Most of us go about our daily routine with a sense of relative safety and security. That feeling of well-being can be quickly shattered by a traumatic event — the kind of unexpected, life-altering occurrence that we are accustomed to watching on the news.
Unfortunately, traumatic events are not unusual. One estimate places a person’s lifetime chance of experiencing a traumatic event at about 70%. For veterans, that exposure can reach as high as 85%.
Exposure to trauma, whether it involves combat, assault, childhood abuse or a natural disaster, has the potential to change the way we experience ourselves and the world around us. This change is physiological as well as psychological, as trauma has the potential to “rewire” victims in significant ways. Although not everyone who experiences trauma will manifest Post-Traumatic Stress Disorder, those who do often perceive themselves as more vulnerable and the world as more dangerous than they did before the trauma. Many of these patients will be chronically suspicious and fearful of their environment, which can have a profound impact on their post-acute care needs.
New trauma requirements for post-acute care
Beginning November 28, 2019, the Centers for Medicare & Medicaid Services will require nursing homes to put in place a process to identify residents who have experienced trauma and to consider the resident’s needs when developing a person-centered care plan. This new requirement mandates that facilities identify residents suffering from acute trauma reactions and those with chronic symptoms, i.e. post-traumatic stress disorder. A major aspect of trauma-informed care involves ensuring that interactions with staff and care routines are developed in a manner that avoids “re-traumatization”.
When establishing a screening process, nursing homes should recognize that while all individuals exposed to a traumatic event have experienced distress, not all of them will develop post-traumatic stress reactions. In the period immediately following a traumatic event, acute traumatic reactions are not unusual, and on a short-term basis these symptoms can be viewed as an adaptive response. That makes it imperative that facility staff, optimally led by behavioral health clinicians, differentiate between acute and chronic trauma reactions.
Distinguishing acute and chronic trauma
It is common for individuals who have experienced recent trauma to exhibit hyper-vigilance, altered mood, increased startle responses and sleep problems. In these cases, processing recent events, to the degree the resident is willing, can go a long way in helping them rebound. At this stage, aggressive pharmacological interventions may actually interfere with the resident’s processing of these emotional experiences and lead them to conclude they are doing fine. This is a critical stage to establish integrated care and involve all disciplines in developing a treatment plan.
In cases of chronic trauma reactions, an individual may have established maladaptive coping strategies and resist treatment. Their symptoms can often escalate due to the change in environment and unfamiliar demands. Significant increases in anxiety, combativeness, and isolation are common. This will frequently lead residents to refuse services and struggle for control of their care routine. These behaviors will often lead staff to conclude that the resident is problematic, as opposed to recognizing them as symptomatic.
Educating staff about PTSD will help them recognize the condition as more than just a psychological state. Trauma, especially severe and extended exposure, leads to a rewiring of the brain’s neurophysiology. Essentially the brain is reset to be hyper-reactive at lower thresholds of stimulation. Residents with PTSD may manifest extreme reactions to seemingly routine events that a non-traumatized individual would likely ignore or experience as relatively innocuous. That’s because the physiologic changes in the brain trigger hormonal responses (fright, flight, and flight) and powerful physiological states that further distort the resident’s perceptions, thinking and interpersonal relationships. These altered physiological states can be very uncomfortable and lead the individual to adopt coping strategies involving avoidance and isolation as a strategy.
Self-medication is very common in trauma, sometimes leading to medication- or drug-seeking behavior that may develop into addiction. The neurophysiological changes and reactions are conditioned and don’t necessarily resolve with time. In the case of PTSD, time is not a reparative variable in the treatment process. Staff members need to be taught that events that occurred decades ago may still have immediate and powerful effects on the resident’s reactions and view of the world.
For example, telling a resident who is experiencing an escalation in PTSD symptoms to calm down will not be effective. As always, the best responses will be unique to the individual, but will commonly involve giving them as much control over the situation as possible and establishing a non-judgmental, supportive atmosphere. Residents experiencing these symptoms are stuck in survival mode based on their perception that they are being threatened. What presents as unreasonable to the objective observer makes perfect sense to the resident based on their perceptions. Asking these residents to calm themselves doesn’t work because, from their perspective, they are in real danger.
It’s not hard to imagine how common nursing home routines could re-traumatize a resident. For example, a resident with a history of physical assault might have a strong reaction to physical therapy, where various manipulations and interventions involving physical discomfort or acute pain are common. Another example would be a resident who experienced the trauma of sexual abuse. They could easily be triggered by the daily routine of being dressed, toileted, or bathed. These situations may quickly make the resident feel unsafe or threatened.
Preparing for trauma-informed care
The facility impact of the new CMS requirements will depend on the resident population in any particular SNF. In the general population, estimates of PTSD are around 8%. With certain groups, for example the military, the rate of trauma reactions is as high as 17%. PTSD in a psychiatric or homeless population is likely to be much higher than the general population. Facilities that serve a high percentage of residents with primary psychiatric issues and/or active duty military experience will likely have a robust percentage of residents who trigger for trauma, while other facilities may have a relatively small number. The bottom line is that you won’t know until you get started.
A road map for complying with the new requirements around trauma can be broken down as follows:
- Staff education. Staff members need to understand the basic principles of trauma and of trauma-informed care. When training takes place, don’t be surprised to see light bulbs go off as staff members finally understand the connection between well-known resident behaviors and the underlying trauma experiences that fuel them.
- Trauma screening. Facilities will need to create a screening process for trauma that is specifically designed to identify residents with trauma history and, potentially, PTSD.
- Diagnosis. An accurate diagnosis of PTSD requires both a history of trauma and level of functioning that is consistent with DSM diagnostic criteria for the disorder. Remember, not everyone who experiences trauma winds up with PTSD.
- Care planning. Person-centered care planning for residents with PTSD should take into account all departments and staff members who have close contact with the resident. Nursing staff, and particularly CNAs, because they spend the most time with residents and provide the most hands-on care, will require the most specific care-planning focus. To successfully establish a culture sensitive to trauma, staff will have to be knowledgeable and sensitive to how their interpersonal approaches will play a key role in mitigating symptoms and avoiding re-traumatization of these residents.
- Behavioral health services. Residents with PTSD can be both highly distressed and very challenging to staff from a behavior management perspective. Following the trauma screening, the facility’s behavioral health team can play a valuable role in establishing a correct diagnosis and developing different facets of the care plan. There could not be a better example of where a strong behavioral health team and person-centered care planning will play a critical role in meeting a resident’s needs.
With some preparation, understanding and training, post-acute facilities can position themselves to comply with CMS requirements and deliver quality, appropriate care to residents who have experienced trauma.
Robert Figlerski, Ph.D., is director of behavioral health services for the Northeast region of TeamHealth.