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Behavioral and Crisis Services in California

by Gregory A. Wagner

With increasing rates of deinstitutionalization, resulting institutional closures, and mandates to use community referenced, “socially valid” procedures to manage and treat challenging behavior, community settings have come under increasing pressures to support people with challenging behavior in the least restrictive means possible. These realties are no different in California than anywhere else. Indeed, recent events have exacerbated these issues in California. These events include a class action lawsuit that increased the rate of deinstitutionalization and resulted in institutional closures. This article briefly describes the California service system and recent deinstitutionalization activities and consequences with regard to community behavioral and crisis supports.

The California Service System

In California, the Lanterman Developmental Disabilities Services Act entitles all persons with developmental disabilities in the state to receive appropriate services. This law also provides for the creation of a statewide regional center system. The regional center system consists of 21 private, non-profit locally-based centers with whom the state contracts. These regional centers are the point-of-entry into the developmental services system for the 58 counties in California. Their role in the system is to coordinate services and supports through generic agencies, or directly fund services and supports. In addition to individualized planning and service coordination, services provided directly by regional centers include assessment and diagnosis, information and referral, advocacy, and resource development. The state directly administers five institutions (developmental centers), and two smaller, specialized behavioral facilities, each serving 50-60 persons. Currently, the system serves over 160,000 persons, approximately 3,800 of whom are served in the state’s institutions.

In the late 1980s, Regional Resource Development Projects (RRDPs) were created at each developmental center to assist regional centers in developing and enhancing services and supports for persons moving into community settings. Each of these RRDPs consists of several state employees who fill a number of roles. For example, these projects monitor persons placed from developmental centers into community settings for the first year of placement, provide a variety of community training opportunities, and provide and/or assist in securing and coordinating clinical services.

Deinstitutionalization

The history of deinstitutionalization in California is very similar to national trends with regard to overall rate. Despite an overall downward trend, however, the developmental center census remained relatively constant from 1987 to 1992. In 1993, a class action lawsuit (Coffelt v. DDS) was filed against the Department of Developmental Services and four regional centers, alleging that too few community living arrangements were being created, resulting in people residing in unnecessarily restrictive institutional settings. A major requirement of the resulting settlement was the reduction in developmental center population by 2,000 people (from approximately 6,000) in a five-year period (1993-1998). This reduction actually took place in two and one-half years, well ahead of schedule. In the process, two centers were closed.

Crisis and Support Services

The increased rate of placement resulting from the Coffelt settlement mentioned above put increased pressures on community crisis and behavioral support systems. In anticipation of these pressures, the settlement included provisions for enhanced crisis intervention services. These provisions required each of the 21 regional centers to develop crisis service proposals. The proposals were based on an initial assessment of local and regional, public or private emergency and crisis services, and corresponding gaps in each geographic area. In addition, crisis proposals were developed through collaborative meetings with relevant agencies (e.g., mental health), providers, and consumers. Finally, the respective roles and responsibilities of the various agencies involved in providing crisis intervention services were delineated (i.e., who is responsible for providing and/or paying for specific services). Plans included provisions for crisis intervention teams, emergency housing, and regional center after-hours response systems.

In 1998, many of these and other provisions were written into law. For example, if a consumer’s placement is failing and admission to a developmental center is likely, the state must arrange for an immediate assessment of the situation, and ensure that the responsible regional center provides necessary emergency services and supports, and convenes an Individualized Program Plan (IPP) meeting of the individual’s service coordinator, service providers, family members, and other key persons as soon as possible. Additional language was written into law to focus on persons with dual intellectual and psychiatric disability diagnoses. These requirements included memoranda of understanding (MOUs) between each of the 21 regional centers and the local county mental health agencies. These MOUs: (a) identify staff in both agencies who are responsible for identifying consumers with dual diagnoses “of mutual concern” and coordinating services for those persons; (b) include a crisis intervention plan with after-hours emergency response capability; (c) include procedures for joint clinical and discharge planning for persons admitted to inpatient mental health facilities; and (d) provide for training of residential and day program staff regarding effective services for persons with dual diagnoses.

Within these general systemic requirements of emergency and crisis services outlined above, a variety of specific preventive and reactive strategies have been implemented. Some examples of specific strategies and activities include:

• Some regional centers have developed consumer “risk profiles” to assist service coordinators and providers in predicting and intervening at early stages of potential behavioral crises. These profiles include environmental antecedents and behavioral precursors predictive of crises.
• Regional centers often maintain lists of behaviorally high-risk consumers, with information on effective strategies with each consumer, and local crisis and emergency services. This information is typically provided to on-call staff via laptop computers.
• Regional centers commonly hold routine multidisciplinary staff meetings to identify at-risk consumers, develop individual crisis plans for those consumers, and problem-solve current difficult cases (e.g., consumers who are at risk of relocation, especially admission to a developmental center; incarcerated; in a psychiatric hospital). In addition, some have internal intensive support services units or pre-crisis screening teams.
• Many regional centers provide enhanced service coordination (i.e., reduced caseloads) for consumers who have been recently placed into community settings from developmental centers and/or have extremely challenging behavior.
• While regional centers primarily coordinate and/or broker necessary services and supports, recent funding has provided for the addition of clinical teams to the centers, allowing for the provision of increased direct services by regional centers staff (e.g., behavioral, medical, and psychiatric). Also, regional center service vendors (behavior analysts, pharmacists, psychiatrists, including University Affiliated Programs) provide additional clinical services.
• In addition to regional center staff and vendors, state development center and Regional Resource Project staff provide clinical outreach services (e.g., behavioral consultation, medication review), training (e.g., managing aggressive behavior, teaching new skills), and technical assistance (e.g., meeting regulatory requirements, obtaining needed resources). Also, developmental centers have university-based psychology internship programs in which interns, under the guidance and super- vision of a developmental center psychologist, provide assistance in transitioning people into the community, and in community behavioral services for consumers whose challenging behavior threatens their placement. These services include functional assessments, development of behavioral plans and strategies, direct therapeutic interactions, and staff training and consultation.
• Interagency collaborative meetings are held in some parts of the state, with participants from regional centers, mental health, criminal justice, and so forth, and training opportunities, workshops, and seminars are provided to those agencies, providers, and families regarding behavioral, psychiatric and crisis issues.
• Telemedicine (e.g., psychiatric and psychotropic medication consultations) has been effectively incorporated into some rural locations, and its use continues to increase.
• Enhanced staffing (including one-to-one with corresponding plans to fade the staff) may be used.
• Peer mentors have been arranged for providers and families with behaviorally challenging consumers.
• Person-centered planning is now required by law as a framework for developing IPPs.

To evaluate the overall quality of services and supports, and consumer satisfaction with those services and supports during the implementation of the Coffelt settlement, a longitudinal study of a sample of class members was conducted. With respect to reported satisfaction with behavioral and crisis services, supplemental supports (e.g., in-home behavioral consultation and intervention, enhanced staffing, etc.) and regional center after-hours phone response tended to get the highest ratings across years, while (not surprisingly) incarceration and emergency rooms received the lowest ratings. A small percentage of people also indicated needs for greater access to mental health counseling/therapy, including access to psychiatrists, and medication adjustment.

Summary

Supporting people with significant challenging behavior and psychiatric needs is difficult in any setting. The supports and services described in this article share many elements with successful models elsewhere. As the trend toward full community inclusion continues, the need for effective, community behavioral services and supports, and psychiatric interventions, will only increase.

Gregory A. Wagner is Senior Psychologist with the California Department of Developmental Services, Sacramento. He can be reached at 916/653-0805 or by e-mail at gwagner@dds.ca.gov.

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Citation: Hanson, R., Wieseler, N., & Lakin, K. (2000). Impact: Feature Issue on Behavior Support for Crisis Prevention and Response, 14(1) [online]. Minneapolis: University of Minnesota, Institute on Community Integration. Available from http://ici.umn.edu/products/impact/141/.

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