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Putting Together Pieces of Trauma-Informed Care Puzzle

      Phase 3 of the revised Medicare and Medicaid Requirements of Participation for long-term care, which will go into effect next month, require skilled nursing homes to provide “trauma-informed care (TIC),” an approach to care that factors in the pervasive nature of trauma and establishes safe and nurturing environments where residents won’t be retraumatized. However, the Centers for Medicare & Medicaid Services haven’t yet provided guidance on this directive, so trying to comply may feel like completing a jigsaw puzzle without all the pieces. Yet if the team thinks of this as ensuring a trauma-informed culture as opposed to just implementing a new regulatory requirement, they can create something that is positive for everyone.
      “It’s important to remember that implementing a true trauma-informed approach to care takes time. It’s not just a matter of adding a few assessment and intervention boxes,” said Scott Janssen, MA, MSW, LCSW, of the University of North Carolina Hospice. TIC, he observed, “is something that should permeate the entire culture from bottom to top, and it should inform the hiring of new staff and the training of existing staff. It also involves policies and procedures on an administrative and clinical level.”
      So where do facilities begin?

      Defining Trauma-Informed Care

      Regarding TIC, the Requirements of Participation say, “The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.” And, to date, that is where the direction ends. For the moment, it is up to facilities and their teams to take the TIC reins.
      It can be challenging to get everyone on the same page when change sweeps in, but it can help to start with a common definition so that everyone is speaking the same language. Although CMS has yet to provide a clear definition of TIC, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) describes it as “adoption of principles and practices that promote a culture of safety, empowerment, and healing.” Taking this a step farther, Ashley Swinson, MSW, LCSW, founder of TIDE Associates in North Carolina, said, “Trauma-informed care is the practice of engaging others and providing care by intentionally considering the impact of their past experiences on their current presentation.” Like everything we aspire to in long-term care, TIC is person-centered — but it is much more as well. It is a fundamental perspective and an integrative framework, said Ms. Swinson.
      Everyone also needs to have a common understanding of what trauma is. SAMHSA defines it as resulting “from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” CMS also uses this definition. While it is important to have some common understanding of trauma, the team also must realize that neither trauma nor TIC is a one-size-fits-all concept. Also, caregivers and clinicians should be careful not to mistake signs of trauma — such as changes in intake, cognition, sleep, verbalization, socialization, activity, and anxiety — for age- or illness-related issues. Although these changes could well be associated with age or illness, the team must acknowledge that they also could be related to trauma.
      Next, getting buy-in from everyone on the team is important. “When you establish this, you get a joint willingness to move forward,” said Ms. Swinson. “We have to be able to talk about trauma-informed care. We are engaging with each other by having the conversation.” To help promote buy-in, it is important to emphasize the benefits of TIC, including lowered care costs and potential reductions in hospitalizations and psychotropic medication use for patients and less turnover, greater satisfaction, and less burnout for staff.
      As with any change, having a champion is powerful. Mr. Janssen explained, “TIC champions are team members who understand the impact of psychological trauma on the lives of patients and caregivers. When trying to understand a patient’s behavior, the champion will ask, ‘Is this related to post-traumatic stress?’ A champion will also think about whether her own behavior is hurtful or insensitive to the needs of a trauma survivor, and this person can shine the spotlight on trauma issues.” For instance, something as seemingly innocent as a humming a song while providing care could trigger a trauma-related memory or experience for the resident.

      The Screening/Assessment

      Unlike some of the screenings and assessments conducted in this setting, TIC can’t just involve a one-and-done checklist. “I would not recommend using a standardized assessment questionnaire or a PTSD [post-traumatic stress disorder] inventory. These kinds of assessments should be left to professionals with the background, knowledge, and skills to use them sensitively and effectively,” said Mr. Janssen. He further observed, “Before thinking about assessing for trauma in a formal or routinized way, I’d start by looking at strategies for building trust, a relational connection, and a sense of safety.” If you jump right to the assessment, he cautioned, “You will likely get inaccurate or incomplete information, and you may create distress in residents or unnecessary barriers to building a relationship based on respect and open communication.”
      Trauma may be entwined with deeply hidden family secrets, Mr. Janssen noted, and these can feel dangerous to disclose. If the team is conducting assessments without specific training beyond just asking questions, this could be disastrous. Imagine, Mr. Janssen suggested, the social worker or intake nurse bringing up trauma with a new resident — who has a history of sexual abuse that she has never revealed to anyone — when she is accompanied by her adult son. “You can see how this could ratchet up pretty quickly,” he said, especially if the practitioner doesn’t have the skills or training to know how to handle such a situation.

      Care Tools

      While facilities may feel pressure to implement a TIC process, they should resist the urge to oversimplify it — such as just creating or adapting a formal clinical assessment and assigning this task to a particular discipline or team member.
      Mr. Janssen said, “I’d think more in terms of screening questions rather than a formal assessment. And I’d start with the kind of observational and conversational style of assessment.” At the least, he suggested, facilities might consider putting a few open-ended questions into the social history section of the resident’s intake. These should also be designed to help identify the person’s strengths and positive coping strategies, as these can be used to help him or her “stay grounded when distressed.”
      The use of mixed formats for TIC may be helpful starting out. This may include self-inventories, checklists, questionnaires, and interviews. Some sample screening questions might include:
      • Have you ever been in a situation in which you were afraid you were going to die?
      • Have you ever experienced something that made you feel less safe in the world or changed you in a way that has made life more difficult?
      • Have you had any experiences in your life that have made it hard to trust/feel happy/express your needs/connect with others?
      There are other tools that can be useful. For instance, the Trauma Informed Care Project has a self-assessment designed to evaluate an organization’s readiness to implement a TIC approach. This is organized into five main domains: supporting staff development, creating a safe and supportive environment, assessing and planning services, involving consumers, and adapting policies.
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      Because a key focus of TIC is to keep residents safe and comfortable and to prevent retraumatization, the goal should never be to push people into talking about traumas. “If people are traumatized but reluctant to talk about it, they may have very good reasons for concealing this,” said Mr. Janssen. For example, they may feel shame, or they may worry they will be judged. “They may not feel safe, especially in an institutional setting … or they may worry about being medicated against their will,” he observed. “It can be very scary talking about something like this under the best of circumstances, much less under the stress of being in a nursing home.”
      If someone doesn’t want to talk, team members must let the resident know that it is okay. Perhaps they can start with a basic life review, talking about happy memories or nonthreatening topics. Nancy Kusmaul, PhD, LMSW, assistant professor at the University of Maryland School of Social Work, agreed. She said, “TIC doesn’t mean forcing someone to address their trauma. Instead, we need to be aware of how trauma is affecting their care.” She added, “We should approach this with an awareness that there might be something there and behave in ways that acknowledge this.”
      Patience and sensitivity will be essential. Ms. Swinson said, “Give people permission to slow down the pace and think through options and recourse beyond the box they’ve been confined to.”

      The Family Plan

      Family involvement may be helpful. However, it depends on the family, the relationship they have with their loved one, and how involved they want to be. When it’s appropriate, family members can provide insights into things such as times of day when the resident is more distressed or triggers that cause the person to be agitated. They also may have clues about how to keep people calm, such as favorite songs or the scent of lavender.The National Comorbidity Survey estimated that in the general population three out of four people over 75 live with trauma. It might be hypothesized that the prevalence of psychological trauma in the LTC setting could be even higher.
      Just as it’s important not to judge or push residents, it’s similarly key not to make assumptions about the family. As Mr. Janssen said, “You don’t know the story of family relationships. Staff need to resist stereotyping and imposing their own feelings on the family. A resident who is sweet and loved by staff could have been abusive to his or her family. Don’t push family into being involved if they resist or just aren’t interested, and don’t judge them for having this reaction.”

      Training Teams: Back to Basics

      Training for teams should include the basics of trauma and TIC. They also should get some training on how to respond to residents who are distressed or withdrawn, and they need to know what signs to watch for that indicate someone is feeling traumatized and needs help. For direct care staff, it may be helpful to have additional training about how to respond to challenging behaviors with a TIC focus. For instance, Mr. Janssen said, “Someone who has been sexually assaulted might get angry or fearful when given personal care. It’s important for staff to respond in ways that are mindful and that wouldn’t escalate the reaction or intensify underlying distress.”
      Team members also need some training in self-care because the greater focus on TIC could trigger retraumatization or undue stress related to their own history or experiences. They may not even realize that TIC may trigger their own trauma. “We need a culture that makes people feel safe enough to be honest,” said Ms. Swinson. If an employee is having a problem with TIC because, for example, he or she is struggling with his or her own traumas, that person needs to be able to ask for help without fears of retribution or judgment. “People should have the opportunity to share TIC responsibilities with others,” said Dr. Kusmaul. She added that having adequate training on how to provide comfort in the moment can increase team members’ confidence. “We can’t just throw people into this. They need to be trained and have the opportunity to ask questions, express concerns, and seek additional training or help as necessary,” she added. “We can’t have facilities and teams without access to behavioral health uncovering traumas without the ability to address them. Team leaders need to figure out their capacity around behavioral health up front.”
      Of course, it’s not enough to have screening procedures in place. Facilities need to have a protocol for what do to if someone is identified as being traumatized or having PTSD. In such cases, a comprehensive assessment by a qualified individual with clinical experience is warranted. All team members should be familiar with these procedures and protocols, especially if they are directly involved in screenings or assessments.

      The Incomplete Puzzle

      Because there are still some missing pieces, we don’t know what TIC will look like over time “unless CMS gives us specific parameters and specific models … or gives organizations the autonomy to develop their own model,” said Ms. Swinson. It’s too early to know what surveyors will expect regarding TIC, but facilities would be wise to detail what is done and the content of any and all conversations and actions regarding TIC. Ms. Swinson said, “The documentation needs to refer to the TIC and include specific details. You need to use language that proves you’re following protocol.” Additionally, she suggested that the record include a rewriting of what assessments uncovered and what the treatment plan includes to address this. The documentation also should note any information about resident choice.
      This is a “work in progress,” Dr. Kusmaul noted. “We will all be learning in the next couple of years. It will take some reflection and deliberate thought to do this well,” she said. In the meantime, facilities will need to put a system in place to monitor their TIC and seek feedback on a regular basis.
      Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for the Society and other organizations.