real reduction experiences holston united methodist home for children greeneville, tn
TRANSCRIPT
Holston HomeStarted as an orphanage in 1895
Multi-program agencyFoster Care (120 youth)
medically fragile, low intensity, therapeutic
In-Home ServicesAdoptions (49 placements in 2003)
special needs, domestic, internationalChild Day Care (100, infant – 5 yrs. old)
Holston HomeDay Treatment School (75 youth, K-12)Residential Group Care & Treatment (84)
Assessment (8)Boy’s Treatment (40 – Lv. 2 & Lv. 3)Girl’s Group Home (8)Girl’s Developmental Home (8)Boy’s Group Home (8)Preparation for Adult Living (12)[2004 Residential Numbers: 50 - 60]
Staff : 200+ in four sites
Why Change?
It looked bad and felt bad 1998 – 1400+ restraints, 2600+ seclusionsHigh number of disruptions, “bouncebacks,” and runaways Some staff began to raise concerns about the therapeutic quality of our “treatment” approachStaff were not given enough skills to appropriately deal with negative behavior
Culture Analysis –Crisis Creators
High staff turnover
Inexperienced staff
Poor training
Shorter ALOS of youth
Higher numbers of more difficult youth
Older youth
Leadership turnoverpoor leadership in
various positions
Perceived lack of support from administrative staffControl-oriented culture of careFear
Restraint ReductionRestraint Reduction
Year Restraints Youth Injuries Requiring Medical
Attention
Staff Injuries Due to Physical
Management(% of overall)
1998 1447 6 36 (71%)1999 660 2 27 (66%)2000 169 0 4 (27%)2001 93 3 12 (34%)2002 169 0 17 (49%)
2003 116 0 11 (31%)
Restraint Reduction
1447
660
16993
169 1160
200
400
600
800
1000
1200
1400
1600
1998 1999 2000 2001 2002 2003
Restraints
Positive Change and Success:
Seclusion ReductionSeclusion ReductionYear Seclusions
1998 2642
1999 2114
2000 1259
2001 940
2002 607
2003 386
2004 201[1st Q = 166 2nd Q = 35]
Seclusion Reduction
2642
2144
1259
940
607386
0
500
1000
1500
2000
2500
3000
1998 1999 2000 2001 2002 2003
Seclusions
Relationship of Restraint Reduction to Seclusion Reduction
-500
0
500
1000
1500
2000
2500
3000
1998 1999 2000 2001 2002 2003
Restraints
Seclusions
Linear (Restraints)
Linear (Seclusions)
Relationship between restraint reduction and seclusion reduction:
r = .91 (p=.01)
Leadership Towards Organizational Change
Senior leadership decision to reduce restraintsMoney and staff resources put into exploring/implementing changeCWLA consultant brought inResearching what others were doing
Buy-in of middle management and direct care supervisorsMore responsibility on directors and
supervisors to hold staff accountable
Using Data to Inform Practice
CQI Tracking of Restraints and Seclusion
Setting % reduction goals
Collecting data in a more sophisticated manner via Restraint Review Committee
Using Data to Inform Practice: Show them the #’s!
2004 HH Injuries to Staff (Jan. – June)4 during Restraints8 during Physical Guidance**Not all may be related to Seclusion
Seclusions are linked to restraints2003: 80% of restraints due to indication
of seclusion
Stopped the use of seclusion July 1, ‘04
Workforce Development
Increased staff training:From 2-4 days orientation to 2 weeksFrom 1 day of “restraint training” to 4 days
of de-escalation and restraint techniques (2 ½ days of de-escalation techniques)
Supervisory training increasedAdded full-time Staff Development
Coordinator position
Reduction Tools
Recently implemented tools:
Individual Crisis Management Plans
Behavior Support Plans
Consumer Roles in Inpatient Settings
14 youth participated in Treatment Model Task Force focus groups on “building relationships”4 family members participated in Treatment Model Task Force focus groups on “building relationships”Youth input on Individual Crisis Management Plan (ICMP)
Debriefing Techniques
After each restraint, the primary staff involved conducts a Life Space Interview (LSI) with the youth.
LSI documented as a part of Serious Incident Report
Informal debriefing for staff involved conducted by supervisor
Concurrent ChangesChange of treatment culture – 1999
Treatment model task forceMove to a relational model of care:“connecting” vs. “controlling”
Training in Mediation – 2001
Year Grievances Founded2000 311 202001 170 242002 58 82003 23 0
Mistakes & SuccessesMistakes
Went cold turkey
Didn’t give other “tools” early on
Some hired-in directors didn’t buy in
Held on to some staff who didn’t buy in
Successes
Support from leadership
Data and goal-setting
Training on staff resistance
Training, Training, Training
Celebration
What We Have Learned
It gets worse before it gets better
When you take away a tool, you have to put another one in its place
Plan thoroughly and prepare staff
Power struggles must be recognized and redirected
Staff have to be supported and empowered
Involve youth – listen and learn
What We Have Learned
Data collection is key – show them the numbers!
Review process is critically important
Restraint Review Committee:Purpose
Tracking through data gatheringEmphasis on detail of report writing
Identifying trends
Sending a message of importance
Giving feedback to staffLearn from mistakes and successes
Meeting Standards -now mandated by
TN DCS