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Ten Years of Prevention: The Vermont Crisis Intervention Network
by Patrick Frawley and Elia Vecchione
With the national movement toward deinstitutionalization, community-based crisis services for persons with developmental disabilities have become increasingly important. This article briefly describes the Vermont Crisis Intervention Network (VCIN), a statewide crisis prevention and intervention program that originated in 1991.
Vermont is a very small and rural state, 157 miles long and only 90 miles at its widest point. Within this area lives a well-spread out population of just over 600,000 people. This combination of population and geography allows for easy statewide communication and cooperation. Throughout Vermont there are nine full-service Community Mental Health Centers with programs for persons with developmental disabilities, as well as six smaller agencies that provide only developmental disability services. These agencies together currently serve an estimated 2,400 consumers in the state’s communities.
The Vermont Crisis Intervention Network’s primary function has always been to prevent the institutionalization of any Vermont resident with developmental disabilities. Beyond this goal the program strives to enhance the clinical services provided to these individuals through the service system in Vermont. This is attempted through a three-tiered service approach. Within the first level, prevention oriented services are provided. At Level II early intervention efforts are evident, and at Level III short-term community-based, crisis residential services are utilized. The network, in collaboration with all of the dedicated community agencies serving individuals with disabilities throughout Vermont, plays a vital role in the maintenance of the stability of the community system.
Level I: The Clinical Network
There are not enough highly trained clinicians practicing within Vermont to cover all of the agencies serving persons with developmental disabilities. Therefore, in order to reduce, and potentially prevent, crises throughout the state the level of clinical expertise within the agencies must be increased. This founding premise was true in 1991 when VCIN was started and it is certainly still true nine years later. There is only a handful of clinicians within Vermont who are capable of providing sophisticated clinical consultation concerning the challenging behavior and dual diagnosis issues presented by persons with developmental disabilities. The occurrence of crises, and especially the need for the relocation of a person with developmental disabilities from his or her home, can be dramatically reduced through the increasing of clinical competencies of the agency staff. A clear primary prevention orientation is evident within Level I.
For the first eight years of the program the primary service within Level I was the clinical network meeting. This monthly gathering allowed for the primary clinical staff from each agency to come together on a regular basis. This year, due to lagging participation, we have redesigned this service to focus upon small semi-annual conferences with a clinical focus. Other functions of Level I include trainings, which may take place at a community agency or may involve specifically selected participants.
Level II: On-Site Consultation
In order to reduce or prevent crises, competencies of clinical staff, direct service staff, and case managers can be increased through on-site consultation. Within Level II, expert clinical services are provided to agency staff at their location and in reference to a specific individual. Most of the Level II activity involves psychological or psychiatric consultation to teams addressing the issues of challenging behavior or dual diagnosis. This is clearly early intervention.
Level II consultation through the network involves a flexible but fairly consistent format. A referral may come from anywhere – state personnel, agency staff, parents, or others. The primary consideration is that the person being referred must qualify for developmental services within Vermont. Depending on the demands of the consultation, one or more of the professional staff may become involved. Some require both psychological and psychiatric expertise, but often the request is for one or the other. As is true in Level I, raising the competence of local staff is among the primary interests of our consultants at Level II. This is a bit more challenging at Level II, where the dynamics at play seem to try to force us into an expert role, dictating plans to staff. Yet, it is important that when the consultation is completed, the staff have learned new skills and have had their confidence raised in their own abilities to solve clinical issues.
After collecting some interview information from staff or case managers, we always spend a good deal of time reading the records of the consumer we are there to assist. Essential information about the history of the problem behavior is often contained in the record. This includes medical issues, medication histories, behavioral treatment histories, and psychotherapy notes. Following the record review our consultant usually spends a good deal of time observing and interacting with the consumer and his or her staff, family, and so forth.
After all of the information has been collected by the consultant, we convene a team meeting to discuss the situation. These meetings include direct care staff, home providers, case managers, and parents and/or guardians. It is in these meetings that an understanding of the situation is agreed upon by the participants and a plan is developed. Many times this phase of the process requires that the participants read a good deal of information about the problem behavior and potential solutions. Often direct service staff, parents, and service coordinators read very technical, clinical articles during this portion of the consultation. It is of the utmost importance that the plan be designed and agreed upon by those who must carry it out. Though there is often a great push to have the consultant devise and write the plan, a plan developed by a consultant is almost always doomed to failure. The people who have to implement the plan must be invested in it and this is best accomplished by their designing and writing it, with necessary assistance.
After the plan is developed and implemented it is important to have ongoing meetings to discuss problems, successes, and modifications to the plan. Depending on the situation, our consult- ants may follow a team for as long as a year, or may be done after a meeting or two. We provide consultations to approximately 50 individuals every year.
Level III: Residential Crisis Services
At times, for a variety of potential reasons, it will be necessary for an individual to leave his or her home. There-fore, for a full community system to operate properly, it is essential to have an alternative setting, offering safe housing, evaluation, and treatment.
Throughout the nine years of the VCIN program, we have had a steadily decreasing number of residential crisis options. In the first year of the program we operated two well-staffed, full-service crisis beds and we also offered four respite options which could accommodate individuals with less acute demands. These options were reduced until we were left operating just one bed in the summer of 1995. These decreases of VCIN resources were a direct result of the increased crisis capacities within the community agencies.
Located on a dirt road in the country, our crisis bed is a two-bedroom, two-story home where only one consumer at a time resides. It is staffed 24 hours per day by one VCIN staff person at a time. Approximately 3.5 full-time equivalent staff are required to operate it in a rotating shift pattern. While a person stays at the residence they are provided with as meaningful a day schedule as possible.
While residing in our crisis house an individual also receives the clinical services described in Level II. In order to facilitate continuation of treatment begun during a person’s stay with us, Level II consultation services are almost always provided in a follow-up fashion once a person leaves.
The sending agency staff, who retain the service coordination role, are responsible to attend a weekly clinical meeting regarding the person residing within the crisis house. The program tries to stick to a 30-day limit, although this is certainly flexible depending on the situation. Annually we serve from 10 to 15 people in this bed, with an average stay of about 22 days. We feel that through Level III we offer people who are in crisis a safe, humane, and clinically sophisticated environment in which they can become stabilized, receive evaluation and/or simply take it easy before returning to their lives within the community.
Dianne’s Story
For nine years the developmental disabilities service system within Vermont has collaboratively provided prevention, early intervention and crisis residential services to its residents with developmental disabilities, such as Dianne.* Dianne was a teenage girl who had experienced a traumatic life of abuse and multiple residential placements. We were called by an agency that was having trouble meeting her needs. She was living with a very dedicated couple who were struggling with some of her challenging behavior. Our Level II consultation to Dianne and her team followed the customary route, with record review, interviews, and observations. The main issue was that she had great difficulty controlling herself when she became upset about anything. Our consultant provided extensive training to Dianne’s team regarding issues of trauma and abuse, attachment, and anger control.
During the course of our consultation, Dianne engaged in some very destructive and aggressive behavior that resulted in her home providers deciding she could no longer live with them. The agency that served her did not have any crisis or respite options available, so they requested a stay at our crisis bed.
Dianne stayed in our Level III service for over a month. She was provided with different medication by our psychiatrist and received short-term anger control treatment. She responded well to her stay with minimal disruptive behavior.
A new agency began a search for a new home for her, and found two potential providers. Both spent time with Dianne, first at our house and then at their homes, and both were interested in having her live with them. Dianne had a stronger liking for one, and her guardian agreed that the home she had selected was a good choice. We began having Dianne spend more time at her potential new home, with some overnight stays. Finally, she moved in.
We continued to provide Level II follow-up services to Dianne and her new home providers. Her case manager had trouble finding a new therapist to continue the anger control treatments, so we offered to provide them until a new therapist was found. Dianne continues to do well in her new home with only minimal contact from VCIN.
* Pseudonym
Patrick Frawley is Director and Elia Vecchione is Consultant and Coordinator of Level III Services with the Vermont Crisis Intervention Network, Moretown. They may be reached at 802/496-7830 or by e-mail at Pjfrawley127@compuserve.com or evecch@aol.com.
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