TREATING AT-RISK BEHAVIORS AT THE ACQUIRED BRAIN INJURY (ABI) UNIT AT EASTERN STATE HOSPITALLINDSEY JASINSKI, PH.D.

ABI PROGRAM DIRECTOR

OBJECTIVES

• Provide an overview of the new ABI unit at ESH

• Discuss approaches to management of at-risk behaviors at ESH

• Staff Training

• Unit Structure

• Environmental Management

• Medical Interventions

• Future Goals and Directions of ABI Unit

MISSION AND VISION

• Promote the highest level of functioning and quality of life through a systematically applied and comprehensive set of empirically supported medical and therapeutic rehabilitative interventions

• Provide individualized, holistic, and compassionate post-acute brain injury rehabilitation in a safe environment

• Focus on learning or re-learning new skills to improve functional independence, and transition to a lower level of care, including the community

OVERVIEW

• 17 beds

• Locked, secure unit

• Private & Semi-private rooms

• 24-hour nursing care

• Licensed as a Long-Term Care Facility

• Anti-ligature hardware, focus on resident safety

• Opened in late Fall 2014

ADMISSION CRITERIA

INCLUSION CRITERIA

• Age 18+

• History of Acquired Brain Injury

• Current Axis I diagnosis

• Meets nursing level of care, unsuccessful in less restrictive care

• PASSR Level II

• Rancho V or higher

• Able to participate in at least 3 hours of therapy/day

EXCLUSION CRITERIA

• Active felony for violent offense

• Primary substance abuse dx

• Any injury without known ABI (e.g. spinal cord)

• Dx of progressive dementia

• Psychiatric dx with no known ABI

• Intellectual disability or developmental disorder w/o etiology to ABI

ADMISSIONS PROCESS

• Referral

• Review by the Admissions Committee Team

• In Person visit

• PASRR Level 1 and 2

• Scheduled admission date

OUR TEAM

ABI SPECIFIC TEAM• Medical Director, Board Certified in Neurology/Psychiatry

• Physical Medicine/Rehabilitation Specialist

• Neurologist

• Neuropsychologist

• Clinical Psychologist

• Clinical Social Worker

• Behavior Analyst

• Physical Therapist

• Speech/Language Pathologist

• Occupational Therapist

• Recreation Therapist

• Registered Nurses

• State Registered Nurse Aids

ESH SERVICES• Music Therapist

• Art Therapist

• Registered Dietician

• Chaplain

• Quality Control

• Infection Control

• Business Services

• Utilization Review

• Medical Supply

• Safety/Environmental Services

• Security

• Laboratory

• Health Information Management

• Information Systems

• Pharmacy

• Radiology

• Risk Management

TREATMENT TEAM APPROACH

Multidisciplinary Interdisciplinary

Transdisciplinary

EXPECTED LOS 3-12 MONTHS

Admission/Transition

(goal development, motivation/engage

ment)

Intensive Rehabilitation(PT, OT, SLP,

Psy)

Increased Community

Integration Focus(Outings,

expanded therapy)

Transition to Community

with Supportive Services

AT RISK BEHAVIORS

• Aggression/Violence

• Toward self: self-harm, suicidal ideation, suicide attempts

• Toward others: residents and staff

• Sexual Acting Out

• Personality Change/Irritability

• Emotional Lability

• Therapy Refusal

• Elopement attempts

• Other behaviors that interfere with progress in therapy or functional independence

ESH PHILOSOPHY/MODEL

Need

Responsivity

Risk

TARGET AREAS

FACTORS OFTEN CONTRIBUTING TO AGGRESSION & AT RISK BEHAVIORS

• Decreased structure

• Staff attention less available

• Difficulty with communication and/or coping

• Environmental triggers

• Poor task persistence/motivation

• Staff inexperience/ineffective

ESH RESPONSE• Highly structured daily schedule

• Low staff to resident ratios

• Intensive Group and Individual Therapy

• Behavioral Support/Level System

• Errorless Learning, Goal Attainment Feedback Loop

• Calming Rooms, Outdoor Space

• P.E.A.R.L, CPI, GIV program

DAILY SCHEDULE  Monday Tuesday Wednesday Thursday Friday Saturday Sunday7:25a Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast8:00a

ADLs ADLs ADLsADLs

ADLs Relax/ADLs Relax/ADLs8:30a8:45a Library9:00a Yoga/Stretch Yoga/Stretch Yoga/Stretch Yoga/Stretch & Goals ADLs ADLs9:30a Goals Group Goals Group Goals Group Yoga/Stretch & Goals Music/Art Therapy10:00a Yoga/Stretch Yoga/Stretch10:30a

Gift Shop     

Gift ShopGoals Group Goals Group

10:45a Chaplain Group ChapelCooking Group11:00a    

11:25a Lunch Lunch Lunch Lunch Lunch Lunch12:00p            12:30p Mobile Library Mindfulness

Weekly OutingMindfulness

Communication Station Mindfulness Mindfulness1:00p

Shopping/Meal Plan   

Gym and Reel Life Gym and Reel Life

1:30p Retrain your Brain  

Double Trouble/Drug Ed2:00p   Healthy Living Group2:30p Check in Group   Family Ties Group3:00p Feelings Group I am a Survivor Group3:30p On unit exercise   Mindfulness4:00p Recreation Therapy Gym/Exercise Recreation Therapy Gym/Exercise4:30p  5:00p Dinner Dinner Dinner Dinner Dinner Dinner Dinner5:30p

HW/Relax/Visitation

HW/Relax/Visitation HW/Relax/Visitation   HW/Relax/Visitation

HW/Relax/Visitation HW/Relax/Visitation6:00p  6:30p

Gym/Exercise Gym/ExerciseAA Group

Gym/Exercise7:00p7:30p  8:00p Wrap up Group Wrap up Group Wrap up Group Wrap up Group Wrap up Group Wrap up Group Wrap up Group8:30p9:00p              9:30p ADLs/lights out ADLs/lights out ADLs/lights out ADLs/lights out ADLs/lights out    10:00p              10:30p           ADLs/lights out ADLs/lights out

GROUP & INDIVIDUAL THERAPY FOCUS

• Distress Tolerance, including Anger Management and Safe Coping

• Social Skills Acquisition

• Emotion Regulation

• Mindfulness

• Communication Skills

• Family Support and Education

• Development of Specific Goals related to psychiatric symptoms and coping

• Promote insight into triggering events, emotions

• Process incidents and use modified behavior chain analysis to explore alternatives

• REPETITION!!!

• Role Plays, In Vivo Training, In the moment coaching to use skills

LEVEL SYSTEM

Level

Privileges

5 Able to have personal computer, cell phone, Ipad use for 90 mins, Home visits

4 All outings (therapy/activity), Ipad use for 60 mins, able to use Wii

3 Therapeutic outings, soda and all snacks

2 Able to go off unit in hospital (e.g. gift shop), Level 1 snacks, no outings

1 Able to have soda & level 1 snacks, can have radio, restricted to unit

0 No technology (computer, cell phone), No outings, restricted to unit, level 0 snacks

• Begin on Level 1/2 at admission

• 100 points = move to next level

• Must maintain 20 points per day to remain on level 5

• -10 points in a day = drop 1 level

• Behaviors (e.g. aggression, elopement, threatening, SAO, etc) = automatic drop to level 0 for safety

• Points awarded for therapeutic and daily functional activities:

• Meal behavior and clean up

• Therapy – groups and individual

• Homework completion, if applicable

• Housekeeping

• ADLs

• 2 points for full participation and appropriate behavior, 1 for partial, 0 for excused absence, -4 for refusal

P.E.A.R.L. (MCMORROW, 2005)

Positive Early

All Reinforce

P.E.A.R.L. CONTINUED…

• Purpose: “encourage a different approach to influencing the lives of persons who are considered disabled, one that emphasizes the interaction between people as the basis of all human existence.”

• Proactive Treatment Interaction—every interaction is a “social exchange” intended to promote greater autonomy

• Teaching, ways to invite greater participation

• Can take place anywhere, anytime

• Can occur regardless of level of functioning

• Promotes an ongoing interaction

POSITIVE

• Interaction is:

• Inviting

• Physical characteristics: warm tone, expression, posture

• Looks interested

• Upbeat, makes request (not command) and encourages interaction

• Not a new skill, but reinforce in our staff, becomes self-reinforcing

• Expectation of 2 positive/neutral statements for every 1 request

EARLY

• Have a social exchange before emotional/behavioral upset

• Not just a “good idea” but rather a job expectation

• Providing support and problem-solving early, prior to a difficult situation develops

• Paying specific attention to antecedents for each individual

• No behavior occurs in a vacuum

• Learning (i.e. coping skills) is most likely to occur at low levels of arousal

ALL

• Use all components of PEARL, with all people, in all settings, all the time

• Comprehensive approach to interactions, idealistic, inclusive

• “Consistent reminder that we are interested in developing more powerful, mutually reinforcing relationships in our lives”

• Based on mutual reciprocity, helps refocus staff

• Sounds easy but in fact most individuals in our setting are there because of behaviors that are unacceptable in the community/home setting making the likelihood that “attack-attack reciprocity” will develop much higher

REINFORCE

• “Interact in a way that acknowledges more independent or autonomous behavior and is intended to result in increased future use of this behavior.”

• Focus on what reinforces more functional behavior: verbal praise, touch, eye contact, tangible rewards

• Also focus on what the desired outcomes are do we want this behavior to continue?

• Reinforce-reinforce exchange: what part of the person’s behavior can you acknowledge?

LOOK

• Identify opportunities to teach as they arise, encourage independence and increase participation in the social community

• Goes against the idea that “teaching” is specific to a particular type of interaction (i.e. didactic), specific discipline (e.g. psychology, SLP, OT, PT) or in a certain setting (e.g. group therapy).

• Engages all staff to focus on what each interaction can produce, rather than imposing an agenda on the resident

• “developing good therapy habits” as important for future functioning as the content of the session or interaction

ERRORLESS LEARNING

• Teaching method minimizing errors

• Contrasted to Trial and Error Learning

• Longer learning acquisition time

• Used for cognitive retraining, but also for learning coping skills, ADLs, engaging in rehabilitation, etc. doesn’t allow for guessing or mistakes

• Empirically supported for moderate to severe cognitive deficits after TBI

• Improves learning, reduces depression/frustration/lack of motivation/anxiety associated with error correction process

• Increased opportunity for positive reinforcement

• Enhances engagement in rehabilitation process, develop good therapy habits, and improves rapport in early stages of intervention

ERRORLESS LEARNING, EXAMPLES

• Cognitive retraining:

• Learn phone number for therapist number is 8167 the number is 816_ the number is 81_ _ the number is 8_ _ _ the number is ______

• Refusing rehabilitation:

• Comprehensive task breakdown, points awarded for increasingly completing the steps over a period of time

GOAL ATTAINMENT FEEDBACK

• Daily goals group to start the day—maintains focus

• Written on footprint as visual cue

• Feedback given at lunch and dinner on level system and goals

• Wrap up group in evening—process goal attainment

• Visual cues also in binder relevant to other goals (e.g. cognitive goals, ADLs, etc.)

CPI (NONVIOLENT CRISIS INTERVENTION)

• Crisis Prevention and Intervention

• Focus on De-escalation, Process each incident to re-focus on future

• C: Recognize lack of control

• O: Orient to the facts

• P: Identify patterns

• I: Investigate alternatives

• N: Negotiate, give choices

• G: Give back empowerment

• Physical interventions are a LAST resort to managing a crisis situation

• Staff highly training on staying calm, de-escalating the situation

CPI, CONTINUED

Anxiety Supportive

Defensive Directive

Acting Out Nonviolent Physical Intervention

Tension Reduction Therapeutic Rapport

CALMING ROOMS

• In development, hospital-wide

• Transdisciplinary approach with Psychology and OT

• Focus on sensory and distraction tools for calming

GIV PROGRAM• Individualized plan for giving the right patient, the right medication, at the right time.

• Verbal de-escalation always attempted first, prompt to use effective coping

• Effective and efficient utilization of PRN medication

• Initial evaluation includes:

• Safety Crisis Management Assessment (SCMA)-triggers and coping

• What medications work and what dose?

• What route works best?

• At what point should medication be administered? Behavioral symptoms documented.

• Benefits:

• Safe environment for everyone

• Decreased symptom burden

• Decreased number of incidents, including staff, peer, and resident injuries

• Allows staff to humanely intervene and respond effectively to a behavioral emergency

SAFETY CRISIS MANAGEMENT ASSESSMENT

Restraint Hours

jul aug sep oct nov dec

Actual

1.16 1.02 0.61 0.35 0.17 0.11

3PMA

1.10666666666667

1.36 1.33 1.18666666666667

0.93 0.66

3PWMA

1.38 1.28 1.13 0.84 0.56 0.31

Exponential

1.231453 1.2760171 1.24121197

1.174848379

1.0053938653

0.80877570571

0.1

0.3

0.5

0.7

0.9

1.1

1.3

1.5 1.381.28

1.13

0.84

0.56

0.31

Actual 3PMA 3PWMA Linear (3PWMA)

SUMMARY

• New unit: environment, culture and milieu very flexible, with solid foundation

• Approach to managing at-risk behaviors is multifaceted

• Staff training through P.E.A.R.L. and CPI

• Highly structured therapeutic environment

• Focus on behavioral and environmental supports

• Maximize psychotherapeutic and medical interventions

LOOKING FORWARD…

• Continue clarifying our mission and vision, while meeting the needs of the community

• Meet unit capacity, while maintaining highest levels of care and staffing ratios

• Integration of ESH services with other providers, continuum of care

• Research: What interventions have the biggest impact for what individuals?

• Opportunities for additional research & training

QUESTIONS???