Responses to a past trauma or triggers can include a wide array of behavioral, psychological, emotional, and physical reactions that might be misunderstood or mislabeled if care is not trauma-informed, said Julie K. Gammack, MD, at the 2021 Virtual Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine.
The Journey to Trauma-Informed Care
Hoarding, nightmares, mood swings, combativeness, and irritability — all may be coping mechanisms and “may be relabeled as delayed reactions to trauma or triggers,” said Dr. Gammack, professor of internal medicine-geriatrics at Saint Louis University School of Medicine during a presentation on trauma-informed care.
Understanding how people can respond to trauma “gives me pause to think about some of these difficult, challenging [behaviors and actions] that we have to work through,” she said. “Is this part of their coping mechanism? Is there something bothering them that we don’t recognize that they’re experiencing? Getting to a better understanding is part of a trauma-informed approach.”
Dr. Gammack emphasized that trauma-informed care “is a journey you take with your facility” and not as simple as finding and using a screening tool. Nursing homes are required by the phase 3 regulations of the Centers for Medicare & Medicaid Services Requirements of Participation to deliver care that is culturally competent and trauma-informed. The regulations took effect in November 2019, shortly before COVID-19 struck.
Avoiding retraumatization is a key feature of trauma-informed care and often requires facility-wide attentiveness. “We don’t always know what the potential triggers can be, but we can try to identify them — a smell, a taste, a sound, lighting, a movement,” she said. With respect to post-traumatic stress disorder (PTSD), it’s underappreciated that “there’s a well-recognized group of older adults who have PTSD that has either been intermittent or that is re-emergent as they get older.”
In her presentation, Dr. Gammack said it’s well documented that older trauma survivors have an increased risk of dementia and can have accelerated physical aging as well. They often reach older age in poorer health and with more difficulty coping with illness and pain, fewer social supports, and more financial stress.
A lengthy but informative manual on trauma-informed care by the Substance Abuse and Mental Health Services Administration (SAMHSA) may be a useful tool for nursing home leaders and staff who are developing protocols and staff education, said Dr. Gammack. Other potential resources include the Institute on Trauma and Trauma-Informed Care at the University of Buffalo (https://bit.ly/3dxj8lp
) and the U.S. Department of Veterans Affairs National Center for PTSD website on trauma-exposure checklists and tools (https://www.ptsd.va.gov/professional/assessment/te-measures/index.asp
The TRAUMA Framework Approach
At Budd Terrace at Wesley Woods, a 250-bed skilled nursing facility that is part of Emory Healthcare in Atlanta, Tashi Chozom, RN, reviewed SAMSHA resources and developed a brief set of questions that she now uses in her role as the admissions nurse. She also developed a six-part framework using the word “trauma” to convey to staff the sensitive nature of trauma and to set the tone in her facility for a trauma-informed approach: trust, respect, atmosphere, understanding, mitigate, and accommodate.
Trauma: Earn the patient’s trust through open communication.
Respect: Respect their desire to disclose information.
Atmosphere: Create a safe atmosphere.
Understanding: Understand “what has happened to you?” rather than “what is wrong with you?”
Mitigate: Mitigate or avoid exposure to situations that may cause retraumatization.
Accommodate: Accommodate the patient’s preferences and values.
Ms. Chozom shared her approach — as well as data the facility collected and analyzed from the first year of implementation — at the Society’s conference via a poster presentation she developed with medical director Sahebi A. Saiyed, MD, and Alexis A. Bender, PhD, a medical sociologist and social gerontologist at Emory University. (Dr. Bender presented the poster.)
Of 480 PALTC admissions from November 2019 to November 2020, 22 (4.5%) reported a trauma experience. Almost three-quarters were reported by women — most commonly sexual assault (53% of these cases). Other types of trauma reported by residents/patients were categorized as complicated grief, racial discrimination, emotional abuse, combat-related PTSD, partner violence, accidents, medical/postsurgery trauma, and COVID-19’s effect on mental health.
Trauma survivors’ stories were shared with the interdisciplinary team, and care plans were created with the goals of preventing retraumatization and offering any help or initiating referrals. Morning huddles were also used to share the residents’ stories and needs, explained Dr. Saiyed in an interview.
“When we started this we had no specific guidance [from CMS] about what we should be asking or doing,” said Dr. Saiyed. Yet “these are issues that affect our patients’ care and how they will do with their rehab ... When you know what they’ve been through, you’ll provide more personalized and compassionate care.”
Christine Kilgore is a freelance writer based in Falls Church, VA.