Building Unified Service Systems If Not Now, When? Yakima, WA September 18, 2006

1. Never the Same Crisis, Twice It’s About Relationships -State/provider collaboration -Provider consortiums It’s About Change -Capacity building -Confidence building Building Unified Service Systems If Not Now, When? Yakima, WA September 18, 2006 It’s About Action -Prevention -Intervention Chris Heimerl 11200 Carmel Ave NE Albuquerque, NM 87122 chrisheimerl@msn.com 505-796-0442

2. Our Mission • We prevent crises from occurring, if one does, we help end it.

3. The Short Course So much of our thought, time and energy are devoted to people’s extraordinary needs-arising due to impairment and disability-that we neglect or overlook people’s ordinary needs-those things we all want in our lives that are sometimes extraordinarily hard to get.

4. The Basics You’ve got to have something to eat and a little love in your life before you can hold still for anybody’s sermon on how to behave. Billie Holiday

5. Disclaimer • Certainty is the sin of bigots, terrorists, and Pharisees. • Compassion makes me think I could be wrong. • Anthony DeMello • The Wellspring of Life

6. New Mexico • 5th largest state geographically • Only 1.9 million people: Over half live around Albuquerque • Low income: <$22K overall, <$17 in rural areas • Culturally diverse: 43% white; 40% Hispanic; 16% Native American representing 19 pueblos, 3 reservations; 1% other.

7. Individuals Served • 3800 individuals receiving services through the Home and Community Based Waiver • 3800 individuals on the Central Registry awaiting services • Over half receive support for mental health/behavioral issues

8. Providers • Residential Home base: 36 Assisted living: 36 Supported living: 42 • Supported employment: 40 • Day Habilitation: 52 • Case management: 21 • Behavior Support Consultation: 72 agencies, 225 therapists • Community Integration: 57

9. Severe aggression toward others. Severe self-injury. Repeated elopement. Absence, shortage, or marginal competence of available resources, most notably medical, psychiatric, and behavior support. Sexual aggression including criminal perpetration. Illegal behavior ranging from misdemeanors to felonies. Drug and alcohol abuse. Acute mental health incident often prompted by issues with psychotropic medication. Current or impending homelessness. Aging and/or failing health of family members, most often parents, providing support. Individual vulnerability to exploitation. Crisis

10. What Works • Collaboration between the Interdisciplinary team, OBS, and the Regional Office. • Formal and informal training events: • Informing potential referral sources regarding the nature and scope of crisis response leads to more reasonable expectations and satisfaction. • Networking opportunities between providers. • Enhance direct staff and family competence to identify, predict, respond to, and recover from crises.

11. What Works • Opportunities for families to receive information regarding all waiver services. • OBS technical assistance in IDT meetings to clarify, evaluate, and resolve problems through effective planning and specific guidance for staff. • Selective denial of requests for crisis response and “pushing back” against referring agencies demands problem ownership and frequently results in newfound capacities and creative problem solving. • Relationship building with clear liaison identification and collaboration with psychiatrists, mental health therapists, hospital mental health units, and law enforcement agencies.

12. Crisis Responders • Experienced direct support providers • Lifestyle and family allow flexibility • Confident, assertive and calm • Quick on their feet, literally and figuratively • Structure and rhythm • 4th, 5th or 6th of 8

13. Expenses Staff time, overtime Travel Stipends* Administration *Rent, utilities, deposits, damages, transportation, respite, therapy, Tier III Revenue Waiver funding General fund allocation SSI Adult Protective Services $

14. Attending special IDT meetings to assist the team with the ongoing assessment and planning of crisis intervention and prevention Reviewing the ISP/BSP/Crisis Plan Developing an Interim Behavior Support Plan/Crisis Plan Referral for specialized assessments-TEASC, Special Needs, Offender risk screening, neuropsychological, medical Consulting, as needed, regarding the crisis with key players on team as new or issues and considerations arise Settings/Consideration Grid. Identify alternate resources if applicable Providing Technical Assistance regarding support implementation Response Tier I

15. Response Tier II • On-site observation • Interactions with consumer observed • Environment • Implementation of ISP/BSP/Crisis Plan. • Modeling • Interaction with individual • Implementation of ISP/BSP/Crisis Plan • Appropriate documentation • Structuring daily routines. • Training staff on consistent implementation of the ISP/BSP/Crisis Plan • Mentoring

16. In-home Tier III supports Tier III services will be delivered in the individual’s residence, if the individual’s needs can be met in that setting. Tier III activities include: 24/7 staffing, to be provided by the existing residential provider Staff of the Private Crisis Provider and OBS will be determined on a case-by-case basis by the crisis response team Maintain IDT involvement in the crisis, in order to restore the individual’s pre-crisis supports and providers Assure appropriate training to support stabilization and return the individual to pre-crisis services and supports Response Tier III

17. Response Tier III • Alternative residential setting • Identifying temporary alternative setting from available providers • Coordinate consumer move to identified alternative setting • Coordinate staff, as needed, from identified agencies • Maintain IDT involvement in the crisis to restore the individual’s pre-crisis supports and providers • Facilitate and manage emergency placement from available providers • Assure appropriate training to facilitate stabilization when returned to the pre-crisis services and supports

18. Settings and Considerations

19. The Four Questions +Michael Smull • What have we tried? • What have we learned? • What are we pleased with? • What are we concerned with? • The fifth question and its questions: • Now what? • -what will we continue to do? • -what will we do less of or stop doing? • -what will we begin or return to doing?

20. Learning the language of behavior. • What is happening? (Antecedents/Precursors) • Then he/she does this . . . (Behavior) • We think it means this . . . (Interpretation) • And we should . . . (Analysis and action)

21. Four Rules of the Universe • Three Roads to Quantum Gravity • Lee Smolin • There is one, only one, universe and it contains everything and everything it contains is connected. • There is one, only one, universe but many observers and every observer experiences a different reality. • In the future, we will know more. • The universe is about relationships, not events.