The Office of Mental
Retardation’s Plan to Support
Elimination of Restraint
through Positive Practices Chapter 1
National Perspective
Elimination and reduction of restraint is a national trend.
“…It is now a priority for SAMSA to work with States…to
ultimately eliminate the use of seclusion and
restraint…There is a wealth of research that physical
force, bodily immobilization and isolation inherent in
the practices of seclusion and restraint are
dehumanizing…” Substance Abuse & Mental Health
Services Administration. Administrator Charles Curie
National Perspective
Six Core Strategies for the Reduction of
Seclusion /Restraint - National Technical
Assistance Center/National Executive Training
Institute 2/25/2005
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Leadership toward Organizational Change
Use of Data to Inform Practice
Workforce Development
Use of Restraint Reduction Tools
Consumer Roles
Debriefing Techniques
National Perspective
Assumption
 Restraints keep
patients safe.
 Restraints keep staff
safe.
Reality
 Each year, 50 – 100
deaths occur nationally
due to seclusion and
restraint.
 For every 100 mental
health aides, 26 injuries
were reported in three
– survey 1996
National Perspective
Assumption
 Restraints are used only
when absolutely
necessary and for safety
reasons.
 Restraints are not used
as, or meant to be
punishment
Reality
 Patients are restrained for
such trivial “offenses” as
refusing to move to
another dining room
table.
 People who have been
secluded or restrained
typically experience a
sense of punishment.
Department of Public Welfare Initiative
Alternative to Coercive Techniques Initiative
(ACT) – Initial goal of eliminating unnecessary
restraints in the children’s service system, and
an ultimate goal of having all Department of
Public Welfare serving systems be restraint free.
 Office of Children Youth and Families (OCYF)
 Office of Mental Health and Substance Abuse
Services (OMHSAS)
 Office of Medical Assistance Programs (OMAP)
 Office of Mental Retardation (OMR)
History
Positive Approaches Subcommittee
Positive Approaches Local Networking
Groups
Restrictive Procedure Workgroup
OMHSAS & OMR Dual Diagnosis Forums
History
Trainings for families, direct support
professional and other support staff
Mental Health Support Process
subcommittee
Statewide Positive Practices Committee
Positive Practices Resource Team (Pilot)
Everyday Lives Values
Accountability
Choice
Collaboration
Community Inclusion
Contributing to the
Community
Control
Freedom
Individuality
Mentoring
Quality
Relationships
Safety
Stability
Success
Positive Approaches Paradigm
Positive Approaches is a worldview in which all
individuals are treated with dignity and respect,
and all are entitled to “Everyday Lives”.
Positive Approaches recognizes that an
“Everyday Life” means being able to make
choices, face challenges, succeed, and
sometimes fail.
Positive Approaches is a characterized by an
integration of values, philosophies and
technologies.
Positive Approaches Paradigm
Positive Approaches asks us to always look at
the context in which we frame our work.
Positive Approaches is grounded in two basic
assumptions:
– People always have good reasons for what
they are doing.
– People always do the best they can with what
they know in that context and at that point in
time.
Positive Approaches
Communication
Assessment
Environment
Hanging in there
Positive Approaches
Environment - An individual's perception of their
environment, and how that environment will
meet their needs may influence their behavior.
Communication - An individual may use a
variety of means to communicate inclusive of
challenging behavior.
Assessment - Formal assessment tools, in
addition to developing a holistic view of the
persons life.
Hanging in there – Staying with the person, and
of critical importance, supporting the team to be
able to stay with person.
Elimination of Restraints
through Positive Practices
MR Bulletin 00-06-09
Effective May 1, 2006
Elimination of Restraints through
Positive Practices
Although the intent of this Bulletin is to guide
activities toward the eventual elimination of
restraints throughout the entire MR Service
system, the bulletin does not prohibit their use.
Restraint is to be considered only as a last resort
and in situations where any person’s immediate
health and safety are in jeopardy. This bulletin
offers best practice suggestions that are part of
an OMR plan to incrementally reduce the
incidents of restraint.
Elimination of Restraints through
Positive Practices
Philosophy of Care
Continuous Risk Management and Quality
Efforts
Reducing Restraints and Restrictive Procedures
Philosophy of Care
The individual is the central focus of the
planning team.
Creating a safe and supportive person centered
environment.
Use and inclusion in the ISP of positive practices
that are known to be effective in helping the
individual.
Philosophy of Care
Prevention and early detection are critical.
Creating a culture of respect and insuring
training for staff that focuses on all forms of
positive practices.
Continuous Risk Management Training
Recommendations
Environmental design, social, physiological and
cultural motivators for behavior, including
information on individuals who have experienced
trauma.
Positive behavioral and support methods that
include techniques to deescalate behavior.
Information on methods for interacting with
individuals who have a dual diagnosis of mental
retardation and a mental illness.
Continuous Risk Management Training
Recommendations
Person centered alternatives to the utilization of
restraint, including the integration of effective
behavioral supports and individual teaching
strategies.
Basic training in body mechanics.
Definitions, policies and the risks associated with
the application of restraint.
Provider Risk Management Process
Recommendations
Ongoing quality improvement directed at
reducing and eliminating restraint.
Policies and procedure for insuring the safety of
individuals in crisis in a restraint free agency.
Procedure for post review of restraints with staff
involved in the implementation of restraints.
Provider Risk Management Process
Recommendations
Procedure for debriefing with the individual, post
restraint, that provides for processing the event.
Internal review committees responsible for post
restraint follow up and the outcomes based on
the review.
Policies of risk management consistent with MR
Bulletin 6000-04-01 entitled “Incident
Management”
Continuous Risk Management
Administrative Review
OMR Recommends
 The County Mental Health/Mental (MH/MR)
Retardation Program or Administrative Entity
should review each provider’s policies on
behavior supports, restrictive procedures and
restraint.
 OMR Licensing Representatives and the
Department Health Representatives, as part
of their annual surveys and program
monitoring, will review provider policies on
restrictive procedures and restraint use.
Reducing Restraints and
Restrictive Procedures
Restraint is not treatment or a substitute for
treatment.
Physical restraint is used only as a last resort
safety measure when there is a threat to the
health and safety of the individual and/or others
And only when less intrusive methods have
been ineffective.
Reducing Restraints and Restrictive
Procedures
Individual Plan Recommendations
OMR Recommends Providers develop
procedures that outline specific steps to be
taken for the elimination of restraint
components in any individual’s plan and
approval of individual specific plans that
contain the following positive components:
Reducing Restraints and Restrictive
Procedures
Individual Plan Recommendations
Information about the occurrence of the problem
behavior and what specific positive practices
that can be used to prevent future occurrences
Justification that the proposed plan contains the
most effective methods of helping the individual
deal with the problem behavior while promoting
the safety of the individual and others.
Information about what procedures did not work
in the past as well as alternatives if the current
procedures prove ineffective.
Reducing Restraints and Restrictive
Procedures
Individual Plan Recommendations
A review of “sentinel events” to learn and
communicate what has worked well in avoiding
the restraint.
The type of procedure to be used with an
individual whose restraint reduction plan
incorporates the possible use of emergency
restraint in order to protect the individual’s health
and safety.
We are already on our way…
Statewide Restraint Data Fiscal Year and Month
FY 2004/05 Total Restraints N=7,048
FY 2005/06 Total Restraints N=5,355 (year to date 4/30/06)
700
600
500
400
300
200
100
0
July
Aug
Footnote
Purpose: For review by the PPC
Date Data Pulled: 4/17/06 and
5/18/06
Sept
Oct
Nov
Dec Data Source:
Jan HCSIS Impromptu
Feb
March
April
May
June
*These data are intended for the Positive Practices Committee (PPC) . They are not to be distributed or shared without knowledge of the
chairperson.
Restraint Fiscal Year 04/05 and 05/06 (year to date 4/30/2006)
FY 2004-05
80,000
72,538
FY 2005-06 (year to date 4/30/06)
73,486
70,000
60,000
50,000
40,000
30,000
9.7%
20,000
7,048
1.1%
5,355
10,000
7.3%
828
1.0%
699
0
Total People Served
Footnote
Purpose: For review by the PPC
Date Data Pulled: 4/17/06 and 5/18/06
Total Number of Restraints
Total Number of Unique Individuals
Restrained
Data Source: HCSIS Impromptu
Census Data from the Gov. Ex Budget 2006-2007
*These data are intended for the Positive Practices Committee (PPC) . They are not to be distributed or shared without knowledge of the
chairperson.
OMR Plan to Eliminate the
Need for Restraint
May 2006
OMR Plan to Eliminate the Need
for Restraint
Developed to complement and correspond with
the principles of the Department of Public
Welfare ACT Initiative
Establishes the requirement for Regional
Positive Practice Committees to review restraint
reduction plans specific to the region in concert
with Regional Risk Management Committees
Charges the Statewide Positive Practices
Committee with the responsibility of reviewing
regional plans
OMR Plan to Eliminate the Need
for Restraint
Sets a goal of twenty percent reduction in
each of the four regions using data from
the Home and Community Information
Systems (HCSIS) during FY 2006 -2007
 Expectation that there will be a 20% reduction
in the number of physical restraints thereafter
 At the end of the fiscal year the restraint
elimination plan will be reviewed with
adjustments in expectations and strategies as
appropriate
Resources to Support Plan to
Eliminate the Need for Restraint &
OMR Bulletin
Regional Positive Practices
Committee (PPC)
Promote and expand interest/leadership within
the County MH/MR Program/Administrative
Entities to build capacity to serve people with
challenging behavior
Develop Regional Restraint Elimination Plans
In partnership with the local stakeholders, plan
and facilitate local Positive Practice Committee
Meetings
Regional Positive Practices Committee
(PPC)
Identify existing resources and gaps within the
local PPC area
Identify steps to address gaps
Identify the regional structure to support the
Positive Practices Resource Teams (Pilot)
Statewide Positive Practices
Committee
Review statewide restraint data
Review Regional Positive Practices Committee
Plans
Make recommendations regarding Regional
Restraint Elimination plans
OMR and OMHSAS Partnership
Positive Practices Resource Team (Pilot)
 Purpose is to identify and develop system resources
that will be dedicated to address issues pertaining to
a person’s behavioral support needs.
 The criteria for referral is the person must be
demonstrating escalating at risk behavioral
challenges and may be at risk for needing enhanced
levels of support not readily available to the provider
 Piloted in Central Region with resources from OMR
Regional Office, OMHSAS Field Office, Selinsgrove
Center, Danville State Hospital, Wernersville State
Hospital
OMR Bulletins
Supporting the Plan
00-06-09 OMR Elimination of Restraints through Positive
Practices
00-04-05 OMR Positive Approaches
00-03-05 OMR Principles for the Mental Retardation
System
00-02-16 OMHSAS, OMR Coordination of treatment and
support for people with a diagnosis of serious mental
illness who also have a diagnosis of mental retardation
00-00-04 OMHSAS, OMR Guidelines for Identifying
Persons with Mental Retardation and Mental Illness for
State Mental Health Hospital Discharge
Next Steps
OMR will integrate the Positive Practice goals
with the Quality Management Framework to
ensure learning, sustainability and connection to
other OMR initiatives
Implement three month pilot of Positive Practice
Resource Team
Regions to complete Restraint Elimination Plans
Next Positive Practices State Wide Committee to
review Regional plans and provide input into
plans
OMR Contacts
Western Region
Northeast Region
Sharon Lipscomb
300 Liberty Avenue
Pittsburgh, PA 15222
412-565-3688
Michele O’Toole
100 Lackawanna Ave.
Scranton, PA 18503
570-963-3212
Central Region
Southeast Region
William Bruaw
430 Willow Oak Bldg.
Harrisburg, PA 17105
717-705-8266
Kathleen Gerrity
1400 Spring Garden St.
Philadelphia, PA 19130
215-560-2247