behaviours-of-concern-care-pathway-v3-4

Specialist Services Division Care Pathway For Behaviours of Concern Version dates September 2016 Original document developed by Dr Samantha Harris, Consultant Clinical Psychologist In collaboration with: Dr Peter Speight, Consultant Psychiatrist Mrs B Browne, Parent and Expert by experience Mr K & Mrs L Tomlin, Parent and Expert by experience Based, with permission, on a document written by Dr Ursula McCann, for Northamptonshire Partnership Foundation Trust, 2008 Page | Contents Section Section Care Pathway Overview Page Introduction Summary Flowchart of Care Pathway Part Service Pathway Step 1: Referral into CCG Locality based Community Team Step 2: Allocation of referral Step 3: Assessment Step 4: Formulation 16 Step 5: Intervention 20 Step 6: Evaluation and Review 31 Step 7: Discharge 34 References 35 Part Appendices 39 Appendix Care Pathway Audit Tool Appendix Comprehensive Care Pathway Flowchart Appendix Other assessments available Appendix ABC Charts and guidance Appendix Example of self monitoring sheet Appendix Measuring Outcomes of PBS Page | Care Pathway Overview Introduction NICE Guideline NG11 (2015) describes a clear approach to working with people who show behaviours of concern It explains that some people with a learning disability display behaviour that challenges, although goes on to state that this is not a diagnosis per se, but the behaviour is a challenge to services, family members or carers The Royal College of Psychiatrists, British Psychological Society and Royal College of Speech and Language Therapists (2007) defined behaviour that challenges as, “…… when it is of such an intensity, frequency or duration as to threaten the quality of life and/or the physical safety of the individual or others and is likely to lead to responses that are restrictive, aversive or result in exclusion.” This definition and the NICE guideline (2015) suggest that behaviours that challenge are constructed socially, often serving a purpose for the individual and resulting from an interaction between personal and environmental factors A Care Pathway is defined as “locally-agreed, multi-disciplinary practice based on guidelines and evidence, where available, for a specific client group” (Overill, 1998) This Care Pathway aims to develop a multi disciplinary approach to working with referrals where the primary concern is a behavior that challenges It is based on two main documents; the NICE Guidance (2015) and the The Royal College of Psychiatrists, British Psychological Society and Royal College of Speech and Language Therapists’ report, ‘A Unified Approach’ (2007) A Positive Behavioural Support Framework is followed, in line with NICE and Department of Health Guidance (Positive and Proactive Care: reducing the need for restrictive interventions, 2014) Appendix outlines an audit tool for this care pathway to encourage self evaluation of the process Appendix shows a comprehensive flowchart of the pathway Page | Summary Flowchart of Care Pathway for Appropriate Referrals Referral into the Community Team for People with a Learning Disability And Initial Triage Assessment Allocation of Referral Referral stays with Community Team Allocated to the appropriate members of the Team High urgency; Referral to CHAT Team ASSESSMENT FORMULATION Different type of professional input may be required Different care pathway may be indicated INTERVENTION MONITOR & EVALUATE DISCHARGE Page | Service Pathway Step Referral pathway Step Allocation Step Assessment Step Formulation Step Intervention Step Monitor & Evaluate Step Discharge Page | Step Referral into CCG Locality Community Team The Locality Community Teams operate an open referral system, thus accept referrals from a wide variety of sources including: self-referrals; family carers, support agencies; general practitioners; education professionals; social services professionals, and so on For a referral to be accepted, the individual must: • Be 18 years or over; • Have a learning disability as defined in NICE Guidance NG11 (i.e significantly reduced intellectual ability , usually an IQ of less than 70, significant impairment of adaptive functioning and onset in childhood); • Be an ordinary resident of Lincolnshire, with a Lincolnshire GP; • Have a health need which is commissioned by Lincolnshire SW CCG, as part of the service agreement with Lincolnshire Partnership NHS Foundation Trust (LPFT) In addition, the service user must be in agreement with the referral, when they have capacity to so If they lack the capacity to agree, LPFT staff will be required to complete a Mental Capacity Act assessment during the first appointment, and will only proceed with the referral if it is in the Best Interests of the person concerned New referrals are received via the Trust’s Single Point of Access (SPA) They are screened daily by the Team Co-ordinators (or allocated deputy) The Crisis Home Assessment and Treatment team provides a service to support individuals with significant, high risk, behaviours of concern in their home environment, which could ultimately lead to a hospital admission This includes supported living, residential and nursing home placements, as well as family homes A separate care pathway is available for these referrals As referrals are screened, any CHAT referrals are forwarded directly to the CHAT team If it is felt the CHAT team are required by any professional working with individuals at other stages of the care pathway, internal transfers occur, and the referred person joins the CHAT care pathway LPFT are committed to providing accessible information about the services it provides, to all who may wish to refer This information can also be found on the Trust’s website Page | Each Community Team comprises of a variety of health professionals including: • Clinical Psychologists; • Psychiatrists; • Speech and Language Therapists; • Occupational Therapists; • Physiotherapists; • Behavioural Support Specialists; • Mental Health and Autism Spectrum Condition Liaison Workers; • Physical and Acute Healthcare Liaison Workers; • Intervention Assistants; • Administrative staff Page | Step Allocation of referral Urgent referrals, which require the Community Home Assessment and Treatment service (CHAT) are forwarded to that service immediately For all new, non urgent referrals, an initial telephone triage assessment is completed within two weeks of the original referral being received This assessment confirms eligibility (which, in some cases, may require further assessment from psychology and/ or occupational therapy), clarifies the reason for referral and establishes the priority level of the referral, whilst also conducting a preliminary risk assessment Information is also gathered about previous contact with services, support needs, communication ability and previous interventions This information is taken to the weekly Multi-Disciplinary Team meeting, to enable allocation to the appropriate professional Referral stays with Locality Community Team If it is felt that the referral is appropriate for a Positive Behavioural Support based assessment, formulation and intervention, the referral remains within the Community Team The referral will therefore be allocated to an appropriate team member Dependent upon level of need and risk, the allocated worker may consider that individual or joint work is required Page | Step Assessment Goal of assessment It is expected that the assessment will provide useful, appropriate and sufficient information to assist in the development of a clear clinical formulation The aim of the clinical formulation is to understand the factors which have led to the development of the behaviours of concern, what causes them and what maintains them This includes the strengths of the person and their carers, and any factors which prevent difficulties arising, for the individual Suggested formal assessments which may be useful, depending upon the needs of the person are listed in Appendix Some of these may also be used on a case by case basis as outcome measures, as advised by the British Psychological Society (2014) The assessment also provides a baseline against which the effectiveness of any intervention can be assessed, particularly with regard to the individual’s quality of life At this point it is essential to support the development of the goals of any intervention, which the person and their carers feel are important, relevant and measurable The goals of the intervention will be part of the outcome measurement, to monitor the effectiveness of interventions This information is reported to commissioners Preliminary Triage Assessment The assessment should begin with a comprehensive review of any available background information It is important that such a review identifies any previous interventions, what they entailed, whether they were successful, and if not, why they failed The following information should be gathered from relevant documented notes: • Family history • Support needs and support network • Life events both positive and negative • Physical difficulties or health issues Page | • Diagnoses • Communication ability • Skills and limitations This background information should be obtained from the clinical notes (requesting historical notes from archives if necessary) and through initial discussions with the referrer, support providers (whether family or paid organisations/ individuals) and any other Community Team members who know the person Risk Assessment The LPFT Clinical Risk Assessment and Formulation tool must be completed for each referral This uses the five Ps framework to ascertain the risk to client and others, and to develop a formulation of the risk factors This leads to the development of risk management systems, which includes preventative strategies and positive risk taking Physical Health Assessment Physical conditions, including pain, are well established as significant contributors to the development and maintenance of behaviours of concern in people with Learning Disabilities Therefore, it is important that this is assessed as part of the comprehensive assessment process This could involve the use of the OK Health Check (Matthews 1997) which is an evidence-based checklist of health indicators that provides a systematic approach to assessing the health needs of people with learning disabilities Mental Health Assessment Behaviours of concern may also arise due to mental illness in people with a learning disability The RCP, PBS and RCSaLT report, Challenging behaviour: a unified approach (2007) outlined four ways in which mental health issues may be associated with behaviours that present a challenge; Page | 10 ACHIEVED Step (cont) - The assessment findings are fedback to the team meeting and a standard letter of confirmation regarding team input sent to service user / carer / GP within four weeks of the initial visit - Letter regarding appropriateness for Learning Disability register sent to GP practice within one month of feedback to the team meeting - A summary of planned assessment and possible intervention completed and sent to the service user / carer / GP within one month of the team feedback Allocation of Referral – Referral stays with Community Team YES NO DATE ACHIEVED N/A FURTHER ACTION REQUIRED? (what, by whom?) COMMENTS – Referral to other service (state service) – Referral to CHAT Type of input required - Referral appropriate for single professional working with the individual - Two or more professionals from the same team working with an individual - Two or more professionals from different teams working with the individual Page | 42 Assessment Lead clinician to identify appropriate assessment/s for the individual (the list is not exhaustive) LPFT required assessments must be completed and stored on Silverlink as required (e.g Clinical Risk Assessment and Formulation, HoNoS LD) APPROPRIATE YES NO DATE COMPLETED COMMENTS Physical Health Health screening by GP including medication review OK Health check Mental Health Mini passad Behaviours of concern Ecology of mental health (Aldridge model) Interview individual and carers Background details and description of behaviours of concern Environmental issues Adaptive behaviour scale Observation ABC Charts Other assessments (please specify) Page | 43 Psychological Formulation YES Appropriate NO N/A DATE ACHIEVED FURTHER ACTION REQUIRED? (what, by whom?) COMMENTS A clear formulation is described in the clinical record Intervention Intervention plan completed / agreed CPA care plan completed / agreed (as required) Mental illness – intervention plan completed, and monitored for effectiveness Physical health problems – treatment plan in place and monitored for effectiveness Specific Intervention for behaviours of concern Reactive strategies (when immediate need identified) Proactive strategies Psychotherapeutic intervention Positive Behaviour Support Plans - Positive environmental change - Differential reinforcement - Extinction - Psycho educational approaches - Functional equivalents - Communication interventions Page | 44 Intervention for behaviours of concern (continued) - Physical Health - Psycho pharmacological intervention - Other type of intervention (please list) YES Appropriate NO N/A DATE ACHIEVED FURTHER ACTION REQUIRED? (what, by whom?) COMMENTS Monitor and Review Effectiveness of the intervention measured, using tools from initial assessment; including HoNoS LD, Clinical Risk Assessment & Formulation Discharge Person discharged from Community Team Report/ letter sent to GP, Referrer and Client’ carer Page | 45 Appendix 2: Care Pathway Flowchart Page | 46 Appendix – Other Assessment Tools Available Structured interview to determine the immediate impact and contextual control of challenging behaviour Adapted from Emerson E, Hatton C, Bromley J, and Caine A Clinical Psychology and People with Intellectual Disabilities, Chichester: John Wiley and Sons, 1998 pg 139 (modified from Demchak and Bossert, 1996) Ask each question separately for each form of challenging behaviour shown by the person What are the activities or setting in which the behaviour typically occurs? What typically happens when the behaviour occurs (i.e what you or others typically do)? Are there particular events or activities that usually or often occur just before an instance of challenging behaviour? Please describe Are there particular events or activities that you usually avoid because they typically result in challenging behaviour? Please describe Are there particular events or activities that you encourage because they DO NOT result in challenging behaviour? Please describe What does……………… appear to be communicating with their challenging behaviour? Please describe Does their challenging behaviour appear to be related to a specific medical condition, diet, sleep pattern, seizure activity, period of illness or pain? Please describe Does their challenging behaviour appear to be related to their mood or emotional state? Does this change following an episode of challenging behaviour? Please describe Does the behaviour appear to be influenced by environmental factors (noise, number of people in the room, lighting, music, temperature)? Please describe 10 Does the behaviour appear to be influenced by events in other settings (e.g relationships at home)? Please describe Page | 47 Assessment of Adaptive Behaviours Adaptive Behaviour Assessment System [ABAS II] (Harrison & Oakland, 2003) Functional Performance Record (Mulhall, 1989) Vineland Adaptive Behaviour Scales (Sparrow, Cicchetti & Ball, 2005) Assessment of Motor and Process Skills (Fisher, 1997) Other Assessments Motivation Assessment Scale (Durand & Crimmins, 1996) Behaviour Problems Inventory (Rojahan, Matson, Lott, Esbensen &Small, 2001) Challenging Behaviour Interview (Oliver, McClintock, Hall, Smith, Dagnan & StenfertKroese (2003) Maslow Assessment of Needs Scales – LD (Skirrow & Perry, 2009) Parenting Stress Index III (Abidin, 1995) Family Relations Test (Bene & Anthony, 1957) Adult/ Adolescent Sensory Profile (Brown & Dunn, 2002) Wechsler Adult Intelligence Scale (Wechsler, 2008) Novaco Provocation Index (Novaco, 2003) Mini-PASADD (Moss, 2002) Page | 48 Appendix ABC chart example Page | 50 GUIDE TO COMPLETING A.B.C CHARTSA.B.C RECORDING CHART Client Name Client Record Number Description of behaviour/s to be recorded The purpose of keeping an A.B.C chart is to establish why a particular behaviour or set of behaviours occurs It is an analysis of all the environmental factors which may influence DATE TIME – what exactly, BEHAVIOUR – what he/she CONSEQUENCES behaviour –ANTECEDENTS the time of day, the people around, their interactions with the client, the activity – what was happening before the actually did/said happened after the available, the demands made on the client etc behaviour behaviour; what you, and others The A.B.C chart will only be useful if ALL episodes of the behaviour are recorded and present, if the did RELEVANT details are filled in in each column This means observing the client accurately and writing down what you actually see; not what you think the client is thinking The interpretation comes later Below is a guide to the things to look for when observing the behaviour you are interested in ANTECEDENTS Write down in this column exactly what was happening immediately before the behaviour occurred In particular, note down any of the following which apply: a Interaction: Was the person interacting anyone? Was this attention positive, neutral, telling off? Had the person been without interaction for a length of time (how long)? b Activities: Was the person engaged in an activity at the time? What was it? Was there no activity available? Had an activity just ended? c Demands: Were any demands being made of the person or a request to something or go somewhere? Describe it d Food/Drink: Was the person waiting for or asking for food or drink? Was food or drink in sight? Had food or drink just been taken away/finished? Page | 51 BEHAVIOUR Before starting a chart, decide which behaviour/s you wish to analyse Write out a description of them at the top of the sheet Then, for each episode of the behaviour/s, write down exactly what the person did, e.g “he slapped me on the leg”, “she put her hand through the window”, “he opened the front door and ran into the road”, “she banged her head on the table”, etc CONSEQUENCES Write down in this column exactly what those around did immediately after the behaviour occurred Note in particular the following: a Interaction: Did the person receive interaction after the behaviour? Was the attention positive, sympathetic, neutral, telling off, restraint etc? b Activities: Was activity taken away after the behaviour? Was activity provided after the behaviour? c Demands: Did any demand or request cease after the behaviour? Was any demand or request made after the behaviour? d Food/Drink: Was food or drink taken away after the behaviour? Was food or drink given to the person after the behaviour? This is not an exhaustive list The objective is to write down any and all of the relevant details It is also very important to sign and date each entry Page | 52 Appendix – self-assessment recording chart Page | 53 Day Time when I felt angr y How angry did I feel – a little bit – quite angry – really angry What did I What did How did I do? othe feel Did I r after hit peo ward anyo ple s? ne say or or shou t or after thro I w was anyt angr hing y? ? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Page | 54 Page | 55 Appendix 6; Measuring outcomes of Positive Behavioural Support (Taken from Emerson, 2001) Outcome Potential approaches Reductions in severity of challenging behaviour Observational methods Inspection of injuries Structured interview with person and/or informants Analysis of incident reports Inspection of injuries received Family and/or care staff have a better understanding of why the behaviour occurs Structured interview Visual analogue or Likert rating scale Modified versions of checklists designed for staff Increased participation in community-based activities Diaries Structured interview with person/informants Visual analogue or Likert rating scale Checklists or questionnaires Increased engagement within the home Direct observation Diaries Visual analogue or Likert rating scale Structured interview with person/informants Checklists or questionnaires Improved interpersonal environment within the home Visual analogue or Likert rating scale Structured interview with person/informants Checklists or questionnaires Person learns alternative way of getting needs met Observational methods Structured interview with person/ informants Increased friendships and relationships Diaries Visual analogue or Likert rating scale Structured interview with person/informants Checklists or questionnaires Family members and/or care staff learn effective coping strategies Visual analogue or Likert rating scale Structured interview with person/ informants Checklists or questionnaires Improved relationships between family member and/or care staff Visual analogue or Likert rating scale Structured interview with person/ informants Checklists or questionnaires Page | 56 Person is able to stay living with their family or in local community Visual analogue or Likert rating scale Structured interview with person/ informants Checklists or questionnaires Person has greater control, more empowered Visual analogue or Likert rating scale Structured interview with person/informants Checklists or questionnaires Person has more frequent social contact Direct observation Diaries Visual analogue or Likert rating scale Structured interview with person/informants Checklists or questionnaires Effective supports are put in place Diaries of service contacts Visual analogue or Likert rating scale Structured interview with person/informants Checklists or questionnaires Person is more contented, more self-esteem Direct observation Visual analogue or Likert rating scale Structured interview with person/informants Checklists or questionnaires Others change their perception of the person Visual analogue or Likert rating scale Structured interview with person/informants Reduction in the use of aversive methods and restrictive procedures Analysis of medication records Recording time spent in restraint/ seclusion Analysis of records detailing restriction of liberty Analysis of risk-taking policies for the person Page | 57