Dipping or Diving: Trauma-Informed Care Expert Has the Answers

November 7, 2019


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Phase 3 of the revised Medicare and Medicaid requirements of participation for long-term care requires skilled nursing homes (SNFs) to provide “trauma-informed care” (TIC). Whether facilities and practitioners are dipping their toes in this or diving in head-first, there are many questions and uncertainties about TIC. In the October 23 AMDA On-The-Go podcast on this important topic, host Wayne Saltsman, MD, PhD, CMD, sought some answers from his guest, Nancy Kusmaul, PhD, LMSW, assistant professor at the University of Maryland School of Social Work.

Dr. Kusmaul started by noting that TIC “has been around in behavioral health for a long time.” However, she said that health care settings “have been much slower to begin this conversation.”

The definition of TIC varies across settings, but the Centers for Medicare & Medicaid Services (CMS) is using this one from the Substance Abuse and Mental Health Services Administration (SAMHSA): “Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” A TIC approach, according to SAMHSA, is “a program, organization, or system that 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, and responds by fully integrating knowledge about trauma into policies, procedures, and seeks to actively resist re-traumatization.”

Dr. Kusmaul noted, “This covers a lot of ground. In the post-acute and long-term care [PALTC] setting TIC broadly is an organizational approach [that] seeks to examine all policies and practices in the organization to prevent re-traumatization.” She further observed, “We’ve begun to realize how prevalent trauma really is in our population, the long-term effects of trauma, and the way in which our health care settings themselves can be traumatizing and re-traumatizing.”

SAMHSA outlines a set of six principles for providing TIC, but “it’s not a specific manualized intervention,” Dr. Kusmaul said. Instead, it involves “approaches to think about when you’re providing care.” The principles are safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues. Once you understand these principles, she suggested, “It’s pretty straightforward to think of ways that these can be applied in the skilled nursing setting and, by extension, to the care of older adults.”

Effective TIC won’t happen overnight, Dr. Kusmaul cautioned: “It is a work in progress. The goal is to every day with every encounter be a little more trauma-informed than you were the day before.” She stressed that CMS has yet to release specific guidance on TIC. However, she said, “There needs to be some level of facility assessment—coming up with what the approaches to trauma-informed care will be and some level of individual care planning for each resident around TIC.” She added, “With every encounter, every interaction between a staff member and a resident, and every interaction between two staff members, we should be thinking about the unintended consequences of our actions and behaviors; and we need to realize that someone who has experienced trauma might experience these differently than we anticipate.”

Training and implementation of TIC can be thought of in stages, Dr. Kusmaul suggested. For instance, the first part is general training across the facility that includes everyone from the receptionist all the way up to the medical director. This involves, she said, “some baseline training on the prevalence of trauma, the possible effects, and things that everyone can do such as increasing safety and being more transparent.”

Dr. Kusmaul stressed that not just anyone should be doing TIC assessments, and that those practitioners doing them—such as licensed nurses and social workers—must have specific training. She also noted: “We need to be clear about the facility’s capacity for available behavioral health services. We don’t want to explore or document trauma history without having some way to address it if the resident wants to.”

Click here to listen to the full podcast and hear much more of Dr. Kusmaul’s insights and thoughts. Check out a full list of archived episodes you can listen to at your convenience. CME is available for these programs.