Matt McCue, M.A.; John Gatling, Ph.D.; Dianne Nunn
New Mexicos system of services for individuals with challenging behaviors is entirely community based. Since July 1997, there have been no state-operated institutions into which persons whose needs can not be met in their community could be placed. Although the role of the institution as a backstop to the community has been overstated (due to declining admissions), there remains a need to address emergencies when they arise.
To address this need, the New Mexico Department of Health Long Term Services Division (LTSD) has established a system of behavioral supports designed to improve the capacity of communities to support persons with challenging behaviors. Included in this system is a Crisis Response capacity, currently operated by the Los Lunas Community Program (LLCP). In addition, the LTSD employs psychologists and other behavior specialists in its regional offices. These resources, combined with the community-based Crisis Team and the existing talents of other community providers, are harnessed to the task of building the capacity of local providers and other support systems. It is the objective of this program to strengthen local abilities, not to relieve communities of their responsibility to serve persons with challenging behaviors.
COMPONENTS OF A CRISIS RESPONSE CAPACITY
The Long Term Services Division of the New Mexico Department of Health created the Office of Behavioral Services in 1997. The purpose of this office is to serve as a centralized organization with regional capabilities for quality control for statewide behavioral services and to provide clinical consultations and professional support to initiatives designed to develop and expand regional crisis intervention capacities on a statewide basis. This office consists of two clinical psychologists, three regionally based master-level behavioral specialists, a planner who is experienced with case management and quality control activities within developmental disabilities service systems and a nationally known expert in the area of behavioral services. From the beginning of the establishment of the Crisis Response Team, this office has been involved in crisis response activities throughout the state.
Among the goals of these crisis intervention activities are to provide adequate supports to the person experiencing the crisis so that major behavioral escalations are prevented and to develop capacities generally for the immediate direct care staff to be able to handle crisis situations. Through the clinical activities of the Behavioral Services Office, expert assistance to regional offices, interdisciplinary teams throughout the state, and to the existing crisis response team has been provided. This assistance has included conducting specific clinical evaluations of individuals in crisis, provision of training to direct care providers and other professional staff, as well as serving as a resource for accessing other statewide services (i.e., obtaining higher levels of funding or when absolutely necessary, emergency referral for inpatient psychiatric services). Additional activities of this office include working with local law enforcement agencies, public defenders, prosecutors and the judiciary to educate them on the needs of people with developmental disabilities who might, at one time or another, come into contact with the legal system as a result of their behavior. This latter aspect of the crisis intervention plan has yet to be fully developed and will be receiving further attention during the current year.
LOS LUNAS CRISIS RESPONSE TEAM
On November 1, 1997, all providers, case managers and state regional office staff were notified of the existence of the Los Lunas Crisis Team and its ability to assist throughout the state.
The Crisis Team at Los Lunas is made up of individuals all of whom have other job responsibilities. That is to say, there are no staff assigned full time to the project. The team members are like volunteer firemen who drop what they are doing when a crisis erupts and address the issue. At Los Lunas, trained temporary staff replace those on crisis duty until the Crisis Team staff return.
When a crisis referral is received, an intake form is completed by one of the two administrators involved with the project. One of these persons is on-call during non-business hours. In addition to administrators, the Crisis Team is made up of psychologists, residential staff, and when necessary, a nurse. Each of these individuals has received additional training in supporting persons with challenging behaviors, as well as training in mentoring other staff in supporting persons with challenging behaviors.
Depending on the nature of the intake, the administration either convenes a meeting of the team to discuss a plan of action or they may elect to assign supports to the situation. Supports are assigned on three different levels. The following is a synopsis of the three tiers of possible crisis resources.
Tier I service includes consultation, staff training and technical assistance offered to the current support providers surrounding the individual. This consultation model may include behavioral review, IDT participation, referral assistance for training or specialized assessment, on-site training, and staff development. Tier I may range from a one-time review and recommendation visit to a series of visits over an extended period of time, although generally not to exceed six months. All Tier I services are anticipated to be offered in settings currently used to support the individual.
It may be determined that in addition to Tier I intervention, trained staff are needed to assist in providing residential coverage while the local system redesigns the support offered the individual. As stated above, these specialized staff are not to replace existing staff. This intervention is offered sparingly with the understanding that local providers will resume full coverage as soon as possible. Tier II services are offered in emergency situations and all parties in the support network are expected to extend themselves toward resolving the crisis.
Tier III is a last resort of brief respite. It may include specialized staff replacing existing staff within current provider settings for a short period of time when one of the precipitating factors prompting referral is due to staff being unavailable, unwilling or unable to discharge their duties. A second possibility is temporarily placing the individual in a respite apartment maintained by the LLCP in Valencia County to accommodate one person when all else fails at the local level. This service is limited to a maximum of four months to allow the Crisis Response Team to collaborate with referring providers in designing more effective local support for the individual, enabling his/her return to their home community. When appropriate, existing staff will follow the individual to this setting and work conjointly with specialized staff. The final option would be as above without existing staff following the individual. It is expected that whatever funding is available for the individual will follow them to this acute respite setting.
In addition to the development of the programs capacity to provide crisis services, the LLCP is involved in the development of local networks of providers who meet periodically to share information and further develop their agencies ability to deal with challenging behaviors. These networks are currently up and running in two of the three sections of the State.
OUTCOMES TO DATE AND CASE STUDIES
Since November 1997, the Crisis Team has responded to 32 crisis situations involving twenty five specific individuals. The breakdown of interventions was as follows: twenty three (23) persons required Tier 1 which included consultation, training, behavior plan developments, etc. Six (6) persons required Tier 2 where LLCP staff were assigned regular coverage duty in the consumers home for up to six (6) weeks. Three (3) persons required Tier 3 supports which entailed stays of one (1) week up to four (4) months in a LLCP residence. Some of these individuals required intervention on several levels. This usually included Tier 1 (Technical Assistance) and Tier 2 (Additional staff support and mentoring).
T. is a 24 year old woman who has a developmental disability and a marked hearing impairment for which she utilizes a hearing aid. T. was first referred to the LLCP Crisis Team in the fall of 1997. She had become aggressive toward her mother and it was requested that staff from the LLCP be assigned to work with her in the home. Crisis Team staff was assigned to be with her during times that she was not at work and provided recreation and leisure activities. Staffing was provided overnight for the first 60 days. After 60 days the crisis team staff was faded out until they were only providing support several hours a day.
During this time, the Crisis Teams psychologist provided support to the family and the staff through the use of training and implementation of a behavior support plan. He remained an integral part of the team for the entire period of intervention. During the first intervention period staff was completely phased out after approximately 120 days.
T. was able to remain in her home for several months after this initial phase. In early January she was hospitalized as the result of an assault on her mother. Upon discharge it was determined that she would not be able to return to her families home and she was moved into a LLCP home. She remained in the home for just over four months. During the time she was in the home, the LLCP crisis team assisted her IDT in maintaining her job, providing quality recreation activities, implementing her ISP and BSP. They also provided assistance in the areas of procuring a stable residential placement, funding for such and transition planning.
T. is now living in a supported living home with two other women and continues with her day placement. Reports are that she is doing very well and enjoys her new found friends.
D is a 28 year old man who receives services from a private residential provider. When his team requested assistance from the Crisis Team he had reportedly destroyed his home. He was living with two other men in a three bedroom home. His house mates were feeling threatened and had requested that he move from their home. The team was not only concerned about D and his house mates, but also his staff who were showing signs of burnout. At the time of referral, the agency was prepared to give D notice that they would discontinue their provision of services as the result of his challenging behaviors and their impact on others.
Members of the LLCP Crisis team attended an emergency IDT meeting and facilitated the following changes in Ds life. He was moved into his own apartment with 1:1 staffing provided initially by members of the LLCP staff. His current provider agreed to continue to provide services. The team also assisted with the application and subsequent approval of outlier funding. Full - time staffing was provided by LLCP for 30 days. At this time, a schedule was set up for the agency staff to begin working side by side with LLCP staff for 2 weeks. Staff from LLCP was then faded out and the agency began providing services full time.
DR is a 63 year old woman who lives alone in her apartment. The LLCP Crisis Team began their involvement during a hospitalization which was the result of cardiac arrest. DR has many health problems which include asthma, cardio-vascular problems, blood problems and arthritis. She requires oxygen frequently and blood draws (pint) on a weekly basis to maintain her health. DR also had difficulty with cooperating with medical procedures, was often threatening to herself, and threw her staff out of her home. When the crisis team intervened, she was in the hospital and several of the agency staff persons were not available to work with her. The agency was struggling with finding appropriate staffing, providing the support she needed both behaviorally and physically and providing the appropriate staff training. The team worked with the agency by providing staff for the first week after her arrival home from the hospital while the agency recruited, hired and trained a house manager. They also provided technical assistance as a member of the interdisciplinary team to develop strategies for behavior support and the provision of quality health care. DR continues to live in her own apartment with staff provided to her 24 hours a day by the agency. Her health has improved and so has her quality of life.
EVOLUTION OF CRISIS CAPACITY IN NEW MEXICO
New Mexicos crisis response system has been in place since November 1997. The current system relies on one agency to provide crisis response services statewide. It is appropriate that early in its evolution, a single entity provide coverage. It is expected however, that this project will lead to the development of local capacity. To that end, the Long Term Services Division (LTSD) will conduct the following activities to encourage local capacity development.
The State will be divided into three (3) sections with a different agency providing services in each. On January 1, 1999, a yet to be identified provider will administer crisis support services in the Northern part of the State. In July of that year, a southern provider will be on line. The Los Lunas Community Program (LLCP) will continue to provide services in the central (Metro) part of the State.
The LTSD has or will hire Behavior Specialists for the three (3) sections listed above. These persons will serve as Behavior Consultants for local providers. They will also be responsible for the organization of local networks of providers which will share information among themselves and to further the development of local capacity.
When all three (3) crisis providers are on-line (in FY 2000) the total financial resources allocated to this process will be $320,000.00 per year. It is expected that with increased local capacity the need for regionalized specialty providers for crisis will diminish starting in FY 2001 or 2002. The resources allocated to regional crisis providers will be reduced. The freed up funds will be assigned to LTSD regional offices to be awarded as grants to providers who need a temporary boost in resources to fund the expenses in meeting a crisis. The proposal is currently in the concept stage. The timing of transfer of financial resources from centralized providers to individual providers dealing with a crisis will be depended upon the rate of capacity development among providers.
For further information contact:
Matthew McCue, MA
Los Lunas Community Program
PO Box 1269
Los Lunas, NM 87031