Overview of the I-START Program & START Professional Learning Community

1. Overview of the I-START Program & START Professional Learning Community Jim Aberg, MAE Webinar Presentation for the Iowa Association of Community Providers September 19, 2019

2. “Time after time, I have found that when people are taken seriously, when they are respected, when their behavior is interpreted, understood and responded to accurately, when they are engaged in mutual dialogue rather than subjected to unilateral schemes of ‘behavior management,’ somehow as if miraculously, they become more ordinary. I know a number of people who have had severe reputations who have shed them when those supporting them listened more carefully .” Herb Lovett, Ph.D. University of New Hampshire

3. Center for START Services • START: Systematic, Therapeutic, Assessment, Resources, & Treatment • I-START is under contract with the Center for START Services, Institute on Disability (UCED), at the University of New Hampshire • START is a person-centered, solution-focused approach that employs positive psychology and other evidenced-based practices • START in the states of New Hampshire, New York, Virginia, North Carolina, Arkansas, Texas, Oklahoma, Washington State, Colorado, California, and Iowa

4. Center for START Services • Other states considering START include South Dakota, Minnesota, Georgia, Wisconsin, and Kentucky • Each I-START team member is nationally certified through the Center for START Services • Each START Program must be nationally certified through the Center for START Services. • I-START goes through their national certification in November of 2019

5. I-START Program Iowa (I)-START provides prevention and intervention services to individuals with intellectual and/or developmental disabilities (IDD) and mental health needs through crisis response, training, consultation, and outreach

6. I-START Mission Improving the lives of persons with intellectual and developmental disabilities, their families, and caregivers by providing crisis response, training, consultation, and outreach to teams and systems

8. I-START Team • Felicia Bates: I-START Program Director/Clinical Director Waterloo • Amber Lacina: BSN, RN, MSN, APMHNP, Medical Director Waterloo • Tiffany Liska: Clinical Team Lead Mason City • Coordinators assigned to Black Hawk, Wright, Cerro Gordo, and Howard County; Rolling Hills and CROSS Regions • I-START expanding to the East Central Iowa Region

9. Appropriate Referrals for I-START Services • The individual is currently at or has been to a psychiatric hospital or any other inpatient psychiatric unit within the past 24 months • The individual is at risk of losing their work and/or home placement due to challenging behavior or unmet mental health needs • The individual is presenting with complex behavioral, medical, and/or trauma related issues and has appeared to deteriorated over the recent months or years

10. Appropriate Referrals for I-START Services • The individual has complex mental health needs that have required crisis intervention, calls to 911, emergency department visits, and frequent medication changes • The individual has a history of multiple community placements over the past 12 months due to challenging behavior • The individual has been referred for additional staffing due to challenging behaviors or has been receiving additional staffing for an extended period of time

11. Eligibility Criteria for I-START Services • Must be 17 years of age • Must have a diagnosis of an intellectual or developmental disability • If diagnosed with a developmental disability, the individual must have three or more life limitations as documented on the Iowa Department of Human Services DD checklist

12. Eligibility Criteria for I-START Services • I-START does not provide Clinical Services to children at this time • Must reside within the MHDS Region • Must meet MHDS income and resource guidelines

13. Intake and Assessment • Once accepted for I-START Services, the assigned Coordinator will be in contact with the team/system within two business days to set up a date and time for the intake meeting • The initial intake meeting is face to face and generally takes about two hours, and involves the Coordinator interviewing the team/system to learn more about the individual. More than one meeting may be needed

14. Intake and Assessment • An Aberrant Behavior Checklist (ABC) is completed as part of the intake process with input from the team/system. The ABC is updated every six months • The ABC measures mental health symptoms in the following areas, irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech • A Recent Stressors Questionnaire (RSQ) assessment is completed as part of the intake process with input from the team/system. It is updated when a crisis occurs with the individual such as police involvement, emergency department visit, or admission for psychiatric hospitalization

15. Recent Stressors Questionnaire (RSQ) • We fail to adequately understand and address the impact of stressors in the lives of persons with IDD • We fail to take into account the stressors individuals with IDD experience as an explanation for their crisis • Due to executive functioning limitations, individuals with IDD struggle to communicate the stress they may be feeling. It is manifested through irritability, flight and/or fight responses • Due to executive functioning limitations, individuals with IDD are unable to cope effectively

16. Old Cherokee proverb: pay attention to the whispers, so you do not have to listen to the screams!

17. The Biopsychosocial Model and START

18. The Biopsychosocial Model and START • The biopsychosocial (BPS) model incorporates interactions between biological, psychological, and social factors to help determine why an individual might suffer from a disorder, affliction, or problem behaviors • Our team has discovered that medical disorders are underdiagnosed and Psychiatric disorders are over diagnosed

19. “If I had an hour to solve a problem I'd spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.” Albert Einstein Interpretation: You can not solve what you do not understand.

20. The Biopsychosocial Model and START

21. Cross System Crisis Prevention & Intervention Plans (CSCPIP) • The CSCPIP is an individualized, person specific written plan of response that provides a clear, concrete, and realistic set of supportive interventions that prevents, de-escalates, and protects an individual from experiencing a behavioral health crisis • The development of the CSCPIP is facilitated by the START Coordinator with the team and system of support for the individual

22. Cross System Crisis Prevention & Intervention Plans (CSCPIP) • A key component of the plan are stages of interventions, including primary, secondary, and tertiary • Primary interventions are what can be done in the setting • Secondary interventions are when advice from on-call, specialist, or I-START Coordinators is needed

23. Cross System Crisis Prevention & Intervention Plans (CSCPIP) • Tertiary interventions are acute crisis intervention and emergency supports, such as emergency department visits and psychiatric hospitalization • Coordinators can provide training to the team and system on how to effectively implement the plan

24. Outreach with Teams/Systems • I-START Coordinators will complete ongoing outreach with the team, as specified in the START Plan • Regular outreach is the most important factor when supporting a team with accomplishing needed goals • Open communication and accountability fostered through regular outreach allows for sustaining positive behavioral change over time 

25. I-START Emergency Response • I-START is on call 24/7 • An essential role of I-START is to provide support and guidance to teams during crisis situation's to prevent unnecessary emergency department visits and psychiatric hospitalization • On call includes immediate telephonic access for all callers and face-to-face supports in some cases • I-START on call number: 641.525.0401

26. Special Hope Foundation Grant Research Study on I-START • Published in the Journal of Mental Health Research in Intellectual Disabilities • Results indicated that individuals supported by the I-START program experienced significant reductions in mental health symptoms and had fewer psychiatric emergency department visits and hospitalizations over time • Findings highlight that utilization of the START model promotes positive outcomes and improves the lives of people with ID and co-occurring mental health conditions

27. 2018 I-START Crisis Intervention Outcomes • A major goal of I-START is to reduce emergency service utilization. Pre and post enrollment data is utilized to assess outcomes. • Total number of crisis contacts: 237 • Number of individuals with contact: 31

28. 2018 I-START Crisis Intervention Outcomes • 85% maintained their setting • 7% transferred to a crisis stabilization • 4% incarcerated or referral for other services • 2% Psychiatric Hospitalization Admission • 2% Emergency Department visit

29. 2018 I-START Crisis Intervention Outcomes • Overall a 49% reduction in unnecessary Psychiatric Hospitalization over baseline • Overall a 28% reduction in unnecessary Emergency Department (ED) visits over baseline • Reductions in ED visits and Psychiatric hospitalization save the county, state, and federal government (we the people) money, results in less strain on the system, and reduces stress in the lives of the individuals and caretakers

30. 2018 I-START Behavioral Health Outcomes • A major goal of I-START is to reduce the frequency and intensity of behavioral health issues that lead to crisis. Based on completion of the Aberrant Behavior Checklist (ABC) assessment (at time of enrollment and every six months), there was a 24.7% reduction in mental health symptoms • Reductions in mental health symptoms result in less crisis and an improved quality of life for individuals and work life for direct services staff

31. I-START and START Education, Training and Learning Opportunities

32. “The world as we created it is a process of our thinking. It cannot be changed without changing our thinking”

33. Continuing Education Team (CET’s) • Two CET’s a year in each MHDS Region • Clinical Education Teams (CETs) are free educational forums designed to improve the capacity of the local community to provide supports to individuals with IDD and behavioral health needs by teaching through discussion of a case • The goal of the CET is to help service system learn how to best support people while improving the capacity of the system through information sharing, learning, and collaboration

34. Continuing Education Teams (CET’s) • A redacted case is presented using a clinical teaching model: those present ask questions, propose diagnoses and treatment options, and they discuss and learn together. Discussion will generate ideas about possible remedies • The CET training is not so much about the person presented, but rather descriptions of the challenges faced, strengths and resources, as well as diagnosis and treatment information so that the individual serves as an example for discussion and further examination • Contact Felicia Bates at fbates@countysocialservices.org to learn more about CET’s

35. START On-Line Training Series • On-line training series is designed to provide innovative and topic-focused training to the I-START team and community partners • Trainings are provided once a month from September through April (typically on the 3rd Friday of the month) • Trainings are free and facilitated by I-START program members in centralized locations within their service region so that participants can learn as a group • Contact Felicia Bates at fbates@countysocialservices.org to learn more about the training series

36. START On-Line Training Series • September 20, 2019: Bereavement & Grief in Individuals with IDD by Kathy Stratigos, MD, Assistant Clinical Professor of Psychiatry, Columbia University • October 18, 2019: START Research, 2019 START National Training Institute Poster Session Winners, Andrea Caoili, Director of Quality Assurance & Research, START • November 15, 2019: Supporting Purpose and Meaning in the Lives of Individuals with MH/IDD, Michael Smull, The Learning Community for Person Centered Practices and Support Development Associates • January 17, 2020: Psychopharmacology & Self Advocacy

37. START On-Line Training Series • February 21, 2020: PERMA: The Family Perspective with an introduction by Alyce Benson, START Project Facilitator • March 20, 2020: Trauma’s Impact on Cognitive & Emotional Development in Individuals with IDD, Stephan Griffin, PhD, Clinical Neuropsychologist and Sherm Fox, MD, Psychopharmacologist • April 17, 2020: Exploring the Overlap of Autism, Sexuality, and Gender-Identify Difference, Dan Shapiro, MD, Developmental and Behavioral Pediatric Consultant

38. START Professional Learning Community (PLC) • A START professional learning community provides professionals with training, knowledge, facilitated discussion, and tools in an effort to improve knowledge of the mental and behavioral health aspects of intellectual and developmental disability across a local, regional, or state system of care.

39. START Professional Learning Community • I-START and IACP are working together with development of a PLC for a select group of IACP members • IACP will be sending out applications for the PLC in October 2019 • In November 2019 up to 16 applicants will be selected and for the PLC • The PLC will be voluntary in nature and for individuals who want to learn how to better and best support individuals with IDD who experience mental health disorders and problem behaviors

40. START Professional Learning Community • Being a participant of the PLC requires the person to make a five month commitment of their time and talents • The PLC participants will meet for one day in early January 2020 in Des Moines for up to six hours to launch the PLC • Other meetings will be conducted via the University of New Hampshire Zoom video conferencing system • Learning will occur through participation in the START on-line Moodle Room Training modules on various key topics related to supporting individuals with IDD who experience mental health disorders and problem behaviors

41. START Professional Learning Community • Zoom meetings will occur one to two times a month, generally 90 minutes up to 2 hours each time • After a Moodle Room module is completed, there will be group discussion regarding the module and an assignment to apply the new learning • Participants will journal about what they learned each session • PLC participants will partner together as study partners to develop a final project (poster and short presentation) for the IACP Annual Conference in May 2020

42. START Professional Learning CommunityMoodlerooms Classes Offered • Introduction to Positive Psychology, 70 minutes: Dan Tomasula • Establishing Healthy, Positive Relationships, 54 minutes: Kathy Honeyman • Character Strengths, 57 minutes: Dan Tomasula • Intellectual and Developmental Disabilities Overview, 50 minutes: Jill Hinton • Mental Health & IDD, Challenges and Issues, 39 minutes: Andrea Caoili

43. START Professional Learning CommunityMoodleroom Classes Offered • Anxiety Disorders & IDD, 74 minutes: Lauren Charlot • Depressive Disorders & IDD, 53 minutes: Ann Hurley • PTSD, Trauma and Stress-Related Disorders, 63 minutes: Jill Hinton • Behavior Support Plans, Identifying Best Practices, 46 minutes: Karen Weigle

44. START Professional Learning Community • A PLC is a train the trainer model. Attendees who successfully complete the PLC can then train others • There will be a cost, to be determined. Funding being explored • If interested in participating in the PLC, email Jim Aberg at jim.aberg@countysocialservices.org

46. Key Information • Jim Aberg: jim.aberg@countysocialservices.org 641.903.5210 • Felicia Bates I-START Program Director : fbates@countysocialservices.org 319.830.2048 • https://www.centerforstartservices.org/ • https://www.centerforstartservices.org/locations/iowa • https://www.countysocialservices.org/index.php/programs/i-start