Trauma-Informed Care

Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physical or emotionally harmful or life threatening. Trauma typically has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. Trauma-informed care is an evidenced-based approach to deliver health care in a way that recognizes and responds to the long-term health effects of the experience of trauma in patients’ lives. Trauma-informed care originated in social work, counseling and psychology.

Complex trauma results from extended exposure to traumatizing situations, often during childhood. Developmental trauma results from multiple or chronic exposure to one or more forms of interpersonal trauma (abandonment, betrayal, physical assault, sexual assault, threats to bodily integrity, coercive practices, emotional abuse, witnessing violence or death). Acute trauma results from exposure to a single overwhelming event, such as an evacuation during a hurricane or other natural disaster. Post-Traumatic Stress Disorder (PTSD) is a recognized mental health condition triggered by a terrifying event.

Trauma-informed approach is a methodology to respond to those who are at risk or have experienced trauma. Examples of trauma are adverse childhood experiences, intimate partner violence, PTSD from war, Holocaust, systemic racism, disaster, grief and loss and transfer trauma. According to the National Council for Community Behavior Health Care, “Trauma occurs when a person is overwhelmed by events or circumstances and responds with intense fear, horror, and helplessness.” Extreme stress overwhelms the person’s ability to cope. There is a direct correlation between trauma and conditions such as diabetes, COPD, heart disease, cancer and high blood pressure.

Trauma-informed care acknowledges the need to understand a patient’s life experiences in order to deliver effective care. Trauma is highly individual. Everyone experiences life events and stressors differently. One size does not fit all. The past matters, and it influences today and tomorrow. Understand that residents may be reliving or experiencing the impact of trauma even if the trauma is not recent. Behaviors and signs need to be considered through a lens of trauma and resilience.

Effective November 28, 2019, the Phase III of the CMS Requirements of Participation take effect and includes the requirements to implement trauma-informed care. §483.25(m) Trauma-informed care states the center 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.

483.40(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 conducted pursuant to §483.70(e), and [as linked to history of trauma and/or post-traumatic stress disorder.
483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being.
483.21(b)(3) Comprehensive Care Plans – the services provided or arranged by the facility, as outlined by the comprehensive care plan, must— (iii) Be culturally-competent and trauma–informed.

In Phase III, under §483.95(i) (F949), Behavioral health, formalized training programs must be completed and documented for all staff who support and provide care for residents that have behavioral health needs. All staff must have knowledge and skill sets to effectively interact with residents (communication, resident rights, meaningful activities.) Person-centered approaches to care should be implemented based upon the comprehensive assessment, in accordance with the resident’s customary daily routine, life-long patterns, interests, preferences, and choices and should include the interdisciplinary team (IDT), the resident, resident’s family, and/or representative(s). Individualized, person-centered approaches to care must be implemented to address expressions or indications of distress. Staff must also monitor the effectiveness of the interventions, changing those approaches, if needed, in accordance with current standards of practice. Additionally, they must accurately document these actions in the resident’s medical record and provide ongoing assessment as to whether they are improving or stabilizing the resident’s status or causing adverse consequences.

The intent of this regulation is to ensure that a resident who, upon admission, was assessed and displayed or was diagnosed with a mental or psychosocial adjustment difficulty or a history of trauma and/or post-traumatic stress disorder (PTSD), receives the appropriate treatment and services to correct the initial assessed problem or to attain the highest practicable mental and psychosocial well-being. Residents who were admitted to the nursing home with a mental or psychosocial adjustment difficulty, or who have a history of trauma and/or PTSD, must receive appropriate person-centered and individualized treatment and services to meet their assessed needs. The coping skills of a person with a history of trauma or PTSD will vary, so assessment of symptoms and implementation of care strategies should be highly individualized.

A person may experience multiple stressors that may be recurrent or continuous and may cause a depressed mood, anxiety, and/or aggression. The resident may be diagnosed following the death of a loved one when the intensity, quality, or persistence of grief exceeds what normally might be expected. Stressors can occur for individuals with or without PTSD or a history of trauma. The resident who has a history of trauma which involves psychological distress, following a traumatic or stressful event, often involves expressions of anger or aggressiveness and some individuals who experience trauma will develop PTSD.

PTSD involves the development of symptoms following exposure to one or more traumatic, life-threatening events and usually develops within the first three months after the trauma occurs, although there may be a delay in months or even years. Symptoms may include, but are not limited to, the re-experiencing or re-living of the stressful event (e.g., flashbacks or disturbing dreams), emotional and behavioral expressions of distress (e.g., outbursts of anger, irritability, or hostility), extreme discontentment or inability to experience pleasure, as well as dissociation (e.g., detachment from reality, avoidance, or social withdrawal), hyperarousal (e.g., increased startle response or difficulty sleeping); and may be severe or long-lasting when the stressor is interpersonal and intentional (e.g., torture or sexual violence).

Although PTSD is commonly viewed as a disorder experienced only by military veterans, it is not exclusively a consequence of combat or war zone exposure. Individuals who have been physically or sexually assaulted or who experienced a terrorist attack or natural disaster, among other things may also be affected by PTSD. Additionally, some older nursing center residents may have lived through a time of genocide and witnessed or been subjected to the intentional and systematic destruction of a racial, political, or cultural group such as that which occurred during the Holocaust in World War II. For an individual with a history of trauma or PTSD, moving from the community into a long term care center can be a very difficult transition and cause worsening or reemergence of symptoms. Additionally, the structured environment of the nursing center can trigger memories of traumatic events and coping with these memories may be more difficult for older adults.

Trauma-informed care realizes the widespread impact of trauma and understands potential paths for recovery. It recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system. Trauma-informed care resist re-traumatization and responds by full integrating knowledge about trauma into policies, procedures, and practices.

The six key principles of Trauma-informed approaches are (SAMHSA, 2014):

Safety
Trustworthiness & Transparency
Peer Support
Collaboration and Mutuality
Empowerment, Voice and Choice
Cultural, Historical and Gender Issues

What can the center do now to prepare for the trauma-informed regulations?

Know the individuals you care for, including histories, mental health, coping, preferences and resilience.
Provide opportunities for residents, family members and all staff to learn.
Identify and build on the strengths of residents, families, staff and the center.
Build partnerships with mental health professionals and community-based resources.
Promote positive engagement among residents, families and staff.

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