PromotingAlternativestotheUseofSeclusionandRestraint
IssueBrief#4Making the Business Case
MARCH2010
About theSeries:
PromotingAlternatives totheUse ofSeclusionandRestraint
The SubstanceAbuse and Mental Health ServicesAdministration (SAMHSA) has developed, in collaboration with partners at the Federal, State, and local levels, consumers, and national advocacy organizations, a series of issue briefs on the use of seclusion and restraint. The purpose of this
series is to provide information on the use of seclusion and restraint throughout the country, efforts to reduce their use, and their impact at the individual/family, program, and system levels. For an overview of the background and history of the initiative to reduce the use of
seclusion and restraints, please refer to the firstissue brief in the series, entitled PromotingAlternatives to
the Use of Seclusion and Restraint— Issue Brief #1:ANational Strategy
to Prevent Seclusion and Restraint in
Behavioral Health Services, which
is available at gov/matrix2/seclusion_matrix.aspx.
Introduction
Seclusion1andrestraint2arecoercive,high-riskcontainment proceduresthat contributetotheproblemofviolenceagainstconsumersandstaffmembers inbehavioralhealthcaresettings.Infact,anestimated50to150individuals dieeachyearasaresultofseclusionandrestraintpracticesinfacilities,and
countlessothersareinjuredortraumatized(Weissetal.,1998).Thesepractices aredetrimentaltotherecoveryofpersonswithmentalillnessesandadversely affectthequalityofcareandthesafetyofallinvolved(diMartino,2003; HuckshornLeBel,2009).Equallyimportant,yetoftenlessrecognized,is
themultileveleconomicburdenthatisinherentintheiruse(Flood,Bowers,& Parkin,2008;LeBelGoldstein,2005).
Basedonclinicalbestpractice,inpatientandresidentialmentalhealthfacilities intheUnitedStatesandothercountrieshaveimplemented initiativestoreduce seclusionandrestraintuse(NationalAssociationofStateMentalHealth ProgramDirectors[NASMHPD], 2009;Nunno,Day,Bullard,2008).Several programsthathavereducedtheirusehavereportedfiscalbenefits(LeBel& Goldstein,2005;MurphyBennington-Davis, 2005;Sanders,2009).These
facilitieshavechangedtheirorganizationalculturesandpracticesandreportthat benefitsandsavingsexceedthecostsassociatedwiththeuseofseclusionand restraint(LeBel,2009).Giventhepotentialsavings,healthcareorganizations shouldreconsiderreducingseclusionandrestraintfroma“bestbusiness practice”imperative.
Thisissuebrief,thefourthinaseries,providesasummaryofarecently developedwhitepaper,TheBusinessCaseforPreventingandReducing RestraintandSeclusionUse,authoredbyJaniceLeBel,Ed.D.fortheSubstance AbuseandMentalHealthServicesAdministration (SAMHSA).Thepaper
describesthesystemic,organizational,andpersonalcostsoftheuseofseclusion andrestraintpracticesaswellascostsavingsrelatedtoreductionintheiruse.
·
U.S. DEPARTMENTOF HEALTH AND HUMAN SERVICES
SubstanceAbuseandMentalHealthServicesAdministration
TheCostofSeclusionandRestraintUse
Althoughthefiscalcostofviolenceagainststaffmembers
(workplaceviolence)hasbeenwell-studied, onlyrecently
hastherebeenanexplorationofthecostsofviolenceagainst consumersassociatedwithseclusionandrestraint(Cromwell etal.,2005;Floodetal.,2008;Huckshorn,2006;LeBel& Goldstein,2005).Thissectionoftheissuebriefwillexamine costsassociatedwithseclusionandrestraintatthesystemic, organizational,andpersonallevels.
SystemicCosts
Thesystemiccostsofseclusionandrestraintarethelarger economicbasesofhealthcarecosts,whichincludeworkplace violenceandorganizationaldisruptionsuchasdecreased productivity andrecruitmentandretentionchallenges.Systemic costsalsoincludepreventableadverseeventsormedicalerrors thatmayfollowseclusionandrestraintuse.Acrosshealthcare, medicalerrorsareaveryseriousproblempotentiallyclaiming
upto98,000livesandcosting$29billionannuallyinhealthcare (InstituteofMedicine[IOM],2000).Psychiatrynowrecognizes seclusionandrestraintasmedicalerrors“…ofcommission, perhapserrorsofomission,causingeithernearmissesor preventableadverseeventsinroutineclinicalpractice”(Grasso
etal.,2007).
TheFederalGovernment, severalStates,andsomeprivate insurersareadoptingnewparametersforcompensating care resultinginmedicalerrorsorhospital-acquired conditions. Specifically,certain“NeverEvents”willnolongerbe compensated (CentersforMedicareandMedicaidServices (CMS),2008;NationalQualityForum,2006;andUniCare,
2008).“Neverevents”aredefinedbyCMSaspreventable adverseeventswithseriousconsequences forthepatient
thatshouldneverhappeninhealthcare(CMS,2008).These “NeverEvents”includetwooccurrences relatedtoseclusion andrestraintuse:(1)deathorseriousdisabilityassociatedwith restraints,and(2)deathorsignificantinjuryresultingfroma physicalassault.Theimpactofthisdecisionissignificant,as publicfundingrepresentsroughly40percentoftherevenue
formentalhealthtreatmentfacilities(U.S.Government
Accountability Office,1999b).
Organizational Costs
Seclusionandrestraintsignificantly increaseanumberof organizationalandhealthcarecosts.Themostsignificantday- to-daycostistheamountofstafftimespentmanagingthese procedures(Floodetal.,2008;LeBelGoldstein,2005).The fullcosttoanorganizationisunknown,butatime/motion/task
analysisconductedwithinoneStatefacilityestimatedthecostof onerestraintepisodetobebetween$302and$354,depending uponthenumberofcontainment methodsused(i.e.,physical,
mechanical, and/ormedication) (LeBelGoldstein,2005).
A1-hourrestraintinvolved25differentactivitiesandclaimed nearly12hoursofstafftimetomanageandprocesstheevent fromthebeginninguntiltheendofallrequiredtasks(LeBel& Goldstein,2005).Collectively,restraintuseclaimedmorethan
23percentofstafftimeand$1.4millioninstaff-relatedcosts, whichrepresentednearly40percentoftheoperatingbudgetfor theinpatientservicestudied(LeBelGoldstein,2005).Flood etal.(2008)report50percentofnursingresourcesareusedto manageseclusionandrestraint-related incidents.Theworkof Cromwellandhiscolleagues(2005)confirmedthatseclusion andrestraintincreasethecostofcareduetoadditionalstaff
timerequiredtoimplementandmonitortheseprocedures.They foundthatthemonitoringtimerequiredduringtheseprocedures representedthegreatestresourceintensity,accountedforthe
mostnursing-stafftime,andsignificantly increasedthedailycost ofcare(Cromwelletal.,2005).
Severalotherseclusion-andrestraint-related costs,suchas physicalinjuriestostaffmembersandpersonsserved,have
beenreportedbyinpatientandresidentialproviders(Huckshorn,
2006;NASMHPD, 2009).Injuriestostaffmembers,inturn, contributetoworkforceinstability(e.g.,turnover,industrial accidents,absenteeism/sick time,replacement costs,hiring costs,training/retraining), whichcanbeextremelycostlyto anorganization(LeBelGoldstein,2005;Unruh,Joseph,& Strickland,2007).
Inadditiontotheseeconomicburdens,organizationsmust addressliabilityandlegalcosts.Liabilitymattersmaybethe mostsignificantfiscalconsequence ofseclusionandrestraint. Manyorganizationshavereportedsubstantialliabilitycosts associatedwiththesepractices(LeBelGoldstein,2005; MurphyBennington-Davis, 2005;Sanders,2009)andseveral organizationalleadersindicatedthatexorbitantliabilitypolicy premiumsareafiscallycompellingreasontochangepractice (LeBel,2009).
Wheninjuryordeathoccursfromseclusionandrestraintuse, litigationcostsandjudgmentsawardedbythecourtsalsohave thepotentialtobethemostcostlyresult(Haimowitz, etal.,
2006;Stefan,2002).Stefannoted,“Tortclaimscaninvolvea numberofdifferentcausesofaction:excessiveforce,medical malpractice, failuretoprotect,assaultandbattery,andfailureto maintainasafeenvironment” (Stefan,2002).Legalactionscan leadtojudgmentsincludingfinesrangingfromseveralthousand dollarstomultimillion dollarsettlementsaswellasincarceration and/orprobationforstaffmembers.
AFamily’sExperience oftheUltimateRestraintCost
TannerWilsonwas9 yearsoldwhenhewasadmittedtoa residential programinIowa.Within24hoursofhisadmission,Tanner’slegwas brokenina physicalrestraint.Hislegrequiredsurgery,a bodycast, andrehabilitation.Hereturnedtotheprogramusinga walker.His legwasbrokena secondtimeina separateincidentattheprogram. Fifteenmonthsafterhewasadmitted,Tannerdiedwhilebeing
TannerWilson
restrainedina “routinepronephysicalhold.”
TannerwasthesonofKarenandRobertWilson.Hismotherrecounted:
Tannerwasouronlychild.Wesacrificedeverythingforhim.Heneededhelp,andthat’s whatwewantedtogetforhim.Weneverthoughtthiswouldhappen.Nothingcanbring Tannerback.Wetrustedthisprogramtocareforhim.Ourlivesarechangedforever.We wouldaskeveryhealthcareleadertolookatthatchildorthatpersonbeingrestrained,as thoughtheywereyourownchild.Tannerpaidtheultimatepriceofrestraint,butwehope hisdeathandhisstorywillhelppeopletothinktwice,thinkaboutwhattheyaredoing, andtonottakepeopletothefloor…therehastobea betterway. Wearegratefulforthe beautifulmemorieswehaveofTanner—becausethat’swhatwehavetogoonthesedays.
CoststoConsumers
Thepersonalcoststoconsumerswhoarerestrainedorsecluded havebeenrecognizedbuthavereceivedlessattentioninthe literature.Consumerscanbephysicallyinjured,anddeathshave resultedfromtheseprocedures(NASMHPD, 2009;Weissetal,
1998).Theymayalsobetraumatizedorretraumatized bythe experience,whichcanresultinlongerlengthsofstay(Calkins& Corso,2007;LeBelGoldstein,2005).Twostudiesofyouthin Massachusetts inpatientandresidentialprograms,respectively, foundthatseclusionandrestraintusenotonlyledtoextended staysbutalsoincreasedrecidivism/readmission tothehospitalor residentialcare(LeBelGoldstein,2005;Thomann,2009).
Asaresultofbeingrestrainedorsecluded,consumersmay
experiencesubjectivecoststointerpersonal relationships, damagetothetherapeuticalliance,andmistrustofthehealth caresystemandproviders(NASMHPD, 2009).Additional personalcoststoconsumersarethe“opportunity costs”incurred whentreatmentisnotprovidedtothosebeingrestrainedor secludedandwhenotherconsumersarenotreceivingcarewhile staffattentionisdivertedtomanageaseclusionorrestraint procedure.Krueger(2009)notedthatfailuretotakeconsumer timeintoaccountcausesnationalhealthcareexpenditures to
besignificantly undercountedandleadstoanoverestimate of productivity andanunderstatement ofactualhealthcarecosts.
AProviderMakesaCompellingPractice andBusinessCase
Oneexampleofcostsavingsandbenefitsofrestraintand seclusionreductionistheGraftonSchool,Inc.Graftonisa large,nonprofitorganizationinVirginiaservingchildrenand adultswithautismandmentalretardation,mostwithcomorbid psychiatricdiagnoses.Followingalongstanding institutional historyofutilizingarestraint-centric approachtomanaging
escalatingassaultivebehaviors,Graftoninitiatedanagency-wide restraintreductioneffortintheFallof2004whenthenewCEO issuedamandate:“Eliminaterestraintswithoutcompromising employeeandclientsafety”(MentalHealthCorporations of America[MHCA],2008;Sanders,2009).Eachregionalfacility wasthenchargedwithcreatinganevidence-based strategicplan toeliminaterestraints(MHCA,2008;Sanders,2009).
Figure1
Grafton’sReducedWorkers’Compensation Costs
Figure2
Graftonfocusedonkeyreductionstrategies,including(1) leadershipoversightandreviewofeveryevent;(2)supporting clientsincrisis;and(3)providingstaffwithnewtraining,tools, andmanagement support.Since2004,Graftonhasreduced restraintuseby99.8percentandwasnationallyrecognizedfor thisachievement (MHCA,2008).Inaddition,Graftonidentified manyfiscalbenefitsandsavingssubsequenttoreducingrestraint use(Sanders,2009).Positiveoutcomesincluded(1)reduced clientrelatedstaffinjuriesby41.2percent;(2)reducedstaff turnover(10percent)withestimatedannualsavingssurpassing
$500,000;(3)reducedemployeelosttimeandlosttimeexpenses (94percent);(4)reducednumberofworker’scompensation claims(50percent)[SeeFigure1];(5)reducedtotalcostof worker’scompensation claims;(6)reducedliabilitypremiums (21percent)andcumulativesavingsinexcessof$1,239,167
[SeeFigure2];(6)reducedworkercompensation experience modification factor(morethan50percent)withacumulative modification changeof62percent;and(7)morethan$483,470
incumulativeworker’scompensation costs savings.Graftonalsorealizedotherbenefitssuch asincreasedstaffsatisfactionandstaffperception ofgreatersafetyonthejob(MHCA,2008).
ThereareseveralimportantfeaturestoGrafton’s experience. First,Grafton’sdocumentation ofan arrayofreductionbenefitsisanimportantfeature oftheinitiativeastheyarenotoftenreportedin restraintandseclusionpreventionefforts.Second, twomonthsafterGraftonbeganitseffort,a
tragicrestraintassociatedsentineleventoccurred redoublingtheleadershipteam’scommitment to theimportanceofreducingandpreventingthe
useofrestraintandseclusion.Third,Grafton studiedtherangeofreductionoutcomes,which arenotoftenconsideredinrestraintandseclusion preventioninitiatives.
CostsAssociatedWithReducing
SeclusionandRestraint
Grafton’sReducedLiabilityPremiumsandCumulative Savings
Sincethebeginningofthenationalinitiativeto preventandreduceseclusionandrestraint,many organizationshavereducedtheuseofthese practiceswithlittletonoadditionalfiscalresources (Huckshorn, 2006).Weissandcolleagues(1998) reported:“…withstrongleadership,thephysical restraintofpatientscanbeminimized—indeed, nearlyeliminated—safely andwithoutexorbitant cost.”Likewise,theGAOfound,“…training
inalternativestorestraintandseclusionand maintaining adequatestafflevelsarecostly,but theycansavemoneyinthelongrunbycreatinga safertreatmentandworkenvironment…” (GAO,
1999a,p.21).
4Promoting AlternativestotheUse ofSeclusionand Restraint—IssueBrief #4:
Successfulorganizationstypicallyreallocatedollarstosupport theeffort(NASMHPD,2009).Ingeneral,thecostsidentified
byprogramsthathavereducedtheuseofseclusionandrestraint include:(1)purchasingand/orimplementingtrainingcurriculato promotepracticechange(e.g.,modelsofcare,crisisprevention, disputeresolution);(2)increasingstaffsupervision;and(3) encouragingstafftraining(e.g.,compensatingstafftoattendor coverforthosebeingtrained,trainercosts,trainingcostssuchas venue,food,technology,materials)(GAO,1999a;NASMHPD,
2009).
CurriculasuchasNASMHPD’sSixCoreStrategies©(NASMHPD,
2009)andtheRoadmaptoSeclusionandRestraintFreeMental HealthServices(SAMHSA,2005)areavailableatnocost,provide comprehensiveinformationandtrainingmaterials,andareshowing positiveresults(NASMHPD,2009;seealsoIssueBrief#2inthis series,MajorFindingsFromSAMHSA’sAlternativestoRestraint andSeclusion(ARS)StateIncentiveGrant(SIG)Program). There areothermodelsandtechnicalsupportpackagesavailablefor purchasethatalsoshowpositiveresults(BanksVargas,2009).
Othercostsassociatedwithseclusionandrestraintreduction effortsmayincludemakingenvironmentalchanges(suchas creatingsensoryorcomfortrooms)andpurchasingsensory itemstoimplementsensory-basedinterventions.Occasionally, environmentalrepairandpropertydestructioncostsmaybe incurred;however,someresearchsuggestspropertydestruction
decreasesduringtherestraint/seclusionreductionprocess.(Banks
Vargas,2009;LeBelGoldstein,2005)
AnumberofStatesandfacilitieshavedevelopedorexpanded consumerrolesforyouth,adults,andfamilies(NASMHPD,2009). Hiringorengagingconsumersbyreexaminingvacantpositions
andconvertingthemintonewadvocacyrolesforpersonsserved and/orfamilymembersmayhelppreventconflict,reducetheuse ofseclusionandrestraint,andchangetheorganizationalculture.
SavingsResultingFromSeclusionandRestraint
Reduction
SystemicandOrganizational CostBenefits
Systemicinterventions includetheadoptionofprogramssuchas NASMHPD’sSixCoreStrategies©curriculum,whichhasshown significantreductioninseclusionandrestraintandresultant savingstosystemsandorganizations.Selectedexamplesinclude JohnsHopkinsHospital,whichreduceduseofseclusionand restraintby75percentwithnoincreaseinstafforconsumer injuries(Lewis,Taylor,Parks,2009);andFloridaState HospitalatChattahoochee, FL,whichreduceduseby54percent andrealizednearly$2.9millionincostsavingsfromreduced workers’compensation, staffandconsumerinjuries,andlength- of-staycosts(FloridaTaxWatch,2008).
MakingtheBusinessCase
Restraintandseclusionarecostlyinallkindsofways–theyarejust plaincostly.Whatevernewcostswe hadwereminimal.Mostofthenew trainingweputinplacetoreduce
restraintandseclusionreallywerejust goodclinicalpracticeandwhatwe shouldbedoinganyway.
—AndyPond,LICSW,Presidentand
CEO,JusticeResourceInstitute
Amultistate,multiserviceresidential andoutpatienttreatmentprovider
TheMassachusetts statewidechild/adolescent seclusionand restraintpreventioninitiativeisanotherexampleofasystemic reductioneffortwithdemonstrated savings(LeBelGoldstein,
2005;NASMHPD, 2009).Overall,thesystemreducedseclusion andrestraintuseby89percentfromFiscalYear2001through
2008andavoidedmorethan34,037restraints—realizing an averageof$1.33millionsavingsperyearandmorethan$10.72 millionincumulativesavingssincethestartoftheinitiative (LeBel,2009).[SeeFigure3].
Organizationsthathavesuccessfully reducedtheuseofseclusion andrestraintreportincreasedstaffsatisfactionanddecreased
staffturnover(Paxton,2009).LeBelGoldstein’s(2005)study ofrestraintreductiononaninpatientservicealsoreportedan
80percentreductioninstaffturnover.Besemerandcolleagues’ (2008)workonrestraintreductionidentifieda42percent reductionindirectcarestaffturnoveranda24percentdecrease inturnovercostsfollowingsystemicchangesandenhancements.
Otherorganizationalsavingsincludereducedstaffabsenteeism (Besemeretal.,2008;Unruhetal.,2007)andreducedstaff injuries(Pollard,Yanasak,Rogers,Tapp,2007).The UniversityofMassachusetts’adolescentinpatientservice reducedtheiruseofmechanicalrestraintby98percentand realizedan86percentreductioninstaffmembers’sicktimeuse (LeBel,2009).
5
Figure3
Massachusetts Department of Mental Health
Child/Adolescent Statewide Program
Restraints/Seclusions (R/S) Prevented and
Savings by FiscalYear(FY)
Moreover,manyorganizationshaveexperiencedsignificantly reducedworkers’compensation andotherworkforce-related costsfollowingseclusionandrestraintreduction(Florida TaxWatch,2008).LeBelandGoldstein’sstudy(2005)of inpatientrestraintreductionfounda91percentreduction
inuse,whichresultedina98percentreductioninworkers’ compensation andmedicalcostsanda77percentdecreasein coststofillshiftsvacatedduetorestraintinjuries.Othercost reductionsattributedtodecreasedseclusionandrestraintuse includereducedworkforcereplacement costs(Paxton,2009; Sanders,2009)andlessmedicationuse(Bartonetal.,2009;
MurphyBennington-Davis, 2005).
ConsumerBenefits
Whenseclusionandrestraintarereducedandprevented, consumersreceivemoreeffectivecare.Theresearchisclear aboutthebenefitstopersonsserved:(1)fewerinjuries;(2) shorterlengthsofstay(LeBelGoldstein,2005;Murphy
Bennington-Davis, 2005;Thomann,2009);(3)decreased recidivism/rehospitalization (LeBelGoldstein,2005;Paxton,
2009);(4)lessmedicationuse(Bartonetal.,2009;MurphyBennington-Davis, 2005;Thomann,2009);and(5)increased positiveoutcomes/dischargesand/orhigherlevelsoffunctioning attimeofdischarge(LeBelGoldstein,2005;MurphyBennington-Davis, 2005;Paxton,2009).Inshort,people
recovermorequicklyandmayexperiencegreatersuccessinthe communitywhenviolenceisremovedfromthetreatmentsetting.
Recommendations
Inordertocontinuetobuildthebusinesscaseforseclusionand restraintreductionandprevention,afewrecommendations have beenofferedbyexpertswithinthefield:
Nationalleadersandaccreditingbodiesshoulddevelopand implementstandardized seclusionandrestraintdefinitionsand consistentmeasurement methodsacrossandwithintheindustry. Withoutcommonparameters,acompleteandaccurateanalysis ofseclusionandrestraintuse,costs,andbenefitsisnotpossible;
Experts,researchers, andorganizationleadersshouldcontinueto studyandpublishonthefiscalimpactandoutcomesofseclusion andrestraintuseandpreventionandreductionefforts;and
Organizationalleadersshouldalsoassesscurrentpracticesthat contributetoconflict,violence,andseclusionandrestraintand considerapproachesimplemented byotherstohelppreventand reducetheiruse.
Conclusion
Thegoalofthisissuebriefwastodescribethesystemic, organizational,andpersonalcostsoftheuseofseclusionand restraintpracticesaswellasthecostsavingsandbenefitsrelated tothereductionintheiruse.Thesepracticesareexpensive, violent,andharmfulproceduresthatprolongrecoveryandraise thecostofcare.Reducingandpreventingtheirusecanyield significantsavings,enhancequalityoftreatment,andincrease satisfactionforthoseprovidingandreceivingservices.Thefull scopeofthefiscalimpactofseclusionandrestraintisstillbeing assessed.
Compellingdataabouttheadverseeffectsofseclusionand restraint,higherstandardsofpracticedemonstrated bymany providers,andeffectiveno-costresourcesareavailabletohelp facilitatereductionandpreventionofseclusionandrestraint practices.Providerswhohavenotbeguntoengageinthese effortswillbechallengedtojustifycontinuingpracticeasusual. StatedmoreexplicitlybytheIOM(2000):
Thestatusquoisnotacceptableandcannotbetoleratedanylonger.Despitethecostpressures,liabilityconstraints, resistancetochangeandotherseeminglyinsurmountable barriers,itissimplynotacceptableforpatientstobeharmed bythesamehealthcaresystemthatissupposedtooffer healingandcomfort....
6Promoting AlternativestotheUse ofSeclusionand Restraint—IssueBrief #4:
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Endnotes
1Seclusionistheinvoluntaryconfinementofapersonaloneinaroomorareafrom which thepersonisphysicallypreventedfromleaving.42C.F.R.§482.13(e)(1)(ii); Seealso42C.F.R.§483.352.
2Restraint isanymanual method, physical ormechanical device, material, or equipment thatimmobilizes orreduces theability ofapersontomovehisorher arms,legs,body,orheadfreely.42C.F.R.§482.13(e)(1)(i)(A).Seealso42C.F.R.
§483.352.
MakingtheBusinessCase7
Acknowledgments
ThisbriefwaspreparedfortheSubstanceAbuseandMental
HealthServicesAdministration (SAMHSA) byKathleen
Ferreiraandisbasedonanissuepaper,TheBusiness
CaseforPreventingandReducingRestraintandSeclusion Use,writtenbyJaniceLeBel,Ed.D.,andcoordinatedby Educational ServicesInc.(ESI)undercontractnumber280-
03-3603withSAMHSA,U.S.DepartmentofHealthand HumanServices(HHS).Leadershipandcoordination ofthe seriesofissuebriefswasprovidedbySAMHSA’sSeclusion andRestraintMatrixWorkGroup.
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Theviews,opinions,andcontentofthispublicationare
thoseoftheauthoranddonotnecessarilyreflecttheviews, opinions,orpoliciesofSAMHSA,HHS,ortheU.S. DepartmentofEducation.
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Allmaterialappearinginthisissuebriefisinthepublic
domainandmaybereproducedorcopiedwithoutpermission fromSAMHSA.Citationofthesourceisappreciated. However,thispublicationmaynotbereproducedor distributedforafeewithoutthespecific,writtenauthorization oftheOfficeofCommunications, SAMHSA,HHS.
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RecommendedCitation
SubstanceAbuseandMentalHealthServicesAdministration.
(2010).PromotingAlternatives totheUseofSeclusion
andRestraint—Issue Brief#4:MakingtheBusinessCase. Rockville,MD:U.S.DepartmentofHealthandHuman Services.
OriginatingOffice
OfficeoftheAdministrator (OA),SubstanceAbuseand
MentalHealthServicesAdministration, 1ChokeCherry
Road,Rockville,MD20857.HHSPublicationNo.(SMA)
10-4514,Printed2010.