PRESENTATION FOR DEPARTMENT OF PSYCHIATRY MEETING JUNE 6, 2012

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

PRESENTATION FOR DEPARTMENT OF PSYCHIATRY MEETING

JUNE 6, 2012

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

MILESTONES:• Interim Status – Fall, 2011 until February, 2012• 2/12 – Arrival of new Program Director Michael Klein, LICSW• 3/12 – Addition of Assistant Program Director Micah Love-Allotey• 3/12 – Exit of Unit Psychiatrist; Interim Coverage Provider John Backman, MD• 4/12 – Arrival of new Medical Director; Providing Unit

Psychiatry Tony Jackson, MD• 2/12 – current: Sorting out substantial additional personnel issues• 2/12 – current: Identifying & remediating unit infrastructure deficiencies• 2/12 – current: Reinvigorating program image with DMH, DCF• 3/12 – current: Infusing unit with Adolescent Program philosophy• 3/12 – current: Increasing coordination with other Adolescent Program units• 3/12 – current: Participating in future planning, including response to RFR, budget

planning, and preparation for move to Worcester Recovery Center and Hospital

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

PERSONNEL, TRAINING, & RELATED ISSUES SINCE 2/2012:• Challenge of “inheriting” and managing 36 FTE “benefited” staff & 6+ residential milieu “per

diems”• Open positions filled since 2/2012 – Assistant Program Director, Psychiatrist*, Activity

Coordinator, Environmental Coordinator (Chef), Driver, Milieu Specialist, 3 residential milieu “per diems”, 3 summer teachers

• Current openings – 3-11PM Shift Supervisor**, 20hr./week Peer Mentor, 1 residential milieu per diem now, 1 res milieu per diem August, Part-time Unit Psychiatrist*

• Two major FMLA situations - Clinician, Shift Supervisor• One benefited Milieu Specialist on military leave• Approximately 4 FTE’s res milieu staff (Benefited? Per diem?) projected as needed for new

hospital configuration (by August ???; by October???)• Clinical staff (Clinicians, OT, Rehab, Nursing) skill-sets and appropriateness re client needs• Interface of program staff with 4 school-year teachers who are not UMass employees• Very substantial training & supervision issues relating to residential milieu staff• 1-2 “critical incident investigations” per month (focus on potential staff negligence)• Mixture, within res milieu staff, of long-time (since Westboro) and quite new personnel• Three shift operation – typical issues- invariably complex• Several management issues in process re new UMass systems (iCIMS, Summit HR)

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

PROGRAM & CLINICAL ISSUES OF ONGOING AND CURRENT CONCERN: • Boy-girl (coed) unit issues – sexuality, complexity of programming given certain differences in

developmental issues for each sex.• “No eject/no reject” admissions can result in need for highly individualized programming which

has unpredictable “staff demand” characteristics – meeting funder and guardian expectations - tricky.

• Management of safety on the unit / in the community in the context of complex systems and conceptual issues, i.e. specific safety decisions must be considered in light of DCF, DMH, UMass, State Hospital, Court, Probation, Human Rights regulations, JCAHO, professional liability and the potential for “investigations”; all of these factors can complicate what may initially appear to be straight-forward decisions.

• Professional “silos” due to placement of the Unit within a highly regulated/bureaucratized State Hospital, operation by a large, complex Medical School, and union issues – all of which complicate the inter-disciplinary issues which are typical of any residential child treatment setting.

• Clinical substance abuse treatment.• Neuropsychological testing; possible need for other specialty assessment (mechanisms to

obtain).• Special education – assessments and ancillary services. • Evidence-informed individual and group tx practice (need for certain time-limited groups likely) .• Psychopharmacology limitations (trials, pace) due to Rogers restrictions.• Potential for changes in programming due to “length of stay” directives from DMH; uncertainties.• Integration-with-Team and risk-management issues relating to extensive use of “mentors”.• Substantial need for vocational/job opportunities in supervised sites; issues in this regard with

State Hospital “rules” about adolescents and adults “mixing” – risks and realities; LOS may limit community-based options.

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

--------------------------------------------------------------EXAMPLE

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

COMMITMENT TO RESIDENT INVOLVEMENT (two current examples):

YOUTH-MANAGEMENT COUNCIL – This component was implemented in 3/2012 by the new Program Director. It replaced one of the weekly “Community Meetings” (there were, at the time, 4 Community Meetings AND 7 House meetings per week – too many from the new PD’s perspective, and this is one of several changes that have been made to mtgs.). Y-M Council involves 4 managers and 3 youth, with an additional “Youth Alternate”. The group meets in the PD’s Office and has focused on several topics, including working on the New Resident Manual Appendices. The Y-M Council will also become the vehicle for Opportunity System status presentations and decisions. It has already become obvious that at least three of the youth involved have increased their “positive opinion leader” roles in the resident community.

CRITICAL INCIDENT QUALITY IMPROVEMENT COMMITTEE – This is a time-limited committee that has been formed as one response to a recent (4/2012) data summary from DMH that, in the opinion of Adolescent Residential Programs management (Caroline McGrath can elaborate), portrayed our programs in a confused manner. Regardless of discussion of the comparative data in that summary, it was decided that the IRTP and the BIRT would each undertake a QA project relating to analysis and reduction of Critical Incidents. At Connections, our committee is comprised solely of line staff (no managers), and we have chosen to include a 14 y.o. resident as a committee member.

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

Opportunity System Roll-outGuidelines for Managers, Supervisors, Staff Mike Klein, LICSW, Program Director

The Opportunity System is being brought online “by us/for us” to push our Connections milieu system towards increased adherence to a “maximum resident involvement recovery oriented environment”. The Opportunity System will, with our program being the last to come on-board, be the standard milieu system across all UMass Adolescent Residential Programs. However, because of differences in the clienteles and lengths of stay across the 4 units, while the System is conceptually one, the details and implementation are different for each of the units. To “make the Opportunity System our own” – managers, staff and youth representatives have worked hard for the past 3 months.Timing:2/20/12 – 6/1/12: All basic elements have been developed & are ready.6/4/12: Staff to receive New Resident Orientation Manual, Appendices, Basic Opportunities Chart, and Roll-out Guidelines6/5/12: 3-4:00 Pass-On Meeting used with staff to review elements 6/11/12: 12:30- 1:30 Specially called meeting with staff to review elements6/18/12: 2-3PM -Youth to receive & be walked thru New Resident Orientation Manual, Appendices, Basic Opportunities Chart6/19/12: 2-3PM-Youth Q&A session re Opportunities System6/20/12: 3-4:15- Monthly Staff Mtg. used to review elements7/5/12: 30 minutes at Rounds used to assign initial youth statuses7/6/12: 30 minutes at Rounds as needed/last minute concerns7/9/12: Implementation of the M-O-C System

Basic Statuses In The Connections’ Milieu System: These are directly adopted from the Transitions’ system – M= Milieu, O= On Grounds, and C= Community. There are two “sub-statuses” which are O/M= Orientation/Milieu and O/C= On Grounds/Limited Community. Assignment to O/M and O/C will be more based on individual youth needs and, as such, will be more determined by staff processes. Each major status (M-O-C) comes with a clear, concrete set of responsibilities and privileges for the youth assigned to the status and these are explained in O/M & provided to residents on a chart:

M=MilieuYouth has been taken off of O/M status at a morning Rounds by the staff Team after hearing (a) from the Clinical Staff that youth has achieved and maintained “safety” status for 5 consecutive days (this is basically that the youth has not attempted a run, has participated in his/her assessment, has complied with medical and psychiatric recommendations [of which medication compliance is key], has not self-injured, and is not persistently/actively psychotic or dissociative), and (b) from the Rehab and Residential staff that the youth has completed his/her orientation quiz (which means that he or she has learned the Unit’s rules [though it is not required at this point that the youth complied with them]).For O/M and M status – areas accessible, jobs, trips & visitation, and personal items, see the Basic Opportunities Chart.O/M usually completed within 2 weeks after admission; M usually lasts 1-4 weeks. However, movement to higher status in this system is not arbitrary – some youth will move more quickly than others; some youth will not reach the highest status during their time at Connections; youth and staff must consider this in order to become comfortable with this system. O=On GroundsSee Basic Opportunities Chart. The O status usually lasts 4-8 weeks. O/C means that the youth is on O status but especially regarding Trips/Visitation limited access to activity off-campus (C status privileges) will be added on a daily review basis in the staff morning “Rounds” meeting, on Friday for weekends; also, the 4 program managers (Director, Clinical Supervisor, Nursing Manager, Assistant Director) may individually add such access). C=CommunityAs resident develops and demonstrates greater skills, individualized community experiences will be incorporated into their treatment. See Basic Opportunities Chart.C status can usually be obtained by a youth after s/he has worked steadily for 3 months; however, it would not be unusual for a youth to require 4-5 months to reach “C”, and there will be some Connections residents who will simply not reach “C” during their time in the program, with one major factor being that their funding source may independently determine that an appropriate step-down is feasible – we expect this will be more likely for younger Connections residents.

Determination of Main (M-O-C) Status: Assignment to the M-O-C statuses will be done through a formal structure noted below which is unique to Connections and which heavily involves youth and staff. (Assignment to O/M and O/C will be more based on individual youth needs and, as such, will be more determined by staff processes. )

It is believed that resident involvement in status assignment will be as important to the success of the new system as the status (responsibility/privilege) assignments for individual residents. Determinations will be made by a structured process involving youth, line and supervisory staff, and managers. The process will encourage major youth involvement/management and involve elements of typical group and public sector “governance” (i.e., voting, representation by peers, secret ballot, majority, etc.).

15-20 minutes at the end of each Community Meeting, twice per week, will be reserved for “status change proposals”. All youth present, usually 10-15, and up to 5 staff will secretly vote (more than 5 staff may be present, but any over 5 cannot vote) on any youth who states his/her wish to “present” for an M-O-C status change to the Program Director’s Youth/Management Council. Youth petitioning the Community Meeting will learn to understand that this step is a “screening”, not a final decision on a proposed status change. The youth in charge of the Community Meeting will, with a single staff assigned to assist him/her, collect the votes, tally them and if a youth receives 60% or more vote immediately indicate to the petitioning youth that his/her request will be moved on to the Director’s Youth/Management Council. No more than 2 youth can be screened in per week.

The Director’s Youth/Management Council will, at its very next meeting (to meet weekly), among other items, consider up to 2 screened in status petitions. The members of this Council will be the Program Director, APD, Clinical Director, Nurse Manager, and three youth, at least 2 of whom are on O or C status and a quorum will require at least 5 of the 7. Any decision to deny a petitioner an improved status will be the result of a majority vote of those present at the Council and require a brief written statement which will be delivered immediately after the Council to the petitioning youth and his staff advocate. A youth whose status improvement is granted will also be promptly notified and that change will go into effect immediately upon notice in almost all cases. However, the Program Director or his appointed stand-in, should he not be present, may implement a “hold” on a status change if they are concerned that there may be either (a) a very substantial “agency risk” issue or (b) a very significant need to review the proposed status change with a funding source (e.g. if there were a condition of probation or a court-order in place which might be interpreted to prevent the desired status change). Such a situation is expected to be infrequent, but if it occurs, it will be the Program Director’s or his designee’s responsibility to resolve this ASAP.

Any youth who is “denied” by the Council may re-petition at the very next Community Meeting – though s/he needs to consider this timing carefully as the Community Meeting will, by the very process know that the youth has just been denied. A youth who is re-petitioning is take the needed time interval so that s/he can state to the Community Meeting what has changed or what s/he thinks will improve his chances with the Council. Also, any “re-petitioner” must be aware that s/he does not “go to the head of the line”. This will be up to the youth chairing the particular Community Meeting, and, again, only up to 2 petitions per week will be considered by the Youth/Management Council.

UMass Medical School / Department of PsychiatryAdolescent Residential Programs

Connections/BIRT – Moving Forward – 2011 to June,2012

THANK YOU !!!

“I am not afraid of tomorrow, for I have seen yesterday and I love today.” William Allen White, 1868-1944

“The trouble with our times is that the future is not what it used to be.” Paul Valery, 1871-1945