Feature Issue on Person-Centered Positive Supports and People with Intellectual and Developmental Disabilities
A Model for Building a Statewide Infrastructure Using a Statewide Tiered Implementation Approach:
In November, 2015, Federal Judge Donovan Frank approved Minnesota’s Olmstead Plan. According to the Minnesota Department of Human Services (2015) the Olmstead Plan is:
…a broad series of key activities our state must accomplish to ensure people with disabilities are living, learning, working, and enjoying life in the most integrated setting. The Plan will help achieve a better Minnesota for all Minnesotans, because it will help Minnesotans with disabilities have the opportunity, both now and in the future, to live close to their family and friends, to live more independently, to engage in productive employment, and to participate in community life.
Collaborating state agencies are expected to build a statewide training infrastructure for implementation of the plan. This infrastructure includes tools and training opportunities for any individual or organization supporting people through Home and Community Based Services (HCBS) that are funded by the Centers for Medicare and Medicaid Services. In Minnesota Statutes, the standards for HCBS are found in what is known as “245D” (see the statute text for the standards at https://www.revisor.mn.gov/statutes/?id=245D).
A major part of Minnesota’s Olmstead Plan includes a multi-tiered system of positive supports for children, youth, and adults with disabilities. In Minnesota, positive supports refer to all practices that include the following characteristics (Young, Anthony, Flint, & Freeman, 2016):
- Person-centered interventions that demonstrate cultural competence and respect for human dignity.
- Evidence-based or “promising” practices.
- Strategies for ongoing assessment and monitoring at individual and organizational levels.
- Approaches that are implemented in combination with more than one practice.
Positive supports are driven by the values inherent in person-centered thinking and planning. Examples of programmatic models with all four criteria include applied behavior analysis, assertive community treatment, cognitive behavior therapy, and school-wide positive behavioral interventions and supports.
To implement positive supports systematically, state agencies in Minnesota are designing training and technical assistance efforts that focus on gathering data to drive these evidence-informed practices.
To implement positive supports systematically, state agencies in Minnesota are designing training and technical assistance efforts that focus on gathering datato drive these evidence-informed practices.
The Minnesota Department of Education (MDE) has been implementing positive behavior support (referred to as school-wide PBIS) since 2004 (Fixsen, Naoom, Blase, Friedman & Wallace, 2005; Sugai et al., 2010). This article describes how the Minnesota Department of Human Services (DHS) is working with MDE to adapt this model to implement a training and technical assistance infrastructure in person-centered practices and positive supports for providers supporting people with disabilities, county systems, and mental health organizations.
Piloting a Positive Supports Training and Technical Assistance Project
The Minnesota Department of Human Services, in partnership with the Research and Training Center on Community Living at the University of Minnesota, has launched a layered person-centered practices and positive supports training system that builds regional capacity of
human service organizations. The goal of this training and technical assistance effort is to build capacity within regions by establishing internal expertise and plans for sustainable practice over time. A variety of training strategies are used including onsite action planning, webinars, technical assistance sessions, coaching, mentoring, and other collaborative efforts.
Person-centered practices include a) person-centered thinking, b) organization-wide practices for promoting person-centered policies and systems change, and c) person-centered planning. Support Development Associates (SDA), a specialized consultation and training organization, has been providing training and technical assistance to the State of Minnesota in person-centered practices. Within SDA’s model, person-centered thinking is a universal strategy taught to staff working within counties and human service organizations. This strategy begins with a shift in thinking to a focus on what is important to and important for a person. Balancing the to and for requires an understanding of what make a person happy and content with what makes them healthy and safe. This balance starts with the person being supported and not with the “system.”
At the organizational level, coaches within counties and human service organizations learn to support other staff as they learn person-centered thinking and make systems changes that embed the values and vision of person-centered practices into practice. Additionally, person-centered practices call for developing or enhancing “valued social roles” (O’Brien & O’Brien, 1998) and providing more opportunities, if desired, to participate in the community. Friend, employee, neighbor, volunteer, student, spouse, parent, advocate, and voter are examples of valued social roles. Person-centered planning is used in individualized planning to build a partnership between the person who is supported and the people who provide support.
Positive Behavior Support (PBS)
Positive behavior support (PBS) is a positive support practice that is included in the organization-wide training and technical assistance effort in Minnesota. PBS refers to a set of tools and strategies for improving quality of life and creating positive social environments. PBS is a value-driven practice that incorporates the principles of behavior and biomedical research with an emphasis on empowering people to identify strategies that are the best fit for each social context.
Person-centered practices call for developing or enhancing “valued social roles” and providing more opportunities, if desired, to participate in the community. Friend, employee, neighbor, volunteer, student, spouse, parent, advocate, and voter are examples of valued social roles.
Two other key elements that are included within PBS – organizational design and workforce and practices for ensuring cultural competence – are included in the curriculum for teams to consider. As mentioned earlier, the overall model used in this statewide training has been adapted from the research and technical assistance in school-wide positive behavioral intervention and supports (Sugai et al., 2010) and implementation science principles described by Fixsen and his colleagues (2005). Three prevention tiers were adapted for human service settings including Universal Strategies for staff and people supported, Secondary Prevention interventions that include early intervention when quality of life is not optimal for a person, and Tertiary Prevention involving individualized PBS processes.
Layers of training are provided in both person-centered practices and PBS. These layers include team-based training, person-centered thinking and planning trainers, person-centered thinking coaches, and PBS Facilitators. These trainings are all tied to organization-wide team planning efforts.
Each participating organization begins the organization-wide planning process by assessing readiness of all stakeholders to begin implementing person-centered practices. Administrator buy-in and active leadership is an important factor as well. An organization-wide team includes administrators, middle management, frontline staff, people receiving supports, family members, board members, and individuals from the community. Five training events are scheduled to deliver information to teams and provide time for discussion and planning.
Teams complete a self-assessment to evaluate strengths and needs related to person-centered practices and PBS including reviewing policy and practices, completing surveys, and reviewing organizational data. This self-assessment process leads to strategic (action) planning to improve policies and procedures, establish staff development including mentoring and performance management, implement specific positive support strategies, and build data-based decision-making systems for continually improving quality of life outcomes for people receiving support.
Each organization-wide team learns strategies for data-based decision making to guide implementation. At the universal organization-wide level, the following types of data are collected:
- Impact of training (numbers of staff involved in implementation, number of people impacted by practices).
- Individual quality of life (QOL) measures.
- Incident reports and other indicators of challenging interactions (e.g. use of restraints, 911 calls, injury documentation).
- Direct observations of positive social interactions.
- Climate, satisfaction, stress, and surveys.
- Staff retention/tenure, sick days.
- Improvements in staff and team-based performance.
Technical assistance includes onsite evaluation by project staff who conduct interviews with key stakeholders, review documents used in programming, observe program activities, and support data collection and analysis. An important focus of evaluation is on changes in quality of life. Quality of life domains identified by Schalock and his colleagues (2002) include:
- Emotional well-being: Feeling empowered and experiencing positive emotions.
- Interpersonal relations: Opportunities for friendship and intimacy, quality of interactions with others.
- Material well-being: Ownership of possessions, meaningful employment.
- Personal development: Opportunities for education and habilitation.
- Self-determination: Setting personal goals, making decisions about important life choices.
- Physical well-being: Optimal health care and nutrition, mobility and general wellness.
- Social inclusion: Natural support networks, inclusive and integrated environments.
- Rights: Experience of ownership of key items and property, allowed due process, privacy and barrier free environments are available.
The Minnesota Team Implementation Checklist was created for teams to assess fidelity of implementation as it applies to multiple positive support strategies.
An important evaluation strategy for organization-wide planning includes measuring the fidelity of implementation efforts. The Minnesota Team Implementation Checklist was created for teams to assess fidelity of implementation as it applies to multiple positive support strategies. Two subscales are added to the fidelity tool: person-centered practice and positive behavior support. Teams use the self-assessment checklist during meetings two to four times a year. Data are summarized so teams can assess progress (see Figure 1). Each item is scored with a “0” when no actions have been taken yet; “1” indicates action planning is occurring to complete the item on the checklist; and “2” reflects a fully completed item. Items reflect important steps that are considered part of implementation (e.g., “Team assesses readiness of people to participate in each person-centered and positive support practices”). A team that has completed all fidelity self-assessment items would, therefore, receive two points for each of the 36 items on the checklist. Figure 1 shows how team progress would be summarized by tallying total number of points obtained divided by total points possible.
Once a year, an onsite evaluation conducted by someone with expertise outside the organization provides objective information about how well person-centered practices and PBS are being implemented. This external evaluation process is used to help teams:
Assess progress implementing features of person-centered thinking and PBS over time.
- Identify goals that will be included in the team action plan.
- Assess the impact of the organization-wide team training.
- Celebrate success as teams make progress.
Table 1 summarizes the evaluation and data collection tools used by teams participating in the training.
Table 1. Summary of Evaluation Questions and Tools
Related Evaluation Data/Tools
What impact did the training have on capacity building?
What are the strengths and needs of the organization?
How well are the practices implemented?
Are there improvements in the conceptual knowledge of the staff?
Are there changes in behavior of staff and people living and working in a setting?
Are there changes in universal quality of life?
The State of Minnesota is using implementation research outlined by Fixsen and his colleagues (2005) to move away from the “one-shot workshop” approach towards ongoing coaching and capacity building at the regional level. The emphasis on person-centered practices provides a value-based foundation for implementing positive supports to improve quality of life, encourage self-determination and independence, and establish valued social roles for people in the community. Data-based decision making strategies help guide systems change and contribute to sustainable implementation over time.
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Retrieved from http://ctndisseminationlibrary.org/PDF/nirnmonograph.pdf
Minnesota Department of Human Services . (2015). Minnesota’s Olmstead Plan: Information. Retrieved from http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=opc_home
O’Brien, C. L., & O’Brien, J. (1998). The origins of person-centered planning: A community of practice perspective. Retrieved from http://www.nasddds.org/uploads/documents/The_Origins_of_Person_Centered_Planning_Obrien_and_Obrien.pdf
Schalock, R. L., Brown, I., Brown, R., Cummins, R. A., Felce, D., Matikka, L., & Parmenter, T. (2002). Conceptualization, measurement, and application of quality of life for persons with intellectual disabilities: Report of an international panel of experts. 40(6), 457–470.
Sugai, G., Horner, R. H., Algozzine, R., Barrett, S., Lewis, T., Anderson, C., & Simonsen, B. (2010). School-wide positive behavior support: Implementers’ blueprint and self-assessment. Eugene, OR: University of Oregon.
Young, C., Anthony, C., Flint, J., & Freeman, R. (2016). Positive supports: Implementing positive supports in Minnesota. Minneapolis, MN: Developmental Disabilities Council Meeting.