Effective services for individuals with ID and behavioral health needs

Who is in crisis, the service recipient or the system?

Joan B. Beasley, Ph.D.2/08

Supporting People Who Have Challenging Behavior

“Essentially, people with challenging behavior are critics of our service system and instead of blaming them, we might use them as an opportunity to review what we are doing and for whom we are doing it”

Herb Lovett,1994

Approximately one in four individuals with developmental disabilities has behavioral health care needs.

Between 600,000-800,000 adults with co-existing mental retardation and mental illness live with (and rely upon) their families

Many of these individuals have health care needs as well:

1. Medication effects2. Neurological impairments3. Genetic syndromes4. Chronic health conditions5. Chronic dental conditions

MH/ID Community Service Elements❚ Service Planning/Coordination❚ Cross Systems/Interdisciplinary Training❚ Outpatient mental health: counseling/psychiatry ❚ Health care and dentistry❚ Crisis Prevention and Crisis Intervention Planning ❚ Residential/Housing/Day/Vocational: Habilitation❚ Respite❚ Inpatient Hospitalization❚ Hospital Diversion/mobile crisis support❚ Psychology/Behavioral Support Planning❚ Family Support/Education/Outreach

Problems with most ID/DD systems:

❚ “Troublesome” behaviors considered unacceptable in many support and service venues.

❚ The last and least served (i.e. latest trends in congregate or institutional living)

Problems with the MH System

❚ Stigma❚ Much more likely to use emergency

services❚ Lack of training (diagnostic

overshadowing)❚ Lack of expertise❚ Medication issues

Effective Service Systems:

The 3 A’s ❚Access❚Appropriateness❚Accountability

Access

❚ Timeliness❚ Array of services❚ Availability❚ Geographic proximity❚ Resources alone should not define

service use…

Appropriateness

❚ Service matches recipients wishes❚ Service allows for self determination

whenever possible❚ Providers have expertise ❚ Service matches needs…

Accountability❚ There is consensus with regard to roles and

responsibilities on the part of providers❚ Services are cost effective❚ Recipient is satisfied with services❚ Services meet objectively established goals❚ Services change with the changing needs of

the service user❚ Listening and mutual respect in the system is

required…

Coordination of services helps to insure effectiveness

Prototypes of coordinated care

❚ Traditional (Case Management)

❚ Integrated (ACT)❚ Cross Systems linkage

Systems Linkage Approach

❚ KEY: Enrich the system (avoid strain)❚ Resources allocated to promote linkages (i.e. the

use of a “linkage team”)❚ Resources allocated to fill in service gaps❚ Services provided across systems❚ Affiliation/linkage agreements❚ Individualized service plans incorporate all

Some Program models in the U.S.

Author(s), Year Program NameBeasley& Kroll, 2002 The Sovner Center/START program (1989)Beasley& duPree, 2004 The Woodbridge ProjectCasner, 1996 Austin-Travis County MHMR CenterCollond & Weisler, 1995 Cambridge Minnesota Regional Support TeamDavidson, Cain, Sloane-Reeves,

Giesow, Quijano, Heyningen & Shoham, 1995

The Rochester Crisis Intervention Program

Rubin, Fahs and Beasley, 2007 The TN START programPatterson, Higgins, & Dyck, 1995 Case Management Mental Health NetworkRambow & Arnold, 1996 The Alaska cross systems approachResources For Community Living,

1993Vermont Crisis Intervention Services

Rudolph, Lakin, Oslund & Larson, 1998

The Minnesota Special Services Program

Woodward, 1993 Interface

START SERVICE ELEMENTS ▲ Affiliation agreements ▲ Crisis prevention planning ▲ Clinical consultation ▲ Emergency assessment ▲ Crisis intervention ▲ Emergency respite ▲ Family respite (planned) ▲ Training ▲ Facilitation of interdisciplinary meetings

Mental Retardation Services

❏ Day/vocational ❏ Residential ❏ Recreation ❏ Habilitative

Mental Health Services

❏ Outpatient ❏ Inpatient ❏ Crisis

UNPAID SUPPORTS ✲ Individual ✲ Family ✲ Friends ✲ Other informal supports

The Sovner Center

Service enhancements❚ Intensive case management/service brokers ❚ Consultation❚ Training❚ Crisis support❚ Respite/hospital diversion❚ Outpatient services❚ Inpatient support

Four essential components

❚ expertise❚ Family support and education❚ Planned and emergency respite

services❚ Cross systems crisis prevention and

intervention planning

Short term Respite Services

❚ diagnosis and treatment formulation❚ symptom monitoring❚ emergency support❚ hospital diversion❚ community transition from hospital❚ family support and education

The Cross systems crisis plan

What is a crisis?

What is the cross systems crisis plan? it must be multi modal

❚ Demographic information❚ Incorporation of mental health/health

symptom management❚ Pbsp? Some similarities and differences❚ Contract between providers❚ Roadmap to prevent the system from

going into crisis

The Six Elements of the Cross-Systems Crisis Prevention and Intervention Plan

1. The Face sheet2. General guidelines3. Hierarchy of behaviors4. Disposition recommendations5. Back-up protocol6. Signature page

Consistency - one cannot implement an effective plan on a part-time, haphazard basis. Protocols of support should be established to promote a positive, methodical response to the problematic behaviour.

Portability - the plan must have the ability to move with persons in the various settings in which they interact - staff and family in all locations must be trained in the interact ional approaches.

Intensity - the frequency and quality of interactions with individuals during the course of the day needs to promote a wellness approach rather than a management model for crisis prevention and intervention.

Change - rearrange the environment or caregivers to become sensitized to stimuli or triggers that cue behaviours, with a focus on prevention of these behaviors manifesting themselves, in other words crisis prevention techniques require educated flexibility on the part of staff and the system of support

Effective crisis prevention and intervention plans

Lessons learned

❚ It is difficult to prove prevention but important to address when dealing with crises.

❚ A crisis is a concern or event that occurs when you do not have the tools to address it effectively.

❚ A “crisis” is in the eyes of the beholder

If its just another form: forget it

❚ The plan will not have value without cross systems collaboration

❚ Requires revision, debriefing and training

❚ Talk, talk, talk, talk

Back-up protocols: roles and responsibilities

Sign the The Signature page!

Other program models:

❚ TNSTART (Tennessee); (includes medical expertise)

❚ UMASS Medical Center inpatient, outpatient and consultation services

❚ Washington State Collaborative work plan

❚ The Connecticut Blueprint (interagency linkage agreement, the Woodbridge Project, comprehensive assessments, resource, development)

Problem with program models

❚ Rarely translated into consistent public policy initiatives

❚ Only available in one location❚ Many models are unable to sustain long

term funding, not part of the infrastructure

❚ Proven track records do not insure ongoing funding

Sustainability

❚ Statewide plans evolved in short period of time

❚ The Medicaid Waiver program❚ Legislated dollars used to develop

projects later included in home and community based waiver and state mental health plan

Uses of the waiver

❚ Massachusetts through the administration of waiver capitated rate along with enhancements on state MH plan

❚ Vermont has a special managed care waiver to include all services as part of capitated rate

❚ Washington state enhancements in state mental health plan along with changes in policy with regard to service development and case management

Difficulties associated with service linkage

❚ Resource issues❚ “Cultural” issues❚ Systemic obstacles❚ Training issues and the need

for expertise

Public Policy Recommendations(Gettings Report, 1988)

❚ Foster interagency collaboration and cooperation at the administrative and public policy levels

❚ Assure that professionals are encouraged to collaborate across disciplines and participate in joint forums for service and treatment recommendations

❚ Develop an agreed upon diagnostic language and protocols for care and treatment to avoid “bouncing back and forth between systems”

❚ Determine efficacy of existing and newly formulated methods of MH service delivery to people with DD

Developing a plan

❚ Create common cross systems goals❚ Avoid duplication of services. Whenever

possible, develop expertise instead.❚ Think outside of the “box”, but❚ Know when specialized services make

sense.❚ Pilot initiatives and measure outcomes. ❚ Plan ahead for funding and don’t forget the

Medicaid waiver!

Strategic planning❚ Is there a written interagency agreement specifying roles

and responsibilities of various agencies?❚ Is there a forum designed to promote interagency

collaboration? If so, how is it designed?❚ Are there standard protocols for comprehensive

assessments that are approved by DD and MH authorities?

❚ Are there cross system initiatives to recruit and train qualified personnel?

❚ Are there contract requirements to insure interagency collaboration and cooperation?

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The Connecticut Blueprint

Interagency linkage agreementWoodbridge ProjectComprehensive assessments

The Need for Mental Health Parity: improved service for all

This goes beyond insurance…

More research is needed to test assumptions with regard to the benefits associated with specific models (systems of care).