Legislation and Promising Practices for Reducing Restraint & Seclusion Use

1. Legislation and Promising Practices for Reducing Restraint & Seclusion Use Restraint and Seclusion in Foster Care Presented by Lloyd Bullard, M. Ed. LB International Consulting, LLC.

2. Introduction

3. Legislation • Children’s Health Act of 2000 (H.R. 4365) • Signed into Law October of 2000 by President Clinton • The Act contains two significant section: • Part H and; • Part I.

4. Children’s Health Act of 2000 • Part H - applies to public and private general hospitals, nursing facilities, intermediate care facilities, or other health care facilities • Part I – applies to public and private non-medical, community-based facilities for youth (as defined by the secretary)

5. Children’s Health Act of 2000 • Part I – required physical restraints and seclusion to only be imposed in emergency circumstances and only to ensure the safe of the child, staff or others • Other less restrictive interventions would have been determined to be ineffective

6. Children’s Health Act 2000 • Restraints or seclusion are imposed only by an individual trained and certified by state recognized body (as defined by the secretary) • Interim Procedures – Supervisory or senior staff with training in restraint and seclusion who is competent to conduct a face-to-face assessment (as defined by the secertary) • Supervisor or senior staff continues to monitor the situation for the duration of the restraint or seclusion • Secretary 6 months to develop standards/States 1 year to develop standards once the Federal standards are implemented

7. Foster Parents and Restraint & Seclusion Use • Cornell University’s Research – Numerous focus groups with children in foster carte and foster parents • Cornell has refused to train foster parents on restraint techniques. • Based on children perceiving that the foster parents were attempting to hurt them • Liability issues related to safety risks

8. Why So Many Restraints? • Caretakers say: • It’s the clients. • They have such severe problems • They often put themselves, other clients, and staff at risk. • It’s necessary to keep everyone safe.

9. But Some Studies Suggest Otherwise • Programs serving similar children have widely varying rates of restraint. • Some programs serving very difficult children have low restraint rates. • Many programs have significantly reduced restraint without changes in their populations.

10. What is it about us? • Our belief that the problem lies with the clients • Focus on management and control as opposed to support and teaching • Lack of staff skills in effective de-escalation

11. Bad News or Good? • Being identified as the source of the problem may sound like bad news or an indictment of caretakers. • But it’s actually good news. • If it really were the clients, we’d be stuck doing thousands of restraints forever. • If it’s us, we can do something about it.

12. Successful Strategies to Reduce Restraint and Seclusion

13. The Issue Brief(NETI, 2003) • Reducing the Use of Restraint and Seclusion: Promising Practices and Successful Strategies • An issue brief that annotates policies and practices that successfully reduce the use of restraint and seclusion • Chapters • Leadership • Organizational Culture • Agencies’ Policies, Procedures and Practices • Staff Training and Professional Development • Treatment Milieu • Continuous Quality Improvement

14. The Issue Brief • Information pulled from a variety of sources as outcomes and data on children is scarce • Project’s own preliminary quantitative and qualitative findings • Subject matter experts • Focus groups findings (Federation of Families for Children’s Mental Health - FFCMH) • Published research findings

15. Leadership(NETi, 2003) • Supportive Executive Leadership • Identify Restraint and Seclusion as a Top Priority • Sustained commitment by the executive leadership team. • Set the Tone • Mission statement supports a violence- and coercion-free environment • Restraint and seclusion are crisis events, treatment failures, and high-risk interventions • Leaders must model the interest, time commitment, and “sell” the initiative to managers and direct care staff

16. Leadership(NETI, 2003) • Supportive Executive Leadership continued: • Provide Training and Resources • Emphasize training in alternatives to restraint and seclusion • Ensure integration of training into practice • Establish an Oversight Committee • Include executive leaders, managers, supervisors, direct care staff, family members, children, and advocates • Committee empowered to implement changes

17. Leadership(NETI, 2003) • Supportive Executive Leadership continued: • Take Responsibility • Administrators shoulder the burden of reducing restraint and seclusion • Maintain Accountability • Executive leader(s) on-call 24 hours a day to whom each incident is immediately reported

18. Leadership(NETI, 2003) • Supervisory and Managerial Involvement • Set the Tone • Send a clear message • Support coercion-free environment, partnerships, choice, and proactive communication • Elimination of the unnecessary use of restraints and seclusion is paramount • Model and Coach • Alternative approaches • High expectations, time commitment, training resources, 24 hour on-call support

19. Leadership(NETI, 2003) • Supervisory and Managerial Involvement continued • Lead Debriefing • Exercise for learning not punishment • Gather data • Discuss • Document timelines

20. Leadership(NETI, 2003) • Elimination by Mandate • Banning restraint use or types, eliminating of seclusion rooms, or use of prns • Constant vigilance and ongoing training in de-escalation • Requires emphasizing behavioral support instead of emergency intervention

21. Organizational Culture(NETI, 2003) • Relationship Building • Facilitates support of positive behavior • Helps de-escalate children in times of crisis • Healthy Relationships are developed over time

22. Organizational Culture(NETI, 2003) • Person-Centered Environment • Needs of the child are at the forefront of care • Use supportive language, and express an unwillingness to label children as “manipulative” or “needy” • Emphasize collaboration rather than compliance • Offer culturally and linguistically competent services

23. Organizational Culture(NETI, 2003) • Staff Empowerment • Youth Involvement • Family and Natural Support Involvement • Treatment Planning • Programming • Participation on Review Team • Advocacy

24. Agency Policies, Procedures and Practices(NETI, 2003) • Comprehensive Assessment • History of aggression, and the physical, psychiatric, and emotional risks of restraint and seclusion • Inform the behavior support and treatment plans • Treatment Planning • Individualized and strengths-based • Developed in conjunction with child and family • Individualized Behavior Support Plan • Identify triggers, successful intervention strategies, and options for self-calming • Communicated to all relevant staff • Revisited regularly

25. Agency Policies, Procedures and Practices(NETI, 2003) • Monitoring • Face-to-face, third party • Assess the physical and psychological well-being of child • Authority to stop intervention if signs of distress are evident • Debriefing • Occurs with the child, witnesses, staff, and family members • Express feelings about the incident and to make a plan to avoid for incidents • Debriefing does not assign blame • Should be carefully documented • Staff Designated to Implement Restraint and Seclusion

26. Staff Training and Professional Development(NETI, 2003) • Training on Trauma-Sensitive Care, Prevention, and De-escalation • AT LEAST 50% of all training should focus on these three core elements • Competency-Based Training • Culturally and Linguistically Competent Services • Tones, gestures, and postures that may be misinterpreted by youth • Frequent Refreshers to Minimize Training Drift • Regular Staff Supervision, Mentoring, and Coaching

27. Treatment Milieu(NETI, 2003) • Treatment Philosophy • Coercion-free and non-punishment based • Trauma-Informed Care • Culture of empathy • Acknowledge that most children have experienced trauma • Restraint and seclusion is re-traumatizing • Staff should know signs of trauma • Positive, Structured Environment • Requires active programming • Well-maintained environment • Behavior Support • Give children anger and anxiety management skills. • Constant role playing.

28. Continuous Quality Improvement (CQI)(NETI, 2003) • Setting Organizational Goals • Collecting and Analyzing Data • Reporting Results • Corrective Feedback Mechanisms • Celebrating Successes • Program Evaluation

29. CWLA Resources

30. Best Practice Guidelines For Behavior Management • Ethical & Legal Framework • Administration & Leadership • Continuum of Intervention • Medical Issues • Professional Development & Support for Caregivers.

31. Reducing the Use of Restraint & Seclusion: Promising Practices & Successful Strategies • Leadership • Organizational Culture • Polices, Procedures & Practices • Training & Professional Development • Treatment Milieu • Continuous Quality Improvement

32. Best Practice Guidelines for Behavior Support & Intervention Training • Organizational Leadership & Culture • Behavior Support & Intervention Training Programs • Risk Factors • Emergency Interventions • Training Process

33. Supervisors Training Curriculum • Changing Organizational Culture • Behavior Support Plans • Program Factors • Family Involvement • Diversity Issues • Reward & Consequence Systems • Supervisory Role • No Blame Culture • De-Briefing

34. Definitions Criteria Monitoring Ordering Post Assessment De-Briefing Family Notification Training Documentation Reporting CQI Plans Prohibited Practices Data Collection Reduction Plans State Regulations

35. Summary • Restraint reduction is a 4-step process: • Admit it’s us who have to change • Look honestly at our contributions to this problem • Attack each of the six areas • Evaluate progress and don’t give up