James Wiltz, PhD
Psychologist & Regional Director
Benchmark Human Services
Indianapolis, IN
Crisis and Intensive Residential Supports in the
Community for Those with Challenging Behavior
April 10, 2015
The Hotel Woodbridge at Metropark, Iselin
The attached handouts are provided as part of The Boggs Center’s continuing education and dissemination activities.
Please note that these items are reprinted by permission from the author. If you desire to reproduce them, please obtain
permission from the originator.
Rutgers, The State University of New Jersey
Liberty Plaza, 335 George Street, New Brunswick, NJ 08901
http://rwjms.rutgers.edu/boggscenter p. 732-235-9300 f. 732-235-9330
4/10/2015
Crisis and Intensive Residential
Supports in the Community for those
with Challenging Behavior
James Wiltz, PhD
DDLS Lecture Series – Boggs Center
Iselin, NJ
April 10, 2015
Today’s Presentation Topics
Introduction:
Some History – how we got here from there
High-Behavior Community Supports:
- Best Practice: Components in the 4-legged stool
Introduction:
Me & who I work for:
• 10 states & DC
• over 8,000 served
• Intensive Residential
Support in 6 states
• Operate two 24/7 Mobile
Crisis Services
• Indiana Crisis Service
2007-2010
• Develop Models of
Support
• Dual Diagnosis
Focus
1
4/10/2015
Dual Diagnosis
1. Intellectual Disability &
2. Mental Disorder (or MI)
• 1982 – Reiss & “Diagnostic Overshadowing”
• 1982/3 – Menolascino & “Dual Diagnosis”
• 1983 – Fletcher & NADD
Dual Diagnosis – Why it is Important
• Future: most people with ID who receive 24-hour
services will have Dual Diagnosis
• Is that future = Now?
• Everyone working with people with ID will
encounter people with Dual Diagnosis
History - Toward Community Services
• First Boarding School in 1848
•
Originally an attempt at Habilitation and Training
(Wolfensberger, 1969)
• Eugenics then Institutional Care
(Switzky, Dudzinski, van Acker, & Gambro, 1988)
2
4/10/2015
Toward Community Services
Kennedy and the
President’s Panel
(Kennedy, 1963; President’s Panel, 1962)
• 112 Recommendations
• Foundation for research and
services
• Included Dr. Elizabeth Boggs
as parent/advocate
Institutions & Community Today
• “Bad old Days” vs. Today
• Historical Context & Evolution of Care
• My Experiences in Three Institutions
• Trends toward Community Care for Many
Institutions & Community Today
• Same Regulations (e.g., ICF/ID)
• Same Values underlying Services
• PCP, ISPs, BSPs, HRCs – and the rest of the alphabet
• Different Funding, though . . .
• . . . and Different intensity of services
•
Psychiatry, crisis response, “hotel” etc.
3
4/10/2015
Stress on Institutions
• CMS & More Pressure for Community
Integration
• DOJ, CRIPA, & ADA
• Costs keep Rising
Stress on Community
Where do “New” people go?
• More Dual Diagnosis & Challenging Behavior
• Highest end of ConFnuum → Community
• Few Institutional Options Left
A Proposed Solution:
•
A Robust Model that Overcomes Barriers
Common Metaphor:
Supports are a 3-Legged Stool
• Each leg is essential or else collapse is certain
• If one leg is missing or incomplete, nothing else
works, period
• Problem: it’s not like real life
• Services for People with ID have never been
complete – that does not mean everything
collapses
4
4/10/2015
Revised Metaphor:
High-Behavior Community
Supports are a 4-Legged Stool
• Each leg is important
• All four legs combined are the most stable
• Just like real life, imperfect services do not collapse
just because something is missing
Sometimes Imperfect . . .
. . . but Still Standing
•
•
•
•
Think of services in Your region of the state
Is every support available?
Probably not, but some parts still work
But should Individuals with ID have to settle for
Rickety Supports?
5
4/10/2015
Supporting People
with High-Behavior
in the Community
Community Partners
4 Legged Support:
Challenging Behavior in the Community
1. Intensive Residential Support
2. Mobile Crisis & Stabilization
3. Linkages between Community Partners
4. Strong Relationships with Government Agencies
4 Legged Support:
Challenging Behavior in the Community
1. Intensive Residential Support
• Highest level within Continuum of Care
• Enhanced Staffing, including Clinical
• Environmental Modifications
• A closer look: ESNs or even Higher Needs
6
4/10/2015
4 Legged Support:
Challenging Behavior in the Community
1. Intensive Residential Support
• ESN = Extensive Support Needs Group Home
• 4 housemates in sturdy home, 3/3/2 staff, etc.
• Does that model work for the most challenging?
• Highlight: Bert from Bethesda
4 Legged Support:
Challenging Behavior in the Community
Bert: A Success Story
• ID & brain injury as child
• Dangerous Behavior
• Lifetime in Institutions, including JRC
• 3 staff, no housemates (yet)
• 3 years at current home
4 Legged Support:
Challenging Behavior in the Community
2. Mobile Crisis & Stabilization
• Call to Crisis Hotline, what next?
• (hint: it depends on the type of service – RFP)
1. Quick, in-home Assessment
2. Then Menu of Options made Available
7
4/10/2015
4 Legged Support:
Challenging Behavior in the Community
2. Mobile Crisis & Stabilization
• Mobile Crisis Units & In-Home Support
• Psychiatry & Telemedicine
• Out-of-Home Support / Acute Stabilization
• Follow-up & High-Risk Prevention
4 Legged Support:
Challenging Behavior in the Community
2. Mobile Crisis & Stabilization & Linkages
• Unique Role of Crisis Team as the Lynchpin of
Linkages between high-risk services (Wiltz, 2013)
• Example – Acute Care subcontract & Building
Capacity within Existing Providers
8
4/10/2015
4 Legged Support:
Challenging Behavior in the Community
3. Linkages between Community Partners
•
Key is to feel like Partners, not Competitors
•
Building Relationships
•
All members of the same team
•
Necessary, but not sufficient
4 Legged Support:
Challenging Behavior in the Community
4. Strong Relationships with Government Agencies
•
Providers must link with Government
•
They are Funders and Customers
•
Legally Responsible (e.g., DOJ)
•
Ensure Accountability & Tie Everything Together
•
Example – State Placement Authority
Summary
• Safe and Effective Community
Placement is Possible, even for People
with Challenging Behavior
• A 4-Legged Stool approach provides
Strong Interconnected Community
Support
• Linkages and Cooperation are
needed: Specialty Crisis Providers are
Uniquely able to Facilitate.
9
4/10/2015
Thank You!
Contact Info:
James Wiltz, PhD HSPP
Psychologist & Regional Director
Benchmark Human Services
[email protected]
812-679-7844
10
References:
Blatt, B., & Kaplan, F. (1966). Christmas in purgatory; A photographic essay on mental retardation.
Boston: Allyn & Bacon.
Braddock, D., Hemp, R., Rizzolo, M.C., Tanis, E.S., Haffer, L., Lulinski, A., & Wu, J. (2013). The State of the
States in Developmental Disabilities 2013. Boulder: Department of Psychiatry and Coleman
Institute, University of Colorado and Department of Disability and Human Development.
R.H., Wieseler, N.A., & Lakin, K.C. (Eds.) (2002). Crisis prevention and response in the community.
Washington, DC: AAMR
Kennedy, J.F. (1963). Mental illness and mental retardation – Message from the President of the United
States (H. Doc. No. 58). Congressional Record, 109, 1837-1842.
Lakin, K.C., & Larson, S.A. (2002). The social and policy context of community-centered behavioral
supports and crisis response. In R. H. Hanson, N.A. Wieseler, & K.C. Lakin’s (Eds.) Crisis
prevention and response in the community. (pp. 3-32). Washington, DC: AAMR
Lakin, K.C., Larson, S.A., Salmi, P., & Scott, N. (2009). Residential services for persons with
developmental disabilities: Status and trends through 2008. Minneapolis: University of
Minnesota, Research and Training Center on Community Living, Institute on Community
Integration.
Larson, S.A., Salmi, P., Smith, D., Anderson, L. and Hewitt, A.S. (2013). Residential Services for Persons
with Intellectual or Developmental Disabilities: Status and trends through 2011. Minneapolis:
University of Minnesota, Research and Training Center on Community Living, Institute on
Community Integration
Mayer, M. (2005). The crisis service crisis. NADD Bulletin, 8, 5
President’s Panel on Mental Retardation. (1962). National action to combat mental retardation.
Washington, DC: U.S. Government Printing Office.
Reiss, S. (1994). Handbook of challenging behavior: Mental health aspects of mental retardation.
Worthington, OH: IDS Publishing.
Reiss, S. & Wiltz, J. (2009, October). Life motives, needs, and intellectual disabilities: Applications for
crisis intervention and quality of life. Pre-conference symposium at the NADD Annual
Conference, New Orleans, LA.
Switzky, H.N., Dudzinski, M., van Acker, R., & Gambro, J. (1988). Historical foundations of out-of-home
residential alternatives for mentally retarded persons. In L.W. Heal, J.I. Haney, & A.R. Novak
Amado (Eds.) Integration of developmentally disabled individuals into the community, 2nd ed (pp.
19-35). Baltimore: Brookes Publishing.
United States Census (2012). Population estimates. Retrieved October 20, 2013, from
http://www.census.gov/popest/data/metro/totals/2012/index.html.
Wiltz, J. & Harris, G. (2013, October). Lessons learned: A new crisis model. Paper presentation at the
NADD Annual Conference, Baltimore, MD.
Wolfensberger, W. (1969). The origin and nature of our institutional models. In R.B. Kugel & W.
Wolfensberger (Eds.) Changing patterns in residential services for the mentally retarded (pp. 59171b). Washington, DC: President’s Committee on Mental Retardation.
Notes
Notes