Overview of the YCS Transition Plan for Implementing the “Six Core Strategies”
YCS is committed to becoming a leader in efforts to reduce reliance on, and use of, physical controls as a means of managing aggressive behavior and mitigating risk. As is well-known, current practice which relies on the use of physical control of children and youth in acute, high-risk crises is no longer acceptable as a means of risk reduction, mostly due to the re-traumatizing effects of physical intervention, which can, and at times is, perceived by residents as “another act of violence.” In addition, the injuries, emotional and physical, sometimes severe, to both residents and staff, argue for a more disciplined and informed alternative.
As is generally well-known, the alternative, best practice, approach being increasingly recommended by most respected leaders in the field of Mental Health [and Intellectual Disability] is referred to as “The Six Core Strategies,” developed by the National Association of State Mental Health Directors (NASMHPD), and author Kevin Ann Huckshorn (“Six Core Strategies for Reducing Seclusion and Restraint Use Planning Tool,” 2008).
Therefore, consistent with YCS’ historic mission of treating children and youth in the most family-friendly and community-like settings, with the use of “best treatment practice(s),” YCS has outlined and is implementing a Transition Plan to incorporate the Six Core Strategies within our existing Continuous Performance Improvement & Program Integrity and Accountability infrastructures.
Additionally, prior to YCS being selected to work with the Department of Children and Families on the federal SAMHSA grant, Promising Path to Success, our agency joined The National Council’s Trauma-Informed Care Learning Community (TIC) to ensure the principles of trauma-informed approaches, and trauma-specific interventions are facilitated in our agency to address the consequences this has on the individual and to facilitate healing of our youth and families.
A brief narrative outline of this Transition Plan and Strategy follows below.
Strategy 1: The critical role of Leadership: Since the remaining five strategies require a significant alteration in organizational policy, and most importantly, practice culture, the Leadership of YCS must be not only present, but ingrained, in the fabric of a successful Transition Plan. This has been accomplished through the appointment of a “Lead Transition Team,” reporting directly to the CEO, composed of Program Project “Champions” (Data, Workforce Development, Crises Tools, Resident Participation and Advocacy, and Debriefing). Some of these project areas are already represented within the agency-wide Central Continuous Quality Improvement Committee (CCQI), while others have a sub-committee to implement, and monitor successful achievement of the Transition Plan.
Strategy 2: Using Date to Inform Practice: This strategy is intended to aggressively collect and review data regarding the current use of restraint (when, day and shift, who, “why,” such as “aggression towards staff,”), and ensuring completion of the feedback circle, that is, using better information (for example, renewed efforts to identify precipitating or trigger events, and reports of “near misses,” or what assisted in avoiding a physical control) to improve practice, specifically the use of physical control(s). YCS’ CCQI and extensive Research Department processes are well positioned to gather, analyze and report the necessary additional data.
Strategy 3: Workforce Development: In order to change the culture of control, and ensure staff confidence in this effort, significant resources have been allocated to the improvement of staff understanding and skill set development. As recommended by NASMHPD and others, this will include reliance on current YCS training modules (for example, Trauma-informed Treatment, Me-First, Customer Service) and an assessment of the need for, and development of, new training modules (especially non-challenging boundary setting, such as Nurtured Heart Approach), which may be necessary to encourage a significant leap in organizational culture and practice, especially management and staff understanding of the new directive that “physical control shall only be used in the face of imminent danger and when unavoidable.”
Strategy 4: Better Use of Existing Tools, and Expansion of Staff (Clinical and Direct Practice) Tool Kit: YCS will continue to use existing clinical tools (i.e., Trauma and Risk Assessments, etc., Safety Plans) which contribute to what are generally considered the identification of “preventive physical control tools,” that is, especially those which identify “trigger events,” and suggest successful resident alternative methods of avoiding an acute crisis, often referred to “coping strategies,” or mood and sensory modulation interventions. In addition, YCS intends to build upon these tools with perhaps better engagement and communication techniques (especially, Nurtured Heart Approach with our two agency Certified Trainers), and a review of innovative practices found in other settings, particularly application of the “comfort room” concept in psychiatric settings to a “comfort space” (also similar to, but an expanded use of, “Free to be me” space and time intervention in Trauma Treatment) for sensory modulation.
Strategy 5: Resident Participation and Advocacy: YCS, will utilize existing means of soliciting critical customer feedback (i.e., Bi-annual Client and Family Satisfaction Surveys, Stakeholder/Community Group[s], Parent Satisfaction Committee, etc.), and incorporating that feedback into more client and family inclusive service delivery. In addition, YCS will examine ways and means of further improving the voice(s) of residents through better use of existing and former residents (some of whom are now employees of YCS) and their families. Key areas identified for Resident/Customer leadership include, an organizational review of “Engagement,” how to welcome and comfort residents and families at admission in order to reduce crises and, reducing Program or “Homogenous Rules,” so that residents can be treated as individual persons, in an “emotionally comfortable environment,” where some natural boundaries and rules may be necessary, but need not be the management and staff perceived basis of (behavior management) treatment. Our current Parent Satisfaction Committee, has a family member who will assist our agency in acting as a ‘system navigator’ for parents during identified meet and greets, admissions, through-out length of stay and assist/support during transitions/discharges.
Strategy 6: Post PC Debriefing Techniques: Build upon YCS’ current practice of “Post PC Debriefing” to include “Reconciliation,” intended to sooth the emotional pain of a physical control for residents, and sometimes staff. Perhaps more importantly, the more advanced Debriefing is intended to prevent a reoccurrence of the PC through an examination of the trigger events, and a serious effort by resident and staff to better identify resident coping/mood and behavior modulation alternatives, and staff introspection and group discussion, with leadership participation.
In summary, YCS has begun this process of converting this narrative Transition Plan into a more traditional CCQI-based Performance Improvement Plan, with clearly described Performance Objectives, Time Frames, and Responsible Units and/or Persons. Moreover, YCS will further emphasize, and find means of enhancing, the message that physical controls are “only be used in the face of imminent danger and when unavoidable.”
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