36Supported living: 42

• Supported employment: 40• Day Habilitation: 52• Case management: 21• Behavior Support Consultation: 72 agencies,

225 therapists• Community Integration: 57

CrisisCrisis

– Severe aggression toward others.

– Severe self-injury.– Repeated elopement.– Absence, shortage, or

marginal competence of available resources, most notably medical, psychiatric, and behavior support.

– Sexual aggression including criminal perpetration.

– Illegal behavior ranging from misdemeanors to felonies.

– Drug and alcohol abuse.– Acute mental health

incident often prompted by issues with psychotropic medication.

– Current or impending homelessness.

– Aging and/or failing health of family members, most often parents, providing support.

– Individual vulnerability to exploitation.

What WorksWhat Works

• Collaboration between the Interdisciplinary team, OBS, and the Regional Office.

• Formal and informal training events:– Informing potential referral sources

regarding the nature and scope of crisis response leads to more reasonable expectations and satisfaction.

– Networking opportunities between providers.

– Enhance direct staff and family competence to identify, predict, respond to, and recover from crises.

What WorksWhat Works

• Opportunities for families to receive information regarding all waiver services.

• OBS technical assistance in IDT meetings to clarify, evaluate, and resolve problems through effective planning and specific guidance for staff.

• Selective denial of requests for crisis response and “pushing back” against referring agencies demands problem ownership and frequently results in newfound capacities and creative problem solving.

• Relationship building with clear liaison identification and collaboration with psychiatrists, mental health therapists, hospital mental health units, and law enforcement agencies.

Crisis RespondersCrisis Responders

• Experienced direct support providers

• Lifestyle and family allow flexibility

• Confident, assertive and calm

• Quick on their feet, literally and figuratively

• Structure and rhythm

• 4th, 5th or 6th of 8

$$

• Expenses– Staff time, overtime– Travel – Stipends*– Administration

*Rent, utilities, deposits, damages, transportation, respite, therapy, Tier III

• Revenue– Waiver funding– General fund

allocation– SSI– Adult Protective

Services

Response Tier IResponse Tier I

• Attending special IDT meetings to assist the team with the ongoing assessment and planning of crisis intervention and prevention

• Reviewing the ISP/BSP/Crisis Plan

• Developing an Interim Behavior Support Plan/Crisis Plan

• Referral for specialized assessments-TEASC, Special Needs, Offender risk screening, neuropsychological, medical

• Consulting, as needed, regarding the crisis with key players on team as new or issues and considerations arise

• Settings/Consideration Grid. • Identify alternate resources if

applicable• Providing Technical

Assistance regarding support implementation

Response Tier IIResponse Tier II

• On-site observation– Interactions with consumer observed– Environment– Implementation of ISP/BSP/Crisis Plan.

• Modeling – Interaction with individual– Implementation of ISP/BSP/Crisis Plan– Appropriate documentation– Structuring daily routines.

• Training staff on consistent implementation of the ISP/BSP/Crisis Plan

• Mentoring

Response Tier IIIResponse Tier III

• In-home Tier III supports• Tier III services will be delivered in the individual’s

residence, if the individual’s needs can be met in that setting. Tier III activities include:– 24/7 staffing, to be provided by the existing residential

provider– Staff of the Private Crisis Provider and OBS will be

determined on a case-by-case basis by the crisis response team

– Maintain IDT involvement in the crisis, in order to restore the individual’s pre-crisis supports and providers

– Assure appropriate training to support stabilization and return the individual to pre-crisis services and supports

Response Tier IIIResponse Tier III

• Alternative residential setting– Identifying temporary alternative setting from available

providers– Coordinate consumer move to identified alternative

setting– Coordinate staff, as needed, from identified agencies– Maintain IDT involvement in the crisis to restore the

individual’s pre-crisis supports and providers– Facilitate and manage emergency placement from

available providers– Assure appropriate training to facilitate stabilization

when returned to the pre-crisis services and supports

Settings and Considerations

Relationships Environments Activities Attributes

Manner of relatingProviders•Competence•Caring•CoherencePeersFamilyFriends

SafetySpaceStimulationParticipationPleasureChoices

MeaningVarietyPurposeExpectations•Goal direction•Challenge•Guidance•Learning style•Routines

CommunicationSocial competenceProblem-solvingCognitionEmotional statusSelf regulationMedicalCultural IssuesSpiritual BeliefsHistory-Trauma

Most of the time

Once in a while

Not too often

The Four Questions +The Four Questions +Michael SmullMichael Smull

• What have we tried?• What have we learned?• What are we pleased with?• What are we concerned with?• The fifth question and its questions:

– Now what?

– -what will we continue to do?

– -what will we do less of or stop doing?

– -what will we begin or return to doing?

Learning the language of behavior.Learning the language of behavior.

• What is happening? (Antecedents/Precursors)

• Then he/she does this . . . (Behavior)• We think it means this . . .

(Interpretation)• And we should . . . (Analysis and

action)

Three Roads to Quantum GravityLee Smolin

1. There is one, only one, universe and it contains everything and everything it contains is connected.

2. There is one, only one, universe but many observers and every observer experiences a different reality.

3. In the future, we will know more.

4. The universe is about relationships, not events.

Four Rules of the UniverseFour Rules of the Universe