Mitigating Risk Webcast PD 092514 - Amazon S3€¦ · improve the unsteady gait. Mitigating risk...

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Course Number 014‐08‐01

Foundations of Recognizing and Mitigating Risk (PD)

This webcast includes spoken narration.

To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation.

The written version of the narration appears to the right of the screen.

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Certificates of Achievement will be available to SCs and SC Supervisors after completing all course requirements. Please view and then save or print your certificate in order to receive credit for this course.

For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and post‐test.

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Hello and thank you for viewing this webcast that provides an introduction to the SupportCoordinator’s role in recognizing and mitigating risk. My name is Sonya Hipple and I work for the Office of Developmental Programs as the Supports Coordination Organization (SCO) Lead in the Central Office. I would like to welcome you to this webcast.

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At the end of this webcast, you will be able to:

• Define key terms including risk and risk factors;

• Recognize your responsibility to promote choice and protect health and safety;

• Identify common risk mitigation strategies; and

• Document risk and risk mitigation discussions and strategies.

This training provides a foundation of risk, risk mitigation, and the SC’s role.

ODP is planning more in‐depth trainings to occur during the 2014 calendar year to enhance the SC’s ability to identify risk, work with the team to mitigate risk, and properly document these activities.

I will now turn this presentation over to a representative from the ODP Consulting System who will be your presenter for the rest of this webcast.

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Hi, I am Sharon Lipscomb.

Throughout this webcast a slide may include links to directly access what is being discussed. These links are also available in the resources section of where you launched this webcast.

To get us started, let’s review the mission and vision of ODP and talk a little about values.

The mission of the Office of Developmental Programs (ODP) is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice, and opportunity in their lives.

ODP’s vision is to continuously improve an effective system of accessible services and supports that are flexible, innovative and person‐centered.

Everyday Lives is the core philosophy and framework of ODP. The fundamental concept of Everyday Lives is that, with the support of family and friends, individuals with disabilities decide how to live their lives and what supports they need.

As an SC, you should be familiar with Everyday Lives and how you can make the principles a reality for those you serve. Central to the understanding of risk identification and mitigation are the concepts of choice, freedom and participant rights.

As part of the Chapter 51 Home and Community Based Services regulations, ODP issued a statement of policy detailing participant rights. The rights under Chapter 51.17 (b) are:

(1) A participant shall be treated with dignity and respect.

(2) A participant may not be discriminated against because of ethnicity, religious affiliation, disability, ancestry, national origin, age, gender or sexual orientation nor be deprived of civil or legal rights.

(3) A participant has the right to be free from abuse, neglect and exploitation and has the right to report abuse, neglect or exploitation.

(4) A participant has the right to voice complaints or concerns about treatment or services.

Individuals we support have all of these participant rights, as well as the same rights as you and I. When an individual puts him/herself at risk, that’s where supporters may need to step in. A challenge we all face is supporting individuals to gain more experience making choices while also educating them about what can happen as a result of those choices.

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Every choice has the possibility of a risk associated with it.

As stated in Chapter 51.3 Definitions, “risk is the likelihood of some undesirable event or negative outcome occurring to a participant.”

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Every human endeavor has some level of risk.

Think about the risks in your life, like walking down the street, driving to work in a car, or eating lunch from a new restaurant.

Why do you take these risks? Why do you make these choices? You make choices and take risks based on what you want and need in your life and your past life experiences.

As an SC, it is your responsibility as part of an individual's team to ensure that the potential risks associated with choices are discussed to support the individual in making informed decisions.

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Risk mitigation is an overall approach to prevent, reduce, and manage the severity of risk.

Risk mitigation is an ongoing process that requires attention to a person’s natural lifecycle.

When people are living Everyday Lives, exposure to risk can change daily.

This requires the team to regularly re‐examine risk mitigation plans and strategies to ensure that they are meeting the current needs of the individual.

As a Supports Coordinator, you are responsible to work with the entire team to develop mitigation strategies and plans, ensure implementation of the plans, monitor for effectiveness, and update them as needed.

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The ability to make choices, succeed or fail, and learn from the process is how a person shapes their worldview and creates a life of their own.

People have the right to make choices and you will find that just like in your own life, some of the choices will have positive results and some will have negative ones. As an SC, it may become tempting to try and restrict a person’s ability to make choices in order to protect them from any harm. It is important to realize that making choices, even ones with possible negative results, is part of achieving an Everyday Life.

Your role as an SC is knowing how best to support the people you serve through their unique life experiences. This means being a part of a person’s team to help them recognize a risky situation, do your best to make sure they understand the risks associated with that situation, and to identify the perceived consequences of taking that risk so that they can make an informed choice and navigate through that risk.

Think about what you consider to be a “perfect” life. Do your friends, your family, your co‐workers have the same idea of what’s “perfect”? Probably not and they have most likely shared their idea of a perfect life as they see it for you. While you may appreciate their advice, you have the choice to live your life the way that you want. This is also true of the individuals you serve.

The team cannot impose their concept of a “perfect” life on an individual. The team must allow individuals to make their own choices every day, even if some of them seem detrimental to their health and welfare. However, when there is a possible serious health and safety risk, it is the team’s responsibility to step in and assist the individual in mitigating risk factors. It is your responsibility as part of the team to know when to intervene when consequences present a serious risk to health and safety of the individual.

Not all individuals you serve are willing or able to actively make choices about all aspects of their lives. The team should be careful in making decisions based on what they think a “perfect” life would be for that person. Rather, they should use their knowledge of the person to help the team craft a person‐centered plan that includes evidence that risks have been discussed and strategies going forward are based on informed choices.

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Health and safety is everybody’s responsibility.

Supports Coordination activities are most effective when you utilize an ISP team that is tailored to the needs of the individuals you serve. The team can also be considered a “safety network” for people and the members can vary greatly from person to person depending upon their life circumstances.

Individuals can include anyone they want in their safety network. Some common examples of who to include are: Family, Friends, Advocates, Law Enforcement, Service Providers, Supports Coordination Organizations (SCOs), Administrative Entities (AEs), community members, co‐workers,medical professionals, support groups, church members and teachers.

Based on this, there are many people that share in the responsibility to protect health and safety. Part of this responsibility is recognizing and mitigating risk. The expectation is that you will work with the team, the community, and any other relevant resources to make every effort to ensure that prompt actions are taken so that risks to health and safety are mitigated.

There is often conflict when team members have differing opinions about the decisions a person makes or a decision that should be made on behalf of a person. You as an SC need to keep in mind at all times that you are responsible to protect the health and safety of those you serve regardless of the conflict that may arise when you attempt to implement plans or strategies to that effect. You may need to build upon your skill set so that you know when to intervene when the potential or actual consequence of a choice represents a risk to health and safety that requires mitigation. Thisoften involves negotiating with multiple members of the individual’s team. Negotiation skills will be explored in future trainings.

You may be concerned that your personal safety may be at risk when you are attempting to protect the health and safety of others. ODP does not expect you to put your personal health and safety at risk. Please talk to your supervisor about your SCO’s policies and procedures regarding potentially dangerous situations.

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Risk factors are attributes, behaviors, health conditions, features of the environment, actions, events or other determinants that increase the probability of an incident or negative result for a participant. For example, two risk factors for an individual falling are dirty eye glasses and an unsteady gait.

Some risk factors are more easily mitigated than others. In thinking about falls, it may be possible to reduce the risk of falling by supporting the individual to clean his glasses. It may be more difficult to improve the unsteady gait. Mitigating risk factors is important in order to lessen the likelihood of risk.

However, despite best efforts, some risk factors will always be present no matter what you do, such as a family history of diabetes or heart disease.

It’s important for you to understand how risk factors work together to create risk for the person. Thinking about the person’s environment, their personal history, and the actions they take gives you important information about risks for the person. You can never entirely eliminate all risk, but you may be able to mitigate some of the risk factors in order to reduce the level of risk for the person.

For example, Bob is 62, has a family history of diabetes, is overweight and loves sweets like candy and pie. You can work with Bob and his team to manage his weight and eat a healthy diet to lessen his risk of getting diabetes, but you will not be able to change his family history.

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The way we treat risks depends on how we link risk to our own lives, experiences, and the things we value.

Since each person has their own perception of risk there is a tendency to create assumptions about risks and their potential negative impacts on a person’s life.

As an SC, you may receive just bits and pieces of information instead of getting all of the facts on the subject and you may base your risk interpretations on this limited information. It is important not to jump to conclusions before having all of the facts.

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For example:You are at an in‐home monitoring visit for Kathy, who lives with her family, where medication documentation is not required. You ask Kathy if she has had any medication changes. Kathy hands you all of her medication bottles. Since you have access to the labeled medication bottles, you can see the date when the medication was last filled. This may give you a sense of if the medications are being taken on a regular basis.

You notice on the first bottle she hands you that the medication label indicates the date it was filled was six months ago. You immediately think that Kathy’s health is at risk because it seems that she has not been taking her medications as prescribed. Further questioning can help you determine if this is the case. You ask Kathy about the medication and the date it was last filled. Kathy tells you that she just got the medication filled last week. After further discussion, she explains that she has been transferring medications from the newly filled bottle to an older bottle she had saved because she finds the older bottle easier to open. Kathy says her hands have been hurting her lately and the pharmacy changed the style of cap on the bottle which is why she has been using the older, easier‐to‐open one to store her medications.

The perception of the risk in this example changed when the SC took the time to talk to Kathy. The SC found that the risk factors that need to be addressed are different than initially thought because additional information was gathered. The SC can now focus on helping Kathy address the pain in her hands as this will require a different mitigation strategy than not taking her medications as prescribed.

As an SC, your perception of risk and risk factors will influence the lives of those you serve. It is important to make sure you ask questions, gain clarification and use that information to try and understand the situations you encounter on the job.

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People spend their entire lives building a knowledge base that helps support their risk perceptions. It is not possible for any two people to have the same exact risk perceptions for all things in life. This is important to keep in the back of your mind when you are working with individuals and their team, because it will help you to understand how members of the same team could arrive at vastly different conclusions about a topic.

When teams do not share the same relative values and risk perceptions, there is the possibility that assumptions made during the risk mitigation process may create a rift between team members that does not allow them to reach consensus. People on the team may begin to see each other’s views as illegitimate, invalid or completely off base when it comes to taking action to mitigate a risk. It is your job as an SC to help a team come together, explore these differences, and still mitigate risk.

You also need to be aware that as technology has advanced and people have gained greater access to information, there has been an increase in the ability to become misinformed about subjects. This age of misinformation has begun to shape risk perceptions across the globe and will most likely be something that you encounter on a regular basis.

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For example: You are at a home monitoring for Dwayne. Dwayne’s mother says she has been reading on the internet that you can put honey directly on wounds in place of antibiotic creams since they both have the same anti‐bacterial properties. You continue to talk to Dwayne and his mother and you find out that his primary care physician has prescribed an antibiotic cream for a pressure ulcer on Dwayne’s right hip. You know that pressure ulcers are damaged skin and tissue that is often a result of staying in a position for too long. You also know that pressure ulcers can cause serious life‐threatening infections if not treated per doctor’s instructions. Dwayne’s mother says that she is not giving him the prescribed antibiotic cream because she wants to treat the pressure ulcer naturally with honey.

It may be safe to assume that Dwayne’s mother is misinformed about the healing capabilities of honey which is placing Dwayne at serious risk of harm. As an SC, it is important that you can recognize when a team member’s knowledge may have been compromised by misinformation. In this situation, you may have similar values with regards to the use and application of medications but that does not mean that it is appropriate to disregard the recommendations of the doctor. For the purposes of the work you do, it is not your job to take your own risk perceptions and values and place them upon the individuals you serve. It is your job to be supportive of strategies that are based on “verified” information about the topic in question. For example, it is generally accepted that medical professionals such as doctors, nurse practitioners and physician assistants are able to give medical instructions and recommendations that are considered to be the appropriate course of action for a medical condition.

If you were Dwayne’s SC, you would want to talk with Dwayne and his mother about using honey and see if they’ve discussed this choice with Dwayne’s doctor. You could offer to support Dwayne and his mother in calling the doctor during the monitoring visit. If Dwayne’s mother is not receptive to your assistance, you need to immediately contact your supervisor as this is a life‐threatening health and safety situation for Dwayne. In this situation, you must act to protect Dwayne’s health and safety; documentation is not enough. Risks that pose an immediate threat to health and safety must be mitigated upon recognition.

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Since our perception of risk and what is considered to be risky varies from person to person, each of us has different views on how much risk is ok in our lives. For some of us, riding roller coasters is a fun form of entertainment. For others, roller coasters are far too risky and we choose not to ride them and to keep our feet on the ground.

The individuals and families that we support also may have different views on how much risk is acceptable to them. In our role as supporters, we need to discuss how much risk is acceptable to each individual and support choices that are in alignment with their level of acceptable risk. Navigating levels of acceptable risk is a delicate balance and needs to be part of the team discussion for each individual.

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Risk mitigation is both a proactive and reactive activity that is most successful when the entire support team is engaged. Regardless if the focus of the planning is proactive or reactive, there are several common approaches to risk mitigation.

Many risk mitigation strategies and plans include one or more of the following methods of mitigation:

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Removal of exposure to a risk factor. Things like the removal of lead paint from a home before you move in could be considered a proactive risk mitigation strategy. Suspending a staff person who is accused of abuse can be considered an effective reactive risk mitigation strategy.

Transfer one risk factor for another less “risky” option. This method could include a proactive approach like offering an individual with diabetes a sugar‐free cookie instead of a regular cookie or a reactive mitigation approach, such as a medication change after intense negative side effects were recognized.

Isolate the person from the risk factor. This is a common approach for risk factors that cannot be easily avoided because exposure to some risk factors is necessary to live an Everyday Life. Let’s talk through an example. Prader Willi is a genetic disorder that causes a chronic feeling of hunger that can lead to excessive eating and life‐threatening obesity and death. When a person has Prader Willi and a restrictive procedure plan is developed that allows for limiting access to food, this is a proactive isolation because you are preventing a person from eating food until they become ill. A reactive isolation would be a situation when a person needs to have their access to poisons in the home, such as cleaning products, limited by locking them because they have begun to seek out and consume these dangerous items. In both these situations, the risk factors are things that the person will most likely need to have in their home to maintain a normal life.

Finally you can train or inform the person how to more safely be exposed to the risk factor if it is something that is not able to be removed, transferred or isolated from the person. A proactive approach to this would be providing a person with training about how to be safe in the kitchen around hot stoves. Things like turning the handles of pots and pans inward so they do not stick out and get knocked over would be a mitigation strategy to help a person more safely enjoy time in the kitchen. A reactive approach to mitigation would be to provide sexual education to a person who has begun to have relationships of this nature. Since the person has decided that they are willing to be exposed to the risk associated with a sexual relationship, the only mitigation strategy that can support their choice in this scenario is to provide training and information related to this activity.

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It is important to note that once risk mitigation plans and strategies are implemented, there is always the chance that the team may find themselves presented with a new risk as a consequence of the mitigation of another.

For example, Leona needs to limit her intake of all fluids due to a medical condition that, if left untreated, would make her at high risk for seizures and death. The team meets to come up with a plan of mitigation that involves increased supervision around fluids, training Leona on her medical condition so that she understands what could happen if she drinks too many fluids, and a restrictive procedure that allows the refusal of access to fluids in certain situations.

The team begins to implement this plan and has found that despite their diligent supervision, education, and restrictions, Leona has begun to have seizures as a result of her fluid intake. The team meets again to try and figure out why their mitigation plan for this risk is not working. One of the team members has noticed that Leona has been spending more time in the bathroom lately than she had in the past. Some of the team members assume that Leona is getting access to water via the sink in the bathroom. During this team meeting, Leona states that she has not been drinking water from the sink in the bathroom, because when she turns on the water at the bathroom sink, it is noisy. She reports that staff often hear this noise and come to check what is going on. So instead of getting water from the sink, she has been drinking out of the toilet.

In this example, the team has been proactive by planning ahead for the issues related to the consumption of liquids but now they are faced with the need to create a reactive mitigation plan in response to the new risk that has been identified.

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When working with the team, brainstorming, making decisions, and creating mitigation plans to keep someone safe and healthy, we need to ensure that we are planning for the least restrictive alternative environment for the person to safely and effectively address their needs and preferences. We also need to ensure that the alternative environment is in an integrated setting that enables the person with a disability to interact with people who do not have disabilities.

Taking risks can enhance the quality of an individual’s life as risk taking may lead to new experiences and learning. We need to keep in mind the value of taking risks as we are planning with the individual, family, and other team members.

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Part of the SC’s responsibility is to document the services they provide to individuals. Documentation includes Service Notes, Individual Monitoring Tools and the Individual Support Plan (ISP). It is important that the SC document not only the risk, but also the steps that the team took to mitigate any risk factors.

The ISP plays an important role in documenting risk. The Health and Safety section of the Annotated ISP states that “For any identified risk, address the level of supervision needed for the individual’s safety and record it in Supervision Care Needs. If a review of incidents is specific to a health and safety focus area, then address that particular issue in that focus area. For example, document fire setting in the ‘fire safety’ focus area.” This section is where ODP expects to see any risks that an individual has and the team’s consensus on how the risk will be mitigated.

During ISP meetings, the team should be discussing whether there are any unmet needs that are resulting in risks. If the person has needs that are not being met and the person is at risk, the team process must ensure that resources and supports that would meet the needs are being provided.

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Let’s talk about this using the example of smoking. An SC may document in the Service Notes that during a team meeting for Endi, the team talked to Endi about the health risks associated with smoking, agreed to schedule a doctor’s appointment for Endi so that he can talk with his doctor about smoking, and that this will be discussed again at the quarterly meeting. The service note states that Endi is making an informed choice to keep smoking. In the monitoring tool, the SC might note this as an issue under the question –“Are all the individual’s identified health care needs being addressed?” and how Endi is aware of the risks but chooses to continue to smoke. These risk mitigation strategies would also be documented in the Health and Safety and Health Promotions sections of the ISP.

It is not enough to simply document the recognition of a risk or risk factors in an individual’s record. The team must recognize how all risk factors present in an individual’s life work together to create a risk. Once the risk has been identified, then mitigation of that risk can occur. Protection of health and safety cannot occur without mitigation. The entire process from discovery of risk through mitigation must be documented.

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Health and safety protections, like the ones we’ve discussed in this webcast as related to recognizing and mitigating risk, are not new to Pennsylvania. As a Supports Coordinator, you have access to many tools that can assist you to ensure that you are well‐prepared to tackle the challenges that occur in the lives of the individuals you serve. Mitigating risk is for everyone, not just people receiving waiver services. This includes waiver, base, SC services only, ICF/ID, etc.

If the tools listed on the slide are understood and utilized effectively, they can help craft an effective support system for people that can minimize and mitigate risk.

Just about every ODP bulletin has a health and/or safety component.

Some bulletins that focus on this area are included on the slide.

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The Chapter 51 regulations also include information about health and safety.

Some sections of the Chapter 51 regulations to reference include §51.17. IncidentManagement, §51.17(a). Participant rights, §51.18. Risk management, and §51.28. SCO requirements for Consolidated and P/FDS Waiver.

The Consolidated and Person/Family Directed Support Waivers are also good resources.

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There are various ways in which we assure that risks are being identified and that steps are being taken to address and mitigate those risks. In essence, we have processes in place that operationalize risk mitigation. We also have processes in place to measure that risk mitigation is being implemented.

Service notes are a mechanism to document the identification of risks and risk factors, the follow‐up action needed to mitigate the risk and risk factors (inclusive of development and documentation of risk mitigation strategies), and the monitoring of risk mitigation strategies. You can access training on service notes by clicking on the link on the slide.

SC Monitoring‐Individual Monitoring Form:

Any of the questions in the SC Individual Monitoring Form could help to identify a risk and the need to develop, document, implement, and monitor risk mitigation strategies. More detailed information can be put in the health and safety, incident management, and barriers to accessing needed medical/behavioral supports questions.

Individual Support Plan: The best way to identify and mitigate risk is to have a true person‐centered plan. The annotated ISP provides very specific direction related to discussion about choice, preferences, and health and safety needs and outlines expectations about what needs to be documented in the ISP to assure it’s implementation. The ISP is also the place to document risk mitigation strategies.

Incident Report – Corrective Action: The Corrective Action section of the Incident Report contains areas and strategies to prevent reoccurrence of incidents and mitigation of future risk factors.

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This training provided an overview of risk, risk mitigation, and the SC’s role. ODP is planning more in‐depth trainings to occur during the 2014 calendar year to enhance the SC’s ability to identify risk, work with the team to mitigate risk, and properly document these activities. ODP will be sharing more information about these trainings as it becomes available.

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This webcast has been developed and produced by the Office of Developmental Programs

Consulting System on behalf of the Pennsylvania Department of Public Welfare, Office of

Developmental Programs.

Thank you for participating in this lesson.

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Mitigating Risk Webcast PD 092514 - Amazon S3€¦ · improve the unsteady gait. Mitigating risk...

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