Information About Minnesota
Understanding Minnesota Requirements
Current best practices have advanced to embrace person-centered practices that are assist people in their integration in all aspects of community life. This is true for all persons, including persons with disabilities. Consistent with these advancements, the Minnesota Department of Human Services agreed in a landmark settlement agreement to ensure that all of its licensed services incorporate positive support strategies.
Shortly thereafter, the Minnesota State Legislature formalized this promise in a statute directing the Department to require positive support strategies in its licensed services.
Minnesota Statutes Chapter 245D
In 2012, the legislature adopted Minnesota Statutes, chapter 245D, replacing law that previously governed home and community-based services. In regards to positive supports, chapter 245D did two things: first, it established prohibitions and limits on the use of aversive and deprivation procedures, including mechanical restraint, seclusion, chemical restraint, time out and programmatic use of manual restraint; and second, it required the use of positive support strategies.
Positive Support Rule
To fulfill the settlement agreement obligations and legislative directives, the Department also proposed a rule to govern positive support strategies for all licensed settings and services and, for providers not already governed by chapter 245D, applies the prohibitions and limits of that chapter to those non-245D licensed services.
Minnesota Olmstead Plan
The United States Supreme court ruled that the Americans with Disabilities Act (ADA) requires states provide services to people with disabilities in the “most integrated settings” appropriate to their needs. An Olmstead Plan is provides a way for a state to outline a clear plan of action to ensure that people with disabilities are able to live in integrated community settings.
The Minnesota Olmstead Plan was developed as part of a settlement agreement related to the Jensen et al v. Minnesota Department of Human Services, et al. Court File No. 09-cv-1775. A Minnesota Olmstead subcabinet committee was formed in 2013 to oversee implementation of this plan.
Defining Positive Supports
The term Positive Support refers to strategies and practices that are:
- Person-centered in nature, sensitive to unique cultures and backgrounds of each individual, and respectful towards people receiving these supports;
- Evidence-based or promising practices;
- Adapted and improved over time using assessment processes to guide use; and
- Often implemented with more than one evidence-based or promising practice as part of a team-based approach.
One way to think about positive support practices is to consider if from the Three-Tiered Model of Positive Supports. The figure below describes how this model addresses the prevention of mental health issues and the occurrence of challenging behavior across three levels by improving quality of life.
When a vision that is articulated by a group of people is made a part of everyday actions taken within an organization, county, region, and state-wide, significant and meaningful work can be achieved.- Fullan, 2005.
Tier 1 includes universal strategies for supporting all individuals in a home or community. The goal at Tier 1 is to implement strategies for social and behavioral health across all persons. Tier 2 includes early identification of problems that may be occurring with simple strategies for addressing social behavior or mental health issues. Interventions at Tier 3 are used to address chronic and severe challenging behaviors or mental illness. Positive support practices used in organizations address different prevention levels. Multiple positive support practices may be needed to prevent mental illness or challenging behavior.
Examples of Positive Supports Include:
- Applied Behavior Analysis
- Assertive Community Treatment
- Cognitive Behavior Therapy
- Dialectical Behavior Therapy
- Person-centered Thinking and Planning
- Positive Behavior Support
- Systems of Care
- Wraparound Planning
- Trauma Informed Practices
- Multisystemic Therapy
- Response to Intervention
- Examples of Positive Supports include:
Implementing Positive Supports
Dean Fixsen and his colleagues completed an interagency review of research related to implementing evidence-based and promising practices in 2005. This review provides a framework for implementing large-scale technical assitance and training efforts. Programs and projects in mental health, education, intellectual and developmental disabilities, juvenile justice, and related human services were evaluated in this synthesis. Read Implementation Research: A Synthesis of the Literature by Dean Fixsen and Colleagues (2005).
In this research synthesis, key elements were identified that are associated with the successful implementation of evidence-based and promising practices. Schools and school districts, organizations supporting persons with disabilities, and mental health centers across the United States are using these systems change strategies to improve implementation outcomes. The systems change strategies describes by Fixsen and his colleagues are referred to as Implementation Science.
Organization-wide, School-wide, Facility-wide, and Center-wide systems Change
The goal of positive support an an organizational level is to first form a team that will work together to assess the strengths and needs of an organization. The team will represent all of the different types of individuals involved including those receiving services, staff members, administrators, family and community members to work together to solve problems. The types of problems that are identified will guide the group to select a positive support practice. Together, the team uses the information gathered to share the decision making process with everyone. Consensus building and buy-in increases when all individuals within a setting contribute to important decisions that are made. Empowering all individuals to work together to use information collected for progress monitoring and systems change helps improve outcomes. Celebration of success using the information gathered provides a powerful model for building community.
Organization-wide teams choose to participate in positive behavior support knowing it requires a long-term commitment. Administrator leadership and direct participation is essential to the change process. Buy-in and consensus-building using a team approach with all individuals (people receiving services, staff, management, family members, etc.) within a particular setting increases the likelihood of effective implementation. Regular team meeting processes employ the use of data to drive action planning over time. Positive recognition and reinforcement are used to acknowledge the hard work of systems change efforts.
Assessing Best Practices
Assessing best practices means that we are gathering information about the positive support we are using and gathering information about:
- measuring quality of life
- assessing changes in challenging interactions
- reviewing how well the practice is implemented (fidelity)
Organizations implementing one or more positive support strategies will use information that is already being collected to assess whether any positive changes are happening to people receiving services. Some additional forms of data may need to be added in order to evaluate the effectiveness of new positive support practices. The team working on the plan to implement a positive support will need to use two types of evaluation:
Formative Evaluation: Assessing a practice during implementation in order to improve its effectiveness.
Summative Evaluation: Understanding the impact a positive support practice has had over time.
An organization-wide planning team will identify key outcomes expected from the positive support practice that is selected. Multiple measures are used to evaluate the effectiveness of a positive support practice. Some of these measures are used to evaluate each individual receiving services while other measures assess related outcomes.
Each organization-wide team will identify the types of data that will provide information needed to evaluate the types of positive support practices.
Evaluating Positive Support Outcomes
- Quality of life
- Satisfaction with supports
- Attendance in work, school, therapy sessions and/or important activities
- Social and regulation skills
- Incidents reported
- Restraint/restrictive procedures
- Improvement in individual plans
- Performance assessment
- Worker compensation
- Staff satisfaction/staff stress
- Staff attrition/injury/sick days