The Centers for Medicare & Medicaid Services recently updated the Rules of Participation to require that long-term care facilities provide trauma-informed care to residents. Failure by LTC staff to recognize trauma histories can result in harm and negligence. 

Yet formal guidance about how to teach, implement, and deliver trauma-informed services in LTC settings is underdeveloped.

An important yet overlooked area where trauma-informed care is needed is among older adults who have experienced homelessness. The pandemic, climate-related disasters and economic turmoil are stressful experiences that have contributed to homelessness across all members of the population. Older adults born after 1954 are at a significantly higher risk for homelessness than those born before. Between 2020 and 2030, the number of homeless older adults is expected to triple

People who experience homelessness age significantly faster than their non-homeless peers. Stresses of homelessness contribute to allostatic load, or the cumulative burden of stress, which is associated with increased incidence of physical and behavioral health morbidities, including dementia, post-traumatic stress disorder, substance use disorders, and serious mental illness. Now, as older adults who have experienced homelessness are entering LTC settings, a trauma-informed perspective has become essential for delivering age-friendly care. 

Trauma-aware care is best conceptualized as a culture in which clinicians and administrators alike recognize that every person may have a traumatic history based on legacies of violence, victimization and resource scarcity. The goal of trauma-informed care is to accommodate the needs and vulnerabilities of trauma survivors while facilitating survivors’ participation in treatment. 

Below are four strategies for improving trauma awareness among staff and administrators in LTC.

1. Upon intake, all clients should be carefully screened for trauma history. Clients may not readily disclose their past traumas; however, we know that certain social experiences increase trauma exposure, including homelessness, military service, history of serious mental illness or substance use disorder, immigration and minoritization

Throughout the treatment process, clients should not be forced to elaborate on their traumatic histories. LTC staff must be sensitive to trauma survivors’ personal boundaries about discussing trauma. Forcing patients to talk about trauma may be provoking and re-traumatizing for patients. 

2. LTC administrators must reestablish physical and emotional safety. People with a history of traumatic exposure have been made to feel chronically unsafe. Staff must be trained to recognize patients’ discomforts and engage in conversations to promote safety if it is compromised. 

It is critical to note that while administrators and staff may not outwardly perceive any physical or emotional threats to patient safety, traumatic wounds are often invisible. Staff should not belittle or minimize patients’ safety concerns. Safety considerations in LTC settings may include times and settings when services are offered, identity of caregivers, and whether doors are left open or locked.

3. LTC staff and administrators must prioritize trust and rapport with clients who have a history of trauma exposure. Given the betrayal that many trauma survivors have experienced, it may be difficult for them to trust LTC staff right away. Trauma survivors have experienced the willful violation of their personal boundaries. 

It is possible for staff to build trust with these patients by remaining respectful and consistent in both consent and confidentiality. Staff should also aim to collaborate with patients to develop a treatment atmosphere that is characterized by a sharing of power. Patients’ preferences should be heard and honored where possible and patients must be considered an expert in their own comforts, safety and needs. 

4. Trauma survivors must be empowered through their treatment. Staff should invite patients to reflect upon their strengths, coping mechanisms and resiliencies that have supported them in their struggles. Asking patients “what matters” in the near and distant future is helpful in aligning treatment to what really matters for the patient and is a cornerstone of age-friendly care. These conversations may pave the way for referrals to therapists who target trauma recovery in therapy sessions. 

Trauma is a complex issue that often goes undetected in LTC settings, particularly among homeless adults. If we ignore the impact of trauma, we risk retraumatizing patients and neglecting a core aspect of wellness in age-friendly care. However, by observing strategies for promoting a trauma-aware culture, LTC administrators and staff can create the conditions for older adults to feel safe, trust staff, collaborate with providers, and ultimately empower the next stages of healing. 

Kelseanne Breder, PhD, PMHNP, RN, is a clinical assistant professor at NYU Rory Meyers College of Nursing, assistant director of behavioral health at the Hartford Institute for Geriatric Nursing, and a board-certified geriatric nurse and a psychiatric mental health nurse practitioner.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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