Trauma Informed Care (TIC) Social Worker Spring Conference

1. Trauma Informed Care (TIC)Social Worker Spring Conference Mia Croyle, MA Toni Kettner, BSN, NHA, CPHQ April 12, 2019

2. Objectives • Describe the Phase III requirements and key terminology related to TIC • Explain trauma and resilience from a historical, neurobiological, and holistic perspective • Identify concepts that create and support a culture of trauma sensitive and responsive care • Define the significance of caregiver well-being and self-care • Identify strategies to prepare for the new TIC regulation • Apply understanding of TIC through case study discussion MetaStar represents Wisconsin in Lake Superior Quality Innovation Network.

3. Overview of Regulations - TIC

4. Regulations • Phase III Requirement - November 28, 2019 • Appendix PP, F 699 • §483.25(m) Trauma-informed care • 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.

5. Regulations • F699 ties heavily to F tags related to assessment, care planning, behavioral health, quality of care and staff training • 483.21 – Comprehensive person-centered care planning • 485.25 – Quality of care • 483.40 – Behavioral health services (as related to residents with history if trauma and/or post-traumatic stress)

6. Trauma Definitions

7. Stress Response • Our body’s stress response is triggered by perceived threats to physical or psychological integrity • State of high alert • Inability to think clearly • Extreme thoughts • Hypervigilance • Attention to threat • Drive to take action • This enables us to survive an immediate threat Image: https://www.flickr.com/search/?text=tiger&license=4%2C5%2C9%2C10&advanced=1

8. Traumatic Stress Response • Chronic stress has a serious impact on our well-being: • When stress is prolonged, severe or recurrent it leads to permanent changes in the brain/body • There is a direct correlation between trauma and diseases such as diabetes, heart disease, cancer and high blood pressure • Common traumatic stress responses are: • Re-experiencing • Hyper-arousal • Avoidance • Preoccupation

9. Trauma • Trauma (Three E’s): • Results from an event, series of events or a set of circumstances • Experienced by an individual as physical or emotionally harmful or life-threatening • Has lasting adverse effectson the individual’s functioning and mental, physical, social, emotional or spiritual well being • Trauma is the Greek word for “wound”

10. Types of Trauma

11. Re-traumatization and Triggers • Re-traumatization • A conscious or unconscious reminder of past trauma that results in a re-experiencing of the initial trauma event. It can be triggered by a situation, an attitude or expression, or by certain environments that replicate the dynamics (loss of power/control/safety) of the original trauma. • Triggers • Signals that act as signs of possible danger, based on historical traumatic experiences, and which lead to emotional, physiological, and behavioral responses that arise in the service of survival and safety.

12. Key Concepts

13. Who Experiences Trauma? • In the nursing home we develop relationships with each other: • Residents • Families/Caregivers • Staff/Volunteers • Many of these individuals may have experienced traumatic events in their lives: • -Disasters -Grief/loss • -Military service/conflict -Racism • -Partner violence -Adverse childhood experience • -Sexual assault -Bullying

14. Trauma in Aging and in Individuals With Disabilities • Age is stigmatized and feared • Individuals with disabilities are more likely to be exposed to trauma • Loss of power and voice • Decreased or difficulty accessing resources • Significant life changes may cause trauma to resurface • May receive differential treatment • Masking and coping may be mistaken for absence of trauma

15. ACE Study • Adverse Childhood Experiences (ACEs) • Household substance use, separation/ divorce, mental illness, battered parent, criminal behavior, abuse or neglect • Examined health and social effect of ACEs throughout the lifespan of over 17,000 Kaiser members in San Diego county • Found that ACEs are common • Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs • Increased ACEs also increase risk for many health problems www.acestudy.org

16. Prevalence of ACEs • Approximately 65 percent or two thirds of the population has experienced at least one ACE • For every 100 residents: • ~35 have had no ACEs • ~26 have had one ACEs • ~16 have had two ACEs • ~10 have had three ACEs • ~12 have had four or more • Do you know which residents those are?

17. Cumulative ACEs and Chronic Disease

18. ACEs and Behavioral Health

19. Holistic Look at Trauma • Brain development and function • Headaches, backaches • Appetite changes • Susceptibility to cold • Intestinal problems • Disturbed sleep • Fear • Loneliness • Helplessness • Dis-association • Outbursts • Flashbacks • Nightmares • PTSD • Anxiety • Depression • Apathy • Isolation • Difficulty trusting • Detachment • Suicidal ideation • Self-injury • Aggression • Struggle to find meaning • Anger at higher power • Desolation, despair • Disconnection from religious community

20. Trauma and the Connection to Behavior • Residents with dementia experience memory loss, altered visual perception, language difficulty and poor judgment • If a resident has experienced a traumatic event in the past, increased stress, re-triggering or re-traumatization will elicit the fight/flight/freeze response • If the resident has dementia these responses may be magnified • We should always consider that a resident may have had a traumatic past experience whenever a challenging behavior emerges

21. Case Study, Looking Beyond the Behavior

22. Supporting a Trauma Sensitive Culture

23. Resilience • Resilience is the process of adapting in the face of adversity, trauma, tragedy, threats or significant sources of stress • Self-compassion • Highly individual • Realize everyone adopts coping mechanisms and everyone has strengths • Knowing your residents’ strengths and resources is key • Relationships/Connections

24. Holistic Look at Resilience • Singing • Dancing • Laughing • Movement • Rhythm • Sleep • Balanced diet • Soothing surrounding • Aroma therapy • Curiosity • Imagination • Self-soothing skills • Learning • Connection • Positive relationships • Belongingness • Storytelling • A higher power • A sense of purpose • A sense of hope • Connection to nature • Reading, reflective writing, mindfulness

25. Culture Shift

26. Five Principles of Trauma Informed Care (TIC)

27. Person Centered Care • BiologicalPhysical • Psychological Emotional • An approach to care that respects and values the uniqueness of the individual and seeks to maintain, even restore the personhood of individuals • Requires a holistic approach • Spiritual • SocialBehavioral

28. Person Centered Care • Truthfulness • Independence • Engagement • Hope • Personal worth and uniqueness • Social confidence • Respect

29. Case Study, Looking Beyond the Behavior

30. Caregiver Well Being and Self-Care

31. Caregiver Well-being • We are empathetic and compassionate by nature • Our own experiences with traumatic events can lead us to experience burnout and compassion fatigue • Compassion fatigue if not addressed can lead to depression, physical symptoms, sleep disturbances, anger/irritability, a decline in work satisfaction, loss of interest in activities and work/personal relationships

32. Caregiver Well-being • Long term care is based on relationships • We communicate through an exchange of stories • A trauma story from a resident may trigger a response on the part of a staff member (vicarious trauma) • Self-care is essential in preventing compassion fatigue/burnout • We tend to place more importance on caring • for other than we do ourselves https://flic.kr/p/4vKjDj

33. Caregiver Well-being • All staff members should have a safety plan • How do you know when you are going to “lose it?” • Emotions/Triggers/Signs • What five things help? • Is there someone on your team you feel safe sharing your plan with? • Teams/relationships are KEY to our well-being

34. Self Care “On the Go” • For Grounding: • Breathing • Close your eyes. Take a deep, slow breath to a count of four, hold for two counts and slowly exhale to a count of four • 5-4-3-2-1 • Five things I see • Four things I feel • Three things I hear • Two things I smell • One thing I taste

35. Preparing for the New Regulations

36. Social Services Assessment Questions • Many tools exist to screen for trauma • Typically they ask very pointed questions which might work for some individuals but not for all • Risk of re-traumatizing/re-triggering • Difficult conversations • Need to identify strengths and coping strategies more than we need to know they have experienced trauma (person centered)

37. Social Services Assessment Questions • These questions are a good place to start: • What have been the most difficult times(s) of your life? • Have you ever been through anything life threatening or traumatic? • What helped you get through those difficult times? (Strengths) • What are some things that you do now to help you manage consequences of having gone through tough times? • Are you aware of any particular “triggers” that may make this worse?

38. Preparing for the New TIC Regulations • Identify resident’s strengths, resilience and protective factors through assessments, interviews and conversations • Understand behavior patterns, triggers and re-traumatization • Create a TIC team • Involve residents, families and staff in learning about resilience and wellness • Deepen staff awareness of cultural competency regarding trauma • Gain insight from family members, staff or other residents

39. Preparing for the New TIC Regulations • Consistent scheduling/routines • Activities that offer safe movement and engagement of the senses • Emphasize choices • Provide opportunities to share life stories • Provide quiet spaces/areas • Develop and build relationships with community mental health providers • Promote staff education/training (ongoing) • Person centered care planning

40. Preparing for the New TIC Regulations • Trauma informed care is a PROCESS not a destination (Quality Assessment Performance Improvement) • TIC does not require us to know that trauma is present or what the trauma involved • Treat everyone as if they have had a trauma

41. Preparing for the New TIC Regulations

42. Resources

43. Resources • https://www.dhs.wisconsin.gov/publications/p0/p00859.pdf • https://www.cdc.gov/violenceprevention/acestudy/index.html • https://www.leadingage.org/trauma-informed-care-resources • https://www.lsqin.org/initiatives/coordination-of-care/post-acute-care-mental-health-video-training-series/ • https://www.traumainformedcare.chcs.org/what-is-trauma/

44. Questions? • Toni Kettner, BSN, MHA, NHA, CPHQ • Nursing Home Project Specialist • tkettner@metastar.com • 608-441-8290 • Mia Croyle, MA • Behavioral Health Project Specialist • mcroyle@gmail.com

45. This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-WI-C2-19-20 021519