Microsoft PowerPoint - Session 3 Trauma-Informed Care
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Session-3-Trauma-Informed-Care COVID-19 PANDEMIC
Trauma-Informed Care: Recognizing and Responding to Residents with Special Needs
Barbara Speedling
Quality of Life Specialist NMHCA - Webinar 2020
F699 Trauma-Informed care
§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.
§483.25(m) will be implemented beginning November 28, 2019 (Phase 3)
What is Trauma-Informed Care?
Trauma-Informed Care understands and considers the pervasive nature of trauma and promotes environments of healing and recovery rather
than practices and services that may inadvertently re-traumatize.
A Trauma-informed Approach (The 4 R's)
· Realizes the widespread impact of trauma and understands potential paths for recovery
· Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system
· Responds by fully integrating knowledge about trauma into policies, procedures, and practices
· Resists re-traumatization
https://www.integration.samhsa.gov/clinical-practice/trauma-informed
The Five Principles of Trauma-Informed Care
· The Five Guiding Principles are;
o Safety; o Choice; o Collaboration; o Trustworthiness; and o Empowerment.
· Ensuring that the physical and emotional safety of an individual is addressed is the first important step to providing Trauma-Informed Care.
http://socialwork.buffalo.edu/social-research/institutes-centers/institute-on-trauma-and-trauma-informed-care/what-is-trauma-informed-care.html
What does trauma-informed care look like?
· Explain why you're asking sensitive questions.
o "I need to ask you about your sexual history, so I know what tests you may need."
· Explain why you need to perform a physical exam, especially if it involves the breasts or genitals. If someone is nervous, you can let them bring a trusted friend or family member into the room with them.
· You can tell them that if they need you to stop at any time, they can say the word.
· If someone refuses outright to have a certain exam or test, or if they're upset about something (like having vaccinations), you can respond with compassion and work with them, rather than attempting to force them or becoming annoyed.
https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562
Re-traumatization What Hurts?
System (Policies, procedures, "the way things are done")
· Having to continually retell their story · Being treated as a number · Procedures that require disrobing · Being seen as their label (ie. Addict, schizophrenic) · No choice in service or treatment · No opportunity to give feedback about their experience with the
service delivery
http://socialwork.buffalo.edu/social-research/institutes-centers/institute-on-trauma-and-trauma-informed-care/what-is-trauma-informed-care.html
Re-traumatization What Hurts?
Relationship (Power, control, subversiveness) · Not being seen/heard · Violating trust · Failure to ensure emotional safety · Non-collaborative · Does things for rather than with · Use of punitive treatment, coercive practices and oppressive language
http://socialwork.buffalo.edu/social-research/institutes-centers/institute-on-trauma-and-trauma-informed-care/what-is-trauma-informed-care.html
Benefits of Being Trauma-Informed
It can improve patient and staff experiences, by: · Creating a proactive approach to safety
· Creating safer physical and emotional environments for clients, families, and staff
· Creating and sustaining opportunities for choice, power and control through increased therapeutic interactions
· Reducing the possibility of re-traumatization
· Improving the social environment in a way that improves all relationships
Benefits of Being Trauma-Informed
· Creating environments that care for and support staff · Increasing the quality of services, reducing unnecessary interventions,
reducing costs · Reducing the number and types of negative encounters and events (e.g.,
seclusion and restraint) · Creating a resiliency and strengths-based focus · Increasing client and family satisfaction · Increasing success and job satisfaction among staff
https://yourexperiencesmatter.com/learning/trauma-informed-care/benefits-of-being-trauma-informed/
ADDRESSING STRESS
· Create outlets for residents and staff to express stressful emotions;
· Develop support groups and discussion programs to provide outlets for emotion;
· Design a process and a place for residents or staff to have a timeout a quiet space.
F740
Behavioral Health Services
· Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
o Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
· The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide appropriate nursing and related services. These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for:
o §483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment.
o §483.40(a)(2) Implementing non-pharmacological interventions.
Behavioral Health
F741 Sufficient staff to provide behavioral health care and services per the annual facility assessment (ref. F838)
F742 Resident who displays/is diagnosed/history of mental disorder or psychosocial adjustment difficulty, a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services;
F743
Resident whose assessment did not reveal/does not have a diagnosis of a mental or psychosocial adjustment difficulty/ documented history of trauma and/or post- traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that development of such a pattern was unavoidable;
F744 Resident who displays/is diagnosed with dementia, receives the appropriate treatment and services.
F838 FACILITY ASSESSMENT
· The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.
o Review and update at least annually, whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment;
o Must address or include a facility-based and community-based risk assessment, utilizing an all-hazards approach;
o The results of the facility assessment must be used, in part, to establish and update the IPCP, its policies and/or protocols to include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, and visitors.
· Note: a community-based risk assessment should include review for risk of infections (e.g., Multidrug-resistant organisms- MDROS) and communicable diseases such as tuberculosis and influenza. Appropriate resident tuberculosis screening should be performed based on state requirements.
Pre-Admission Screening and Resident Review (PASARR)
· The Level I PASARR SCREEN must be completed prior to admission to a RHCF for every person, for any reason and any length of stay.
o Exemption for residents admitted for short stay less than 30 days. o If still a resident on day 31, a PASARR Level I SCREEN must be completed
· As soon as a person has been newly diagnosed with a mental illness and/or intellectual disability/developmental disability.
· Upon significant change mental or physical per MDS criteria
· Level II Recommendations incorporated into the comprehensive care plan
Behavioral Health Assessment Considerations Adjustment Difficulties
· Impaired verbal communication; · Social isolation (e.g., loss or failure to have relationships); · Sleep pattern disturbance (e.g., disruptive change in sleep/rest pattern as related to one's biological and
emotional needs); · Spiritual distress (disturbances in one's belief system); · Inability to control behavior and potential for violence (aggressive behavior directed at self or others); and
· Stereotyped response to any stressor (i.e., the same characteristic response, regardless of the stimulus).
Assessment
When, Where, and How...
What is PTSD?
PTSD (post-traumatic stress disorder) is a mental health problem that some people develop after experiencing or witnessing a life-threatening event, such as: · Combat · A natural disaster · A car accident; or · Sexual assault
What are the symptoms of PTSD?
· Reliving the event · Avoiding things that remind you of the event · Having more negative thoughts and feelings than before · Feeling on edge
Primary Care PTSD Screen
· The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) is a 5-item screen that was designed to identify those with probable PTSD.
· Those screening positive require further assessment from a mental health professional.
· The results of the PC-PTSD-5 should be considered "positive" if a client answers "yes" to any three of the five items about experiences in the past month related to an event.
Source: https://www.ptsd.va.gov
Primary Care PTSD Screen
· Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:
o A serious accident or fire o A physical or sexual assault or abuse o An earthquake or flood o A war o Seeing someone be killed or seriously injured o Having a loved one die through homicide or suicide
· Have you ever experienced this kind of event? YES or NO
o If no, screen total = 0. Please stop here. o If yes, please answer the questions below.
· In the past month, have you ...
o Had nightmares about the event(s) or thought about the event(s) when you did not want to? YES or NO o Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you
of the event(s)? YES or NO o Been constantly on guard, watchful, or easily startled? YES or NO o Felt numb or detached from people, activities, or your surroundings? YES or NO o Felt guilty or unable to stop blaming yourself of others for the event(s) or any problems the event(s) may
have caused? YES or NO
How is PTSD Treated?
· Cognitive Processing Therapy (CPT) or Talk Therapy · Medication · Prolonged Exposure Therapy (PE) exposure to the thoughts, feelings,
and situations that the person has been avoiding. · Stress Inoculation Training (SIT) SIT teaches skills for handling
stressful situations that can help manage PTSD symptoms.
Helping Residents With Mental Disorders
· Anxiety · Major Depression · Schizophrenia · Schizoaffective Disorder · BiPolar Disorder · Obsessive Compulsive Disorder
Mental Disorders and Related Conditions
Residents diagnosed with a mental disorder may have additional illnesses: · Anxiety disorder · Post-traumatic stress disorder (PTSD) · Attention-deficit hyperactivity disorder (ADHD) · Substance abuse
How to Communicate
Verbal and Non-Verbal Communication
· Keep all your verbal communication simple, brief, and specific.
· Nonverbal communication refers to how you say it-your tone of voice, posture, eye contact, facial expression, and physical distance between speakers.
How to Communicate
· Expressing positive feelings: Maintain eye-contact; say exactly what pleased you and how it made you feel.
o Use phrases like "I would like you to...." or "I would really appreciate it if you would....."
· Use phrases that display confidence:
o "I know you'll do fine." you can handle it. o " I'll trust you will work it out "You'll make it!"
When to Communicate
· Don't discuss something important when you are angry or upset;
· Be prepared to think clearly, listen well, and focus on constructive solutions; and
· Before talking to the person, take as much time as you need to calm down.
Guidelines For Non-verbal
Communication:
1. Stand close to the person, but don't crowd his/her personal space.
2. Convey interest, concern and alertness through your body posture and facial expression.
3. Maintain eye contact with the person. 4. Speak calmly and clearly
STATEMENTS OF ENCOURAGEMENT
Phrases that display confidence:
o "I know you'll do fine." you can handle it. o " I'll trust you will work it out "You'll make it!"
Phrases that recognize effort and improvement:
o "Look at how much you accomplished so far." o "Looks like you put a lot of work into that."
BIPOLAR DISORDER TREATMENTS
Keeping a Life Chart Even with proper treatment, mood changes can occur. Treatment is more effective when a client and doctor work closely together and talk openly about concerns and choices.
Keeping a life chart that records daily mood symptoms, treatments, sleep patterns, and life events can help clients and doctors track and treat bipolar disorder most effectively.
Obsessive compulsive disorder: symptoms and behaviors
OCD · A psychiatric disorder characterized by obsessive thoughts and compulsive
actions, such as cleaning, checking, counting, or hoarding. · OCD, one of the anxiety disorders, is a potentially disabling condition that can
persist throughout a person's life. · The individual who suffers from OCD becomes trapped in a pattern of repetitive
thoughts and behaviors that are senseless and distressing but extremely difficult to overcome. · OCD occurs in a spectrum from mild to severe, but if severe and left untreated, can destroy a person's capacity to function at work, at school, or even in the home.
Managing Symptoms and Reactions
1. Compulsions:
· Learn Patterns and Reasoning · Channel Hoarding Behavior to Productive Activity
2. Rituals and Routines:
· Validation vs. Reality Orientation · Practice Behavior Modification/Reward Systems
3. Building Bridges:
· Reassurance · Encourage Diversionary Activity to Address Anxiety
HOARDING
Reasons for Saving · Sentimental
"This represents my life. It's part of me."
· Instrumental "I might need this. Somebody could use this."
· Intrinsic "This is beautiful. Think of the possibilities!"
HOARDING
Hoarding Rating Scale (HRS)
0 1
2
3
4
5
6
7
8
Not at all
Mild
Moderate Severe
Extremely
Difficult
1. Because of the clutter or number of possessions, how difficult is it for you to use the rooms in your home?
2. To what extent do you have difficulty discarding (or recycling, selling, giving away) ordinary things that other people would get rid of?
3. Do you currently have a problem with collecting free things or buying more things than you need or can use or can afford?
4. To what extent do you experience emotional distress because of clutter, difficulty discarding or problems with buying or acquiring things?
5. To what extent do you experience impairment in your life (daily routine, job / school, social activities, family activities, financial difficulties) because of clutter, difficulty discarding, or problems with buying or acquiring things?
Tolin, D.F., Frost, R.O., & Steketee, G. (2010). Psychiatry Research, 30, 147-152.
SUBSTANCE ABUSE F740 Behavioral Health Services
· "Substance use disorder" is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems or disability.
o (Adapted from: Substance Abuse and Mental Health Services Administration (SAMHSA) definition found at http://www.samhsa.gov/disorders/substanceuse).
SUBSTANCE ABUSE Assessing Trauma
Trauma and trauma-related problems are common risks factors in substance abuse.
· About 60% of men and 50% of women experience at least one trauma such as a disaster, war, or a life-threatening assault or accident at some point in their lives.
· Nearly 8% of the population has PTSD in their lifetimes, and PTSD is highly comorbid with other disorders such as panic, phobic, or generalized anxiety disorders; depression; or substance abuse.
DRUG ADDICTION Recognizing signs of drug use or intoxication
Obtain information on signs/symptoms for the following substances at:
https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112
o Marijuana o Barbiturates, benzodiazepines and hypnotics o Meth, cocaine and other stimulants o Hallucinogens (LSD, PCP) o Inhalants (Household cleaners, glue, paint thinner) o Opioid painkillers
Therapeutic Activity Challenges
· Mandated social distancing: individualized activities over groups · Human resource deficits due to COVID-19 Pandemic · Insufficient technology and to reach the greatest numbers · Shrinking community support and involvement
Benefit of Conversation
University of Exeter: "One Social Hour a Week in Dementia Care Improves Lives and Saves Money: Person-centered activities combined with just one hour a week of social interaction can improve quality of life and reduce agitation for people with dementia living in care homes, while saving money."
ScienceDaily, 16 July 2017
"Sheltered Workshops"
A facility or program, either for outpatients or for registrants of an institution, that provides vocational experience in a controlled working environment. · For registrants with dementia the workshop also offers the opportunity
to find comfort in doing familiar tasks. · For the non-traditional registrant who plans to return to the
community, the workshop provides an opportunity education, life skills programming, and helps prepare the registrant for community reintegration.
101 ACTIVITIES ANYONE CAN DO
1. Listen to music 2. Make homemade lemonade 3. Count trading cards 4. Clip Coupons 5. Sort poker chips 6. Rake leaves 7. Write a poem together 8. Make a fresh fruit salad...
Source: Alzheimer's Association Web Site www.alz.org
Creative, Artistic, and Expressive Therapies for PTSD
· Expressive Writing: is a brief intervention that instructs individuals to write about their deepest thoughts and feelings about a stressful event without regard to the structure of the writing
· Dance and Body Movement Therapies: propose that one's negative, emotion-laden experiences are represented in the body in the form of tension and pain.
· Art Therapy: involves residents using some medium (e.g., painting, drawing, collage) to represent their feelings or emotions related to their trauma;
· Music Therapy: engages residents to use music in a variety of ways (e.g., playing music, beating a drum, listening to and sharing songs) to encourage emotional expression in a non-threatening environment.
Creative, Artistic, and Expressive Therapies for PTSD
· Drama Therapy: creates safe, playful environments where patients are able to act out anxieties or conflicts due to their trauma
· Nature Therapy: involves a set of related activities that utilize a mix of relaxation and creative approaches involving nature.
· Mindfulness Therapies: focus primarily on observing one's internal and external states and accepting one's past experiences, so as to better tolerate the distress associated with trauma reminders
Source: Creative, Artistic, and Expressive Therapies for PTSD By Joshua Smyth, PhD and Jeremy Nobel, MD, MPH
Ensuring Staff Competency
Quality Review
· Review and revise education and training to ensure regulatory compliance and quality care;
· Review and revise education and training to keep pace with the demographics revealed in the facility assessment;
· Assess the skills and interest of the educator(s); · Update and enhance teaching tools and resources; and · Improve opportunities to monitor the application of the education and skills beyond the
immediate post-test and more frequently than an annual performance evaluation.
Ensuring Staff Competency
Education Necessary to Phase 3 Compliance
1. Residents' Rights on Capacity Determinations/Abuse Prevention;
2. Regulations concerning use of bed rails/informed consent;
3. Assessment, Care Planning, and Treatment in Behavioral Health:
1. Post Traumatic Stress Disorder (PTSD) 2. Mental Disorders 3. Traumatic Brain Injury 4. Intellectual/Developmental Disability 5. Addictions: Substance use/Alcoholism
4. Non-Pharmacologic Intervention/Meaningful Activity
Bspeedling@aol.com 917.754.6282 www.barbaraspeedling.com Creating Meaningful, Satisfying Lives One Person at a Time
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