6/25/2018 RW1 RW2 Understanding Crisis Needs for Tennessees IDD - - PDF document

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Understanding Crisis Needs for Tennessee’s IDD Community

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Panelists

• Bruce Davis, Ph.D., LBA, BCBA-D, SrLPE, LPC, Director of Behavioral and

Psychological Services, Department of Intellectual and Developmental Disabilities (DIDD), Nashville, TN

• Kris Roberts, M.S., BCBA, SrLPE, Former Intensive Consultation Team Director
• Zachary Stevens, MS, LBA, BCBA, Clinical Director, Practical Behavior Analysis,

Nashville, TN

• Luke Crabtree, Executive Director, Project Transition, Philadelphia, PA
• Michelle Palmer, Program Supervisor, Project Transition, Knoxville, TN

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Learning Objectives

At the conclusion of this training, participants will be able to: 1. Describe challenges experienced by persons with IDD when they need mental health services. 2. Describe systemic components in place for the crisis prevention and intervention. 3. Identify gaps in the current service system and strategies for making the system more effective.

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Slide 1 RW1 Robin Wilmoth, 12/20/2017 RW2 start with the basic rights of the person then the HCBS settings rule, restrictions then the roles and responsibilities of the FHHRP

Robin Wilmoth, 12/20/2017

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Introduction

• A Difficult Life

– Often disrespected – Low expectations – Unreasonable expectations – Lack of control over their lives

• Exposure to Stress and Trauma

– High rate of unrecognized abuse/trauma (ACEs - Adverse Childhood Experiences) and their impact on adults – 70% people with IDD have ACE-like experiences – 35-50% also have a co-occurring mental health disorder

• The Results

– Risk to self and community – Police intervention – ER visits and psychiatric hospitalizations – Coercion/Restriction

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Kris Roberts MS, LBA, BCBA, SrLPE BEHAVIORAL CRISES AND COMMUNITY INTERVENTION

Zachary Stevens, MS, LBA, BCBA Clinical Director Practical Behavior Analysis, LLC www.practicalbehavior.com

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CLIENT-RELATED CHALLENGES: CRISIS BEHAVIORS

• Physical Aggression
• Self-Injurious Behavior
• Property Destruction
• Elopement
• Threats of Harm, Homicide, or Suicide

SYSTEMIC COMPONENT: BEHAVIOR ANALYSIS SERVICES

• Assess the functions of problem behaviors
• Develop Behavior Support Plan to treat behaviors
• Identify crisis-level responses
• Implement and monitor implementation of treatment

PREVENTION OF PROBLEM BEHAVIOR

• Antecedent Modification
• Environmental Enhancement
• Priming
• Manipulating Motivation

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A BEHAVIORAL CRISIS

Crisis-Level Response Occurs Behavior Support Plan - Crisis Responding Agency crisis response plan Law Enforcement/Mobile Crisis Hospitalization/Respite

GAPS/PROBLEMS: THE CRISIS RESPONSE ITSELF

• Law Enforcement contact
• Could this reinforce the crisis-level behaviors?
• Are there any other possible consequences?
• Reinforcers available at hospitals/respite
• Attention from other individuals and staff
• Access to tangibles (food, drinks, medications, etc.)
• Temporary escape from environment

WHEN ARE WORDS JUST WORDS?

• Threats of Harm, Homicide, or Suicide
• What if the individual has never acted upon such threats?
• Risk of reinforcing inappropriate behavior
• Increased likelihood of future crisis responses

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MAKING THE SYSTEM MORE EFFECTIVE

• Identify whether individual is truly at risk contingent upon verbal

threats

• Withholding crisis responding for verbal threats
• Assessing risks associated with crisis responses for the individual
• Developing alternative crisis responses based on whether

reinforcement is likely

14 Project Transition Proprietary & Confidential

Systems of Support (SOS)

Behavioral health services for individuals with I/DD and co-occurring mental health and/or behavior disorders delivered through TennCare MCOs June 27, 2018

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Systems of Support Mission

“Building integrated systems of support through innovative partnerships and collaboration to empower Tennesseans with I/DD to live the lives they want in their communities”

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Strengths and Challenges

Strengths

• The Department of Intellectual and Developmental Disabilities (DIDD) has consistent thought leadership in working with persons who have

intellectual or developmental disABILITIES (I/DD) who are experiencing Behavioral Health challenges

• Evidence-Based Practices
• Person-Centered Practices
• Encouragement Network
• Other states are watching TN’s leadership with the I/DD population
• Entire Medicaid population in Managed Care since 1994
• 3 national MCO’s operate statewide
• LTSS leadership and others leverage a settlement agreement in litigation to increase person-centered practices
• State Transformation Leadership Group (STLG) pushing Person Centered Practices through all levels of the System
• improving delivery system to persons with I/DD

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Strengths and Challenges

Challenges

• Cost
• About 3% of TennCare members account for 50% of the cost
• Many of those persons benefit from the Systems of Support
• Physical health, behavioral health, and LTSS are not always tightly coordinated and aligned
• Multiple Systems (Medicare, Medicaid, MLTSS, DIDD, RMHC’s, State Centers, DOC, etc.) touch our Members’ lives
• Each System is “optimized” to be efficient on its own
• Very difficult to navigate across systems
• High turnover rates among direct service providers
• High employment rate in major metro cities in TN leads to DSP’s leaving the industry for higher pay jobs
• Many Champions and DSP’s would benefit from increased training and awareness of Person Centered Practices and effective

approaches to working with Persons who have I/DD and experience behavioral challenges

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Systemic Component: Systems of Support

• Developing and supporting the individual’s support system through training to recognize trigger, de-escalate crisis and stabilize
• Assist the person in achieving greater independence and improved quality of life, free of challenging behavior, and a higher degree of

stability and community tenure

• Decreasing the frequency of crisis events
• Increasing one’s ability to remain safe in the community, and out of the hospital
• Build the capacity of the system to better support individuals with I/DD who experience challenging behavior—creating more effective

Systems of Support

Project Transition Proprietary & Confidential

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Resources - Systems of Support

• Person-centered assessment and crisis prevention planning
• Comprehensive face-to-face person-centered assessment
• Discussions with caregivers (paid or unpaid), family members/conservators, etc.
• Comprehensive review of physical and mental health diagnoses and emotional concerns that could trigger need for behavior

intervention

• Identification of medications which could impact behaviors
• Development of individualized Crisis Prevention and Intervention Plan (CPIP)
• Easily understood, individualized, person-centered, and predictive of actions the person’s system of support can take when

needed

• Updated on an ongoing basis, and as needed following any crisis requiring intervention and/or stabilization services

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Resources - Systems of Support

• Training of the Champion and Circle of Support (for paid and unpaid caregivers) in the CPIP to equip them to:
• Provide positive behavior supports to effectively manage day-to-day situations and environments
• Crisis Situation: Identify  Address  Intervene  De-escalate
• Development of community linkages and cross-system supports based on the individualized needs of each member and in

accordance with the member’s CPIP

• 24/7 crisis intervention and stabilization response
• Assist and support the person or agency who is primarily responsible for supporting an individual with I/DD who is experiencing a

behavioral crisis that presents a threat to the individual’s health and safety or community living arrangement, or the health and safety of others

• Work in collaboration with mobile crisis, the provider or family caregiver to stabilize, divert from unnecessary/inappropriate

inpatient, and support sustained integrated community living

• Over time, the SOS team gains ability to anticipate and prevent behavioral escalations, reducing the need for crisis intervention by

the SOS provider

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Existing Resources - Systems of Support

Supported Housing/Community Living Supports Family Support Program Day programming Project Transition Case management

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Be involved before mobile crisis to help de-escalate the behaviors in the home Have mobile crisis aware of who we work with to contact us if any SOS member is referred to mobile crisis Advocate in the hospital as needed to prevent out of home placement Develop a working relationship with all mobile crisis statewide

Resources – Collaboration and Goals with Mobile Crisis

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• Work with Member Champions to improve their ability to support their loved one
• Solution: Person-Centered training with Michael Smulls
• Development and implementation of the cross-system crisis plan
• Lack of inpatient providers for adults with IDD
• Crisis Stabilization Units
• Acute placements
• Limited resources for individuals not involved with the DIDD waiver or ECF Choices
• PCPs and psychiatrists lacking resources needed to adequately treat individuals with and IDD diagnosis
• Significantly enhanced training opportunities for licensed professionals

Gaps and Potential Solutions - Systems of Support

Project Transition Proprietary & Confidential

Discussion

• Summary

– Challenges – Gaps – Solutions

• Panelist Responses
• Questions

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Thank You!

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