3/10/20 1 2 This presentation will: • Review planning and implementation of Tier 3 and 1 PBS Implementing a PBS continuum in a adaptations in a large public sector psychiatric hospital. large public psychiatric hospital • Describe the unique challenges of designing and implementing a positive practice model in a public sector psychiatric setting, particularly related to staff Meredith Ronan, Psy.D. engagement and promoting culture change. 17th International APBS Conference Miami, Florida March 13, 2020 • Assess empirical and qualitative outcome data to gauge utility and value of PBS programming (Tier 1 and 3) in inpatient psychiatric facilities. 1 2 3 4 Worcester Recovery Center and Hospital Worcester State Hospital (WRCH) 3 4 5 6 Patient Population Primary Components of Clinical Care • Multidisciplinary treatment teams include • 2 Court evaluation Units and 8 Continuing Care psychiatry, psychology, social work, units (26 patients per unit) occupational therapy, peer specialists, and • Length of stay- average 200 days nursing. • Demographics: ~25% Women, 75% Men • Medication administration and education. ▫ Diverse population • Opportunities for individual and group • Diagnostically: therapeutic interventions including a variety of ▫ Severe and persistent mental illnesses evidence-based treatments. ▫ Complex co-morbidities (physical/medical/cognitive) 5 6 1
3/10/20 7 8 Overview and Rationale PBS Consultation Service • Challenging behavior is a significant concern in • Introduced September 2015 through a inpatient settings. collaboration of Clinical/Hospital • Associated with a range of negative outcomes: Administration and Psychology and Nursing Patients: Staff: departments. • Restrictive practices • Injury • Aim to reduce rates of aggression/violence and • Prolonged hospitalization • High stress occurrence of restraint and seclusions • Poor quality of life • Burnout • Focus on patients with the most challenging • Low job satisfaction behaviors and intensive treatment needs in the state/DMH system. 7 8 9 10 Program Development PBS Program Initiation • Year 1 (September 2015-August 2016): ▫ Developed PBS consultation program and began individual case intervention. • Initial efforts were heavily focused on: ▫ Developed collaborations with four continuing care units ▫ Getting buy-in from staff (i.e., nursing) • Year 2 (September 2016-August 2017): ▫ Established a postdoc program and served two more continuing care units ▫ Collecting behavioral data to inform decision-making • Year 3 (September 2017-August 2018): and PBS planning ▫ Expanded individual consultation/intervention services to two more units ▫ Working directly with patients to engage and model ▫ Began planning for Hospital-Wide Tier 1 (Primary Prevention). specific intervention strategies. • Year 4 (September 2018-August 2019): • Significantly divergent from implicit models of care, ▫ Ongoing maintenance of individual PBS caseload, including increased beliefs about psychopathology, and challenging consultation capacity. behavior. ▫ Continued planning and began implementation of Hospital-Wide PBS implementation. • Shift from viewing problem as originating within the • Year 5 (September 2019-present) person and treated at the individual level à ▫ Reduced caseload capacity due to loss of postdoctoral position and part-time recognizing and emphasizing the role of funding for psychologist. environment and context. ▫ Ongoing planning and implementation of Hospital-Wide PBS, including intensive training and support with nursing department. 9 10 11 12 Medical Psychologists Psychiatrists Providers DMH – Dirty Words Clinical Social Occupational Treatment Workers Therapists • Behavior Problem Team Nurse 1 st Shift Managers • Behavioral Willful Nurses 1 st Shift 2 nd Shift (4) • Behavior Plan Coercion MHWs Nurses (8-12) Direct (3-4) Administration PBS • Reinforcement Reward Care Consultant Staff 3 rd Shift • Consequence Punishment 2 nd Shift Psychologist Nurses 3 rd Shift MHWs • Positive Good (2-3) Nurse (8-10) MHWs Supervisors • Attention Problematic (6) Guardians Human (Family or Rights Patients Legal) Officers 11 12 2
3/10/20 13 14 Patient Demographics Patient Demographics • Numerous lifetime psychiatric hospitalizations • 45 patients served throughout 4 ½ years of service (15+), and some have been continuously • Age range: 16-66 institutionalized for 10 or more years. • Diverse representation of gender, race/ethnicities, • Have displayed behaviors that posed a high risk to staff and were described as having been and primary/preferred languages unsuccessfully managed at other settings/facilities. • Primary psychiatric diagnoses: • Many are the highest users of specialized staffing ▫ schizophrenia spectrum disorder statuses (e.g., 3:1, 2:1, 1:1, Constant Observation ▫ autism spectrum disorder (CO)). ▫ post-traumatic stress disorder ▫ 20% require some special status daily or at all times, ▫ borderline personality disorder ▫ 40% have been on status at some point in time or for ▫ developmental/intellectual disability partial hours of the day ▫ 40% have not typically required special staffing ▫ neuro-cognitive disorders (other than 15” checks). ▫ obsessive compulsive disorder 13 14 15 ASSESSMENT • Record review • History • Collateral (staff) Challenging Behaviors • Antecedents/Consequences interviews • Ecological factors • Patient interview • Functional analysis • Data collection/analysis • Primarily include aggressive behaviors (i.e., INTERVENTION verbal and/or physical attempts or actual assaults). ◆ System ◆ ◆ Individual ◆ ◆ Environment ◆ PROACTIVE REACTIVE § Family • 75% of the cases in the program have physical § Response § Facility § Skill development § Physical factors strategies § Community aggression as the primary target behavior. → Individual therapy § Interpersonal (reduce severity § State → Communication § Programmatic of behavior) → Coping skills • Self-injurious behaviors and intrusive behaviors § Staff approach have also been targets for intervention. IMPLEMENTATION § What needs to be done and who is responsible? § Training & supporting staff § Shifting traditional perceptions and responses to challenging behavior OUTCOMES Data-based Decision Making 15 16 Proactive Strategies Ecological/Environmental Strategies • Interventions designed to reduce triggers or antecedents to problematic • Goals: behaviors by making changes environment to better fit the person’s characteristics and needs. ▫ Improve the person’s overall quality of life • Challenging behavior often occurs because there is a mismatch ▫ Give the person more control over his or her life between needs and environment: ▫ Teach the person skills (e.g., communication, • Physical Factors: coping/tolerating distressing experiences) ▫ Setting, light, noise, crowding • Interpersonal Factors: ▫ Reduce the need for restrictive/reactive strategies ▫ Communication/culture • Includes : ▫ Social interactions ▫ Ecological/Environmental Strategies ▫ Clear and consistent expectations • Programmatic Factors: ▫ Positive Programming ▫ Choice, predictability and control ▫ Focused Support Strategies ▫ Activity Scheduling ▫ Instructional methods ( LaVigna and Willis, 2009) ( LaVigna and Willis, 2009) 17 18 3
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