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Contents of This Update:
• FAQ – Supports Program Update Q&A from 5.12.16 Webinar • DDD Olmstead Resource Team Trainings • Trinitas CARES & S-COPE Webinar Schedule • Trinitas CARES & S-COPE Webinar Slides – 6.21.16 Mental Health Aspects of Dual Diagnosis
New Jersey Department of Human Services Division of Developmental Disabilities
www.nj.gov/humanservices/ddd
FREQUENTLY ASKED QUESTIONS
SUPPORT COORDINATION WEBINAR 5/12/16: SUPPORTS PROGRAM UPDATE
ENROLLMENT QUESTIONS:
1. Will new grads enter through Interim or directly into the Supports Program? It is the expectation of the Division that most grads will enter directly into the Supports Program. Upon assignment, the SC should review the 2016 Graduates Supports Program Enrollment discussion Points for Support Coordinator (form located at http://rwjms.rutgers.edu/boggscenter/projects/njisp.html) with the individual and family. Responses will dictate the manner in which to proceed. It is only due to the utilization of a Self-Directed Employee or attendance at DDD funded Summer Camp that a graduate would enter into Interim. In the case of Summer Camp, Supports Program Enrollment may only require a delay in planning.
2. What if an individual graduates in May because he is in private school? If an individual meets criteria (21 years of age, functional eligibility and Medicaid eligibility) services may begin the day after graduation regardless of the graduation month.
3. Will individuals go into Supports Program if they are going into a DDD contracted day program? There are no contracted services in the Supports Program; all are fee for service. The Supports Program utilizes a fee for service approach. It maximizes the individual’s ability to choose supports based on discreet services rather than a program. Many previously contracted providers are Medicaid and DDD qualified to provide supports in day habilitation, career planning, and community based supports. Please check with the provider to ensure the specific service has been approved.
Updates & Information From DDD
June 27, 2016
All graduates will be enrolled in the Supports Program unless they are going to use DDD funded camp services, or want to hire a Self-Directed Employee through the Fiscal Intermediary. Those are the only two exceptions. A particular Provider not being “ready” is not an acceptable reason for a Graduate to not go into the Supports Program. However, please note if entry into system is prohibited due to adequacy of provider network, please notify your mentor of all explored options. The case will then be administratively reviewed.
For Non-grads/New Presenters, you will need to review the “Supports Program Pre-Screening Checklist” to determine if they are a candidate to move into the Supports Program at this time. This document can be found on the Boggs Center website under DDD Supports Program when you access the site via the I-record (SC Forms). If you identify anyone other than a 2016 graduate who can enter the Supports Program, contact the Supports Program Director, Jennifer Joyce, at [email protected] to check before enrolling.
4. Is Supports Program enrollment voluntary for individuals? All new presenters and graduates must be evaluated by the SC to determine if they will be enrolled in the Supports Program, or will receive services through Interim. The SC is to use the “Discussion Points for Supports Program Enrollment- 2016 Graduates” and the “Supports Program Pre-Screening Checklist” to make that determination. Both documents are found on the Boggs Center website under the DDD Supports Program section.
5. Should we continue using Camp as a Talking Point as enrollment ended in early May? Families can still access camp through private pay, but DDD is no longer accepting camp referrals. You will need to determine if the individual is already scheduled to attend camp via DDD funding as this will delay Supports Program enrollment.
6. Can an individual be enrolled in Supports Program if they are currently or wish to receive respite services? Respite services are an available service in the Supports Program. The only exception is Camp services. Please review Supports Program Manual Section 17.17 (page 140-144) for service description, parameters, and implementation practice.
7. Where can we find the Supports Program Prescreening Checklist? Both the “Discussion Points for Supports Program Enrollment- 2016 Graduates” and the “Supports Program Pre-Screening Checklist” are available on the Boggs Center SC website. This can be easily accessed through I-record when clicking on “SC Forms” found under the Resources and Events tile on your dashboard.
PLAN QUESTIONS:
8. If we do a revision and zero out the weeks that have units towards the end of the plan year will this free up the funding to be used for something else? As long as the service duration date is still active, the I-record allows you to edit upcoming weeks as often as the family needs you to do so. If they want to free up the budget for another service, they can do so by going into any existing service and editing any future obligated funds.
9. If we do a revision and shift/reassign allocated funds to another service, what happens to the excess carry-over units? The carry over units cannot be recouped if the service is ended. The unused days/funds remain in that line item. What you can do is edit upcoming weeks to account for the unused days that occurred earlier in the service duration period, so that those days can be used and no excess funds are left in the service line unnecessarily. Units must be used within the plan year. There is no carry over from year to year.
PROVIDER QUESTIONS:
10. What if the provider is not Fee for Service? The Division has openly shared the direction to the fee for service system through written publications, webinars, in person training sessions, and various websites. All interested providers (existing or new to NJ) should visit the FFS Implementation website at: www.nj.gov/humanservices/ddd/programs/ffs_implementation.html or the Supports Program website at www.nj.gov/humanservices/ddd/services/support_coordination.html.
11. Who should those providers who need approval be referred to at the Division? You can refer providers to Section 9 (page 51) of the Supports Program Policies and Procedures Manual for the provider enrollment process and the following website: http://www.state.nj.us/humanservices/ddd/programs/sppp.html If they continue to have questions, they can email the following helpdesk for assistance: [email protected]
All interested providers should consult the Division’s Fee for Service webpage at: www.nj.gov/humanservices/ddd/programs/ffs_implementation.html for information, forms, tools, and resources. Additional guidance is available from the designated helpdesk [email protected]
12. If a provider is approved for Supports Program but doesn't want to start because they are confused about billing and procedures, who should the provider contact at DDD for clarification? There is a dedicated helpdesk at: [email protected]. Providers may also review the Molina website for their billing guidance (see last question for Molina contact info).
13. Can providers refuse to serve individuals tiered "C" and below that have been receiving day habilitation plus transportation through contracted slots? Providers reserve the right to establish their own intake eligibility and may accept or deny services to anyone they feel they cannot properly support within our fee for service system. However, the provider must have clear admission and discharge policies that are shared with the individual/family. Exclusion of individuals based on tier may impact their reputation with families and their overall business success, unless the program is specializing services and supports to people with more or less support needs.
14. Is there a time frame for current Day Programs only offering contracted slots to transition to Fee for Service? Due to DDD systems change, all providers have been encouraged to begin the process to transition to fee for service as at some point in the future contracts will not exist. At this time, a final date has not been established.
PCPT QUESTIONS:
15. Can spell check be available on the PCPT?
At this time, the PCPT is being built into the iRecord, so this should be addressed in the near future. For now, you may choose to use Word and then cut and paste into the document.
16. Will the PCPT be generated (like the NJISP) by iRecord and when will electronic signature be available? Yes, the PCPT will be available in the iRecord in the near future. Until it is released in iRecord, the PCPT must be completed and uploaded as a separate document. All sections of the PCPT need to be completed, even if the information is also captured in a tile found on the iRecord. An electronic signature will be available in the future, but is still under development.
17. How many days do we have to complete plans for new graduates?
Once the “Supports Program Participation Enrollment Agreement” is uploaded, you have 30-days to complete the plan from that day. It is expected that you have a plan in place within 30-days of assignment if not enrolling in the Supports Program, but no plans should be later than the date of graduation if services are needed right away.
SERVICE QUESTIONS:
18. Will personal training be available in the Supports Program? How can I show documentation to a client's family who wants to start personal training because they know friends who have personal training? Personal training is not an allowable service in the Supports Program. If the service already exists in an Interim plan, the person may continue to utilize the service, even upon plan renewal, until enrollment into the Supports Program. Please refer family to the Supports Program Policy and Procedure Manual Section 17.10 Goods and Services description. The exclusion for personal training is highlighted in Section 17.10.5.1.2 (page 116).
19. What if we have someone in the Interim system who is up for plan revision or plan renewal and would like to continue services at a provider that is not yet available in the Supports Program? At this time, individuals in the Interim system may continue to choose their current provider. However, all providers are strongly encouraged to review supports available in the new system and pursue Medicaid/DDD approval as the system transition will continue.
20. Will individuals be able to utilize goods and services from out of state providers in the Supports Program? This will be allowable in the Supports Program. The Division will review all goods and services requests and make a determination for approval.
21. Do individuals in Supported Employment from DVRS and contracted Supported Employment from DDD have access to full budgets? Are these considered a duplication of services? As an Employment First State, all activities related to employment are fully supported and encouraged. Budgets are not adjusted for any employment activity. The Duplicative Services Policy for Medical Day, Extended Employment, and Mental Health Programs can be found in Section 8.6 (page 49) of the Supports Program Policy and Procedure Guide.
22. Please talk about transportation available through the Supports Program. Please qualify which transportation companies work independently of programs. The Division recognizes that transportation is an important support for all individuals. Under the Supports Program transportation will be available through Transportation Providers as well as Self – Directed Employees. Please review Section 17.22. A Provider Database is now available for which you can search for transportation providers. For more assistance and to locate statewide transportation providers, please contact [email protected]. Day Habilitation Providers will be required to provide transportation within a designated catchment area for no additional cost to the budget and will need to publicize their catchment area. The agency may transport beyond this catchment area so check with the provider. The budget can be utilized for transportation to day providers when outside of the catchment area.
NJCAT QUESTIONS:
23. How often will the Division require a NJCAT reassessment? The Division will routinely request individuals to be reassessed every 5 years. If necessary to be completed sooner due to a significant change for the person, contact your Division Mentor for assistance.
24. Will families be told how their responses on the NJCAT are translated to the scores & tiers? In order to protect the validity of this measuring tool, it is necessary for the focus when completing the NJCAT to be on accurately identifying the support needs of the individual in all settings (home, community, work). The Informant should know the individual well and be able to answer questions regarding the individual’s ability to perform self-care tasks, what their specific medical needs are and whether they require assistance with these needs, and the need for Behavioral support.
BILLING/MOLINA QUESTIONS:
25. Please clarify when we can bill. Do we submit the initial voucher to DDD for $239.81 once we upload the enrollment even if the plan is not approved yet? Payment is only made when a deliverable is achieved. Uploading the Supports Program Enrollment Agreement is not a deliverable. You may bill when a plan is approved, and for completed Monthly Monitoring Tools for individuals that have existing plans. For graduates, you may also bill for attendance to an IEP meeting that occurred after the individual was assigned to your agency. However, please note that only one deliverable is paid per month. Once a Supports Program plan is approved, the first voucher for the plan approval is paid by DDD (you will submit a paper voucher, as you do for all your Interim participants). After this initial payment, all other monthly payments for Supports Program individuals are billed directly to Molina.
26. Is there a Molina webinar? It is recommended that you contact Molina directly with your request. Molina contact and information can be found on their website at njmmis.com or providers can call Molina’s Provider Services Call Center 800.776.6334 or 609-588-6036.
* Foryourconveniencethetrainingsthataremarkedwithanasterisk(*);thetrainercanalsotravelandprovidethistrainingatanagencysite(i.e.GroupHome,AgencyOffice,DayProgram,etc.)
* Classeslabeledwithnumbers(1),(2),(3),(4),and(5)arepartofasequenceandneedtobetakenasasequence.
* PLEASENOTE:Trainingclassesbeginpromptlyatadvertisedtimes.LatearrivalswillnotreceiveaCertificateofAttendanceandwillbeexpectedtorescheduleforthefullclass.Whenregisteringforclasspleaseensuretoprovidethefullnamesoftheattendeeseitherviaemailorbyphone.ThosewhoarenotonaregistrationlistthedayoftrainingwillnotbeadmittedtotheCentralOfficebuilding.
Division of Developmental Disabilities Olmstead Resource Team
July 2016 Training Schedule
Location: DDD Central Office Questions: (732) 424-5260 5 Commerce Way Suite 100 Hamilton Township, N.J. 08691
Directions: Click the link below for map https://www.google.com/maps/place/5+Commerce+Way+%23100,+Trenton,+NJ+08618/@40.2013003,-74.6581221,17z/data=!3m1!4b1!4m2!3m1!1s0x89c15ee8c971f52f:0x29df07836ddfe663
Registration: Please email the trainers in the email addresses listed with each workshop description.
Monday July 11th, 2016
10:00-12:30 Basic Principles of Applied Behavior Analysis for Direct Support Staff* 1:30-3:00 Developing Positive Interactions between Direct Support Staff and Individuals*
Tuesday July 12th, 2016 10:00-12:00 Tube Feeding: How Caregivers Can Keep People Healthy
Wednesday July 13th, 2016 10:00-12:30 Functions of Behavior (1) 1:30-3:00 Understanding Functional Behavior Assessments and Behavior Support Plans (2)
Tuesday July 19th, 2016 10:00-12:00 Data Collection and Interpretation (3)
Friday July 22nd, 2016 10:00-12:00 Mealtime Strategies and Techniques*
Tuesday July 26th, 2016 10:00-12:00 Training Behavior Support Plans (4) 1:00-3:00 Teaching Functional Skills (5)
Wednesday July 27th, 2016 10:00-1:00 Understanding Pica from a Behavioral Perspective: Managing the Environment for Prevention*
Thursday July 28th, 2016
10:00-12:00 Five Frequent Health Problems*
Training Course Descriptions
* Foryourconveniencethetrainingsthataremarkedwithanasterisk(*);thetrainercanalsotravelandprovidethistrainingatanagencysite(i.e.GroupHome,AgencyOffice,DayProgram,etc.)
* Classeslabeledwithnumbers(1),(2),(3),(4),and(5)arepartofasequenceandneedtobetakenasasequence.
* PLEASENOTE:Trainingclassesbeginpromptlyatadvertisedtimes.LatearrivalswillnotreceiveaCertificateofAttendanceandwillbeexpectedtorescheduleforthefullclass.Whenregisteringforclasspleaseensuretoprovidethefullnamesoftheattendeeseitherviaemailorbyphone.ThosewhoarenotonaregistrationlistthedayoftrainingwillnotbeadmittedtotheCentralOfficebuilding.
PHYSICAL / NUTRITIONAL and HEALTH MANAGEMENT
Managing Dysphagia for Community Providers* Creating a safe dining experience is of utmost importance as individuals’ transition from developmental centers to group homes and other programs in the community. This training will provide a comprehensive overview on Dysphagia and the risk it poses for individuals. Attendees will receive instruction on preventing aspiration, diet textures, effective feeding strategies and correct positioning during meal times. This training is geared toward Group Home Managers and Nurses but is also applicable to direct support staff and professional staff. For your convenience, the trainer can also travel and provide this training at an agency site (i.e. Group home, agency office, day program, etc.). Certificates of attendance will be awarded upon completion. Please email the trainer Ambika Bhattacharya, M.A. CCC-SLP to register at [email protected]
Tube Feeding: How Caregivers Can Keep People Healthy*
Alternative methods of feeding, such as feeding tubes, have unique risks. Complications can lead to major medical issues and hospitalization. However, these problems can be avoided or treated early if they are recognized. Since care staff work with individuals throughout the day, they are able to notice subtle changes in behavior before severe health emergencies arise. This in-service educates care staff who work with tube-fed individuals. It explains what the most-common risks are, how they happen, and how they can be prevented. For your convenience, the trainer can also travel and provide this training at an agency site (i.e. Group home, agency office, day program, etc.). Certificates of attendance will be awarded upon completion. Please email the trainer Rachel Stahl, M.S. CCC-SLP to register at [email protected]
Mealtime Strategies and Techniques* There are many things to keep track of at mealtimes, and many individuals with disabilities are at high risk of
dysphagia (swallowing disorder). This training is a companion course to Managing Dysphagia, and it provides additional insight and practical information on how to make dining a safe, calm, and pleasant experience for everyone. Topics of instruction will include: how to set up the meal, how to effectively cue the individual at mealtimes, and what to watch out for when individuals are eating. There will be a brief review of dysphagia and we will also discuss ways to improve oral hygiene and why it is so important for overall health. The training is appropriate for direct support staff and professional staff. For your convenience, the trainer can also travel and provide this training at an agency site (i.e. Group home, agency office, day program, etc.). Certificates of attendance will be awarded upon completion. Please email the trainer Rachel Stahl, M.S. CCC-SLP to register at [email protected]
5 Frequent Health Problems*
The individuals we work with, who have developmental disabilities, are at increased risk for other health problems. This presentation serves to highlight five of the most frequently occurring problems: Aspiration pneumonia, Constipation, Dehydration, Seizures, and Urinary Tract Infection (UTI). This training is appropriate for direct care and administrative staff. It will increase awareness and understanding of these health concerns and equip staff to prevent them or manage them when they occur. Please note that this course is presented by an allied healthcare professional, not by a nurse, and it provides introductory and preventative information on this important topic. The trainer can also travel and provide this training at an agency site (i.e. Group home, agency office, day program, etc.) Certificates of attendance will be awarded upon completion. Please email the trainer, Rachel Stahl, M.S. CCC-SLP, to register at [email protected] BEHAVIORAL SUPPORT
* Foryourconveniencethetrainingsthataremarkedwithanasterisk(*);thetrainercanalsotravelandprovidethistrainingatanagencysite(i.e.GroupHome,AgencyOffice,DayProgram,etc.)
* Classeslabeledwithnumbers(1),(2),(3),(4),and(5)arepartofasequenceandneedtobetakenasasequence.
* PLEASENOTE:Trainingclassesbeginpromptlyatadvertisedtimes.LatearrivalswillnotreceiveaCertificateofAttendanceandwillbeexpectedtorescheduleforthefullclass.Whenregisteringforclasspleaseensuretoprovidethefullnamesoftheattendeeseitherviaemailorbyphone.ThosewhoarenotonaregistrationlistthedayoftrainingwillnotbeadmittedtotheCentralOfficebuilding.
To register for the Behavioral Support workshops please email the trainer
Delia Sequeira, M.S. BCBA at [email protected]
Basic Principles of Applied Behavior Analysis for Direct Support Staff*
The workshop will cover basic concepts and principles of behavior science. It will present the information in a way that can be useful for agency staff in order to implement behavior support plans, active treatment and improve overall interactions between staff and Individuals. This series is applicable for any direct support staff of any agency. Certificates of attendance will be awarded upon completion. For your convenience, the trainer can also travel and provide this training at an agency site (i.e. Group home, agency office, day program, etc.).
Developing Positive Interactions between Direct Support Staff and Clients* Either Basic Applied Behavior Analysis for Direct Support Staff or Functions of Behavior are prerequisite for this workshop. Once the basic concepts and principles of behavior are covered, staff will be presented with information on how to create and maintain positive interactions with clients by applying the material covered in the basic concepts and principles workshop. This series is aimed towards all agency staff (direct support staff and professional staff). Certificates of attendance will be awarded upon completion. For your convenience, the trainer can also travel and provide this training at an agency site (i.e. Group home, agency office, day program, etc.).
Understanding Pica from a Behavioral Perspective: Managing the Environment for Prevention* This presentation is an introductory training on Pica, ingesting inedibles, as viewed through Applied Behavior Analysis. It will cover basic information about Pica, how to manipulate the environment to prevent it and the applied behavior analysis approach explained in layman's terms. This series is aimed towards all agency staff (direct support staff and professional staff). Certificates of attendance will be awarded upon completion. For your convenience, the trainer can also travel and provide this training at an agency site (i.e. Group home, agency office, day program, etc.)
Functions of Behavior (1) Function is one of the most important pieces of information one can have about behavior in order to understand it, work to reduce challenging behaviors and increase appropriate replacement behaviors as well as other functional skills. The training discusses the why of behavior along with some basic principles of behavior. This is the first class of a series that is aimed towards the agencies’ professional staff (i.e. Behaviorists, Behavior Specialist, Program Coordinators, Managers, Directors, etc.). Certificates of attendance will be awarded upon completion.
Data Collection and Interpretation (2) Functions of Behavior workshop is a pre-requisite for this workshop. In order to determine how to change behavior it is important to be able to identify behavior of interest, operationally define it and measure it.
* Foryourconveniencethetrainingsthataremarkedwithanasterisk(*);thetrainercanalsotravelandprovidethistrainingatanagencysite(i.e.GroupHome,AgencyOffice,DayProgram,etc.)
* Classeslabeledwithnumbers(1),(2),(3),(4),and(5)arepartofasequenceandneedtobetakenasasequence.
* PLEASENOTE:Trainingclassesbeginpromptlyatadvertisedtimes.LatearrivalswillnotreceiveaCertificateofAttendanceandwillbeexpectedtorescheduleforthefullclass.Whenregisteringforclasspleaseensuretoprovidethefullnamesoftheattendeeseitherviaemailorbyphone.ThosewhoarenotonaregistrationlistthedayoftrainingwillnotbeadmittedtotheCentralOfficebuilding.
Understanding how to collect data and interpret it is the most important step in the analysis of target behavior progress. The workshop will focus on providing the tools to do this as well as demonstrate how to collect behavior data and interpret it. This series is aimed towards the agencies’ professional staff (i.e. Behaviorists, Behavior Specialist, Program Coordinators, Managers, Directors, etc.). Certificates of attendance will be awarded upon completion.
Understanding Functional Behavior Assessments and Behavior Support Plans (3) Functions of Behavior workshop is a pre-requisite for this training. Understanding documentation that relates to Individual’s behaviors is imperative to provide quality services. The training will cover the particulars of what a Functional Behavior Assessment (FBA) is, how one conducts an FBA and how that leads to the creation of a Behavior Support Plan (BSP). This workshop is composed of a 2 hour lecture. This series is aimed towards the agencies’ professional staff (i.e. Behaviorists, Behavior Specialist, Program Coordinators, Managers, Directors, etc.). Certificates of attendance will be awarded upon completion.
Training Behavior Support Plans (4)
Understanding Functional Behavior Assessments and Behavior Support Plans is a pre-requisite for this workshop. Proper training of Behavior Support Plans (BSP) for all staff that will be working with an Individual is imperative to achieve successful behavior change. This workshop will look at best practice methods of training BSPs for staff to competency, and how to measure staff performance. This series is aimed towards the agencies’ professional staff (i.e. Behaviorists, Behavior Specialist, Program Coordinators, Managers, Directors, etc.). Certificates of attendance will be awarded upon completion.
Teaching Functional Skills (5) Data Collection/Interpretation is a pre-requisite for this workshop. This workshop will focus on the basic strategies for teaching functional skills to Individuals. The focus of a BSP is not to only decrease pinpointed challenging behaviors. It is to also to be used as a tool to provide teaching strategies for appropriate replacement skills. This workshop is composed of a 2 hour lecture. This series is aimed towards the agencies’ professional staff (i.e. Behaviorists, Behavior Specialist, Program Coordinators, Managers, Directors, etc.). Certificates of attendance will be awarded upon completion.
UPCOMING WEBINARS FOR SUPPORT COORDINATORS Trinitas Regional Medical Center
CARES & S-COPE
Behavioral Aspects of Dual Diagnosis July 19: 12 p.m.-2 p.m. Dr. Esralew will review how to determine the behavioral support needs of adults with dual diagnosis across home, program and work settings. We will discuss the importance of a Functional Behavioral Assessment, the difference in ABA and Positive Behavior Supports, the components of an effective behavioral shaping program and how to best advocate for consumers to receive relevant and needed behavioral supports to improve consumers’ quality of life outcomes. To Register: https://attendee.gotowebinar.com/rt/3768478622680505604
Suicidality & IDD September 13: 11a.m. – 1 p.m. Save the Date – Registration Info Coming Soon!
6/27/16
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Mental Health Aspects of Dual Diagnosis
Presenter:LucilleEsralew,Ph.D.
CARES&S-COPE
TrinitasRegionalMedicalCenter
Objective for Today’s Webinar
– OverviewchallengesforindividualswithdevelopmentaldisabiliLesandco-occurringmentalhealthdisorders
– ProvideinformaLonforSupportCoordinatorsregardingrelevantservicesandsupportsforindividualswithdualdiagnosis
– ProvidesuggesLonsregardingworkingwithfamiliesthathavearelaLvewithdualdiagnosis
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What is Dual Diagnosis MI/DD?
� Theco-occurrenceofanintellectualordevelopmentaldisabilityandmentalhealthdisorder
� Examplesinclude:
› AconsumerwithCerebralPalsyandBipolarIDisorder
› AnindividualonthespectrumandObsessiveCompulsiveDisorder
› AconsumerwithDownSyndromeanddepressionand/ordemenLa
Mental illness or mental health disorder?
q MentalillnessisatermusedtorefertosevereandpersistentpsychiatricproblemssuchasSchizophrenia,SchizoaffecLveDisorder,BipolarDisorder,MajorDepression,severeOCD
q MentalhealthdisordersrefertoanyofthediagnosesthatcanbefoundintheDSM-5,DM-IDandmayincludeGeneralizedAnxietyDisorder,Phobias,depression,impulsecontrolandadjustmentdisorders
q MentalillnessdenotesmoresignificantmentalhealthchallengesandusuallyinvolvesmedicaLon,psychosocialintervenLonandpossiblehospitalizaLon
q MentalhealthdisordersmayincludepsychosocialintervenLons,mayincludemedicaLon,usuallydonotneedinpaLenthospitalizaLonanddonotinterferewithwork,relaLonshipsorindependentliving
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Dual Diagnosis (MI/DD)
� Controversyastowhetherornotdevelopmentallydisabledadultsaremoreorlesspronetopsychiatricillnessthanthegeneral,non-disabledpopulaLon
� IndividualswithIDDexperiencethesamerangeofmentalhealthproblemsthatcanbefoundinthegeneralpopulaLon
� DependinguponcontraindicaLons,individualswithIDDaretreatedwiththesametypesofmedicaLonasisthegeneralpopulaLonrelevanttotheirdiagnosis
Impact of MIDD on development
– AmentalillnessisanoverlayuponalreadyexisLngdeficitsassociatedwiththeperson’sdevelopmentaldisability
– Thisleadstoproblemsinlearning,peerrelaLonships,behavior,employment,communitylivingandacquisiLonofage-appropriateadapLveskills
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Co-occurring disorders
– AuLsmandOCD
– AuLsmandBipolardisorder
– SpectrumDisorderandPsychosis
– FragileXandrageissues
– CertaingeneLcdisordershaveabehavioralphenotypewhichincludeaggression,self-injury,etc.
MI/DD
– Unliketheirnon-impairedpeers,individualswithbothI/DDandpsychiatricillnesshaveexcessdisability
– IndividualswithMI/DDaremorelikelytolook“sicker”andmorebehaviorallydisorderedthantheirnon-I/DDpeers
– WithregardtoMHdisorders:individualswithIDDaremorelikelytobeundiagnosed,misdiagnosed,undertreatedormistakenlytreatedbecauseofdiagnos/covershadowing
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DSM Equivalents
� ThecriteriaformentalhealthdisorderslistedintheDSM-5mayneedtobeadjustedtothepsychiatricpresentaLonofdevelopmentallydisorderedadults
� S/SofmentalhealthdisordersormentalillnessmayincludebehavioralpresentaLon(aggression,propertydestrucLon,self-injuriousbehavior)nottypicallyseeninthenon-DDpopulaLon
� TheDSM-5willsoonhaveanupdatedcompanionvolume:
DM-ID2
Assessment Challenges
– DiagnosLcOvershadowing– Masking
– CogniLveDistorLon– ResponseBias– LimitedlinguisLccompetency
– NeedforemoLonaleducaLon/poordifferenLaLonofmoodstatesandthinkingproblems
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Medical Issues May Mimic Psychiatric Problems
- InfecLonssuchasURIorUTI- Pain(dental,gastric,migraine)
- Thyroidimbalance
- ChangesinseizureacLvity- AdverseresponsetomedicaLons
Issue that May Confound or Complicate Crisis Presentation
– LackoflanguageskillswhichmaypredisposelowerfuncLoningconsumerstowardsdisrupLveandaggressivebehaviorsasaformofcommunicaLon.
– OrganicbasesfordevelopmentaldisorderthatrepresentcompromisedCNSandhigherlikelihoodofimpulsivebehaviors
– LowerI.Q.associatedwithpoorrepertoireofcopingskills
6/27/16
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Suicide Risk Assessment
TRIAD:
1) Doesthepersonhavethemeanshurtherself?
2) Doesthepersonhavetheopportunitytohurtherself?
3) Doesthepersonhavetheintenttohurtherself?
Establish Context for Presenting Symptoms
� IsthispersonpresenLngonaweekendorholidaywhenlessstaffisavailable?
� Didtheconsumerhaveanargumentwithsomeoneinhis/herresidenceorworkprogrampriortopresentaLon?
� Wastherearecentchangeintheconsumer’srouLneorsupportsystem?
� IsthisabehavioralproblemandnotapsychiatricdecompensaLon?
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Psychiatric versus Behavioral Problems
Psychiatricillnessdoesnotcausebehaviorproblems,butmayincreasethefrequency,intensityorduraLonofunwantedbehaviors
Unwanted/maladaptive behaviors
Psychiatric illness
Poorly developed coping skills
Environmental triggers and
stressors
How to establish baseline?
– Havefamiliesandstaffspecifybehaviors(operaLonalize)
– Howlonghasthisbeengoingon?– DoesitvaryintheduraLonorintensityofthebehavior?– IfbehaviorvariesinduraLon,frequencyorintensity,whatarethe
condiLonsunderwhichthisvariaLonismostlikelytooccur?
– WhatarethecondiLonsunderwhichtheindividualdoesnotexhibitproblembehaviors?
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Multi-Axial Diagnoses
AxisI PsychiatricDisorders,AuLsm,LearningDisabiliLes
AxisII ID,PersonalityDisorders
AxisIII GeneralMedicalCondiLons
AxisIV PsychosocialStressors
WHODAS WorldHealthOrganizaLonDisabilityAssessmentScaleTowhatextentdoesthepersonexperiencehim/herselfasdisabledbyamentalhealthdisorder?
Persons with IDD are more likely…
– Tohaveco-occurringmedicalproblems
– Tobeimpulsive
– Todemonstratepoorself-monitoringandself-regulaLon
– Tobepoorsocialproblemsolvers
– Tohavelimitedself-calmingskills
– TohavelimitedlanguageskillswithwhichtoletothersknowaboutsubjecLveemoLonaldistress
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When to Call 9-1-1
– Whentheconsumerisbehavinginadangerouswaytohimselforothers
– WhenusualstrategiestocalmdowntheconsumerorstabilizethesituaLonarenotworking…
Depression
– Sad– SleepandappeLtedisturbance– Lossofinterestinpreviouspreferred
acLviLes
– Thoughtsaboutdeathorself-harm
– Tendencytoself-isolate– LessenedproducLvityatwork– Increasedirritability
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Anxiety
– Excessiveworry– Physiologicaldiscomfort
– Fear– Avoidanceofstressors– Sleepdisturbance
Obsessions & Compulsions
� FearofcontaminaLonandwashing� FearofharmingselforothersandrepeaLng� Fearoflosingcontroloraggressiveurgesand
checking� Intrusivesexualthoughtsorurgesandtouching� ExcessivereligiousormoraldoubtandcounLng� Forbiddenthoughtsandordering/arranging� Aneedtohavethings“justso”
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What is Obsessive-Compulsive Disorder?
� Obsessions=thoughts� Compulsions=acLons
� Anobsessionisathought,image,orimpulsewhichrepeatedlyoccursandoverwhichthepersonfeelslimitedcontrol
› Theobsessionmaybeexperiencedasdisturbingandintrusive.Forinstance,apersonmayhaveaworryorfearwhichhe/sheknowsisunrealisLc.Howeverneednotbeexperiencedasdistressing…
OCD and ID
– RepeLLvebehaviorsandspeech– Inabilitytoprovidereliableself-reportsofinternalsubjecLvefeelings
– Emphasisonbehavior,observablecomponents
– Someindividualsmaytrytohideorreducecompulsivebehaviorbecauseofaconcernforsocietaldisapproval,othersmaynotbeawareofsocietydisapprovalandsomaynotseektoreduceoreliminatecompulsivebehaviors
– AggressionmaybethepresenLngsymptomofOCDinID– Towhatextentwouldanindividualonthespectrumwhoexhibitsstereotypies
ofrepeLLvebehaviorsbeconsideredasmeeLngcriteriaforOCD?
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OCD and ID
– SomebehaviorsexhibitedbyconsumerswithOCDaredifferentthanbehaviorsobservableinthenon-DDpopulaLon:
§ Flippingobjects
§ Swingingobjects§ Probingbodyparts
§ Picking/pullingskin,nose,lip,etc.
§ Pullingone’shair/eyebrows
IDD and Trauma
� Mayincludephysiologicalsignsofanxiety
� MayinvolvenewseparaLonfears
� Maytaketheformofsleepchanges
� MayleadtheadulttowithdrawfromusualacLvityandsocialcontact
� MaytaketheformofanewavoidanceofcertainpeopleorsituaLons
� Mayinvolvethedisplayofhighlysexualizedbehaviorsoraggression
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MISDIAGNOSES
– FlashbackscanbemistakenforhallucinaLons
– Hypervigilanceseenasparanoia– Numbingmaybeviewedasdepression
– Hyper-arousalmaybeseenasanxietyormooddisorder
– AvoidantbehaviormaybediagnosedasSchizoidorAvoidantPersonalityDisorder
RESPONSE TO TRAUMA BY PERSON WITH I/DD
– Responsemay:
– includephysiologicalsignsofanxiety
– involvenewseparaLonfears
– taketheformofsleepchanges
– leadtheadulttowithdrawfromusualacLvityandsocialcontact
– taketheformofanewavoidanceofcertainpeopleorsituaLons
– involvethedisplayofhighlysexualizedoraggressivebehaviors
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Bipolar Disorder
– Cyclicmooddisordercharacterizedbydepressedandmanicphases
– BipolarIdisordermaybeassociatedwithpsychoLcfeatures
– BipolarIIdisordermayincludehypomanicepisodesandnotfull-blownmania
– Disturbanceinsleep,appeLteandenergylevelprominentinacLvephases
Thought Disorder
� Problemswithrealitybasedthinking› HallucinaLons,mostlikelyauditory› Delusions;grandeur,persecuLon,etc.› PoorrealitytesLng› Schizophrenia,SchizoaffecLveDisorder,PsychoLcDisorder,
NOS• NomoreprevalentinMI/DDpopulaLonthaningeneral
populaLon.• Concernregardingmisdiagnosis• ConcernabouttheuseofanL-psychoLcstotreatnon-psychoLc
disorders
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Impulse control disorder?
– InapopulaLonofindividualswithIDD,therewillbeheightenedneurobehavioralproblemsassociatedwithcompromisedCNSfuncLoning
– Towhatextentisimpulsivity(anger,sexual,etc.)abyproductofdevelopmentaldisorder?
– TowhatextentdoesapersonmeetcriteriaforapsychiatricdisordersuchasImpulseControlDisorderorIntermioentExplosiveDisorder?
Presentation to ER associated with Borderline Personality Disorder
– BPDcanbeassociatedwithparasuicidalbehaviorsandextremeemoLonaldysregulaLon
– Notuncommonlylinkedwithmooddisorders– NoevidencethathospitalizaLonisbeneficial;maypromotedramaLcacLngoutbehaviors
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Who Delivers What Service?
– Psychiatrists,APNsprescribeandmonitorpsychoacLvemedicaLons
– Iftheconsumer’smedicaLonsareprescribedbyaPCP(anyphysiciancanprescribeanymedicaLon)oraneurologist,itisprobablywisetoincludeconsultaLonwithapsychiatristorAPNonaregularbasis
– LicensedPsychologists,SocialWorkersandProfessionalCounselorsprovidecounselingandpsychotherapy
– BCABAsandBCBAsconductAppliedBehaviorAnalysis
– ThereisnocurrentcerLficaLonforindividualswhoprovidePosiGveBehaviorSupports
– ThereareNADD-cerLfiedcliniciansbytheNaLonalAssociaLonforDualDiagnosisNADD-CC
The Role of the Psychiatrist
– Apsychiatristisaphysicianwhospecializesinthediagnosisandtreatmentofmentalhealthdisorders
– PsychiatristsprescribeandoverseethemedicaltreatmentofmentalillnessthroughtheuseofpsychoacLvemedicaLons
– Mostpsychiatristsdonotoffertherapyalongwithmedicaltreatmentofmentalhealthdisorders
– InsomecasesconsumersseeAdvancedNursePracLLoners(APN)whoaresupervisedbyPsychiatrists
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Psychiatrist?
– WhenthereisachangefrombaselinebehaviororfuncLoningforaperiodof2weeksinanyofthefollowingareas:
§ Sleepproblems
§ AppeLteproblems
§ Changesinenergylevel(lethargy/mania)
§ Increaseinthefrequency,intensityorduraLonoftargetbehaviors
§ Consumerreportshearingvoicesorseeingthings
The Role of Medication
– ManagementofMood
– Addressdelusions,hallucinaLonsandnegaLvesymptomsofthoughtdisorder
– Addressimpulsivity
– Helpswithanxiety– IsnotasubsLtuteforbuildingrelevantcopingskillssuchasanger
andstressmanagement
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Co-occurring Mental Illness and Developmental Disability
� DosingofmedicaLonmaybedifferentforthispopulaLonbecauseofhighoccurrenceofmedicalcondiLons
� ItmaytakelongertostabilizeindividualswithIDDonmedicaLoncomparedwithgeneralpsychiatricpopulaLonduetoco-occurringmedicalproblems
Family Members
� DescribetheprocessofevaluaLontofamilymembers
� Keepthefamily“intheloop”
� CalluponaclinicianorpracLLonertoconferwithfamilies
� HelpfamiliesunderstandtheiropLonsregardingtreatmentfortheirrelaLvewithdualdiagnosis
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How Can Families Help?
� UnderstandthenatureoftheirrelaLve’smentalhealthdisorderincludingusualmedicaLonthatareeffecLveintreaLngthespecificmentalillness
� EncouragetheirrelaLvetoresumeusualrouLneandexpectaLonsassoonaspossibletotheextenttolerated
� Workalongsidestafftoprovidesupports,andopportuniLestodevelopageappropriatesocialandemoLonalcopingskills
Providing Structure
– Clearsequenceofevents– ClearexpectaLonsaboutbehavior– IfusingconLngencymanagementapproach,
clearlinkbetweenbehaviorandrewardsordisincenLves
– Predictability– PlanningaheadforLmeswhentherewillbea
breakinrouLne(vacaLon,summerbreak)
– ProvidetheconsumerwithposiLvepracLceconcepts.Whatcanthisindividualdotofeelbeoer?
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Emergency Plan
– Workwiththefamilytodevelopanemergencyplan:
ü Howcaneveryoneinthehouseholdremainsafe?
ü Whenshouldthefamilyphysician/treaLngpracLLonerbenoLfied?
ü WhenshouldthefamilybringtheconsumertotheEmergencyRoom?
Referral to Counseling
� TheconsumerneedstobeverbalenoughandhavesufficientrecepLveaswellasexpressivelanguageskillsinordertobesuccessfulincounseling
� TheconsumerneedstobemoLvatedtobeoerunderstandandchangemaladapLvebehaviors
� Theconsumerneedstobewillingtoworkwiththecounselor/therapist;successfulcounselingcannotbemandatedbyothers
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Counselor?
� WorkwiththeconsumeronbuildingsocialandemoLonalcopingskills
� Helptheconsumerlookathisownbehaviorandbecomeabeoerself-monitorofmood,thinkingandbehavior
� HelptheconsumerdevelopmoreeffecLvecopingstrategiestodealwitheverydayhasslesandstressors
� IncorporatewellnessandrecoveryprinciplesintodailyacLvity
The Behavior Specialist
� TheBehaviorIntervenLonistshouldbesomeonewhoknowsabouttheprinciplesoflearningandhowtoapplylearningtheorytodevelopaplanthatreducesunwantedbehaviorandincreasesadapLvereplacementbehaviors/skills
� TheBehaviorIntervenLonistneedstoworkalongsidetheconsumer,familyandstaffinordertoincreaseeveryone’scompetenciesindealingwithstressors
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Partial Care?
– IftheconsumercannotworkorparLcipateinadayprogrambecauseofmentalhealthproblems
– IfaconsumerhasrecentlybeenhospitalizedonapsychiatricunitandisnotreadytoresumeworkorusualacLvitybutneedsastep-downfrominpaLenthospitalizaLon
The Sy Sims Approach to Behavioral Health
– Aneducatedconsumermakesthebestcustomer(True!)
– AskthepracLLonerforhercaseconceptualizaLonofwhatiswrong,whatthepracLLonercanrecommendtoeffecLvelyaddresswhatiswrongandapproximatelyhowlongthepracLLonerthinksitwilltakebeforeyouwillseesomeposiLveoutcomes
– Iftheconsumerisonatreatmentplantheconsumerandfamily/staffshould:
– A)Knowwhatisbeingaddressedandhowitisbeingaddressed
– B)theroleoftheconsumer,thefamilyandthestaff
– C)requestameeLngwiththepracLLonertoreceiveperiodicupdatesabouttheconsumer’sprogress
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Whom Do You Call?
– MobileresponsefromlocalPsychiatricScreeningCenter
– Ifnotimminentlydangerous,callappropriateTrinitasteam:
Ø CARES1-888-393-3007foradults21+withIDD
Role of inpatient psychiatric hospitalization
– Reducedangerousness– RapidtranquilizaLon
– Assessment
– ObservaLon
– MaybeopportunitytotrialintervenLonthatcanbeconLnuedincommunity
– Hand-offtocommunityprovideror(inthecaseofsomeonewhodoesnotstabilize)hand-offtohigherlevel,longer-termcaree.g.countyorstatehospitalizaLon
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Reasons for long-term hospitalization
– IndividualisnotstabilizedonmedicaLonaserashort-termstay
– Individualhasactedinwaysthataredangeroustohimselforothersandfamilyorprovideragencyisnotlongerabletosafelysupport(disposiLonproblem)
State hospitalization and MI/DD
– PromotelongertermstabilizaLonontherapeuLcmedicaLonregimen
– Prepareforcommunitydischarge
– HelpdevelopskillsthatwillresultincommunityintegraLonandcommunitytenure
– HelpeducatefamiliesandprovideragenciesonwellnessandrecoveryprinciplesandpracLces;directtorelevantMHresources
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Mental health Supports for Families
– CARES1-888-393-3007– IntensiveFamilySupportServices
www.mhanj.org/intensive-family-support-services
– MoM2MoM1-877-914-6662(MOM2)ubhcrutgers.edu/call-center/peer
– NAMIwww.naminj.org732-940-0991
– CountyMentalhealthAssociaLonswww.mha+county
– FamilyCrisisHandbookwww.sccatnj.orgorwww.njamha.org/documents/FamilyCrisishandbook.pdf
Questions? Lucy Esralew [email protected] 908-966-3033
