Facilitating Treatment Adherence: Training & Advocacy Tips

1. Facilitating Treatment Adherence:Training & Advocacy Tips Norm Dahl, Ph.D., BCBA Mount Olivet Rolling Acres’ Metro Crisis Coordination Program 612/869-6811 NormD@MetroCrisis.Org

2. Ineffective behavioral supports increases persons’ risks of: • Failing to make and maintain important relationships. • Failing to learn new adaptive skills. • Being over-medicated. • Being hurt due to preventable causes. • Injuring others. • Having “911” called on them. • Separations from residential and/or vocational programs.

3. Likely culprits contributing to ineffective behavioral support • Assessment fails to ID the function and situations that set the occasion for CBs. • Interventions are not matched to the function and/or they do not target suitable replacement behaviors. • Interventionists are inadequately trained. • Interventionists receive inadequate follow-up support.

4. Of those culprits, the prime suspects are… • Inadequate training of interventionists. • Inadequate follow-up support.

5. Med. Administration 4-hour classroom training. Clearly defined expectations. In-class knowledge checks. Instructors demo proper med passing protocol. Knowledge is assessed via written post-test. Analogue performance assessment. In-situ performance assessment. Protocol for noting & addressing errors. BSPImplementation Review Tx recs at IDT mtgs. DSPs are rarely present. A supervisor, who is not properly trained to implement the protocol, is expected to train subordinates. Knowledge is not assessed via a written post-test. Performance assessments, analogue or otherwise, are rarely carried out. Procedures for assessing and addressing implementation errors are rarely in place. Common training practices

6. The problem is not with the DSPs • Our first job must be to ensure DSPspossess the knowledge and skills needed to implement support plans. • Our next job is to make sure they use their knowledge and skills. • In short, people must: (a) know what to do, (b) know how to do it, and then (c) choose (or are motivated) to do it.

7. Training & Follow-up are key • Good training can provide people with the knowledge and skills they need to properly implement behaviors plans. • Good training is a first-line risk mgmt. tool. • Practice helps people refine their skills. • Follow-up, in the form of monitoring with immediate feedback, improves knowledge and proper use of skills.

8. Keys to effective treatment(oops, I mean keys to effective training) • The clinician starts by defining knowledge and performance standards. • The clinician trains all who are expected to implement the plan. • At the training, the clinician provides a succinct written account of the: (a) rationale, (b) intended outcome, and (c) what interventionists need to do (i.e., the performance standards).

9. Effective Training (continued) • The clinician reviews the document & describes each component of the plan (i.e., the rationale, goals, procedures). ~ I like to include a treatment integrity check list or a treatment monitoring tool along with the written plan (more in this later). • The clinician demonstrates how to implement the procedures in the plan. ~ I like to use the monitoring tool as a cheat sheet to ensure I don’t miss anything and encourage trainees to do the same.

10. Effective Training (continued) 5) The clinician demonstrates how to use the monitoring tool and provides feedback to interventionists. 6) Everyone takes turns playing the role of the consumer, the interventionist, and the monitor/feedback provider. 7) The clinician describes how monitoring is as much a part of the plan as the implementation protocol.

11. Agenda from a recent DSP training • Review training document & monitoring checklist (demonstrate how to do/use both). • Role-play/practice implementing the protocol. • Role play/practice using the monitoring checklist. • Role play/practice providing feedback. • Discuss the importance of consistency. • Reach consensus on an implementation and monitoring schedule.

12. Why Monitor Implementation? • It sends the message that proper implementationisimportant&expected. • It’s the only way to know if treatments are being implemented as planned. • It provides a forum for praising desirable implementation and correcting improper implementation. • It allows you to assess the client’s responsiveness to the plan.

13. Keys to effective monitoring • Identify the person(s) responsible for monitoring. • Make sure everyone knows what the monitoring plan entails. • Use a monitoring tool to reduce subjectivity & minimize observer drift. • Monitor all interventionists.

14. Effective Monitoring (continued) • Monitor when CBs are most likely. • Monitor frequently at the outset. • The more significant the risks posed by persons’ CBs, the more frequently their plans should be monitored. • Make sure people know they are being monitored(and what’s being monitored). • And finally, monitor a monitor’s monitoring from time to time.

15. Treatment Integrity/Monitoring Checklist (Example I) Equipment is available and in proper working order: _____ _____ Door & window alarms; (similar to a fire drill, periodically set off alarms to see if they are working. ____ _ Cell phone. (is it available, is it charged?) _____ Locks on doors work properly? Direct Observation: _____ Alarms are armed when ___ is on site? _____ Doors are locked when ___ is on site? _____ ___’s shoes are locked up? _____ Staff are running the levels program and following his schedule? _____ Staff immediately prompt ___ to return to living room should he stand at the doorway? _____ If ___ did not comply within 3-s, staff escorted him to the living room? Regarding outings: _____ Before opening the door to the house (or a vehicle) staff remind that he needs to walk directly to the designated location _____ Practice (spot check on random basis or review at weekly staff meetings): _____ Staff can paraphrase the 911 script? _____ Staff can paraphrase the PRN protocol? _____ Staff can identify and describe Level I (precursor) behaviors? _____ Staff can describe and/or demonstrate at least 3 of the protocol included under Level I? _____ Staff can describe and/or demonstrate at least 3 of the daily interaction protocols? Data (spot check on a random basis) _____ Collected consistently? _____ Collected accurately? _____ Person who assesses data collection practices should provide feedback to staff. _____ Review data during weekly house meetings.

16. Treatment Integrity/Monitoring Checklist (Example II) Date_______ Staff Observed ______ Staff Observing______ Task 1 Task 2 Task 3 1 Presented card options…… ______ ______ ______ 2 Gave 15-s to choose……… ______ ______ ______ 3 Presented card up to 3 x….. ______ ______ ______ 4 Chose for him if necessary.. ______ ______ ______ 5 Allows for an alternative.… ______ ______ ______ 6 Gave 3+ w/in task choices.. ______ ______ ______ 7 Gave 15-s between choices. ______ ______ ______ 8 If needed, gave help to complete 1st step of task….. ______ ______ ______ 9 Ignored CB if it occurred… ______ ______ ______ 10Praised choosing/task comp ______ ______ ______ 11Gave token upon task comp ______ ______ ______

17. Treatment Integrity/Monitoring Checklist (Example III)

18. Why Provide Feedback? • You greatly increase the probability that the plan will be implemented as intended. • You greatly increase the probability that the plan will produce the desired effects.

19. Keys to Effective Feedback • Feedback should be immediate. • Periodically throughout, if it won’t interrupt the flow of implementation, • Or, in a summative fashion at the end of implementation. • Only positive feedback from senior-level supervisors should be delayed. • Feedback should be private • Positive & corrective should both be provided in private.

20. Effective Feedback (continued) • Feedback should be sincere. • Feedback should be based on a specific set of standards to which DSPs have been sufficiently trained. • Feedback should be behavior-specific.

21. Effective Feedback (continued) • Start feedback sessions by focusing on something the person did right. • Corrective feedback should inform people of what they “should do” not what they “shouldn’t do.” • End the session by reiterating what a person did right or by commiserating about how it takes practice and a lot of concentration to develop new skills.

22. Additional things you can do as a clinician or trainer • Pitch Tx recs. as being consistent with beliefs held by stakeholders. • Address behaviors important to DSPs. • Include at least 1 rec. they will have little difficulty doing. • Provide a self-monitoring tool. • Build in choice opportunities for DSP. • Establish reasonable expectations for change.

23. As an Advocate… • Share your belief in the plan with staff. • Invite mgmt. personnel to attend team meetings and share an expectation that the plan will be implemented as written. • Don’t allow changes in a plan until you assess if the plan was implemented with integrity.

24. As an Advocate (continued) • Include proper implementation of the BSP as an item in persons’ RMA&Ps. • Include monitoring on RMA&Ps as well. • Make sure BSP training is included in the “special training” section of ISPs. • Ask that certain implementation responses be documented on persons’ medication administration records.

25. As an Advocate (continued) • Request data on DSPs’ implementation behaviors in addition to behavioral data. • Ask for a plan that specifies how implementation will be assessed and how errors will be addressed. • If non-adherence is an issue, find out why. • Insufficient training or follow up? • Competing responsibilities?

26. As an Advocate (continued) • Higher up in the County • Include Tx adherence as a performance standard in contracts. • Before offering additional funding for staffing, make sure there is a specific plan for how the time will be used. • Request data that allow you to assess if (and how) the additional service you are purchasing is being provided. • If you fund 1:1 staffing, you should expect continuous therapeutic engagement.

27. Take Home Message • Minimize undesirable outcomes (risks) by taking BSP implementation as seriously as you take proper med. administration. • Increase adherence by ensuring people get a chance to practice implementing the plan during initial training. • Increase adherence with monitoring. • IncreaseadherencebyofferingF-Back. • Advocate for monitoring as an integral component of behavior support plans.

28. And one more thing you can do • Make a referral to MCCP for refresher training and the development of a treatment adherence protocol. • Typically, because these referrals will not include an assessment or treatment recommendations, only 60-80 “units” of service will be needed. • Approximately ½ the time of a typical referral. • Call MCCP @ 612/869-6811.