1. Journey to the
North Star2006 - 2013
Transforming behavior support in Hamilton County, Ohio

2. Building Relationships, Changing Culture
In August 2006, an extensive review began at Hamilton County Developmental Disabilities Services (HCDDS) of the
ways in which individuals with disabilities are supported in interacting positively with others.
This review started a transformation of the traditionally aversive* beliefs and methods surrounding interactions with
individuals who exhibit challenging behavior. The emerging structure driving this transformation – a classic cultural
shift - became known as The North Star Initiative.
To start the transformation, several staff joined together to collect and discuss data from customer satisfaction sur-
veys, accreditation reviews, incidents, behavior support plans, and observations of those who work most closely with
individuals.
Staff who participated in this review represented several departments within Hamilton County DD Services, including
Adult and Children’s Services, Quality Assurance, Major Unusual Incidents and Prevention, and Behavior Support.
The need for this review was driven by:
• Common knowledge among some staff that individuals with aversive plans were not successfully
transitioning off of them and methods in the plans were not positively impacting behavior
• Unapproved behavior support techniques happened frequently
• The Ohio Department of DD accreditation review in 2006 cited behavior support procedures as needing
improvement
• A new Superintendent and Adult Services Director at HCDDS had great interest in supporting people with
disabilities positively and encouraging increased interaction with their communities
* In 2012, restrictive became the standard behavior support term, replacing aversive. Since the word aversive
was operative in the period of time documented by this publication, it will be used throughout this publication.
Building Relationships,

3. Conclusions from the review led the group to the primary objec-
tives of reducing aversive plans and building positive relationships
between people with disabilities and those who support them.
Since 2006, The North Star Initiative has grown into a dynamic
movement, infusing not only HCDDS but also partner agencies
with the philosophy, resources and tools to promote positive
behavior support.
As of 2012, 20 agencies supporting more than 500 people have
joined with HCDDS in developing and implementing positive be-
havior support philosophy and methods.
“It takes a long time to make a cultural shift. It was the first time we took on
a project with people who crossed so many departments. It took a long time to
get it off the ground because we had to get so many people together.”
Peggy Kurz
Director of Community Services, HCDDS
Former Director of Adult Services

4. Reducing Restrictive PlansReducing Restrictive
Aversive (restrictive) plans are defined by the Ohio Department
of Developmental Disabilities as the use of manual, mechanical or
chemical restraints and/or the seclusion or restriction of rights. At
the time of the initial data reviews in 2006, 88 aversive plans were
in place, with seven of those using time out/seclusion.
Plans that included time out/seclusion were prioritized for elimi-
nation. To accomplish this, staff who worked with the individuals
and had been using restrictive techniques were re-trained and
coached about more positive approaches and implementing them.
Success in aversive plans came gradually over the next two years.
Time out/seclusion was soon eliminated from all aversive plans,
and the number of aversive plans in general dropped in half.
The state average for aversive plans is 2.6% of people served per county. HCDDS’s average is
.005%.
From data collection and review in 2009 by statewide behavior support advisory committee
affiliated with The Ohio Department of Developmental Disabilities

6. Developing TrainingDeveloping Training Materials and Resources
One of the first tasks of the North Star Initiative was
to develop training materials and resources for staff
to drive a cultural shift away from aversive techniques
and toward building positive relationships. Resources
included TIP SHEETS and teaching curriculums called
TRY THIS and NOW I GET IT.
The TIP SHEETS and TRY THIS provide information about
specific mental health and developmental disability di-
agnoses and how those co-occurring diagnoses impact
how staff respond to individuals.
The Now I Get It curriculum uses video clips to share
successful teaching strategies for direct line staff. The
curriculum was presented at state and national confer-
ences for the National Association of Developmental
Disabilities and TASH, an international advocacy and
best practice association.

8. Promoting PositivePromoting Positive Behavior Support
In August 2008, partner agencies that support individ-
uals throughout the community in residential, work,
and other settings were invited to join the North Star
movement at Hamilton County DD Services. This pro-
gram was named The North Star Advantage.
Provider partner staff spend a majority of time with
individuals. Consistent, well-qualified staff are vital to
building positive relationships. Embracing positive be-
havior support and changing the culture system-wide
required offering the most comprehensive training
and support to program managers and direct support
professionals employed by provider partners.
Key components of North Star Advantage
• Prescreening
o viewing a DVD of daily interactions
o on-site visits
• Training before Direct Support Specialists
offer direct support
o individual rights
o Major Unusual Incident reporting
o developing positive relationships
o crisis prevention
o first aid/CPR
o support guidelines for the individual
• Additional training within the first 90 days
o self-determination
o overview of positive supports
o tips for success
o formal crisis prevention
• Ongoing training as requested by the agency
• Mentoring
33% of unapproved behavior supports at HCDDS
are not health and safety related but occurred be-
cause staff did something that escalated behavior
70% of these occurred with residential providers
data collection and review in 2009 by statewide behavior support advisory
committee affiliated with The Ohio Department of Developmental Disabilities

9. The video component depicts a realistic day in the life of a direct service provider. It has helped potential employ-
ees decide if the job is a good match for them. The tours allow individuals to give input as to their likes and dislikes
of a prospective employee. This process has helped participating agencies hire better-suited candidates and has
contributed to reducing turnover rates.
The training components are vital to start new employees with important information that helps them be successful
with the people they are working with. Assigning a mentor to each new employee has also helped in retaining new
staff. Behavior Support Specialists at HCDDS host sessions to train partner agency trainers on all aspects of positive
behavior supports. Partner agency trainers take this information back to their agencies to change their own cul-
tures.
The average cost of staff replacement is estimated at 50-150 % of the salary of that staff. Through North Star Advan-
tage regular meetings, training and mentoring, agencies are guided in reducing staff turnover and accessing HCDDS
resources like behavior support consultation and mentoring.
Second year North Star Participant Keith Hammond of Easter Seals TriState (formerly Jewish Vocational Service)
credits North Star with inspiring his agency to reorganize processes that have positively impacted behavior support.
Keith said that the work floor has been reorganized in ways that support people in performing their work better,
and that the agency has seen a decrease in incident reports because of this.
When the first group of North Star Advantage participants completed their work in 2008, members wanted to
continue regularly meeting because of the benefits from interactions with peers and colleagues. Now, North Star
Advantage groups from all of the combined years meet as a separate group from the current year’s group for addi-
tional training.

10. Journey to the North StarJourney to the North
Training is an important part of North Star Advantage. It is extensive and ongoing support for provider agen-
cies. A series of trainings began in 2010 to teach new and existing Direct Support Staff at each adult center
operated by HCDDS about the principles of positive behavior support. This series is called Journey to the North
Star.
This value-based training series was designed to initiate conversation with staff to develop empathy for indi-
viduals served. Videos, biographical time lines, PATH Plans, and Life Boxes are used.
Timelines guide a person’s team in talking through a person’s life history and capturing it on paper using high-
lights and dates. This tool helps show the changes and patterns in a person’s life that impact his or her behav-
ior, and often pinpoints where a team needs to change its standards for that person to support them better.
PATH (Planning Alternatives for Tomorrow with Hope) is a team-facilitated planning process that was devel-
oped by Marsha Forest, Jack Pearpoint and John O’Brien. PATH is one of the most useful tools for listening,
planning and discovering what a person with disabilities wants for his or her future. The plan is captured in
graphic form that is more easily understood by many people with disabilities and those who support them.
Life Books or Boxes are three-dimensional graphic depictions of a person’s life history, similar to scrapbooks,
though they can be in any form – videos, boxes, books, etc. They are created with the person and his or her
team of supporters. Often, in the creation of them, patterns and details emerge that help the team under-
stand a person better and why he or she might have different behavior patterns.

11. Navigators
Provider partners involved in North Star each have a navigator who is a
staff person at HCDDS. This navigator is the go-to person for that provider
who puts them in touch with resources quickly so the provider doesn’t
have to spend a lot of time searching for resources.
Mentoring Program
Purpose
To provide opportunities to beginning Direct Support Staff (DSS) to develop
their professional and personal skills.
Rationale
Research and observation tells us that staff who do not feel supported can
develop negative attitudes, poor performance, and leave the field.PATH plan by individual served

12. Goals
Mentors will develop the skills to provide as-
sistance to beginning direct service staff
• Communication
• Problem solving
• Coaching
• Conflict management
Beginning Direct Support Staff will develop or
enhance skills
• Planning, organizing and managing
workflow
• Relationship building
• Keeping accurate documentation
• Problem solving
• Knowledge and understanding of all
rules guiding services
• Communication skills
Expectations
Chairperson at each participating agency to coordinate the
program
• Oversee the selection, training and assignment of
all mentors in their agency
• Facilitate training for mentors and new employees
• Conduct follow-along to monitor success
Mentor
• At least one year employment in the field
• Ability and desire to have a collaborative
relationship with a new employee
• Commitment of the time to meet at least 18 hours
over the first six months with the new employee
HCDDS
• Provide support and training materials to agency
chairpersons
• Provide training videos for new staff
• Facilitate recognition for mentors at the HCDDS
annual banquet

13. Expectations, continued...
Mentor Responsibilities
• Plan and conduct an orientation meeting with
the DSS
• Orient the DSS to location of forms and supplies
• Review the staff procedure manual and answer
questions
• Review Behavior Support Procedures, MUI rule,
and other health and safety information
• Maintain confidentiality between the mentor
and DSS
• Provide and document guidance and coaching
Direct Service Staff Responsibilities:
• Participate in professional development opportunities
• Meet with mentor as scheduled
• Provide feedback on the mentoring process
• HCDDS provides free training resources and
consultation - through enhanced training and support,
provider staff deal more effectively with difficult situations
“Until North Star, we struggled for
a formalized way, a structured for-
mat, to develop supportive relation-
ships with people served, not just
casual relationships. We’ve seen a
decrease in turnover of direct care
staff and unapproved behavior sup-
port. Mentors have supported new
staff with time and attention and
caring that supervisors often have
limited time to do.”
Steve Koons
Rehabilitation Director, Ohio Valley Goodwill
2008 North Star Advantage

15. “One of the greatest benefits I’ve
received from North Star Ad-
vantage is the chance to regu-
larly talk to other provider part-
ners and professionals and share
best practices. I’ve learned that
not everything’s going to work,
and that it’s ok to go through
a process of figuring out what’s
best for the individual. “
Keith Hammond
Program Manager, Easter Seals TriState
(formerly Jewish Vocational Service)
2008 North Star Advantage

16. “North Star has engineered a complete 180 degree turn in how we hire and orient new
staff. Before hiring, everyone’s on the same page and everything’s written out. You know
who to call and what the processes are.”
Niel Hartman
Program Director, Visionaries & Voices
2008 North Star Advantage

17. “North Star has caused UCP to have a good evolution of growth programmatically and per-
sonnel-wise. We’ve experienced better selection of appropriate candidates and less turnover,
and we have a more structured selection and orientation process.”
Katie Brenner
Program Coordinator, United Cerebral Palsy (UCP)
2009 North Star Advantage

18. “It’s been a benefit to staff who have not worked
with individuals with disabilities before. I think
we’ve been a benefit to North Star participants
who might not have worked with our popula-
tion before. It’s certainly helped us not be a silo in
serving people with disabilities who also have drug
or alcohol issues.”
Stephanie Miller
Program Manager, Talbert House
2008 North Star Advantage

19. The PresentThe Present
Throughout 2012, the combined North Star group of agencies explored the basics of trauma-informed care. This
built upon a two-day training with Tonier Caine* that was held in 2011, and gave agencies a new perspective on
supporting people with behavioral concerns. This group also was invited to explore a systematic method of sup-
porting people called the “Sanctuary Model.”
Staff in the adult centers of HCDDS continued to learn about North Star through the Journey to the North Star
series. A second series is being developed and staff who complete the first series will embark upon the second.
Other departments of HCDDS have begun Journey to the North Star. Staff in the Community Services Department
and agency schools are interested in participating in the series.
The combined group was invited to spend time with Dr. John McGee, the founder of Gentle Teaching and a national
speaker on positive support for people with behavioral concerns. This continued the trend of bringing in people
from across the country who have innovative and positive messages for supporting people, such as Tonier Cane and
Dr. David Pitonyak.
To improve supports to people with behavioral concerns, the Human Rights/Behavior Support Review Committee
(HR/BSRC) of HCDDS reviews Major Unusual Incidents and Unapproved Behavior Supports (UBS) to identify patterns
and trends. This committee also debriefs after incidents and reviews timelines. Based on this analysis, behavioral
support is offered to the agency involved.

20. The Present, continued...
Another effort to improve supports was collaborative meetings with the Southwest Ohio Developmental Center
(SODC) to improve placement outcomes for people transitioning out of SODC. This group also looks at admissions
to SODC to ensure that community supports have been exhausted prior to placement there. In addition, planning
is underway for the next class of North Star participants as well as for the combined group from previous years.
*Tonier is an internationally sought-after speaker who was featured in the documentary “Behind Closed Doors: Trauma Survivors and the
Psychiatric System,” and is the subject of an award-winning film “Healing Neen.” She’s a team leader for the National Center for Trauma-
Informed Care, with the National Association of State Mental Health Program Directors, a consumer advocate who speaks world-wide
on trauma, incarceration, and recovery; and a case manager and Director of Advocacy Services for a private non-profit in Annapolis, MD.
She survived a childhood of unspeakable abuse, unrelenting violence, and betrayal by systems that were charged with helping. She was
arrested 83 times and convicted 66 times of crimes related to prostitution, drugs, and alcohol. When she was incarcerated and pregnant
in 2004, someone finally took the time to ask “What happened to you?” instead of “What’s wrong with you?” It is at that moment she
began her journey to become a survivor and for the first time in her life began to live with more hope than fear. The impact of trauma
is realized by every age group, race, ethnicity, socio-economic group, gender, community, and workforce. As Ms. Cain shares her story,
audience members find themselves challenging their professional and personal beliefs. Her experience illustrates the consequences that
untreated trauma has on individuals and society at-large, including mental health problems, addiction, homelessness and incarceration.

21. The FutureThe Future
Future plans for North Star focus on spreading this transformative paradigm throughout the agency by increasing
the groups of people exposed to its components and driving the concepts deeper by developing additional trainings
and conversation around important topics.
To increase the breadth of North Star, staff in the Community Services Department and agency schools will continue
the Journey to the North Star Series. Additionally, staff in agency adult centers will finish their first Journey series so
that everyone who works in an adult center will share this common approach.
An exciting component of this will be the training of trainers. Assistant Directors from each adult center will join
the Journey groups to learn the process of facilitating Journey discussions. The vision is that each adult center will
have an in-house North Star expert who will keep the flame alive. A second Journey series will be facilitated at each
site where groups have completed the first Journey series.
While the first Journey series focused on self-awareness and personal growth, the second series will focus on care-
giving styles and interpersonal effectiveness. Ongoing training will also focus on increasing knowledge and aware-
ness of issues that adult center staff and school staff identify. It is anticipated that the HCDDS psychologist will lead
these.
Plans for North Star beyond HCDDS involve bringing in yet another new class of provider participants and growing
the combined group of providers as the current group finishes. This combined group will identify issues and ideas
that they would like to explore during the coming year.

22. North Star Initiative TimelineNorth Star Initiative
2006
• Small group of staff start Internal review of aversive plans,
unapproved behavior support
o individuals were not transitioning off of aversive plans
o plans were not working
o unapproved behavior support data collected and studied,
included drug interventions
o Ohio Department of DD Accreditation review cited
behavior support plans as needing improvement
• Change in leadership
• Larger group PATH planning; field trip
to Louisville to learn about SPEAK (simi-
lar program)
• North Star Big Group holds first meeting in August and creates mission
o Our North Star is to eliminate aversive plans
o Four sub groups formed to study data and develop action steps
- Internal Roles
- Training
-the Co-Occurring Initiative grew out of this group
- External Roles
- Transition
-schools to adult centers
-institutions to community
-co-occurring – Dr. Ed Comer – “We don’t understand each other’s worlds”
-tip sheets came out of this group

23. 2007
• External Roles Sub Group plans pilot called North Star
Advantage to spread concept throughout Hamilton
County by joining with community partners
o Adopt HCDDS ideals
o Develop tools and resources
o Work together to reach our North Star
• Training subgroup developed structure and content
for providing comprehensive training to agencies
and staff to embrace positive behavior support
o Tip sheets
o Crisis Prevention Intervention
o Self Determination
o Positive Behavior Supports
 o Behavior Support Coordinator position
created to work with Behavior Support Specialists
• Mentoring Coordinators developed
in each agency; shared experiences
and materials with other agencies in
North Star
• Navigator roles were formed
for Behavior Support Specialists to
be liaisons and coaches with provid-
er agencies of North Star

24. 2008
• North Star Advantage Pilot begins with five agencies - Goodwill, OVRS, Talbert, V&V, RHC
• Best practices presentation at Kansas Neurological Institute annual conference, Kansas City, Mo.
• Training starts to introduce and implement North Star Initiative
• Mentoring training offered to provider reps
•Behavior Support Specialists start quarterly meetings with Service Facilitation Teams
• Behavior Support Specialists start training with staff at Adult Centers
• Six month review of participating North Star Advantage agencies
• Co-Occurring Initiative from transition committee becomes separate initiative
o high risk mentoring partnership with Cincinnati Human Relations Commission
• Quarterly review of participating North Star Advantage agencies
• Consultation with Dr. Pitonyak about North Star Advantage

25. 2009
• Four agencies from first pilot graduate
• Second set of agencies from North Star Advantage begins – JVS, Starfire, RHC, Total Homecare, Support Care
• Pilot becomes “North Star Advantage”
• Psychiatrist Dr. Morrison hired to work with CRG
• First group of high risk mentees graduate
• TASH Presentation at national conference in Pittsburgh – Peggy Kurz and Matt Briner

26. 2010
• Second set of agencies graduate North Star Advantage - JVS, Starfire, RHC, Total Homecare, Support Care
• Third set of North Star Advantage begins - GMR, CORE, LADD, AMT Group, Empowering People, Premier Providers
• Journey to the North Star Training Series started for direct support professionals in agency buildings
o Series of six 30-minute small group activities
o Seven or eight staff each time
o Goal is to reach all adult center staff
o Kidd is first adult center
• Try This curriculum rolled out that includes 10 additional positive approaches to behavior support
• Combined Group of all North Star Advantage Participants starts meeting because previous
year’s groups wanted to stay connected
• Co-Occurring Resource Group (CRG) holds first “Coming Together” conference with more than 200
professionals from across the state
• Second group of high risk mentees graduate
• Final plan using time-out/seclusion is discontinued

27. 2011
• Third set of North Star Advantage graduates - GMR, CORE, LADD, AMT Group, Empowering People,
Premier Providers
• Fourth set of North Star Advantage begins – Reva Supports, Associated Health Care,
Stepping Stones, Petermann, Medacare, Wesley
• CRG hosts second “coming together” regional conference with more than 200 participants
• Public school district staff introduced to North Star through tip sheets
• Positive behavior support naturally becoming part of the culture
• Celebration of the North Star Initiative with all previous groups
• Last group of Journey to the North Star at Kidd; other adult centers in various stages
• TASH presentation at national conference in Atlanta – Peggy Kurz, Dawn Freudenberg, Matt Briner
• NADD presentation on the CRG and tools for success

28. 2012
• Fourth set of North Star Advantage graduates - Reva Supports, Associated Health Care, Stepping Stones,
Petermann, Medacare, Wesley
• Journey to the North Star completed at Kidd and Franks Adult Centers
• Journey to the North Star training begins at agency schools with Direct Support Staff
• Journey to the North Star training begins at agency schools with Direct Support Staff
• Journey to North Star training begins with Service Facilitators
• Service Facilitators moved from regional locations spread throughout the county
to one building near downtown in Queensgate
• Fifth set of North Star Participants started in the North Star Advantage - Caring Hearts Home Health Care,
Community Supports, Inc., Just For You Supported Living, and ResCare Ohio

30. For more information about the North Star Initiative in Hamilton County
http://providers.hamiltondds.org
click on Northstar Advantage
Matt Briner, Behavior Support Coordinator
Matt.Briner@hamiltondds.org / (513) 794-3300