11

Implementation of Positive Implementation of Positive Behavioral Interventions & Behavioral Interventions &

Supports (PBIS)Supports (PBIS)

in a Children’s Residentialin a Children’s Residential

Mental Health Treatment ProgramMental Health Treatment ProgramVeronica P. Arellano, O&E ManagerVeronica P. Arellano, O&E Manager

Andrew Pane, Milieu Activities Therapist Andrew Pane, Milieu Activities Therapist

Georgetown Training Institute ConferenceGeorgetown Training Institute Conference

Orlando, FLOrlando, FL

July 2006July 2006

22

Context and Reasoning for ChangeContext and Reasoning for Change To achieve improved To achieve improved

outcomesoutcomes Poor outcomes cited Poor outcomes cited

nationally for residential nationally for residential services services

High cost of services, in High cost of services, in context of diminishing context of diminishing resourcesresources

Effectiveness of community Effectiveness of community based servicesbased services

Focus on permanency and Focus on permanency and the effect foster care has the effect foster care has had on severing family had on severing family connectionsconnections

To implement evidence To implement evidence based services including based services including PBIS, TF-CBT, and Parent PBIS, TF-CBT, and Parent Management TrainingManagement Training

To utilize residential services To utilize residential services as an intervention, not a as an intervention, not a placementplacement

To increase youth and family To increase youth and family connections and sustainable connections and sustainable community supportscommunity supports

To ensure consistent To ensure consistent implementation of a implementation of a strength based, needs strength based, needs driven, family centered, driven, family centered, individualized and culturally individualized and culturally relevant philosophy relevant philosophy in all in all aspects of careaspects of care

To partner with families and To partner with families and ensure family involvement in ensure family involvement in all aspects of careall aspects of care

33

Phases Change ProcessPhases Change Process

Phase 1 - Data Phase 1 - Data GatheringGathering

Focus groups with Focus groups with families and childrenfamilies and children

Staff questionnairesStaff questionnaires Customer questionnairesCustomer questionnaires Reviewed 7 years of Reviewed 7 years of

internal datainternal data Literature review of Literature review of

Evidence-Based Evidence-Based PracticesPractices

Benchmarking other Benchmarking other residential programsresidential programs

Attendance at “Best Attendance at “Best Practices” conferencesPractices” conferences

Phase 2 – Phase 2 – ImplementationImplementation

Implemented PBISImplemented PBIS Family FindingFamily Finding Family Inclusion Family Inclusion

Practices and Practices and ProceduresProcedures

Community Based Community Based PracticesPractices

Switch to Mental Health Switch to Mental Health Model vs. Day TX.Model vs. Day TX.

Developed Transitional Developed Transitional ServicesServices

44

Residential Services Residential Services DescriptionDescription

4 RCL (Rate Classification Level) 14 cottages, 4 RCL (Rate Classification Level) 14 cottages, capacity of up to 10 children capacity of up to 10 children

Two units for children ages 6-12 yearsTwo units for children ages 6-12 years Two units for youth ages 12-18 yearsTwo units for youth ages 12-18 years 3 are co-ed and 1 is all male3 are co-ed and 1 is all male

Array of ServicesArray of Services

Comprehensive Comprehensive assessment of all life assessment of all life domainsdomains

Family TherapyFamily Therapy Individual TherapyIndividual Therapy Intensive case Intensive case

management and linkage management and linkage to community activitiesto community activities

Nursing servicesNursing services Psychiatric Assessment Psychiatric Assessment

and Treatmentand Treatment

Psycho educational Psycho educational and and psychotherapeutic psychotherapeutic groups Academic groups Academic support support

Family FindingFamily Finding Family Partner Family Partner

ServicesServices Medical/Dental Medical/Dental

Assessment and Assessment and LinkageLinkage

Recreational, Music Recreational, Music and Art Therapy and Art Therapy

Therapeutic milieu Therapeutic milieu based on PBIS based on PBIS principlesprinciples

55

Youth CharacteristicsYouth Characteristics

ResidentialResidential

GenderGender MaleMale 59%59%

LanguageLanguage EnglishEnglish 95%95%

EthnicityEthnicity African AmericanAfrican American 13%13%

CaucasianCaucasian 30%30%

Latin AmericanLatin American 46%46%

OtherOther 12%12%

Age at EntryAge at Entry 13 to 18 Years Old13 to 18 Years Old 54%54%

% of Out-of-Home % of Out-of-Home PlacementsPlacements

3 or More3 or More 79%79%

CAFAS at EntryCAFAS at Entry Severe (140 and Higher)Severe (140 and Higher) 69%69%

66

Youth CharacteristicsYouth Characteristics(cont.)(cont.)

ResidentiResidentialal

History of History of AbuseAbuse

PhysicalPhysical YesYes 64%64%

SexualSexual YesYes 40%40%

Drug/AlcoholDrug/Alcohol YesYes 77%77%

77

Why PBIS?Why PBIS?

Evidence in schools that approach creates pro social Evidence in schools that approach creates pro social positive environmentspositive environments

Alignment with agency philosophyAlignment with agency philosophy

Goodness of fit: congruent with behavioral approach Goodness of fit: congruent with behavioral approach already utilizedalready utilized

Focus on increasing quality of life, achieving broad Focus on increasing quality of life, achieving broad goals and supporting portable skillsgoals and supporting portable skills

Use of a proactive and educative approach to support Use of a proactive and educative approach to support elimination of “control based” interventions including elimination of “control based” interventions including restraintsrestraints

Eber, Sugai, Smith, & Scott (2002); Scott & Eber (2003 a & b) Eber, Sugai, Smith, & Scott (2002); Scott & Eber (2003 a & b)

88

PBIS Implementation PBIS Implementation StrategiesStrategies

PBIS Overview Training for all staffPBIS Overview Training for all staff

Hired a Consultant who observed each cottage to understand Hired a Consultant who observed each cottage to understand current operations and provided 3 8-hourcurrent operations and provided 3 8-hour trainingstrainings on Functional on Functional Behavioral Assessment and Behavior Support PlansBehavioral Assessment and Behavior Support Plans

Developed an implementation work teamDeveloped an implementation work team

Developed a “Support team”Developed a “Support team”

Developed behavior and cottage management systemDeveloped behavior and cottage management system

Reviewed past point and level system, developed new systems Reviewed past point and level system, developed new systems based on values matrixbased on values matrix

99

Living Situation at Exit

0%

20%

40%

60%

80%

100%

Pre-EBP Post-EBP Pre-EBP Post-EBP Pre-EBP Post-EBP Pre-EBP Post-EBP

Willow Sequoia Penn East Ruth Mallery

Home Foster Family More Restrictive Other

1010

Reason for Discharge

0%

20%

40%

60%

80%

100%

Pre-EBP Post-EBP Pre-EBP Post-EBP Pre-EBP Post-EBP Pre-EBP Post-EBP

Willow Sequoia Penn East Ruth Mallery

Planned Discharge Tx Goals Not Met Neutral Missing Information

1111

Average Number of Restraints Per Month

0

86

01

12

9

3

0

24

68

1012

14

Willow Sequoia Penn East Ruth MalleryAvg

. Num

ber

of R

estr

aint

s

Pre-EBP Post-EBP

1212

Average Number of Assaultive Behaviors Per Month

0

8 7

32

16

11

5

0

5

10

15

20

Willow Sequoia Penn East Ruth MalleryAvg

. Num

ber

of A

ssau

ltive

B

ehav

iors

Pre-EBP Post-EBP

1313

Facilitative FactorsFacilitative Factors Agency and PBIS philosophy alignmentAgency and PBIS philosophy alignment Sponsorship and resources from managementSponsorship and resources from management

Open to concerns and seeing resistance as helping to inform the change Open to concerns and seeing resistance as helping to inform the change processprocess

Acknowledging staff and celebrating successesAcknowledging staff and celebrating successes

Outcome and Evaluations DepartmentOutcome and Evaluations Department Data management practicesData management practices Using electronic record to gather and report dataUsing electronic record to gather and report data

Use of change methodology and quality improvement techniquesUse of change methodology and quality improvement techniques Clearly delegating tasks to specific people with timelinesClearly delegating tasks to specific people with timelines

PBIS Trainer/consultant became familiar with program, built PBIS Trainer/consultant became familiar with program, built relationship with staff and maintained on-going support for relationship with staff and maintained on-going support for implementation.implementation.

Resource binders and booksResource binders and books

Developing Program Procedures to support implementationDeveloping Program Procedures to support implementation Structuring discussions of BSP in team meetingsStructuring discussions of BSP in team meetings Development of a “Support Team” and an Operations work teamDevelopment of a “Support Team” and an Operations work team Building PBIS job expectations into staff evaluationsBuilding PBIS job expectations into staff evaluations

1414

ChallengesChallenges Implementing significant change while caring for children 24-7Implementing significant change while caring for children 24-7

Deciding what practices to discontinue to make room for new practicesDeciding what practices to discontinue to make room for new practices

Development of a sustainability planDevelopment of a sustainability plan

Considering multi-systemic needs and regulations, particularly in terms of Considering multi-systemic needs and regulations, particularly in terms of documentationdocumentation

Maintaining focus and prioritizing PBIS implementation with multiple other Maintaining focus and prioritizing PBIS implementation with multiple other demandsdemands

Learning curve on how to utilize data to inform practiceLearning curve on how to utilize data to inform practice

Establishing consistency and accountability across three shifts, 20 staff and Establishing consistency and accountability across three shifts, 20 staff and registryregistry

Overcoming agency culture “flavor of the day”Overcoming agency culture “flavor of the day”

1515

ReferencesReferences

Scott, T.M. & Eber, L. (2003). Functional Scott, T.M. & Eber, L. (2003). Functional Assessment and Wraparound as Systemic Assessment and Wraparound as Systemic School Processes: Primary, Secondary, and School Processes: Primary, Secondary, and Tertiary Systems Examples. Tertiary Systems Examples. Journal of Journal of Positive Behavior Interventions, Vol 5 (Positive Behavior Interventions, Vol 5 (3), 3), pp 131-143.pp 131-143.

Eber, L., Sugai, G., Smith, AC.R., & Scott, Eber, L., Sugai, G., Smith, AC.R., & Scott, T.M.T.M.

(2002). Wraparound and Positive Behavioral (2002). Wraparound and Positive Behavioral Interventions and Supports in the Schools. Interventions and Supports in the Schools. Journal of Emotional and Behavioral Journal of Emotional and Behavioral Disorders, Vol Disorders, Vol 10 (3), pp 171-180.10 (3), pp 171-180.