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Developmental Centers Initiatives Underway
Statewide Approaches to Developmental Center Services
The DC system is designed to provide a full array of services and supports, including a variety of specialty services equipped to provide care. To maximize the existing resources and expertise, and to promote the interest of continuous growth, the Department set forth a statewide initiative in 2009 to develop Best Practice Guidelines to raise the bar in service delivery in critical areas. This initiative was built using the leadership of each DC and the Department who identified critical clinical and programmatic changes needed within the DC system. The starting premise for this initiative was that the solutions developed would be implemented on a statewide basis, as one system as opposed to separate entities.
The workgroups were composed of representatives from each facility with expertise in their respective area, including consultants from the Consortium on Innovative Practices who were assigned to provide the clinical expertise and a national perspective of standards. The charge of each workgroup was to develop a comprehensive set of guidelines outlining best practices, with an emphasis on consumer-driven outcomes and a framework for consistent implementation statewide. Specifically, the workgroups were to:
- Provide an analysis of what is needed to implement a system approach,
- Develop Best Practice Guidelines for each focus area, that would be implemented on a system wide level, and;
- Develop a framework and methodology for self-assessments that include development of a plan for guideline implementation.
Following development of the Best Practice Guidelines a Self-Assessment Team (SAT) was established in each of the areas identified. The purpose of the SAT was to assess each facility's current compliance level to the Best Practice Guidelines and to review the outcomes with the DCD Deputy Director. Additionally each DC is responsible to develop a plan of action for ongoing implementation.
The four areas are:
- Protection from Harm to enhance the Department's expectations for a safe environment with a climate of intolerance for abuse, a plan for oversight of critical incidents and a program of safeguards that ensure that known threats are minimized.
- Physical & Nutritional Supports focusing on the minimization and mitigation of risks associated with aspiration, choking, gastroesophageal reflux, skin breakdown, constipation, dehydration, malnutrition, and falls.
- Behavior Supports to improve the provision of positive approaches to residents whose behavioral challenges have limited their individual successes in many settings.
- Health Care Services improving services to ensure they are appropriate, pro-active and timely preventative, routine, acute, and emergency health care that meets their individual needs.
a. Protection from Harm
People receiving services at a Developmental Center must be provided a safe living environment. A safe environment includes a climate of intolerance for abuse, a plan for oversight of critical incidents such that individual and group protections are implemented promptly, and a program of safeguards that ensure that known threats are minimized.
In order to provide a safe living environment and ensure the delivery of each person's program of supports and services, a comprehensive quality assurance program tracks and analyze outcomes, patterns and trends in order to inform organizational change processes. Remedial organizational measures will be tracked on an ongoing basis to ensure that issues are addressed and appropriate outcomes are achieved and sustained through a team-centered risk management program.
A system for Protection from Harm includes, but is not limited to:
- Zero Tolerance culture for abuse and neglect
- Comprehensive staff training
- Special Incident monitoring
- Investigations of significant incidents
- Comprehensive quality assurance system
b. Physical & Nutritional Supports
People residing in a Developmental Center receive Physical and Nutritional Support focused on an improved collaborative approach to therapeutic and medical intervention and the minimization of risks associated with aspiration, choking, gastroesophageal reflux, skin breakdown, constipation, dehydration, malnutrition, and falls.
An appropriate physical and nutritional system is one in which the team forms a proactive cohesive approach so that assessments are proactive and comprehensive and risk is minimized. Once these assessments are completed, members ensure consistent implementation and identification of potential symptoms associated with decline through a comprehensive monitoring process.
At the core of an effective physical and nutritional support system is a competent interdisciplinary Physical and Nutritional Support Team that provides ongoing support and review and ensures each individual is provided with effective, appropriate, and timely nutritional and physical supports to meet their individualized health care needs. Included in these supports is:
- A method to identify all individuals initially as well as ongoing who are at an increased risk of physical and nutritional decline.
- Comprehensive assessments for those individuals who have been identified as being at an increased risk.
- Development and implementation of comprehensive plans.
- A system that proactively identifies signs and symptoms associated with physical and nutritional decline and contains clear clinical pathways for team members to follow.
- A training system that ensures ongoing staff competence.
- A monitoring system that effectively measures implementation, knowledge and effectiveness of supports.
c. Behavior Supports
People living in the Developmental Centers are in need of additional support and treatment through a living and working environment that provides meaningful relationships, interesting and engaging activities, real choices, emotional support, and treatment with respect and dignity at all times. Positive approaches that focus on developing relationships and skills are the mainstay in achieving personal goals. When undesirable behaviors interfere with an individual's ability to move forward in their life, we strive to help them replace those behaviors with positive behaviors that better meets their needs.
Behavior Support services must include actively applying strategies that assist the individual to succeed. The implementation of Behavior Support Services must include maximizing the opportunities for the individual to experience positive consequences. Restrictive interventions are last-resort procedures, used only when all other methods have been ineffective.
The successful implementation of Behavior Support services must include protection of the individual's physical and psychological well-being, as well as protection of their civil rights. In order to achieve this goal, staff must be well trained and prepared. There also must be oversight to ensure adherence to all regulatory, legal and ethical guidelines and requirements.
A system of positive behavior support services addresses:
- Positive approaches in all environments
- Standardized psychological and behavioral assessment procedures
- Positive Behavior Support Plans
- Interdisciplinary processes and roles
- Informed consent and oversight of any restrictive interventions
- Data collection, monitoring progress and program revision
- Peer review
- Staff training
Over the past two years the Department has been working directly with each DC in restrictive intervention reduction efforts. These efforts have provided increased focus and attention on the uses of restraints, system wide review of current policies and procedures and ongoing discussions regarding contributing factors associated with restraint use. Currently most areas of restraint use have shown a downward trend over the past two years, and at three of the five facilities the use of programmed prone containment has been eliminated from all resident plans.
d. Health Care Services
Residents of the DCs will be provided with appropriate, proactive and timely preventative, routine, acute, and emergency health care that meets their individual needs. Policies and evidence-based clinical practices will guide the general and preventative medical care. A comprehensive plan to address the major health areas includes a data based approach, designed to demonstrate which interventions are effective or ineffective. Enhanced physician participation in the interdisciplinary approach to providing services and the creation of individual plans is essential to a system of effective health care. Direct support staff and nursing personnel must also be active team participants in effecting the best possible health care services for each person. Key components of a comprehensive health care system address:
- Well trained staff
- Health care assessments, diagnoses, treatments, and follow-up monitoring
- Specialized health care services
- Medication administration
- Health care quality assurance program
- Peer review
- Mortality review