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System-Wide Implementation of Tiered Supports to Proactively Prevent Crisis and Positively
Impact Quality of Life
Reinventing Quality Conference Baltimore MD
August 2014
Objectives
Share general information on Missouri Agency Tiered Supports
SW-PBS /Mo Tiered Supports model alignment
State-level implementation strategies
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To systemically prevent crisis… & To be successful:
...a person needs meaningful relationships, a predictable environment, and the opportunity to develop skills.
...the families and agencies need the knowledge, skills, tools, and support necessary to teach & encourage desirable behaviors & prevent challenging behavior.
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“React, Train & Hope”
REACT to Problem Behavior
Select & ADD
Practice
Hire EXPERT to Train Practice
Expect, and HOPE for
Implementation
WAIT for New
Problem
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Implementation science has excellent
evidence for what does not work
None of the old ways for system change work ALONE
Just disseminating information to folks does not lead to them using it
Just training does not lead to doing
Laws and compliance based efforts do not work
Leading people with incentives or money does not work
Trying to get implementation (doing new stuff) without ongoing support and resources does not work
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What might we do instead?
Look for and implement “root” level solutions
Develop system level supports to these new solutions
Prioritize prevention
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Development of Mo-DDD Tiered Supports Systems
1:1 crisis behavior management ineffective and expensive-”focus on putting out fires”
System wide approach necessary for effectiveness and best use of resources
Modeling after Mo-SW state level systems- “not re-inventing the wheel”
Person Centered Process – focus on QOL
To implement must have training, coaching, mentoring and system support
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COST EFFECTIVE
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15,682
2704 0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
Individual Consultation Number ofhours of BRT time
Tiered Supports Number of Hours ofBRT Time
State Wide Totals of Individual Focused and Tiered Consultation Hours
527
1262
0
200
400
600
800
1000
1200
1400
Individual Consultation Number ofIndividuals
Tiered Supports Number ofIndividuals supported by Agencies
State Wide Totals of Individual Focused and Tiered Individuals Served
So how is Missouri working to do this?
Tiered supports process
We build or enhance systems
And collect data
To implement practices
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Agency Tiered Supports
Has many characteristics in common with Missouri’s School-wide Positive Behavior Support Initiative
Improves systems by using Person Centered Strategies
Decreases need for higher level of behavioral support services
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Emphasis on State Level Implementation Plan
Design and implementation of
Practices, Data, Systems Individual
Building/agency level
Regional
State
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Mo DDD Tiered Supports Model
Regional Behavior Resource Team
State Level Leadership Team
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Unit of implementation = Agency or Family
- System of Recognition of implementation
-Trainings to be designed for Implementation phases
-ASSET
-EMT (incident reports)
-Big ‘3’
Agency/Family team – design and implement systemic Universal Strategies
Mo SW Model
Regional Consultants
State level Leadership Team
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Unit of Implementation = School Building
- System of Recognition (Bronze, Silver Gold)
- Training designed for implementation phases
- SET
-ODR
-Big ‘5’
School Team to design implementation of school wide Tier 1 and 2 strategies
Systems
Data
Practices
SW-PBS/Tiered Supports state-level implementation alignment
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State Wide Tiered Support Structure
Tiered Support
Leadership Team
Regional BRT
Agency Coach
Agency Tiered Support
Implementation Team
Leadership Team – Invited behavior professionals from regional behavior resource teams charged to develop and implement state level planning to support the BRT functions
Regional BRT – Regional DD staff charged with providing training and targeted technical assistance for agency implementation of DD Tiered support Agency Coach- identified by the provider agency to be the chair of the Agency Tiered Support Implementation Team and liaison for Regional BRT (pre – req skills from SWPBS?) Agency Tiered Support Implementation Team – identified by the provider agency to develop and implement agency specific Tiered Support Implement
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The Coaching Process
Initiate
•Contact with Administrator or Family Head of Household •Set up meeting to provide overview of process and benefits
Inform
•Describe ASSET process and purpose •Review Tools of Choice Training •Confirm interest and commitment •Develop Agency Tiered Supports Implementation Team (A Team)
Evaluate
•Set up meeting with A-Team •Complete Asset with A-Team assistance •Review Results of Assessment with A-Team and Admin
Action Plan
•Decide on areas of focus and steps for improvement and measurement of progress •Develop action plan for A- Team tasks and Coach Tasks with Team •Include Tools training and setting up system to implement •Set up regular meetings to review and assist
Review
•Coach – Set regular review times for data with A-Team effects of interventions assist with interpretation of data and problem solving/decision making
•Assist A-Team to set up systematic review process for data sharing with Admin
Reinforce
•With A-Team design reinforcement for staff for implementation and data collection •With Region/SB 40 design recognition process for Agencies who participate and successfully implement •With BRT Steering committee design reinforcement for BRT coaches and Agencies successful implementation
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MO SWPBS Outcomes
Number IEPs (special plans for problems) approximately 20% Overall number of office discipline referrals Administrative and discipline time for staff and principals
Improved academic performance for students Staff morale and retention Academic teaching time
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Missouri’s DD wide Tiered Supports Expected Outcomes
Need for Behavior Support Plans Overall number of incident reports (CERs or EMTs) Time spent addressing crisis and behavior problems
Increased learning and achievement of ISP goals Staff morale and retention Increased productive time for learning and meaningful life activities Quality of Life
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Essential Components of Tiered Supports Model
Healthy, Positive, Enriched Environment
Administration/ Family decision maker(s) support, participation & leadership
Common approach to teaching & providing encouragement for what to do and what not to do
Clear, consistent, positive expectations (behaviors)
Procedures for teaching expected behaviors (and functional skills)
Continuum of Procedures for encouraging expected behaviors
Continuum of Procedures for discouraging undesirable behaviors
Procedures for coaching, feedback, re-teaching and re-evaluating effectiveness of procedures used by family and staff
Data Based Decision Making
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Environmental Evaluations (ASSET)
The Agency wide Systems Supports Evaluation Tool (ASSET) is designed to assess and evaluate the critical features of agency wide effective tiered supports.
ASSET results are used to:
1. Assess features that are in place
2. Determine goals for agency wide effective supports
3. Evaluate on going efforts toward agency-wide support
4. Design and revise procedures as needed , and
5. Compare efforts toward agency –wide effective support over time.
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Sample ASSET results:
0 2 4 6 8 10 12 14 16 18
Regional/State Support
Agency Leadership
Data-Based Decision Making
Systems of Reinforcement
Teaching and Encouraging New Skills
Positive Interactions and Relationships
Life Values Defined, Taught and Encouraged
Choice and Communication
Schedule/Predictability/Meaningful Day
Physical/Social Environment
Total
Agency
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Where are we now? State-level
33 agencies have committed to participation and are active We have some automatic data systems Anecdotal reports and preliminary data from agencies are positive Reduction in restraints and incidents with several agencies after 9-12 months of implementation Regions report less crisis events for agencies participating vs those that are not
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An Agency Example
Future Care Inc.
Small agency – residential supports for 12 individuals in 3 person settings
Rural region of state with one mid size town
Has always been agency of good standing
Individuals and staff are long term
Many of the individuals came with “severe reputations”
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Future Care, Inc.
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Future Care, Inc. and Rolla BRT
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Future Care, Inc. and Rolla BRT
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Future Care, Inc. and Rolla BRT
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All Reportable Incidents
4
6
4
7
1 1 0 1 0
1
2
3
4
5
6
7
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Distinct Count Consumers
April-June 2012
July - Sept 2012
Oct - Dec 2012
Jan - Mar 2013
April - June 2013
July - Sept 2013
Oct - Dec 2013
Jan - Mar 2014
6 8
14
9
1 1 0 1 0
2
4
6
8
10
12
14
16
Count of Event Report
April- June 2012
July-Sept 2012
Oct - Dec 2012
Jan - Mar 2013
April - June 2013
July - Sept 2013
Oct - Dec 2013
Jan - Mar 2014
Agency committed to participate 4/30/2012
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Incident reporting system changed in September 2012
Comment from another agency
“We are 100% down (staff turnover) from last year, which is seems crazy. The major, major changes have been being part of the ASSET and implementing and encouraging tools of choice among our staff and individuals. It has had an amazingly positive impact on our agency so I wanted to thank you both, and the rest of your team!”
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Agency Report of Impact on Staff Retention
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0
20
40
60
80
100
120
140
160
FY 2013 FY 2014 Current Year
Staff Turnover rate
Pe
rc
en
tag
e t
ur
no
ve
r
Annual comparison of Staff Turnover Rates
•
*incomplete
Data Types for Analysis at State, Regional and Agency
Levels
Utilizing existing data systems
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State Wide Comparison of EMTs per Quarter
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0
5000
10000
15000
20000
25000Non-Tiered Support Agencies
0
5000
10000
15000
20000
25000Tiered Support Agencies
Regional Analysis
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Regional Analysis of Support Coordinator Reported Issues
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0
100
200
300
400
500
600
700
800
900
1000
Health Staff Issues Environmental Safety Money Rights
KRO Tiered Agencies Issues Compared Across Fiscal Years
FY 2012
FY 2013
FY 2014
Regional Analysis of Human Rights Committee Referrals
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Agency Level Analysis Tool
Incident Types Monthly Frequency for Identified Time Period
Quality of Life Measures
NCI survey results Medications
Health
Home
Employment
Respect, Rights and Safety
Relationships
Choice
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Emphasis on State Level Implementation Plan
Design and implementation of
Practices, Data, Systems Individual
Building/agency level
Regional
State
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Contact Information
Terri Rodgers, Ph.D. BCBA, LBA
Julie LePage, M.S. BCBA
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