1 Real Reduction Real Reduction Experiences Experiences Commonwealth of Massachusetts Commonwealth of Massachusetts Department of Mental Health Department of Mental Health Janice LeBel, Ph.D. Janice LeBel, Ph.D. Director of Program Mgmt., Child & Adol. Director of Program Mgmt., Child & Adol. Division Division Nan Stromberg, MSN, APRN,BC Nan Stromberg, MSN, APRN,BC Director of Nursing – Licensing Division Director of Nursing – Licensing Division
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Real Reduction ExperiencesReal Reduction Experiences
Commonwealth of MassachusettsCommonwealth of MassachusettsDepartment of Mental HealthDepartment of Mental Health
Janice LeBel, Ph.D.Janice LeBel, Ph.D.Director of Program Mgmt., Child & Adol. DivisionDirector of Program Mgmt., Child & Adol. Division
Nan Stromberg, MSN, APRN,BCNan Stromberg, MSN, APRN,BC
Director of Nursing – Licensing DivisionDirector of Nursing – Licensing Division
o State Mental Health Authority• Licensing oversight of acute care system• Contract monitoring of continuing care/state system
o Emphasis of SMHA• Setting standard of low/no R/S utilization• Promoting change
o Statewide Restraint Reduction Initiative• All Child & Adolescent Inpatient Providers (33)• Both acute & continuing care (500 + beds)
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How did we know we had a problem?
The Quantitative Perspective
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A Review of the DataA Review of the Data
o Restraint use withkids increasingeach year
o Children/Adolescents using more S/R
o Systemicdiscrepancies
66.5
6.9
0
100Rate per
1000 Patient-days
Hospitals A and B
Acute Care Hospital Comparison - 2000
High Utilization
Low Utilization
Restraint Episodes per 100 Admissions (Licensed Facilities)
Pre-Initiative
0
25
50
75
100
125
150
1998 1999 2000
Years
Ep
iso
des p
er
100
Ad
mis
sio
ns
Child (L) Adult (L) Adolescent (L) Mix CA (L)
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How else did we know we had a problem?
The Qualitative Perspective
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Overburdened with R/S Forms Overburdened with R/S Forms from across the Statefrom across the State
We knew there was too much restraint & seclusion when the We knew there was too much restraint & seclusion when the forms were practically upforms were practically up over over our heads.our heads.
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A Painful Pattern & A Painful Pattern & Restraint RecipeRestraint Recipe
Challenging behavior by kid → limits set by staff → kid escalated → staff more restrictive → kid lost control → R/S took place
• Over-reactivity – focus on control • Safety means containment• Lack of early intervention and support• Lack of crisis planning• Staff blamed the kids because they lacked training
Changing the Paradigm: Changing the Paradigm: Sorting Myth from RealitySorting Myth from Reality
More money More staff New staff Micro-management of
staff Traditional training
Using resources flexibly Core staff New staff attitude & open
to change Valuing & empowering
staff Enhanced training:
coaching, modeling, mentoring & supervision
Does notnot require DoesDoes require
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Changing the Paradigm: Changing the Paradigm: Sorting Myth from RealitySorting Myth from Reality
Flexibility with the Environment
Collaboration
Negotiation/Dialogue
Rewarding the Positive
Active use of Data
State of the Art Environment of Care
Control
Confrontation/Limit-setting
Reacting to the Negative
Strict Data Collection
Does notnot require DoesDoes require
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Multi-Year PlanningMulti-Year Planning
Fundamental Plan Create a R/S Reduction TeamR/S Reduction Team Consumer & Family Involvement Best Practice Conference Kick-Off & Provider
Strategic Planning Quarterly Statewide Grand Rounds Annual Provider Presentation Forums
The GoalTo change culture, practice & “root” the Initiative by: Communicating & educating Continually reviewing & planning Regulating
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Re-wrote the DMH Regulations, Re-wrote the DMH Regulations, Effective April 2006, DMH Regulation 104 CMR 27.12Effective April 2006, DMH Regulation 104 CMR 27.12
Focus on prevention – not just ‘safe application”
o Prevention requirements: o Crisis Prevention Planso Assessment of Trauma and potential for re-
traumatizationo Program Quality Improvement Planso New Policies and Procedureso Increased Education for Staff o Sensory Resourceso Active use of Data
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Re-wrote the DMH Regulations, Re-wrote the DMH Regulations, Effective April 2006, DMH Regulation 104 CMR 27.12Effective April 2006, DMH Regulation 104 CMR 27.12
o Restrictions if Used o Shortened renewal time for orders (2 hours)o Prohibition of prone restrainto Clarified and tightened seclusion definitiono Prohibition of mechanical restraint for children
under 13o Intensive “real-time” review of long restraints
by facility director and medical directoro Debriefing Requirements
ConsumerStaffAdministrative Review
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For some … For some … a bit of reluctancea bit of reluctance
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Broadening the Perspective: Broadening the Perspective: Improving Care for ChildrenImproving Care for Children
o Models of Care o CPS, PEM, DBT, PBS, Holistic, Resiliency,
Relational, Trauma Systems
o Child, Adolescent & Family Perspective
o Public Health Approach
o Crisis Planning
o Understanding Trauma
o Sensory Approaches
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Coming to our SensesComing to our Senses
o Sensory Assessment: What’s your diet?What’s your diet?o Sensory Intervention: A universal experienceo Giving children and staff greater array of Giving children and staff greater array of
alternative toolsalternative toolso Broad Application:
Treatment, early intervention & crisis planning
Touch: Renewed consideration
o Touch Assessment Supported by the literature Arm & hand massages, weighted items, pressure
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