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Susan Morris RSW Johanna Lake PhD Krishnan Dhir RSW               Andrea Perry OT Reg(Ont)

Yona Lunsky PhD, CPsych

Crisis Prevention & Emergency Care: Comparing Practice Change

NADD, Baltimore, MD.October 2013

Objectives

• Introduce and discuss crisis prevention and ED tools

• Review current evidence for:o Crisis plan and ED use among people with IDD 

• Evaluate 2 approaches to practice change:o Practice as usual (crisis plans)o Structured approach (ED tools)

• Share and compare strategies for practice change

Crisis Planning & ED Tools

• Crisis Plano Strategies for individuals, families, service 

providers and emergency responders to follow during periods of crisis

• ED Toolso About Me: My Health Information

o Relevant health info, recommended strategies, how to support patient 

o Exit Interviewo Summary of visit, information for follow‐up care

How do you ensure tools are used with fidelity in your organization, 

or with partner organizations?(e.g., emergency departments)

“Most people are in favor of progress, it’s the change they don’t like.”

Anonymous

What is a crisis? of Crisis

“Acute disturbance of thought, mood, behavior, or social relationship that requires immediate attention as defined by the individual, family, or community”

(Beasley & Kroll, 1999, APA 2002)

“We realized as parents we could not maintain his security any more. We can’t control him physically. We can’t ensure his safety. He absolutely needs to be in a safer environment.”

Is this familiar?

What has been your experience of families in crisis?

What does the research tell us about crisis and ED use by 

people with IDD?

Crisis Planning 

• The prime objective of crisis planning is to develop a strategy for individuals, families, service providers and emergency responders to follow during periods of crisis (Beasley & Kroll, 1999) 

• Persons without a crisis plan are twice as likely to visit an emergency department than those who do not have one (Lunsky, Balogh & Cairney, 2012)

ED use by people with IDD & Dual Diagnosis

• A psychiatric diagnosis is often first identified during a crisis and often in the emergency department or during an inpatient admission (Bouras & Drummond, 1992; Reiss, 1990) 

• Adults with a dual diagnosis are 3‐4 x more likely to be frequent visitors to ED  than the general population (Lunsky et al, 2011)

• 45% percent of individuals living with IDD receive a psychiatric diagnosis within a two year period (Lunsky 2012) 

History of previous admissions Mild disability Living with family No crisis plan  Lack of family MD  No involvement with criminal justice system

Risk Factors for ED visits:

What is the presenting issue?

Behaviour ChangeAggression?

Recent trauma or abuse (bullying)

Pain…

Trouble with roommate

Self‐harm?

Caregiver illness

Move/change in residence

Unemployed

Drug or alcohol use

How do ED Staff Feel?

“We don’t see a lot, but when we do, they are time consuming

and difficult…

Sometimes the same person comes 3 to 4 times in a row".

“How can I engage with this person?

…We don’t have that expertise.”

How do families and people with IDD feel?

Lack of respect• Rights• Forced procedures• Treated for a different 

complaint Consent

• Not given opportunity

Chemical and physical restraint• Prior to alternative approaches

Lunsky & Gracey, 2009

“They said they couldn’t keep her anymore so they sent her home.

The same day they sent her home, she ran away.

She has never taken the bus on her own but that day she took herself to another hospital.”

“This lady said to me ‘you come in here all the time and this and that…’ She argued with me. I was upset about it so I just left and went to another hospital”

“It was a bit difficult because the more people came in with other problems, the more anxious she got. Its not like a regular individual who could understand the wait.”

“They don’t understand that it is hard to be cooperative when I am agitated.”

What does this tell us?

1. Some, perhaps many, crises can be prevented.

2. The experience of service within an ED can be improved.

“After all is said and done, a lot more is said than done.”

Knowledge Translation

Knowledge translation is the exchange, synthesis and ethically‐sound application of knowledge – within a complex system of interactions among researchers and users – to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system

Canadian Institutes of Health Research

See one, do one, teach one: Practice As Usual

Implementation Stages: Structured Approach

National Implementation Research Network

Still to come.In progress.

#2. Structured Approach

#1. Practice as Usual

DD CARES: Improving emergency care for people with IDD

Crisis Plans

Case Study 1: Crisis Plans

Crisis Plan Implementation

Still to come.

Crisis Plan Content   (Beasley & Kroll, 1999)

• Face Sheet ‐ demographics, communication, medical• General Guideline ‐ strengths, interests, what works• Signs and symptoms of behaviour leading to crisis

o Hierarchy of behaviouro Potential reasons for behaviouro Interventions at each stage

• Disposition recommendations – respite, specific hospital• Back up protocol – who to call in crisis, emergency supports• Signature sheet – client, family, providers

Goal of Crisis Plan Qualitative Review 

Find out how crisis plans, a best practice, are currently implemented.

Crisis Plan Qualitative Review

• Participants completed a sample crisis tool based on an individual with a dual diagnosis and complex needs (with staff input as required) and then responded to the following questions: o What sections of the tool were difficult to completeo Identify processes/supports required within their organization 

to effectively complete the tool

• Analyzed 142 TIP homework responses from 2009‐2012

1. Complexity ‐ overlapping forms, behavioural continuum,    collaboration‘Perhaps the most challenging part  of the crisis planning and implementation) would be establishing working partnerships and collaboration between agencies, hospitals and other services

2. Language ‐ cross sector differences, cultural issues‘..Most of our clients are adult immigrants and they usually do not have a formal diagnosis back in their home

Outcomes What sections of the tool were difficult to complete?

3. Obtaining information

History

‘..this individual was discharged from jail with no ID, has no doctor, only has a father that has limited contact

Diagnosis‘The client I am using the tool with has never been formally diagnosed with a cognitive delay..’

Outcomes What sections of the tool were difficult to complete?

4. Staff knowledge and skills re consent, collaboration, behaviour, diagnosis

‘Not coming from a mental health background but as we support more and more people with a dual diagnosis, I would have to educate myself more with the terminology..’

‘Breaking the behaviour down into four stages was a bit of work as the behaviours do not always go in a smooth direction’

‘..Behaviour is definitely a symptom of .. Mental health and/or physical health, but my fear would be indicating it on a form that a crisis service or mental health service would see the issue solely as behavioural…’

Outcomes What sections of the tool were difficult to complete?

Outcomes: What processes/supports are required to effectively complete the tool?

• Agency Practiceso Information collected at intakeo Integration of forms across the organizations and with best practices 

o Articulation of the difference between a behavioural support plan and crisis prevention and support plan

• Training o Consento Psychiatric diagnosis and medication o Information gathering from families, other resources, archived files

o Interprofessional practice – case conferencing, chairingo Biopsychosocial framework and behavioural hierarchyo Crisis prevention techniques o Understanding the role of ED, how to work effectively with ED

Case Study 2: DD CARES

DD CARES is a quality improvement initiative that endeavors to act on previous ED research by working with ED practitioners to create and implement tailored resources, tools, and education for use in the ED, to promote improved care for patients with DD

Interdisciplinary team involving CAMH, Sunnybrook, and developmental sector staff

About DD CARES

• Funded by the Ministry of Health and Long‐Term Care, Health Systems Research Fund (HSRF) (PI: Yona Lunsky)

• DD CARES is an interprofessional quality care initiative involving researchers and clinicians, working to create and implement tailored resources, tools, and education for use in the ED. 

Goals of DD CARES

1. Quality of care goals

Better ED care for people with IDD in Ontario

2. Research goals

Structured Approach

Still to come.In progress.

Now

•Patient Toolso About Me: My Health Information (Passport)o Social Stories: What to expect in the EDo Sensory Toolkit o Communication Toolso Exit Interview (Dear Dr./Dear Patient letter)

•Discharge Packageso Community Resourceso Crisis Plans

Quality of Care: Resources for Patients

Quality of Care: Resources for Staff

• Quick Contact Sheet o Developmental sector resources

• Financial Sheeto Funding sources for people with intellectual 

disabilities

• Resource Bindero DD CARES Binders (e.g., assessment 

strategies, Health Watch Tables, communication tools, reference materials)

o Cue Cards/1 pager

In‐person roundsE‐learningJob aidsIntranet & portals Skills workshops & case discussionsEmbedding resources into existing practicesEducational videos

How are we implementing tools?

Lunch and Learn

Pancake Breakfast

Coffee Cards

Case Review

Evaluation Research 

‐Measurement of Emotions, Skills and Attitudes Towards Patients with Intellectual Disability ‐Evidence of regular tool use‐Interview feedback from staff, patients, caregivers, &  community agencies

‐Routine processes & procedures, improve quality, coordination & transition of care, enhance patient & provider satisfaction with care

Full Implementation

‐Measurement of Emotions, Skills and Attitudes Towards Patients with Intellectual Disability ‐Expanded Evidence Based Practice Scale‐Tool tracking sheet, case reviews, observations, self‐reports, staff feedback, patient feedback 

‐Enhance knowledge of IDD, use of tools, perception of tools, improve & adapt care

Initial Implementation

‐Training opportunities identified‐Awareness of supports‐Protocols developed

‐Establish onsite champions, structural supports, feedback & management strategy

Installation

‐Measurement of Emotions, Skills and Attitudes Towards Patients with Intellectual Disability  ‐Readiness for Change Assessment ‐Process Map‐Anecdotal information

Evaluate awareness, barriers, engagement, processes

Exploration

Assessment MeasuresOutcomesNIRN Stage

Outcomes: Exploration Phase

Why Care? What are we going to do?

o Engagement and awareness raising was challenging:o Low frequency population o Busy ED o Training schedules already fullo Competing priorities/projects

o Tools introduced and their fit discussed

Outcomes: Installation Phase

• Alignment and integration into current practices and procedures benefits from:

•Interdisciplinary input from the team•Learning of the many ED protocols

•Lots of ideas suggested for implementation…tools refined accordingly

What needs to be put in place?

Outcomes: Initial Implementation Phase

• Coach needs to be onsite• Case review….should have been sooner• Continual promotion• Importance of feedback loops• Meet, review and revise processes

Let’s try it out!

What’s next? 

Still to come

In progress Still to come

Now

Completed

Evolution of ‘our’ Structured Approach 

2005‐ 2012‐13 2013‐2014 2014 2015

Research to Practice

Pilot work

Expansion of pilot Scaling up

Evaluation

Research generation

Discussion

What is your approach to implementing policy or practice change?

How do you engage with and evaluate the uptake of practice change?

Thank You