With a new regulation surfacing, providers show that residents’ psychological well-being is just as important as their medical status.
Trauma. It’s something that vast numbers of people experience at some point in their lives, whether it be through cataclysmic events such as a natural disaster or combat, or adverse experiences such as physical, emotional, or sexual abuse.
Trauma may come in many forms and through many experiences. Experts say that more than a third of the general population in the United States alone experience trauma at some point in their lifetimes.In a long term or post-acute care center, trauma can be found in residents, young or old, who’ve had earlier or recent life-changing events occur. “It’s easy to overlook those who have long histories of lower-level trauma and those right under our noses on the rehab units who may be in the early throes of their response to a very recent event that is traumatic for them,” says Richard Juman, PsyD, national director of psychological services at TeamHealth.
Trauma in Post-Acute Care
Post-acute rehabilitation centers are full of people who are at risk for demonstrating trauma-related issues, Juman says. “A quick definition of post-traumatic stress disorder [PTSD] is that it is a ‘disorder that develops in some people who have experienced a shocking, scary, or dangerous event.’ Now think about the folks we treat in short-term rehab. Many or even most of them have recently been through an event that could be described in this way: a broken hip, a car accident, a stroke, surgery, an unplanned hospital stay.”
By the time they arrive in a center for rehabilitation, they are still in the early stages of coming to terms with those traumas, he says. Indeed, the fact that these individuals are often confused, disoriented, depressed, or anxious comes as no surprise.
Seeing the Red Flags
While the symptoms of PTSD can overlap with those found in other psychiatric disorders, including dementia, there are some “red flags” that are more unique to PTSD. For example, “flashbacks” or a sense of reliving the trauma is a common symptom, as are bad dreams. “People with PTSD may go to great lengths to avoid re-experiencing thoughts, places, or events that remind them of the traumatic experience,” says Juman. “They may generally be easily startled and have angry outbursts.” In addition, he says, it’s these individuals that are at higher risk for substance abuse.
One of TeamHealth’s clinicians reported on a case on which he was consulted after staff members expressed confusion about a resident’s clinical symptoms and diagnosis. The resident presented with a labile mood, frequent outbursts, and oppositional, demanding behavior, all of which are commonly expressed symptoms of a variety of psychiatric disorders. Upon interview, however, the resident related that he had spent many years in the military, and that his service included prolonged combat exposure. A secondary trauma occurred when his wife was killed in the World Trade Center attack on 9/11.
These traumas caused him to become socially withdrawn and isolated prior to admission to the facility. Upon admission, he experienced significant nightmares and panic attacks. All of this clarified the resident’s diagnosis and came to drive care planning in a direction that would not have been realized without an accurate diagnosis of PTSD.
Annette Wenzler is chief nursing executive of Signature HealthCARE-Hometown, overseeing clinical operations of the 57 centers that fall under the provider’s Hometown designation in rural areas. What she has observed in long term care is that residents have experienced a great number of types of trauma like the death of a spouse, years of physical and/or mental abusive family relationships, and long-term effects of heavy substance abuse.
Is there a difference in the reactions of young and older residents? “Yes, there are differences in the types of trauma and the reactions to them if you have a 34-year-old MVA [car accident victim] quadriplegic versus an 82-year-old who has lost her husband of 60 years,” Wenzler says. Those differences may include sudden outbursts of physically acting out or aggressive behavior versus more self-reclusive behavior.“
But as humans, we all react differently to these life experiences based on our coping mechanisms,” she says. These experiences may manifest into extreme reactions to simple issues, like anxiety, nightmares, seclusion, combativeness, physical reaction to personal care, sexually acting out, and substance abuse.
New Focus on Trauma-Informed Care
A new regulation targeting trauma is coming to long term and post-acute care providers in November 2019. Part of the Medicare and Medicaid Requirements of Participation for nursing centers and published in the State Operations Manual, the regulation requires facilities to 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 retraumatization.
According to the Federal Register, trauma survivors, including veterans, survivors of large-scale natural and human-caused disasters, Holocaust survivors, and victims of abuse are among those who may be residents of long term care facilities.
Karl Steinberg, MD, CMD, is a long term care geriatrician in Oceanside, Calif. He is chief medical officer for Mariner Health Central, which operates skilled nursing centers in northern and southern California, and medical director of Life Care Center of Vista and Carlsbad by the Sea Care Center in Carlsbad, Calif. He says the main thing about the new regulation is visibility.
Wenzler says that Signature has a team that has been focusing on the new regulation—and they are ready for it. To her, the regulation may bring to light that trauma care is in all shapes and forms. “It is and always has been about providing care for those residents by meeting their needs, their goals, their concerns and lifestyles at their point of need,” she says. “It will bring in more need of education related to trauma and understanding of how to deal with consequences of unresolved trauma through the lifespan.” Improvement is needed in these areas, she says.
“We need to continue to learn, improve our processes in order to provide the best possible care we can for those who we serve and will in the future serve,” she says.
Education plays a leading role, experts agree. Staff need to be educated about how people with PTSD may react to various situations and how the interpersonal and environmental aspects of life in post-acute care play a huge role in helping a resident comfortably adjust, says Juman.
For example, the way that staff members respond to fear responses, combative behavior, refusals of care, anxiety, and isolative behavior should be shaped by an understanding of the underlying PTSD. Residents with PTSD are trying to maintain what is, for them, a safe environment, and the ways that they go about that are often perceived as unusual or “difficult.”
An Important Element
Providers can start by asking the center’s behavioral health professionals to provide inservice training and consultation to the direct care staff, Juman says. The next step is to—on an individual basis—identify the triggers that each resident with PTSD may respond poorly to. “Although every person with PTSD is different, it’s just intuitive that an individual with PTSD as a result of combat exposure might be triggered by different sources than a rape victim or a survivor of physical and verbal abuse in early childhood,” says Juman. “How we interact with these residents, who is assigned to care for them, and even what types of TV shows or movies might contain material that activates a PTSD response should all be considered in order to provide optimal care.”
Treatment Shouldn’t Be Left Only
to mental health professionals, for good reason, says Juman. “Treating PTSD in the post-acute setting isn’t something that can be left to the consulting behavioral health providers, because the way that the environment responds to the resident is always going to be the most important element.”
Although good person-centered care delivered by an interdisciplinary team is a hallmark of all good skilled nursing care, it’s especially important in considering trauma care. That is because PTSD has physiological, neurological, behavioral, and psychological components, but medication is of limited value in addressing chronic PTSD, he says. So it takes a team effort to address all of those concerns.
Juman was asked to consult with a newly admitted resident who presented with severe panic attacks, insomnia, oppositional behavior, and nightmares.
The staff were initially looking to address these as separate problems—an approach that will often lead to overmedication—as opposed to viewing them all as symptoms of an underlying PTSD. Juman says it was important for staff to understand that the resident perceived the facility as a fundamentally unsafe environment, and that the benign and neutral interactions that they were engaging in with him were nevertheless threatening to the resident. So rather than use medication to address each of the problem areas individually, the team’s focus made a simple shift by asking themselves before every interaction with the resident: “What can I do to help the resident feel safe here, and come to trust me and the facility?” The emphasis was placed on avoiding any staff interaction that could retraumatize the resident by being experienced as coercive, manipulative, or punitive.
Over time, as the resident came to view the staff, and the facility, as safe, there was a significant diminution of his symptoms.
By recognizing that traumatic experiences and closely related, co-occurring disorders tie closely to behavioral health problems, Signature has begun to build a trauma-informed environment across care settings.
Its approach includes an understanding of the particular trauma a resident has suffered and an awareness of the impact that it can have across treatment settings within the nursing center and to the resident personally.
Signature’s trauma-informed care utilizes a strengths-based service delivery approach that is grounded in understanding the trauma, the impact the trauma has on both the resident and the care partner, and how opportunities are created through the trauma to rebuild and empower the resident as well as the care partner.
Importantly, the provider’s approach also involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize the individuals who may have a history of trauma.
Signature and its affiliate, Serenity HealthCARE, work with their care centers to promote understanding in various aspects of trauma-informed care, including: how to recognize trauma-related reactions, how to incorporate treatment interventions for trauma-related symptoms into the overall care plan, how to enhance the system to prevent further trauma, how to conduct psycho-educational interventions, and how and when to make an outside referral for further evaluation and specific treatment.
Keys To Success
When asked about best practices in treating individuals with trauma, Wenzler points to tried and true methods that put oneself in the shoes of a resident with trauma. The first step is building competence among staff and if the facility doesn’t have them, establishing program standards and clinical guidelines that support the delivery of trauma-sensitive resident services.
Another best practice is to recognize that trauma-related symptoms and behaviors originate from a resident adapting to traumatic experiences, Wenzler says. Once a staff member takes this step, it’s a little easier to view trauma in the context of the resident’s reality and perceptions, she says. The last step is to create a safe environment to reduce the likelihood of retraumatization.
Consistent assignment is a tool that Wenzler says can boost a center’s efforts. Even though staffing has been challenging for all providers in the health care world, Signature strives to maintain and has been successful with maintaining the same, consistent staff. “This not only builds trust with the trauma residents we serve, but it allows us to further identify even small changes needed to not only the resident’s physical needs but also their mental and spirituality needs,” she says.
Words, combined with sincerity and passion, can move an individual’s recovery in the right direction. The trick is being supportive, says Steinberg. “Similar to discussing end-of-life issues, trauma histories can be challenging for some long term care professionals—and residents—to talk about,” he says.
Asking open-ended questions, exploring the current impact of past trauma with residents, and mainly just providing unconditional support and compassion can go a long way, he says.
Being More Effective
Birmingham Green is a campus based in Northern Virginia that operates three different care centers—a skilled nursing center and two assisted living communities. Residents range from 33 to 103 years of age.“Trauma has always been there, but we are just paying attention now in a more open manner and perhaps able to be more effective in how we treat it,” says Joan Thomas, chief clinical officer for behavioral health, director of community relations, and administrator at the District Home, one of the assisted living centers. Thomas puts emphasis on treating every resident and patient holistically, no matter their background.
One of the most powerful weapons for fighting symptoms of PTSD is a Labrador named Vincent. He came to Birmingham from Veterans Moving Forward, an organization that aims to make a meaningful difference in the lives of veterans and increase their safety and independence within their homes and communities.On most days, Vincent can be found in the special care unit with residents that have cognitive issues. “Through just his presence, he is able to sense when people are feeling anxious or afraid,” says Thomas. “Our bodies secrete certain smells when we’re in that state. It’s really amazing. And he’s just the most handsome dog.”
Thomas recalls a time when an individual recently was very agitated and upset and didn’t want anyone near her. When Vincent approached her, she immediately and visibly calmed down. “He just goes and sits,” says Thomas.
While Vincent still belongs to Veterans Moving Forward, he lives at the Birmingham. Of course there are other ways to handle symptoms, says Thomas. “Aromatherapy, keeping a calm voice, minimizing bells and whistles, and becoming familiar with what could upset someone all help tremendously,” she says.
Getting to Know You
Whenever anyone is admitted into a care setting, Birmingham’s staff embark on a process of getting to know the new resident and inquiring into past histories of trauma. Thomas recalls a former resident some years back who would go through periods of distress. Certain noises triggered them. Knowing and vetting the details of her condition was worth the effort, Thomas says.
She points out that just moving into a long term care environment itself can be a traumatic experience. “You’ve got lots of losses,” she says. “You’re moving into a new environment and leaving your home. The very active process of moving into an environment can be traumatic. Recognizing that and giving voice to those feelings is very important.”
Keeping It Going
Thomas says that the typical process for noting a person’s trauma involves the care plan. “When you get to know your folks, you’ll have an understanding of what may trigger them, and you can incorporate it into their care plan—like don’t turn the TV on loud,” she says. Then, staff have 24-hour standups to review resident progress and discuss concerns or health status, along with any mental or emotional issues.
A key to keeping a strong focus on residents with trauma is continually training staff, says Thomas. “Provide responses in a compassionate manner. And as it relates to trauma, the more we can imagine or relate to the individual, the more effective we can be,” she says.
“We have folks that have had some horrific events in their life,” she says. Thomas recalls a gentleman who lost his son and then his daughter not long after. It was one thing after another. “Providing him a safe space so that he could process that was really important,” she says.
Birmingham works closely with mental health providers. A psychiatrist is on site one day a week, and a psychologist runs an empowerment group for residents, which is a great source of peer support, says Thomas.“The group really helps them feel safe, share their feelings, and participate in the community.”
Success in trauma care may come in many forms, say providers. “I see infinite successes from seeing a smile, to drying a tear, to empowering our residents to live life to the fullest without repercussions,” says Wenzler. “It’s about living life with joy and dignity.”
Joy and dignity, mixed with a little creativity, can be a powerful thing. In an effort to preserve meaning for residents, a Signature center in Rogersville, Tenn., gathers personal story information when admitting a veteran for care. With permission, the center then places that resident’s picture and information on an Honor Wall. The Honor Wall is a dedicated place to honor all veterans living in the center, and it stays in place year-round.
“The residents, wanting a place that was special to them, decided to update the Honor Wall themselves,” says Wenzler. It’s something that they continue to do to this day.
Success in trauma-informed care can also mean moving forward, one step at a time.
Juman recalls one of the very first residents he worked with in skilled nursing—Joseph was a 25-year-old who suffered from PTSD as a result of multiple traumas. Growing up in a home filled with neglect, emotional abuse, and domestic violence, his neighborhood was also riddled with random violence and crime.
He joined a gang in his early teens, witnessing and participating in severe violence. He was admitted to the facility after having been shot in the back, an event that left him paralyzed, with just limited use of his upper extremities.
“After that new trauma, it was enormously difficult for him to come to feel safe in a facility full of people who would come into his room uninvited, with roommates and caregivers who were strangers, with sights and sounds that were unfamiliar and, at times, jarring,” says Juman. It took quite a while for facility staff to understand his history and his unique challenges and triggers so that he was eventually able to feel safe.
“And that’s when the next phase of our treatment was able to begin, that of helping him create a plan for a meaningful life despite his limitations,” says Juman. “But that is another story.”
Article source: Provider Magazine
Written by: Amy Huaiquil