Long-Term Care in the Community: Crisis Services and ... · Stabilization for Individuals with Developmental Disabilities ... Access Clinic/Access Clinic South ... Female – 33%

1

Long-Term Care in the Community: Crisis Services and Stabilization for Individuals with

Developmental Disabilities

Justin Kuehl, Psy.D. & Debora Zamacona Hermsen, M.S.Milwaukee County Behavioral Health Division

Presentation Overview What is the Community Consultation Team (CCT)?

How does the CCT fit within the Milwaukee County Behavioral Health Division continuum of care?

Why was the CCT developed?

Who does CCT serve?

What specific services are provided by CCT?

Milwaukee County Behavioral Health Division

2

Milwaukee County Behavioral Health Division Acute Inpatient Psychiatric Services

Intensive Treatment Unit (ITU)

Women’s Treatment Unit (WTU)

Acute Treatment Unit

Child and Adolescent Inpatient Services (CAIS)

Day Treatment Program Dialectical Behavioral Therapy (DBT) Team

Recovery and Stabilization Therapy (RST) Team

Proposed Intensive Outpatient Programs (IOP)

Community Access to Recovery Services (CARS) Division Targeted Case Management and Community Support Programs

Comprehensive Community Services (CCS) and Community Recovery Services (CRS)

WIser Choice

Crisis Services


Crisis Services Psychiatric Crisis Service (PCS)

Observation Unit

Crisis Mobile Team (CMT)

Crisis Assessment Response Team (CART)

Access Clinic/Access Clinic South

Crisis Stabilization Houses

Crisis Resource Center

Community Consultation Team (CCT)


Long-Term Care Services

Hilltop1988-2015

3

Community TIES

Community Consultation TeamD.O.B.

January 26, 2015

CCT Staff Members

Dr. Gary Stark Clinical Program Director - Psychology

Debora Zamacona Hermsen Psychological Associate

Kristine Evans Developmental Disability Specialist

Patricia White Registered Nurse

4

The Community Consultation Team (CCT) is a service designed to help support adults with developmental disabilities to live successfully

in the community

Developmental Disability

A condition in which an individual has a diagnosis, with onset before age 22, of:

Intellectual Disability

Autism Spectrum Disorder

Brain injury

Cerebral palsy

Epilepsy

Or, another neurological condition similar to Intellectual Disability


Onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains, which must meet these 3 criteria:A. Deficits in intellectual functioningB. Deficits in adaptive functioningC. Onset of intellectual and adaptive deficits during the developmental period

5


DSM-IV: Mild ID: IQ level 50-55 to 70

Moderate ID: IQ level 35-40 to 50-55

Severe ID: IQ level 20-25 to 35-40

Profound ID: IQ level below 20 or 25

ID, Severity Unspecified: presumed ID but untestable


Two Areas of Impairment:1. Persistent deficits in social communication

and social interaction2. Restricted, repetitive patterns of behavior,

interests, or activities

Symptoms must be present in the early developmental period


DSM-IV:

Autistic Disorder

Rett’s Disorder

Childhood Disintegrative Disorder

Asperger’s Disorder

Pervasive Developmental Disorders NOS

DSM-5:


6

CCT services are largely proactive,

prevention-orientedways of addressing

behavioral challenges and crises in this

population

Three Specific CCT Services

1. Consultation Services

2. Staff Training

3. Crisis Line and Mobile Team

Consultation Services

Working in a preventative manner to try to manage risks in the community and reduce

the likelihood of significant behavioral and mental health issues and crises

7

CCT is available to work with:

Adults who have a developmental disability

Providers of residential services (group homes, adult family homes, etc.)

Families and guardians

Providers of day program services

MCO care managers, nurses, and consultants

Behavioral specialists

Law enforcement

Specific consultation services:

Behavioral assessments

Direct client support

Consultation with PCS and Observation Unit

Serve as a “liaison” between clients/families and service providers

Behavior Support Plans, Crisis Plans, Police Safety Plans

Consultations in 2015

Formal consultations – 34

Most common referral sources:

MCO case managers (24%)

Family/guardian (24%)

BHD Observation Unit (24%)

Client gender:

Male – 67%

Female – 33%

8


Developmental disability diagnoses:

Intellectual disability – 79%

Autism spectrum disorder – 36%

Cerebral palsy – 9%

Seizure disorder – 9%

Traumatic brain injury – 3%

9


Psychiatric diagnoses:

Mood disorders – 67%

Impulse control disorder – 36%

Schizoaffective disorder – 18%

Anxiety disorders – 12%

PTSD – 9%

Personality disorders – 9%

Schizophrenia – 9%

ADHD – 6%


Targeted behaviors:

Physical aggression toward others – 76%

Physical aggression to property – 52%

Self-injurious behavior – 42%

Verbal aggression – 33%

Elopement behavior – 15%

Disruptive behavior – 12%

Noncompliance – 12%

Incontinence – 9%

Suicidal ideation/gestures – 9%

Inappropriate sexual behavior – 6%

Ingesting non-nutritive items – 3%

Behavioral Assessments

Description and history of target behaviors

Daily routine

Setting events

Environmental triggers

Function of behavior

Replacement behaviors

Skill deficits

Interests/potential reinforcers

Sensory assessment

10

Recommendations

Setting up the physical environment

Address physical/sensory needs

Meaningful daily routine

Address social and developmental needs

Increase self-esteem

Build up relevant skills

Address mental health needs

Reinforce adaptive functioning

Case Examples

11

Direct Client Support

Problem solving

Empathy/encouragement

Positive attention/reinforcement

Socialization

Decrease desire for BHD admission

Case Examples

Staff Training

Provide a comprehensive educational curriculum designed to increase staff

job-related knowledge and skills

12

Focus is on providing participants with detailed information and

meaningful experiences concerning various aspects of care for adults with

developmental disabilities

CCT workshops are offered at no charge to those who provide services to Milwaukee County residents who have

a developmental disability

CCT Workshops The Nature of Intellectual Disabilities (4 hours)

Autism Spectrum Disorder (4 hours)

Developmental Disabilities and Mental Illness (4 hours)

Understanding Challenging Behaviors (4 hours)

Basic Behavior Modification Techniques (4 hours)

Positive Behavior Support (4 hours)

Managing Threatening Confrontations (6 hours)

Risk Management and Community Safety (4 hours)

Teaching Skills for Successful Community Living (4 hours)

Detecting and Managing Physical Illness (4 hours)

Stress Management for Staff (6 hours)

Personal Wellness for Caregivers (4 hours)

13

The Nature of Intellectual Disabilities

Help caregivers better understand people who have an intellectual disability so they can better support them in achieving greater independence and success in the community


Help caregivers better understand the characteristics of individuals who have an autism spectrum disorder and work with them more effectively

Developmental Disabilities and Mental Illness

Provide an overview of several mental illnesses that may co-occur with an intellectual or other developmental disability as well as trauma issues and how these affect functioning

14

Understanding Challenging Behaviors

Examine factors that could potentially contribute to the occurrence of challenging behaviors in the context of doing a “functional behavioral assessment”

Basic Behavior Modification Techniques

Provide an overview of various common clinical interventions that can be used to try to modify challenging behavior and strengthen more adaptive behavior

Positive Behavior Support

Changing the physical and interpersonal environment and a person’s skills so that he or she is able to get needs met without having to resort to challenging behavior

15

Managing Threatening Confrontations

Help staff be more aware of the “stages of escalation” of challenging behavior and how to support clients in each stage

Risk Management and Community Protection

A variety of potentially dangerous situations are considered involving challenging behaviors, symptoms of mental illness, and medical risks

Teaching Skills for Successful Community Living

Review methods to teach and strengthen daily living, social, and communication skills of clients

16

Detecting and Managing Physical Illness

Consider some common medical conditions that persons with developmental disabilities may present with and how to address these

Stress Management for Staff

Review the nature of stress and potential negative (especially health) consequences, then describe and practice a variety of stress management techniques

Personal Wellness for Caregivers

An overview is provided of numerous lifestyle factors that can impact one’s health and wellness in order to help staff take better care of themselves

17

CCT Workshops

In 2015, over 300 community providers/staff participated in at least one CCT workshop

Average rating of presenters (1 – 5 scale) = 4.6 (92%)

Overall satisfaction with workshop (1 – 5 scale) = 4.7 (94%)

Crisis Line and Mobile Team

Community Consultation Team is available to assist community providers, families, and

clients by phone or in person during client behavioral crises

CCT phone line:

414-257-7797

CCT is available for follow-up consultation after a crisis to help

modify support plans and decrease the likelihood of recurrences

18

CCT staff may be involved with individuals admitted to BHD’s Psychiatric Crisis Service or the Observation Unit and

are available to follow the person after discharge

Hours of Service

BHD CCT staff cover the daytime hours

8 AM to 5 PM Monday through Friday

Dungarvin CCT staff cover evening hours

5 PM to 9 PM on weekdays

8 AM to 5 PM on weekends and holidays

Crisis Mobiles in 2015 Total – 83

Client gender:

Male – 53%

Female – 47%

Most common locations seen:

Residence – 36%

FMLH – 20%

St. Joseph’s Hospital – 13%

St. Mary’s Ozaukee Hospital – 5%

19

Crisis Mobiles in 2015

Developmental disability diagnoses:

Intellectual disability – 74%

Autism spectrum disorder – 17%

Traumatic brain injury – 7%

Cerebral palsy – 2%

20


Presenting problems:

Physical aggression – 22%

Suicidal ideation/gestures – 20%

Overdose – 13%

Self-injurious behavior – 12%

Agitation – 12%

Threatening – 8%


Non-Emergency Detentions – 42

Emergency Detentions – 41

Emergency Detention outcomes – 81% lifted

Assessments

Violence risk

Suicide risk

Safety issues

Need for further evaluation

Need for hospitalization

Disposition

21

Suicide risk assessment

Risk factors

current/past psychiatric diagnoses

key symptoms (hopelessness, impulsivity, command hallucinations, etc.)

history of past attempts, history of SIB

family history of suicidality

stressors (significant recent losses, recent humiliating events, on-going medical illness, intoxication, etc.)

access to firearms


Protective factors

adequate coping skills

adequate frustration tolerance

religious beliefs

absence of psychosis

social supports

responsibility for children (or beloved pets)

positive therapeutic relationships

future orientation


Suicide inquiry

ideation (frequency, intensity, duration)

plan (timing, lethality, availability, etc.)

behaviors (past attempts, aborted attempts, non-suicidal self-injurious behavior, etc.)

intent (extent to which person expects to carry out a plan and believes it would be lethal, ambivalence about dying, etc.)

22


Risk level and intervention

high risk likely necessitates suicide precautions and hospitalization

medium risk may need hospitalization or at least increased supervision and a crisis plan

low risk may need referral for outpatient treatment and/or symptom reduction, environmental modifications

Psychiatric Crisis Services (PCS) Assessment

Discharge to home/community Discharge to the Crisis Stabilization Houses Discharge to the Crisis Resource Centers Transfer to Genesis Transfer to a private psychiatric hospital Transfer to a medical facility Admission to OBS Admission to a

BHD Acute Inpatient Unit

Case Examples

23

CCT Website

www.mkebhd.com/cct

Description of CCT services

Content and schedules for training workshops

Hours of service

Resources

News

Staff

CCT Phone Number

414-257-7797

BHD Crisis Line

414-257-7222

Questions?Justin Kuehl, Psy.D.

Chief Psychologist

[email protected]

Debora Zamacona Hermsen, M.S.

Community Consultation Team

[email protected]

Documents

Long-Term Care in the Community: Crisis Services and ... · Stabilization for Individuals with Developmental Disabilities ... Access Clinic/Access Clinic South ... Female – 33%