FC304: Bio-behavioral Inpatient

John McGonigle: [00:0013] Thank you very much. I am excited to be here. And as you see, the presentation today is on a specialized acute inpatient program for individuals with Autism Spectrum Disorders.

A little bit more on background. I've been in inpatient hospital programs actually for 35 years. Helped set up programs, assessment programs, for inpatient hospitalizations. The John Merck program, which is in Pittsburgh, it's part of Western Psychiatric Institute, was one of the original cast members of that program when it started years ago. 1975 I think is when it started.

So, this program -- and it was based on working with children, at that time, with neurodevelopmental disabilities. And also, obviously, with cooccurring conditions, comorbid conditions, a variety of those being medical conditions, psychiatric conditions, across all involvement in terms of cognitive impairments from severely affected kids to superior ranged gifts range of intelligence.

So, we had a -- there was a basis for setting up a bio-behavioral program. It is across the lifespan. So, there are kids that come into the program -- actually, one of the youngest kids was 3 years of age. And then we have them all the way up to seniors, 85 and 90, that come into the programs. So, it's based on this dual diagnosis, intellectual and developmental disabilities with mental health or behavioral concerns.

We got a grant from the Department of Public Welfare and Bureau of Autism Services to set this program up. And that really was based on a number of crisis calls that came into me and in the group. And these are adults. So, a lot of them were adults, their kids as well, that have been in crisis. Some of the people have been in inpatient programs, in and out of inpatient programs. They're called the revolving door. So, they're in for a short stay, they have an episode or an incident, a crisis. They're in the hospital. They'll stay for a couple of days and then they're back out again. So, it's a revolving door.

And then there is also this other group that had significantly challenging behaviors that would be in an emergency room somewhere in the state, three and four days in the emergency room in restraints, and medicated because they're waiting for beds to open up and other things. So, there clearly was a need for setting up a program like this.

So, what we did, it was based on the way we did business in terms of assessments -- and I'll talk about past and present. Another thing that we'll talk about is specifics on what is in our program, how do we use our assessments. And that's everything. Assessing medication effects, medication reconciliation, which we'll look at as many medication trials as possible that the person has been on prior to coming in the hospital just so that we don’t get involved in recreating another problem. So, somebody may had a -- have a trial of Depakote two years ago and failed disastrously. And then they come in the hospital and then somebody may start them up again on Depakote without knowing that there was a failed trial.

So, what we'll do is really take time to look at all of the past medications. We'll look at the dosages, we'll look at effects, how it was measured. We'll also look at the reason for change or why someone discontinued that. And that'll help us also on the recommendation side.

And I'll talk about three or four cases. After I give you the information and how we assess, how we review things, what instruments we use, and then we'll talk about a couple of cases. Walk you through based on the information that you have on the process piece.

So, let me start a little bit with just past and present. If you've had any experience or exposure to inpatient programs over the years, you'll see that they have significantly changed in terms of how the assessments are done, the interventions, how they're monitored, measured. If you had any experiences in the '70s, actually the '60s and '70s, if you had a family member, if you were in hospital programs during those days you were probably subjected to some pretty involved, restrictive interventions or programs. Punishments in those days.

[00:05:00] And again, when we talk about literature-based or evidence-based and best practice, if you look at intellectual disabilities in the 1960's and 1970's, and see what kinds of interventions were implemented for somebody who was aggressive, I mean, you would see things like shock and water mist, aromatic ammonia programs. And these were, in those days, evidence based. And I'm glad that we've come a long way. But there's actually still programs that use those interventions across the country.

So, there's things that have changed, and I'll talk a little bit about that. And we've changed with those times as well, even though we are in an acute psychiatric hospital, mental health, behavioral health, we operate under the guides of the Positive Approaches philosophy in terms of our interventions.

So, if we look at some of the past practices, we actually have moved from this culture of control -- and somebody comes into the hospital, assessment is done, they have these referral concerns, aggression, self-injury. And the job in the past was not only to control the behavior, but actually control the person as well. I mean, that was the mindset in those days. So, we really have shifted to this culture of care and support.

So, we're getting to know more about the person, which is important. Understanding the person. And we're getting a little bit of better idea of the cause of some of the presenting concerns or problems. So, we'll take the time now to get -- ask questions, to observe, to get prior information, to determine are these referral concerns, you know, are they a recent onset? Are they chronic? Are they something they've been there forever, but just maybe increased? Those are all significant bits of information for us.

Length of stay, as you know, if you've even been in the medical surgical side, you're in and out of the hospital quickly. That’s actually happened on the behavioral health side as well.

When I started in 1974, actually the average length of stay was three years in those days in an inpatient hospital program. That's the average. So, we had some people that were there for five years.

Today, you're lucky if you're in there in the psychiatric hospital 7-10 days nowadays. I mean, it's just really a brief stay. So, one of the positive things that we're able to do with this specialized program is take the time. And I'll talk about how it's covered, who pays for this. But in terms of having more time to really systematically evaluate programs is great because we can do that.

So, our length of stays actually will vary depending on your presenting problems, the support plan. It'll also be determined on who we'll be discharging to as well. So, we have all of these other levels of mental health care today that we didn’t have years ago. And we

have community treatment teams in some areas. So, people can still leave the hospital in acute phase of their illness but not be dangerous, not be a danger to themselves or others. But they could still be delusional. But if we can hand them off to a physician and the nursing team, then they can leave the hospital a little bit more quickly. So, we work -- you'll see that we work with teams and consult with teams as well.

So, even though the length of stay is shorter than it was years ago, and acuity is actually higher, believe it or not, for patients that are in inpatient hospital programs because all of those other levels of mental health care, from BHRS services, to partial to intensive outpatient programs to community treatment teams, all of those levels of care out there so we can hand them off. Bu the patients that are in the hospital nowadays in acute care facilities, they failed in terms of being responsive to those levels of care. So, that's why they're in the hospital.

Protocols. As you see up here, we go down the list. In the old days there were protocols. They were one size fits all. So, if you came in the hospital, whether it's medicines, depending on the physician, or the intervention, everybody got the same thing. And it's not that way today. All programs are individualized. No protocols in the hospital.

If you're in the drug and alcohol pop program or if you're in an eating disorders program there may be some specific protocols on medication withdrawal or eating or food intake and things like that. But there are no protocols.

Diagnosis. Talk about the old days compared to now. We are very accurate now in diagnosing, in terms of finding out what is the psychiatric syndrome that's coming into play here? And that's even for people that are severely, intellectually involved, nonverbal, may have autism.

[00:10:00] Years ago, if somebody were hitting themselves, they'd be probably put on medication right away without finding more information about why is that person hitting themselves? Today we can take a look at -- and even according to the DSM, we can actually look at behavioral equivalent. So, you may see anxiety as a symptom, but the expression of that, that anxiety, could be self-injurious behavior depending on the person.

So, we take our time to look at those symptoms. An example -- even on interviews when you're asking higher functioning individuals, folks with Asperger's, trying to determine is there an anxiety disorder. You may hear things like, on an interview, what's it feel like walking out, going out of your house? And you'll hear an expression like I feel like I'm a needle in-between two bricks. Now, what would that mean to anyone? But if you can probe, press, ask more questions, then you can find out the person's overwhelmed with anxiety. And this could be just behavioral approaches that are used to help that person kind of navigate. But also, they may need some medications.

But what we would do, and you'll see in our assessments, that we would always look at the motivation for the behavior prior to using any kind of medications.

So, we're are more accurate in terms of diagnosing. We're also looking a lot at the Axis III, which are medical conditions now. So, we have medical conditions that actually that are presented as the -- expressed as the presenting problem. Aggression, self-injury, noncompliance, oppositional behavior. And that may be related to pain. Could be a tooth abscess for somebody who starts to hit themselves, or ear infections when they stick pencils in their ear and break their eardrums because it hurts, to relieve the pressure. Unless you have somebody that's nonverbal, you got to take the time to look at that.

So, those are some of the things that we would look at in terms of diagnosing.

Other things there, old generation meds. The old ones, there's still some people that use the old medications. Thorazine. I've seen that used a good bit in some -- even some of the younger kids which, you know -- again, it's very -- it's an old medication. You have to figure out what you're treating, and how is it monitored?

And there's more side effects to those things than benefits to the patient. So, you have to monitor that as well. And you'll hear some of the instruments and -- if anybody's on medication, you're supporting someone with medications, if they would have some side effects, making sure that an involuntary, abnormal movement scale in AIMS is completed. Just simple routine. You could it do it on a -- it's a couple of minutes to do it on your well checkups. But a lot of people don't do that. Something that’s important.

Chemical restraints, which is basically by definition, you're delivering so much medication it lowers the level of consciousness, it lowers motor activity. And believe it or not, chemical restraints was an actual treatment, a therapy in the '70s. It was an intervention. So, somebody comes in with high aggressive behavior or self-injury, they would give them a lot of medications and they would just kind of sit and not move at all. And then they would -- the physician would back down off of the medication so that the person would be able to ambulate. If you've ever seen people with shuffles -- you don’t see much of that today, but that's basically what happened. And they would back off on the medication so the patient, person, wasn't aggressive.

Today, we can't even use the term. We can treat symptoms, and it has to be specific and individualized to that patient, but chemical restraints are not acceptable at all in any place. And it's easy enough to look at, finding out are you using the medications for a chemical restraint? You know, what type of medication? What's the dose of the medication? Is it for a child or adult? So, there are ways that somebody can easily evaluate that.

The biggest areas of change though are in these behavioral areas. So, we've moved from this behavior modification. The interventions are all behavioral. And we've moved from behavioral modification to behavioral supports. And a lot has to do with -- it's how you describe it and the mindset.

In the '50s, '60s, and '70s, behavioral modification had this kind of reduction mindset. Our job was to eliminate or reduce the problem. And it had a functional behavioral assessment, but really wasn't used in those days, in the early days. Now it's required, and which is a good idea.

So, the idea of reducing behaviors was equated with punishments. So, patient had to feel something unpleasant in order to make the connection I shouldn't hit myself or I shouldn’t do that. So, if you look at any history of interventions in psychiatric hospitals, you'll see behavior modification.

[00:15:08] So, we're using behavioral supports. The other things that are occurring now, we're moving away from the suppression and reduction techniques.

So, punishment is not the way to go. We know that. Punishment, if it's effective, it'll work in your particular setting or in your situation. It doesn't generalize. And there's so many problems associated with delivering something unpleasant to someone. Think about in your life situations, if you've ever experienced something unpleasant. If it were truly unpleasant, you're going to avoid that in some way. And sometimes you're going to do extreme behaviors to escape and avoid that.

So, the other thing is it doesn't generalize, it doesn't leave the hospital and go out into the community unless you have the intervention there as well, and it can cause trauma as well. And it's a huge part. So, we're trying to stay away from that.

And so, the seclusion rooms. It goes with seclusion rooms. Although, psychiatric hospitals have seclusion rooms. Their safety and they keep people safe. In the old days it was used as a therapy. It was part of therapy. It was called contingent seclusion is what it was. So, a patient was aggressive, they'd go into seclusion or you'd hold them or go into restraints.

Today a lot of the rooms have closed. So, they've shifted those seclusion rooms to -- they're called sensory rooms, comfort rooms, reflection rooms. So, there's a shift in that.

And then we've looked at using functional behavioral assessments, functional behavioral analysis. And you've probably heard a lot about that, and it is critical. We would use that prior to implementing any kind of intervention. We really would like to know, what's inherent in the person? Is it part of some of the issues that you're dealing with? Is it part of their personality? Or is it something that was just started two months ago when they lost their mother or father? Or was it a transition? Is it a change from living at home and going to the community?

So, you have this adjustment period. We see a number of people like that when they're living at home for all of their years and then they'll go a residential program, they'll be there for three or four days and they'll end up in the hospital just because of the difficulty with adjusting to the change.

So, with all of those things, those are all the issues that we've dealt with in the past, have experienced with challenging populations.

So, the bio-behavioral -- we'll call it the bio-behavioral track. It's supported by the DPW, through the Bureau of Autism Services. As I said, it was established -- we established the Merck program years ago and it's within the Merck program and it's based on best practice and evidence-based interventions as you maybe heard in the introductions. I chair the national committee for the National Association for Dual Diagnosis. We're developing certifications for organizations who serve people with intellectual disabilities, neurodevelopmental disabilities including autism.

So, really focused on making sure that the practices are -- they understand the population, they know what instruments to use for assessments, and they are systematic in terms of determining treatment effects and not just delivering interventions without knowing what's going on.

And it is hard. When we say best practice, I don’t think there is a best practice. I don’t think -- because again, there's so many different presentations. There are evidence-based interventions and supports, and that's really what we focus on. As you see the population here, intellectual disabilities and developmental disabilities with mental illness.

Focus on outcomes. So, our program really focuses on assessments actually prior to coming in the hospital. So, we'll do baseline if we can get information prior to coming in. And oftentimes we do. So, the referral process, once we know that somebody is being recommended for coming into the program, we'll have a little bit of time to talk to families, talk to caregivers, residential programs, and we'll do some baseline in the community assessments. So, we want to know what's going on there because when they're discharged, would like to know, you know, not only did they improve during hospital stay, but how long does it maintain after?

And [indiscernible 00:19:35] of the family and the person are involved in the treatment team process. So, it's individualized to the family.

We have a streamlined admission process and it really includes the referral coming through the Bureau of Autism Services. So, we may get a call, or Bureau of Autism Service, or somebody from the state may call them and they'll talk about this case and then we'll review it and say does it make sense to bring this person in?

[00:20:02] There's a clinical team at BAS that can provide the service as well in terms of going to the community and providing consultation. But these are patients really who have failed all of those interventions.

And then also looking at the medical assessments for the diagnostic purposes as needed. Now, we'll bring in the expertise, as you'll see. We have a variety of disciplines and programs across our system. We can bring in neurology. We can bring in allergists. We can bring in dental group to look -- to see if there are any concerns or issues related to underlying medical conditions. So, we'll do the physical health assessments and functional skills assessments as well.

Our programs include -- just in the hospital, we have child and adolescent and adult psychiatrists on board. Behavioral psychologists who do the assessments, training of people, and they'll also do the consultations on the discharge side as well. [indiscernible 00:21:04] therapists, psych nurses, nurse practitioners, physician assistants. We have creative and expressive arts therapists. It's like classroom. We also have a school as well. We're approved for a school program. But the creative expressive arts run groups and do some sensory things with the folks.

So, we could have access to a variety of people as you see here, depending on what the needs are and what their concerns. Nutrition sometimes is an issue for some folks. Irritable bowel that might be painful, that causes somebody to hurt themselves or gag or their hand down their throat.

Other areas of subspecialty, and these are the folks that we can bring in depending -- it's not for everyone. If a person would need somebody that's -- we have a question of seizure-related problems, somebody may have temporal lobe epilepsy, or complex partial type seizures that are aggressive or self-injurious during it, we would bring in neurology to take a look at that person. We would send them for an EEG. In a lot of cases, too, even using medicines nowadays because of all the black box warnings on it, really have to do a good job in doing those pre-assessments before somebody starts on some medications.

So, we'll -- again, bringing in these groups, if they need it. And its based on diagnosis. If there's a question or concern that we think that someone may benefit from more information from GI for nutrition, then we would do that.

So, I mentioned about one of the keys. It is family-centered in decision-making. So, the families are at the table. We have actually contact daily with the family. It's up to the families, but we'll contact them daily. They're phone calls. And you'll see, we talk about barriers. One of the barriers is our location. So, sometimes parents aren't able to get in if they're on this end of the state. But we have direct contact with them daily on information.

We're also developing some telemedicine, too, so that hopefully the parents don’t have to travel in for treatment team meetings. We do it over the phone right now, but it'll be nice to have some face-to-face.

So, we encourage them to become active members, the families. They come in for visitations. There are some people that actually -- families from Philadelphia area that come up, stay at the Ronald McDonald House up at Children's Hospital. So, they'll stay there, and they'll do their visits for a couple of days. Couple different ways that we can help out.

Community focused. Obviously, the folks are coming from certain areas, homes. Our goal really is to get the person back home, back to where they lived before. So, we're interested in connecting with residential programs. The physicians that are involved, the treatment teams that are involved, because of that generalizing and transferring the information, they're also invited to participate in our meetings as well. So, we'll have these meetings and they can hear about the treatments and interventions that are going on.

The doctor-to-doctor transition is critical, though. A lot of times we'll use medicines maybe in the hospital that the community psychiatric or physician in the community isn't aware of or has difficulty using. So, as soon as they go back the physician will change it back to the old medications. That happens after you spend a couple of months trying to make some shifts or changes.

So, training. A component of our program, obviously. It's training of others of what we do. That's really what makes it -- the treatments generalized. It makes them stick in terms of after they leave. So, it is critical. And I'm sure you're working in the field, Autism Spectrum Disorders, training exemplars, training everyone in consistency is really the way to go, the approach to use with helping to generalize some of these things.

[00:25:09] So, we do transition planning. We evaluate and monitor.

Teaming with other teams. I mentioned that before. We're using multi-modal approaches. Some of the programs can be very intricate, but these can be meaning that there may be a lot of components to it, that they could be used or generalized. We really wouldn't design anything or develop anything that you couldn’t do in your community program or in your home. Wouldn't make sense for us to do that.

But the multi-modal approach, another critical thing to know about working with people on the spectrum, is we know that there's no one cause and there's really no one treatment. Everybody is individual as an individual and responds individually to these programs. So, it's real important to look at every area when we're designing programs.

This is the course of the hospital stay. So, if people come through the program, as I mentioned before, if you look at the bottom line down there, you'll see the community hospital and then again, community. We try to get -- on the way in we'll get the referral. We'll talk to the referring agency to get as much information. We'll do some acuity rating scales prior to coming in. So, we get an idea of what's the acuity level of the person. There may be other rating scales that we use.

I think everybody that comes through has already a diagnosis. And oftentimes what we'll do is look at differential diagnosis. So, they may come in with autism, but they may also leave with anxiety disorder or mood, depending on history, response to treatments or therapies that we can get an idea. Did we uncover something else? And then we make some recommendations on that.

So, we'll have community assessments. Once they come in the hospital, we'll do the same rating scale. Do the acuity scale. We want to get an idea on the way in the door when they're in the program, how do they present?

And then our interventions. This is a phase here that can take anywhere between two weeks, believe it or not, to about two months or three months. Depending on what we're looking at. We have some patients that come in that -- there's a term, it's called polypharmacy that some patients may have three medications from the same drug class, just again, just to quell or try to treat behavioral symptoms. It takes a while for either titrating, getting rid of some of the medications. And it's just -- and it's somebody who may not know the interactions or how to work with the patients and actually can cause a lot of the problems that we're seeing when they come in the door.

So, during the intervention phase we'll do the functional behavioral assessments, we'll do all of our therapies and treatments, and then once we find out what works, then we begin to train everyone. And that includes -- if they're close, we visit the school. If it's distance it's a challenge to do that, but we can do that on the discharge side if it's necessary. But we've gone to schools and workshops.

And then after the discharge we can provide either follow up consultation or we actually can do a booster session, meaning that we go and meet with the team or whoever is involved, and we can provide some consultation to that.

What's nice about this project is it provides that flexibility. If you have an inpatient stay, it's rare that anybody can leave the inpatient because you can't cover the costs for that. But with this particular program, with the grant, we're able to do that. And that's the nice part about being able to give everybody the information.

So, child, adolescent, and adult. We use the DSM-TR diagnosis. These are the inclusion criteria, so obviously having a diagnosis of autism spectrum or autism, Asperger's, PDD. Folks will come in with that diagnosis. So, we're not uncovering anything on that side.

We also look at the payer. So, we do -- we have a variety of insurance companies that we deal with. Again, if we can bill for services under insurance, that's going to be the first thing that we'll do. And then if insurance -- and this often happens, you probably experience this. Sorry if insurance runs out. Or the insurance company calls, and we say well, there aren't any problems today. He had a good day. Patient may have been sick, but we had a good day. Low problems. They will cut payment that day. We're done.

So, this helps in those cases. We haven’t had an issue like that, but the grant can help us keep somebody in the hospital a little bit longer for those evals.

[00:30:02] And even at that, we won't discharge. We have a policy that we wouldn’t discharge even if the insurance company says no. If we continue to need -- the person continues to need services. So, we'll find all that out. And it won't exclude anybody from coming in at all.

Did they meet medical necessity criteria? Any program that you go into, you're going to have meet some kind of medical necessity. And this is an inpatient program. So, the medical necessity in this case is probably danger to self and others, because it's an acute care psychiatric hospital, and that would be what -- the person would have to have some kind of behaviors that are danger to themselves or others.

So, exclusion criteria. Obviously if there's no psychiatric condition, they have complex life-threatening medical conditions, we're not a medical hospital. What we do and what we have done, if people -- somebody comes in the hospital, you may be titrating medications, major seizure disorder develops. What we'll do is transfer them to our med surg hospital,

it's stabilized, and then they'll come back over. So, we're able to work in that way. But we have -- we're not a medical facility in terms of providing intensive medical care.

Drug and alcohol and addiction problems, and then also violent behavior. We're talking about homicidal, people who've been in and out of jails. Those folks would probably be served in another facility. It's an individual basis. Even though they may be in jail or may be -- have charges of homicidal behavior, but it may be that they misunderstood the person. So, we'll take a look at that. It wouldn't automatically exclude. Those are just the folks that we wouldn’t take in the hospital.

So, the Phase I part, they're admitted, they have been determined to be in the crisis, and then what we do is have a direct admissions team. So, BAS and us will sit down, we'll look at the information, and then determination will be made to come in.

So, the second part is bringing the person in and getting them stabilized. Obviously, being in a safe environment is critical. Patient is safe, family and community are safe, and that's a primary goal on the way in the door.

And then what we'll do is look at types of assessments and determine what we will do. From day one the treatment team will begin the assessments, working with families. And you see this clinical pathway here.

If anybody's worked with me in the past knows that I'm kind of focused on pathways. I like to know who's involved, who's doing what, because oftentimes there's a lot of miscommunication. We're talking about a group -- I refer to them as complex needs, and that means that whether you're a child or adult, you're probably going to cut across at least three service systems. At least. You know, behavioral health; in a child, education; their medical conditions.

So, if you look at the people that are involved in each of those systems, they may have three case managers. They may be doing the same thing. So, pathways really reduce redundancy. So, I kind of focus on pathways in terms of who's doing what, how we -- and I'll show you an example how we monitor, how we do this.

Phase III of continued stays. So, if we have these different phases coming in the hospital, doing the assessments. Things have been stabilized and now we'll kind of look at these other diagnostics that we may need. And again, EEG, neuropsychological evaluations, dental. Any of those. More comprehensive eval. Sleep studies may be indicated for some folks.

And this is continuous where we can also project the length of stay during this phase, so obviously if somebody's coming in, high rates of behavior, question of a seizure disorder, lots of medications, then they're going to be there for a while because first of all we'll look at the medication. We're going to do EEG, but we're also going to take a look at titrating, or reducing some of the medications rather, and seeing how the person is with the reduction of the medications. And that's done in this continued stay.

So, we can actually look at folks over a period of time.

Clinical tracks and the pathway model, and we'll see that in a few minutes here, this is what it does. It really -- when you're working with -- it's a management tool that if you're working with multiple agencies, it really has one person -- everybody's operating from the same plan, at least looking at who's responsible for getting the EEG done? When's it done? Is it completed? Who's connecting with outpatient services? Who's connecting with

BHRS services? Is it done? So, somebody can monitor and measure that, and we have a nurse that does that on the unit.

[00:35:15] Clinical process. It's based on best practice models. We use least restrictive modalities, and I'll show you what that is a little bit later in terms of least restrictive treatment options within the hospital. What do we do from adapting the environment to looking at crisis plan? A safety plan for the individual. We're outcome measures driven, cross-systems assessments. In the pathways, this really what a pathway does. It decreases the redundancy. And things, if you tried it before, it didn’t work, we should know that. It also can decrease the length of stay and treatment.

So, it's multi-systems across agencies. Families are involved in this. Families have responsibilities within the pathway. If you say you're coming to visit weekly, we should know that. You should be here weekly. And if it doesn’t happen then -- there's a variance there and somebody's responsible for letting the family know that. So, we try to keep everybody together.

So, here's an example of what it looks like. All the disciplines that are involved. So, a pathway has some things that are done in the first 48 hours. If patients are staying two weeks, what's done at week two? What's done at week three? So, just an example.

This is a psychiatrist. So, he needs, on the way in the door, he or she needs to review the records, the lab work, face-to-face evals, diagnostic. And you see that right side over there? Was it done? Yes. Is it a variance? Meaning it wasn't done, and we'd like to know what was the reason? Why didn’t the lab results come back? Should've been back by now. So, it really kind of keeps a close tab on different disciplines. So, that's psychiatry. These are just a couple of folks that are involved in the process.

So, nursing assessments. So, we'll do side effects profiles, monitor vital signs, educate patient about meds. And I just pulled some of them out. There's other ones in this area. Same kind of thing happens that -- were these things completed?

Now, this was in 48 hours. So, at the end of two days, somebody should sit down, and all of those areas should be checked that they should be completed. And if not, we need to know why and get it done.

Social work. So, on the way in the door, first thing, consent forms signed. We get HIPAA information to the families. Did we complete any kind of emergency contact? All of these things again are critical for assessment on the way in the door.

And then our behavior analysts. They're responsible for reviewing things and setting up rating scales. Direct and indirect observations on the presenting concerns or problems.

Our treatment team. So, when you're sitting down with the treatment team, if you get involved, these are the players that are typically around the table. As you see, the core people that we talked about. Everybody reviews it, and actually for these cases, we have daily treatment teams initially just because we want to stay on top of everything. And then, as needed basis. Sometimes, again the families that can't come in all the time, so they'll come in for a few meetings. Case workers or community treatment team members. But these are really the group that's involved.

Approaches. They are using medicine. So, this is the way we think about it. Indication, obviously, what medications are used? And medications are used a lot of different ways. I guess probably the two most consistent ways and the best ways is, is it diagnosis driven? So, somebody's diagnosed with a particular disorder and there may be medicines that are

on board. If you have a mood disorder, bipolar disorder, then you're going to have mood stabilizers, antidepressants. So, those are one way to do it.

Another way is symptom specific. So, somebody presents with some symptoms. There's medicines. The indication is for that symptom, and then you monitor and track what happens to the symptoms.

As I said earlier, just saying anxiety is it's presented so differently in persons with autism. We get the more specifics on the behavioral equivalents. So, we would look at -- it's as I mentioned before, a fellow had anxiety. I feel like a needle between two bricks. We would take that statement and actually ask him, do you feel this way today? So, he would be able -- he or she would be able to tell us that they feel any better, or is it lessened. And there may be something different.

So, what you hear, you really have to press. You have to really ask a lot of questions.

And obviously starting medicines slow. Start low, go slow. Monitor effects of the medications. If their blood level's involved, you're going to increase the medicines, look at the blood levels, and then obviously we're looking at symptoms. That's the thing that you want to know. Is it increased or decreased?

[00:40:13] You're going to assess the benefits. We use rating scales. We use monitoring and measuring. There's a number of them. If you're using stimulants, obviously, for your kid programs. The Conners in IOWA program. We use Beck, the inventory -- depression inventories. Hamilton anxiety scales. For more involved populations, the aberrant behavior checklist is excellent, not only for symptoms but actually for medication. Same response to medication, a 50-point questionnaire.

So, there are measurements that you can use. It's just more than saying yes, there was an increase or a decrease. We're not seeing it. And we have to get measurements from a few people. Assess the risks as well, and benefits of that.

And the principles, obviously. Medications always follow a functional behavioral assessment. That's the first thing that you have to do to determine ideology or some of the reasons. Now, if you have a person who is extremely self-injurious, there may be medications that would be used not as a sedation, but you might use that as a first line just to reduce the self-injury. But it always does require a functional behavioral assessment.

Looking at history. Any lab exams. They shouldn’t be using medications. You see this -- it's our kind of motto. Motivations before medications. They should only be used following an assessment. And these are some of the things on -- I mentioned before, a term, it's called medication reconciliation. Again, looking at as much as you can, looking at what worked in the past. What didn't work? Why did it fail? So, we'll be getting information.

And these are all these drug classes here. We'd like to know the medicines. What doses somebody was on. How was it monitored? Was it a good trial? Did they only use it for a day or two and then quit? Those are things that are kind of important to know. And was it effective? And if it wasn't, then what was the reason for discontinuing the medication?

Well here, yeah, this is really the approach. You have start somebody on medications for some symptoms. If they're a blood level medicine, you're going to look at the blood levels. Making sure that they're within therapeutic range. You're going to monitor the side effects of that. So, as you go up on the medicine, look at the blood level, and you're going to

make sure that there aren't any adverse side effects to that. And then keeping an eye on the symptoms as well. It's kind of basically how we look at that over time.

And then the way that it's treated. We do our assessments and then again, it's looking at the symptoms. Are there any other things? And differential diagnosis can include a lot of things. The medical side, drug and alcohol, just a variety of things that come into play.

And then there'll be a working diagnosis. So, on the way in the door, admission, somebody may leave with a different diagnosis when they come in. The diagnosis really drives your therapies and treatments. And sometimes you're not accurate. Sometimes you may start with something and then the response to the medicines -- you may start with depression. Person may be in the hospital a period of time and all of a sudden you have a manic episode. If you're in a couple of months we may see that. So, we may start out with depression and then end up with some other diagnosis. Bipolar, mood problems. So, we use a working diagnosis.

Treatments. Medicines are used. Do we get a response? If we do, great. If we don't, partial response? Are we missing something? Or is there any other thing that we can add to the medicine that already started?

So, we have the models here. And this is the model that we use in the unit here. So, Bio-Psycho-Social models. We look at the biological, the psychosocial, the psychology part, the developmental part, and also the social part.

Interventions are based on the functional behavioral assessments. And also, I see this descriptive, and I'll explain what that means when I show you a case in a little bit. When you're looking at the function of behavior, a lot of times it's escape avoidance, it's attention.

A descriptive analysis of the behavior is critical. How does it look? It's referred to sometimes as topography. So, even though you may get that the person's aggressive at 9:00 every morning when they go to group or they do something, what's the behavior look like? How does it present? Because there may be other things that are going on there. So, a description of how it looks.

[00:45:04] Applied behavioral analysis. So, we know that ABA approaches are the most effective for folks on the spectrum. And that can be a variety of things, from everything from young kids with discrete trial training to token economy systems, but it's the measurement. It's the implementation. It's the measurement of the response to those treatments. They're evidence-based, and as you see that we have active participation.

So, when we talk about motivations, kind of this thinking beyond environment, escape avoidance, and attention. These are all areas where patients, people, will have challenging behaviors, problem behaviors. Even from a biological standpoint, the genetics part. And actually, we refer some people for evaluation genetic studies just based on history, family history, presentation. Person looks a little atypical maybe that we might have genetics involved to do a consult.

Physiological. The medical -- people have tooth abscesses, I mentioned earlier, that may engage in self-injurious behavior. So, we'll take the time to really look at all of these areas.

We design our programs -- this cognitive executive functioning area especially for higher functioning individuals. Folks with Asperger's have difficulty controlling impulses. So, limited capacity for working memory. Meaning they can't hold a lot of things in their -- lot of

bits of information in their head at one time. So, they become overwhelmed quickly and then you have these meltdowns or other things that occur.

And then we need to know how the person processes information. How much goes in? Is the person more visual or verbal? And that'll help us when we design our behavioral support plans.

Our interventions on the units. So, this is really the programs that operate here. So, in the old days on that reduction side, or behavior elimination, see some pretty severe and intrusive interventions. Those are no longer applicable here.

So, we have advance directives. Positive approaches is something that everybody should know about. But it really just -- it's just understanding the person. Looking at human rights issues. Opportunities to develop relationships and express yourself. So, we take that into account because we work with a variety of families, variety of religions, that oftentimes we have to be careful of the -- if we're using incentives, foods that we use for some religious issues. We get all of this information. Or movies that somebody may watch. So, we're aware of those things.

Positive reinforcements the big things. You see we go up the ladder here.

Reduction programs. The only things that we offer right now, or that we do in the hospital, and these are unpleasant consequences, meaning these are something that the person doesn’t like. So, we'll call it response cost. We will take an activity away. Somebody who's slated to go to the gym for having a problem. And that's -- when you get up to that point, all of these other ones have really exhausted.

And then we'll use time out for some of the kids. And then modified compliance training. So, if somebody's throwing something, we will physically direct them into the prompt. Not hand-over-hand, but physically direct them to pick up the activities. And they can choose not to if they -- well, not choose, but they don’t have to do it. So, we're really sensitive to using anything that would be unpleasant, would cause trauma, recreate a trauma for someone. And that's the extent of that.

Our least restrictive treatment model operates -- this is how we operate within the hospital. So, if you can think about people that are escalating, that are having difficulty with responding to any interventions that are going on. First thing we would like to know is what caused these things or what's causing the problem? So, we try to take a little bit of time to figure that out. But what we would do is adapt the space or the environment. So maybe a person is in a specific area of the unit for their treatment or therapy. They're with someone all the time. They're not on one-to-one's all the time, but they're in constant [indiscernible 00:49:38] of someone. There are some people that are on one-to-one's obviously because it -- somebody has to be there quickly. And if somebody is psychotic and they're -- have been aggressive, frequent aggression, somebody has to be around them. Or self-injurious.

So, the first thing is adapting physical space, designated place to have their treatments. We adapt the communication areas. We begin interruption redirection.

[00:50:03] So, this is kind of thinking about somebody who isn't responding to those lower levels. We use counseling programs. Contingent management. We have self-assessment, self-monitoring. I'll talk a little bit later about that and how that comes into play as a treatment.

Cognitive behavioral therapy and incentive program.

We'll offer relaxation training. This is usually where if a PRN is offered -- we don’t deliver PRNs. Actually, it's an agreement between the physician and the patient, that and parents in some cases, if the person needs something to help them calm down. So, on the escalation, if they're not responding to these counseling and behavioral programs, we'll offer them a medication. They can just say no. Don’t want it. But we won't deliver it forcefully. There's no forced medications or anything like that. But sometimes it works.

And actually, some of the medical journals and nursing journals actually have studies that show adapting the environment negotiation rather than control. PRN medication has its place. It's not delivered after the person has the problem.

How many of you ever worked with somebody that's escalating, you'll give them their one milligram of Ativan, and they're just off. They just blow up. It's either first, the person's too far gone, and if you're working with neurodevelopmental disabilities, you can actually activate the person. You give another medication. And the first one didn't work, you give another one, they get more disruptive. And it just keeps going. So, you have to really be able to assess that. But it has its place.

We'll ask the person to go to a calming area. So, you get the picture.

And all the way down to these -- see this blocking pads? We have these pads that are two foot by three. We just hold it in front of you. So, if somebody is assaultive, you're throwing things, you're going to hold the pad in front of you. It's not a charging. It's just putting space between you and that patient and not putting your hands on the patient. That's kind of the last resort. If you think about somebody who is really out of control. So, we'll use blocking pads.

And then what happens, too, if we put our hands on someone and they kind of fall to the floor or run away and sit down and they're non-assaultive -- you see that staff time out? What our staff is trained to do is step back. We don't proceed anymore. Once the person -- imminent risk and danger is gone, we look at the environment and we go up to the top and say can we adapt anything else? Do we need to get people away?

So, we'll do everything we can in terms of interventions. And then there are people that have individualized safety plans. So, they may be physically directed to their room. People will put -- physically take one arm and the other arm and go. We don't use physical management as a contingency. We don’t use it as a behavioral technique. But that's our least restrictive treatment model.

Outcome measures. So, I mentioned about the data that we have. So, what we do on the way -- like, we have some things that we do at preadmission, admission, and over a period of time. And I just put categories here. But there are instruments that are in each one of these areas.

So, acuity ratings are important. We want to know, how high is the acuity of somebody walking in the door? And then what did the community see? What did we see? And then at discharge we'll do that to see the acuity should go down.

Indirects. Interview and rating scales. There's a variety of rating scales. This has to do a lot with the behavioral assessments. So, we'll use a variety of rating scales.

We'll do direct observation. So, those two things are in place. Not only do you do the assessments, but you also see the person.

Change assessments. We're going to use instruments that are sensitive to change. I mentioned a couple earlier. I mean, you're doing the depression inventory or an anxiety or a DY-BOC, a Yale-Brown obsessive behavior compulsive scale, you'll see changes in that, the degrees. So, we use that.

If a patient starts on a medication, we'll get some baseline assessment. We'll do the rating scales over time and compare those. So, those are done over a period of time.

Diagnostics. This could be specific to -- if we have a concern, is someone depressed? Or is someone anxious? Someone hallucinating? We would do rating scales specific to those areas.

And then parents and family. We'll do parent ratings. Stress, parental stress index. Obviously, you want to know. And stress does go down in most cases because they're in the hospital. So, parents go home, and they can breathe a little bit, take a little break. But they're still anxious about their son or daughter or their family member that's in the hospital. But it does go down just getting a little break in-between.

[00:55:05] And then our discharge planning. So, we'll do a [indiscernible 00:55:07] that we'll look at somebody over a period of time initially and then over time. And that's something that somebody can use after discharge. So, I want you to do the [indiscernible 00:55:17] person. You can have that done all the way up until they're seniors.

Here's a procedural checklist. So, we want to look at the fidelity and the integrity of programs that we're using. Behavioral psychologists on the floor will grab a chart, they'll grab this form, and they'll do an observation. So, they'll go back and look at a patient, look at a staff person, and with a couple questions they're going to look at. There's specific behaviors that the programs are implemented for. So, they're going to be looking at those in the behavior observed. They're also going to look at how often the program's implemented.

So, if a person is disruptive 10 times or if a person hits somebody 5 times, and the program was only implemented 2 times? That's a problem. It's somebody needs some training in that. So, we'll do that. And we also ask these questions here. Does the patient have an individual plan? Is there a plan on the chart or on the unit? If there isn't, then there needs to be one. We want to know why.

What's the purpose of the program? This is important. You ask your staff, the people that you work with, you may have a program in place, and you'll say well, what's the program do? Is it for increasing or decreasing a behavior? It should be increasing. Well, when you hear decreasing then couple things. You have to think about maybe the program needs to be changed, or that's the interpretation understanding of the staff. Even though you've written a positive behavioral support plan, the interpretation of the staff is we're going to get rid of this thing. And that helps us with being able to train the staff to think of it in a different way.

Did they implement the program according to the rules, the guidelines? So, you have a program with five steps in there. It's very easy just to draw a line down and say yes, no. Did the person implement step one? Yes, no. So, you may see that if you're using time out, maybe the person's talking to the kid or to the person in time out. So, step two is inconsistent. You're not following the plan.

So, that's how we measure all of these things and making sure that people are being consistent in that. And if there is a problem, we're going to give feedback. So, this is

documented. It has nothing to do with raises or getting fired or anything like -- it's just simply saying are people -- and this is -- staff was initially concerned about that. When they were -- said well, are you going to use this to get rid of this? No. This is just -- it has to do with how the programs are implemented on the unit.

And then where do they go for additional training?

And here's our program. So, it's kind of a model of the program. So, we have behaviors. Those are the reasons for designing the plan.

And then the second question is what's the ideology? What do these behaviors mean to the person? Now, this is -- if you work in -- under a joint commission, accreditation, CARF accreditation, these are all in line with their standards. So, they want to know what's the problem? We have -- what's your understanding of the patient? What are the replacement, now that you know about the patient? Now that you know what the ideology is, what are you going to do? What are you going to teach alternative? What other behaviors?

So, somebody's aggressive for attention, then you're going to teach them to be -- to gain attention in another way and not being aggressive. That's basically how it works. So, we have specific interventions there.

Also, listening to the diagnosis. What does the person come into the program with? Is there anything that -- maybe that the person has from a diagnostic standpoint, medical or other, that could actually explain some of the reasons why you have the behaviors. So, the person might have obsessive compulsive and Tourette's, that needs to be taken into consideration as well.

So, you see there's duration and event recording and frequency. So, they're pretty standard, but they're also rating scales that are used as well.

And then our procedures are according to least restrictive treatment model.

So, somebody's discharged and there's kind of a -- you get a discharge summary and recommendations, but this is kind of a face sheet that has a couple of things on it. Presenting problems.

And I found out over the years we often don't speak the same language. So, somebody from parents or agencies will refer somebody and they would say well, it takes the forever to do things. A statement like that. It doesn't mean anything -- it doesn't meet a diagnostic category. But if you really look closely at it, it's OCD or it could be part of a depression.

So, what we'll do is we'll see the psychiatric symptoms, the behavioral presentation, what the function is, and then our recommendations on interventions. And there's a report that also goes along with it, but those are the things that kind of will be along discharge. So, this is kind of a quick, easy way to look at what people are doing or what was done.

[01:00:16] The levels of admission, I'll go quickly through this and get to some of the data and a couple of cases. So, there are four levels, people that come through in the bio-behavioral track.

Level I is a patient here, obviously, who is well-known to us through either our outpatient or prior treatment in the hospital. They've been in before and they're back. But they're well-known to us. So, there's clear diagnosis. We've established it already because we've known the person over a period of time.

As I said before, if we see a person five times, we may not be accurate on the diagnosis on the first or second time, but the fifth time we should know what's -- by the fifth time we should know what's going on. These are things that we'll look at or they're clear and well-established diagnosis, yes. The goal really is more of a medication. Sometimes it is just adjusting medication. Somebody had too much, somebody stopped taking their medication.

We've actually had one patient that was switched from a pill, because they couldn’t take the pill and the parents wanted an injection. So, they came in for a week and that was it. We switched from the pill, because he would gag and be disruptive, but had no problems with parents giving an injection or a physician giving an injection rather. But that was switched. And so, it was a very short stay.

This is similar that maybe just the medication and stabilize. This is a Level II patient. So, you see stabilizing and takes two to four weeks. So, they're also known to us. It's not clear, maybe there's something that came into play here that we're not clear, that the referring agency isn't clear about, so we'll do our -- try to clarify the diagnostic picture. Kind of the differential on this. And then we'll need additional assessments and treatments. I'm sorry, additional assessments to figure out what's going on.

Level III are our more complex patients. So, these are the ones that are going to be staying a little longer. The ones that have been in emergency rooms and restrained and lots of medications. Change quickly. So, these are ones that we'll take our time on. As you see, they're six to eight weeks stay, and sometimes they're longer. But it takes us at least that long, especially if people are coming in with couple of different medications or a combination of them.

And the Level IV patients, these are the most challenging, and only from the standpoint that because of their behavior, they're difficult to place. Nobody wants them. So, we'll have one or two of these folks that will be sitting for a long period of time until we activate. Until we have to call state, county people. We have to really get everybody sitting down at the table to develop and design a plan or a program for this person. But that's why they stay. They'll say well, we don’t have anything in our county that can support, or anybody that can work with them. So, it takes a little bit longer.

All right. So, couple of the cases here and we'll leave some questions. So, these are -- I have a couple here. I pulled bits and pieces out of things, so you get a flavor of how at least the kinds of patients that are coming through here.

So, here's a 15-year-old female. History of aggression, physically striking others. Head banging. There was also reported of hearing voices and I think there was a -- there's a question of seizures with this. You see possible related to seizures. And we'll hear things, or you'll hear things like well, it came from out of the clear blue. Or nobody was doing anything, and this person just started hitting themselves. Or throwing things.

And then after the incident you ask them what happened. If they're verbal, they'll say I don’t know. I have no idea what happened. So, they kind of blank out. You'll hear those kinds of terms.

So, this was kind of similar to that in ways. And the person, this kid, was on homebound instruction because could stay at school. So, they needed a safe environment. Brought them into the hospital.

Here's our pathway. This is the one to two weeks. So, we completed our psychiatric evaluation and history. I'm not going to walk through everything, but just point out some things. You just have to know that that pathway tells us we have to do these things in a couple of weeks. The important things are connecting with families, they're involved. We're looking at the medications and finding out what was used before, what should we stay away from?

[01:05:00] We needed a nutrition consult on this one because I think there was some concerns that maybe some foods caused these outbursts. So, it was -- well, seizures or it was after meals or something caused this person to explode.

And then disposition planning.

This talks about week three. So, we say there's a question of seizures. So, we had an EEG consult to see did we find anything? And with these kinds of seizures the chances of you really finding anything, because they're really -- we're talking about complex partial or temporal lobe epilepsy, they really happen deep inside the brain and it’s -- surface reading is usually what you'll see for these clonic-tonic movements. In these cases, if you work with someone who has these kinds of outbursts -- I mean, they're clearly seizures. You have to know what you're looking for, and I'll explain that, but you typically wouldn't pick it up on a EEG. So, it'll come back and it's normal. But it’s not. You have to really -- as I said, describing the behavior. How does it look? That's really going to be the key for kind of differentiating some of these things.

So, we had nutrition involved, seeing what the person ate. I think this person had diarrhea and then some other things, and that was one of the concerns.

So, just quickly on seizures. This isn't this person but get an idea if you have some concern. So, the approach, the approach that we use, obviously what we know about seizures, they come in clusters. Right? So, you can't predict it. You can't say it's 7:00, unless you can trigger it with some kind of noise. Or there are some people that respond that way. But most cases, you can't predict it. You can't say at 7:00 they're going to have a seizure.

So, what we look at are the -- and I just pulled some of these out. So, we have a couple in May, a couple in August. And you see the behavior analysis, meaning this is what it looks like. Screaming and head holding and lip biting. Just like this. So, that was the presentation. Very intense. So, you have this baseline, this intense behavior, and then it goes away. Actually, it goes away as quickly as it starts. There's little modulation in it. It goes from a low level, you have your behavior or meltdown or whatever it is, and you're back down to it again, back down to the baseline.

So, that's when you see -- if you see the consequences over here, you see that regardless of what anyone does -- so, we have somebody that's rocking, holds head, screams. Nothing happens. Stops in two minutes. This one here, mom and dad watching TV, screaming, they used interruption redirection. It stopped in a minute. I think they were out at a mall for this one here. Shopping, out of the blue, screaming, lip biting. They went to a quiet area of the mall. Took three minutes. Calmed. And then the last one, playing. Loud noises. Could've been a bang or something. Screaming, hold heading, nothing.

So, when we're looking at seizures it's topography. How does it look? It's very important. And they're seizures, so they're involuntary movements. You're not going to see the clonic-tonic, but you will see possible rhythmic eye blinking, pursing of lips, forehead creasing. And with these behaviors, they're usually grab and hold. So, they're going to

grab onto you, just hold tight. And if you look at them, you'll see that they're kind of a fixed gaze. And there's no kind of startle response or anything. If you've ever worked with someone like that, it's very intense, and then it stops within three minutes or two minutes. So, you have this pattern. Periodic, regardless of what you do, intervene, there's no set ideology or thing that starts it, but it always ends the same way. It's quickly.

So, those are things that we would look at in determining of any seizure related. Even thought the EEG comes back normal, we're going to look at some of those rhythmic things. If you're really good, and if the person is grabbing onto you and you can see their eyes, there are some people that will have their pupil dilations. One will be like a saucer, huge, and the other one will be pinpointed. And that's very -- I mean, if you get that close. And we've had people that were able to do that, because your pupils are equal and reacting to light. In a seizure you would have these things independently going on.

A show of hands. Anybody worked with someone who has pseudo seizures? These are actually how they develop in a lot of cases. Could be brought on by stress, anxiety, but also, they can look like a real seizure. It's the reinforcement that occurs after the seizures or shortly after it that causes them to do the same thing. So, it may look like a seizure, but based on the experience, what happens -- so they have a problem, they may even be on the floor, somebody gets some water, somebody reinforces them, and that will continue to occur. Obviously, you need to attend to it, but in terms of differentiating, is this something that is true or not? In a lot of cases, anxiety will bring these things on. Sensory issues also bring them on.

[01:10:05] This is the woman that had -- this is the question. This was a question about psychosis. There was psychosis, seizures, and this was a self-report. So, this was a report that she wrote. Eyes are twitching, I'm feeling sad about -- talking things in my head. So, people would say she would talk to herself. And then this was a key here as well. So, any time you're working with someone who has meltdowns, and if they're able to self-report and they have this I smell or a sensory feeling, it smells like -- in this case, it was smelling onions. That was something that came over here. So, when you asked the report -- if you get those presentations, then you're going to look definitely more closely at seizure kinds of things.

That was the diagnosis after week four. We came up intellectual disabilities, some mild. Complex partial seizure. Temporal lobe epilepsy. And that's where we were from a diagnostic standpoint. Just treatments. Just so you know what was done. You get the idea of how it progresses through week four.

So, you see five through eight, eight weeks, we worked on a variety of other things. We're doing family sessions, calling the family, we have transition and integration planning. So, we're going to do a plan that can generalize to the community.

This is just data. We looked at -- I pulled out a couple of things. So, the idea of looking at the aggression and self-injury. So, we see that there was a reduction. This is the baseline measure. The behavior program in itself started to reduce. We did a self-assessment. Up there, self-assessment, self-monitoring. And the medication was Depakote that we treated the temporal lobe epilepsy with and the mood problems. And it went down. So, the combination of -- this is across the first month. She was there for another month and did excellent. So, that's how that data looks.

17-year-old, referral. This was a question of a catatonia. Changes in vegetative -- eating, sleeping affective changes, stopped eating, required feeding tube. No participation

activities. Isolates the room. Minimal on task. His affect was blunted. Fixed gaze. And there was also this question of psychosis. Paranoid. When he got better, he was able to tell us that it was like being in a fishbowl. People were looking at him and that's where it looked like psychosis because he was kind of vigilant around who was around.

Pathways. You get the idea. The same thing we did with the first one. Nursing assessments. Any time we have somebody with catatonia we're automatically going to look at trauma history or drug and alcohol immediately because those are things of major concern.

And then again, connecting people to the treatment team. It just talks about what we did across a couple of weeks. We did the GI consult, EEG, blood tests. Before we started changing medications or adding medications.

So, his was a diagnosed autistic disorder. Ruled out catatonia, mood, bipolar disorder to NOS. History of seizure disorder in this case here.

So, week four continues. We're doing tracking, monitoring. You see family sessions. We completed all of our diagnostic, our labs, all of that. And then we continue to titrate medicines because she was being treated for psychosis on the way in the door. We added -- I believe we added Ativan to the -- because we were concerned about the catatonia, and actually it was very effective in reducing a lot of anxiety.

This was across six weeks. Activities, baseline, first two weeks she was in her room all the time. We started the medication changes and she improved. She came out and was engaging in at least eight activities a day and then she ended up coming on for about six hours a day.

Wasn’t in her room, couldn't bring her out of her room. If you did, she'd just sit. Wouldn’t respond to anything. He. Why am I always saying -- this was a 17-year-old guy here.

This was the last case and I'll take some questions -- this was an extremely challenging case from the eastern area. History of self-injurious, punching face, slapping. He came in with a helmet on. Our job was really to get a better look at what was going on, eliminate the helmet, reduce the helmet.

So, acute decompensation. Safe environment was needed. Positive behavioral supports. Looking at medications. Now, he was on actually a derivative of -- the way this was used, this is actually -- it's an opiate antagonist and it was, I guess, I'm assuming, I didn’t read it from the reports, that it was used for self-injure. I guess the opiate peptide theory of some -- right. It was, yeah. Naltrexone, [indiscernible 01:15:17]. But at any rate, we're assuming that's what it was used for.

[01:15:22] So, our job was really to take a look at that. Does it make any sense? So, he had a helmet on, and we were evaluating these medications.

So, okay. We had the eval first couple of days. Begin the assessments, indirect observations. You get the drill here. Functional assessments. Blood tests.

Trauma. That was the other thing. Again, we're looking at trauma consults. We had a trauma specialist come in to do a consult. There was nothing that was found in history or anybody reported. So, we kept on going.

The thing I want to mention about ongoing functional behavioral assessments for people -- for behavior specialists, you just don’t do this once. An FBA really is ongoing. So, don’t

think the work is done once you've completed it. You're looking at responses to interventions and treatments. That's more information around function of behavior. So, it really takes us a while to figure it out.

Daily treatment planning. Data. We said daily contact. We're beginning to wean the helmet. So, we're reducing use of helmet. We have staff around. We're interrupting and redirecting when he's head hitting. We're changing medicines as we go along.

This was the diagnosis. Anxiety was a big issue with this guy. And when we look at the opiate peptide theory, it's based really on an addiction's model. That somehow the drive and need to hurt yourself opens up the floodgates and you get this euphoria or this rush, and that could be the mindset. And I don't, again, I don’t know what -- if that was the line of thinking at the hospital where this fellow came from, but it makes sense from literature standpoint. But that's the diagnosis there.

And long story short, we adjusted the medications, got him off of his meds, and -- let me get to the data here. So, we continue monitoring. He was here with us for -- you see this is 9 weeks through 12 weeks. 13-16, we're still titrating medications. We had him out of his helmet by now. We're doing weekly inter-agency. We had to get the county and state involved in this one only because there was no place for him to go.

So, when we get to the 16 weeks, this fellow is in great shape. He's just on the unit and no need for that level of care. So, we're still on the 24. So, he was with us for a long time.

So, here's our data collection. So, if we look at admission -- I don’t know if you can see this down here. We have admitting -- all the admitting medications. And these are the behaviors. So, it's a lot of activity in there. As you see, he was hitting himself, punching himself, banging his knees over a period of time. So, this is baseline data from when he first came in.

We see these changes in medications. So, we're getting rid of the meds and then we're -- he was also on Moban when he came -- which is an older antipsychotic medication, along with a Cogentin to treat some of the side effects.

So, as you see over a period of time, as we discontinue these things, we have some variability in behavior. As we go over time, he had a sleep problem, so we're looking at adding Melatonin and that we addressed that issue as well. Once we got the sleep -- reduced the medications, he started to improve significantly as you see here.

And then the last thing that was done was adding a Risperdal, 1 mg TID. And for the rest of the time he was here, he was great.

So, this is kind of an example of somebody who comes in with a lot of medications, we try to simplify it, reduce it, collect the data and information, and then get them off to the next level of care. And it continues.

So, that’s the end of it. He was discontinued. This is discontinued meds, as you see. It's a lot less than when he came in.

So, that's the approach that we use. Our challenge is in barriers for the program. The number one thing is distance. So, the idea of this program actually was to replicate this. So, we wanted to set this program up, kind of work the bugs out of it, get all the ways to assess. And then train other hospitals in how to set up a program so people don’t have to travel across the state.

Communication's an issue. I can tell you, just trying to connect with other treatment teams, it's -- you can count on people not taking responsibility. You know, when they're in the inpatient program it's like well, they're there and we don’t have to worry about this. Basically, that's the way sometimes some organizations think.

[01:20:15] So, coordination. Collaboration with others. Flexibility across systems. I mean, these are -- you know, you hear the term thinking out of the box all the time. I mean, this really is what you have to look at with this population. I mean, the creativity that you have to have in order to have them live in a community, go back home.

It does work, though. I mean, we've had probably about 11 cases that have come through. We haven't had one that come back into the hospital. So, they're staying out. Some of them require a lot of support. Some of them require staffing levels that are pretty high. But again, that's up to the agencies and everybody to work on.

Again, distance to location, traveling from the east side. Disposition planning. Finding a facility. Because they'll be sitting in the hospital and there's no place for them to go. We get frustrated by that because we're finished with everything we need to do, but nobody's moving on him. But we'll work -- you know, we work with the agencies.

A couple things to think about and I'll wrap it up with this. This is what makes it work. Establishing that trust between everybody, giving correct and accurate information. Taking responsibilities. You got to respect the opinions of people as well in terms of what kinds of interventions or programs you can implement. Assessments that are needed.

So, everybody doesn’t need an EEG coming in the door or an MRI coming in the door, but some people will say they have to have it. Unless it makes sense from a diagnostic standpoint, or information coming in, there's really no reason to do it. And while they're in the hospital we can also look at that as well. If it's necessary, then we would recommend it and do it.

So, you're including the consumer and family, being creative, and the teamwork. So, I'm going to wrap it up with that.