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The last-minute guide to trauma-informed care
The last-minute guide to trauma-informed care
With trauma-related F-tags beginning in less than two weeks, many providers have spent months training their staff and feel quite prepared to manage this sensitive aspect of resident mental health care.
For those who might not be completely ready for the Nov. 28 start date, I offer below some basics on trauma-informed care practices. While none of us know exactly how the survey process will play out, these fundamentals can make it less likely to run afoul of regulations.
The Concept
The general idea of trauma-informed care is that residents who have had exposure to trauma can experience increased sensitivity to interactions in the long-term care setting that “trigger” old feelings and reactions. For instance, Bob, a resident who was physically assaulted several years ago, feels very unsafe and distressed when other residents become agitated.
The Symptoms
An individual who has experienced trauma may have symptoms of Post-Traumatic Stress Disorder (PTSD), such as an exaggerated startle response or repeated intrusive thoughts of the event. Using our example above, Bob shouts loudly in alarm when other residents are noisy or frightening, showing an exaggerated startle response.
The Goal
The new F-tags are an effort to increase awareness that the nursing home environment can trigger past experiences of trauma or exacerbate current traumas and to encourage facilities to make every effort to avoid re-traumatization.
The Interview
The first step in complying with the regulations is to determine whether or not a resident has a current or past experience with trauma. The challenge of the interview is to avoid the possibility that the manner in which the questions are asked becomes traumatizing in and of itself.
To minimize this possibility, hold the interview in as private and discreet a manner possible and “normalize” the process, explaining to interviewees that all residents are being asked about their past experiences.
Increase the interviewee’s sense of control by offering them the option not to answer any items if they feel uncomfortable.
For the entire article, visit: The last-minute guide to trauma-informed care
’Tis the season to help families address end-of-life care
’Tis the season to help families address end-of-life care
The holiday season will soon be upon us and with it will come out-of-town family members visiting their loved ones in long-term care settings.
Early November is a good time to increase the focus and training on customer service so that the facility is performing at its best when those infrequent but important guests arrive. It’s also a suitable moment to consider how to best aid families in discussing end-of-life care for their aging relatives.
Visitors who haven’t seen loved ones in several months may notice a physical or cognitive decline, making them more aware that life’s end is approaching. The holidays are also a time when several family members may be together and can discuss end-of-life concerns in collaboration.
While many residents will have completed advance directives upon admission, there are others who haven’t done so and those whose desires have changed. In addition, there are other details that may need addressing, such as readiness for hospice care, funeral arrangements, a last effort to repair fractured relationships or a chance to say good-bye.
Families invariably need assistance with these conversations and, as those who provide care to the ill and dying, this is a good opportunity to showcase the organization’s compassion and expertise in this area.
For the entire article, visit:
’Tis the season to help families address end-of-life care
How to apply the best antidepressant — other residents
How to apply the best antidepressant — other residents
Centers for Medicare & Medicaid Services directives ask facilities to be more attentive to behavioral health issues such resident depression and trauma, and to manage dementia and other behavioral problems while reducing or eliminating psychotropic medications. Providers wondering how to accomplish this tall order might consider turning to a generally overlooked resource — their residents.
Don’t get me wrong. I firmly believe that past traumas, long-standing mental health problems, and depression and anxiety triggered by the tumult of admission should be addressed by mental health professionals such as consulting psychologists like me.
Just as firmly, however, I know that positive connections between residents can alleviate many of the problems associated with physical decline and institutional living.
Shared friendships can give meaning, purpose and joy to the lives of elders, including those with advanced dementia. I know I’m not the only one in the field who has witnessed nonsensical conversations between two confused elders who delight in each other’s presence — and the challenges that come when one of the pair departs.
Moreover, just this week McKnight’s wrote about a study reporting on the success of a peer mentoring program between residents. The “Java Mentorship” offered residents weekly training sessions incorporating 26 different modules, including “how to be a mentor” and “how to support someone who’s grieving.” When they completed the educational program, the trainees visited with other residents who were socially isolated. At the conclusion of the program, the mentors — mostly women about 80 years old — showed significantly reduced feelings of depression and loneliness.
For the entire article, visit:
How to apply the best antidepressant — other residents
Life on the road as an LTC shrink
Life on the road as an LTC shrink
Last week I flew from New York City to Indianapolis to speak at a conference on severe mental illness in long-term care. From there, I drove to Chicago to offer my thoughts about behavioral health at a risk management event.
It wasn’t exactly a world tour, but I did come away with some interesting observations regarding our field.
My first stop was the severe mental illness (SMI) conference organized by the Indiana State Department of Health. The goal of this event was to improve care for Indiana residents diagnosed with SMI.
Nationally, rates of severe mental illness in LTC have doubled between 2000 and 20171. At 10%, Indiana has about an average number of SMI individuals, yet, with conferences like this, it’s leading the way in addressing this nationwide problem.
After recognizing that the mental health pendulum went too far in the direction of deinstitutionalization, Indiana has also revamped its psychiatric hospital system and increased the number of beds available, including geropsychiatric beds.
To see the number of residents with schizophrenia and bipolar disorder for your state, county and facility, create a map in one minute on LTCFocus.org, a fascinating, user-friendly Brown University website.
(By the way, I’m editing this article in my office on the rehab unit and a resident with bipolar disorder just stopped by for the third time this week — and it’s only Tuesday! As I was saying, it’s a national issue.)
One challenge that needs to be further addressed with regulators is how to comply with directives to avoid using individuals “for labor,” while at the same time allowing residents living with mental illness the opportunity to engage in meaningful, esteem-building activities.
Conference attendees told me, for instance, about a resident who enjoyed pulling weeds in the garden, but surveyors perceived this as problematic. Perhaps having more guidance and flexibility around volunteerism would help.
Life on the road as an LTC shrink
What worries me about trauma-informed care
What worries me about trauma-informed care
I was relieved last month when I saw that my fellow Psychologists in LTC member, Lisa Lind, Ph.D., had written an article for McKnight’s about Preparing for trauma-informed care in LTC. As McKnight’s resident behavioral health expert, I was feeling like I should write something on the subject, but I was struggling with how to do so given my apprehensions about it.
Now that Dr. Lind has provided a practical guideline, let us turn to what’s kept me up at night.
While I think it’s a good thing to pay more attention to the emotional experience of residents, I’m worried about how asking them about their traumas will be implemented in the field.
As a psychologist, residents talk to me about their painful past experiences every day. I’ve heard about children born of rapes, hidden abortions, violent childhood homes and all manner of intensely personal information, to which I was often the only one told after a lifetime of carrying a secret. It is a sacred honor to be the listener to a late-life unburdening and it comes after trust has been established over time.
Traumas are sensitive emotional wounds and I’m concerned that in their well-meaning efforts to comply with the new F-tag directives, staff members and surveyors will be poking these emotional wounds with a big stick.
There are many aspects of the situation which contribute to my uneasiness:
- Nursing homes are medically focused institutions. An in-service training or two won’t make up for the general lack of psychological training of the staff.
- Teams are still having difficulty identifying major triggers for psychological evaluation in the present day, such as an amputation or the death of a roommate.
- There are cultural and generational differences in comfort in discussing one’s personal life.
- There’s very little privacy in nursing homes. Roommates and residents seated near nursing stations and team rooms frequently overhear discussions of their peers’ personal information despite staff efforts at discretion.
For the entire article, visit:
What worries me about trauma-informed care
Severely mentally ill residents: Staff training, teamwork needed
Severely mentally ill residents: Staff training, teamwork needed
As I discussed in Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave, long-term care has a growing population of severely mentally ill (SMI) residents, with the number of residents diagnosed with schizophrenia or bipolar disorder approaching 20% in some states as of 2017.1
In addition, 46.3% of LTC residents were diagnosed with depression in 2015 and 2016.2 Some were undoubtedly individuals with severe, chronic depression.
People with SMI generally enter nursing facilities for rehabilitation following a fall or some other health crisis. Discharge choices can be limited due to coexisting medical and mental health problems, leading them to become long-term residents despite their relatively young age (an average age of 62 versus 77 in the general nursing home population3).
A review of research on individuals with mental health problems, Physical illness in patients with severe mental disorders, finds that people with SMI have a greater likelihood of physical illness than those without SMI. The authors of the study note that “important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision…contribute to these poor physical health outcomes.”
Their research suggests multiple points at which long-term care providers can intervene to assist SMI residents.
Medical assessment
Nurses and physicians can be taught to recognize health problems typical of the SMI population so that they’ll be alert to the increased risk of illnesses such as diabetes, metabolic syndrome, obesity-related cancers, cardiovascular diseases, osteoporosis, hepatitis B/C, tuberculosis, impaired lung function, poor dental status and other concerns.
Staff members who are comfortable physically assessing older residents might need additional training to be at ease evaluating SMI individuals, who may be more physically imposing because of their relative youth, come across as unfamiliar or frightening in their presentation or be themselves uncomfortable with medical tests or interventions.
For the entire article, visit:
Severely mentally ill residents: Staff training, teamwork needed
Ageism of elders affects their LTC experience
Ageism of elders affects their LTC experience
“There’s no one here to talk to,” a new resident, Claire, said to me, “They’re all so old!”
Claire was in her early 80s but thought of herself as two decades younger. She, like most residents I’ve encountered, have their own prejudices about aging and older adults. It negatively impacts them in a wide variety of ways, including in their long-term care experiences.
Social isolation
Residents may dismiss their peers due to their perception of them as old, infirm and uninteresting, keeping themselves isolated and preventing the opportunity to gain friends or at least “rehab buddies” who can support them through the taxing process of getting back on their feet again.
In busy, understaffed facilities (and what nursing home isn’t?), catalyzing resident engagement with one another isn’t just a nice thing to do, it can meet vital needs that staff members wish they had time for. With assistance in getting over their initial prejudices, residents can not only encourage one another, they can ease anxiety, mourn losses together and notify workers if a neighbor appears lethargic or depressed or about to fall.
All departments, not just recreation, can make efforts to connect like-minded individuals. One of my favorite things is to be a “matchmaker,” introducing women who enjoy similar activities or men who hail from the same county or country. Matchmaking can begin with something as simple as seating a potential friend next to someone’s “good” ear and commenting, “Did you two know you both … [fill in the blank]?”
Effect on adoption of mobility aids
Societal prejudices against growing old and “weak” keep many seniors from acknowledging their growing frailty. They may eschew tools such as canes, walkers or hearing aids because they “don’t want to look old”1 or be treated as such. Most of us in the business of long-term care recognize the irony that by avoiding these devices, elders are more likely to come through our doors. We might speculate that they’re also more likely to return once discharged.
In addition to training on residents how to use mobility aids, therefore, it may be beneficial to acknowledge and address the resistance that short-term residents might have to using these items upon their return to the community.
I’m thinking a short movie could do it.
For the entire article, visit:
Ageism of elders affects their LTC experience
Secret shoppers in LTC
Secret shoppers in LTC
Posing as customers, “secret shoppers” deliver the inside scoop to management about their experiences with various service providers. They can be invaluable to management in all kinds of situations, including long-term care, though there are special challenges there.
Secret shoppers are perhaps best known for retail settings. But they’re also used in hospital settings. A controversial recent New York Times article noted how faux patients arrive in emergency departments with contrived symptoms that allow them to observe the proceedings. The information provided is used to alter procedures and enhance training with the goal of improving customer satisfaction.
According to the article, “Undercover in a Hospital Bed,” personal details that explain poor customer service ratings can leave hospital executives “spellbound.” In one example, a secret shopper reported that staff members were dismissive of patient concerns and squabbled among themselves. Poor teamwork made her doubt the quality of the care she was receiving.
The findings inspired the hospital to create and train employees on new norms of staff behavior, including staying off cell phones and learning more about the lives of the people presenting for care. Obvious long-term care parallels can be assumed, but there’s more.
Reactions
There were a wide variety of comments on the New York Times piece. Hospital insiders affirmed the necessity and benefit of this stealth approach. Others deplored the waste of resources used on the deception. A few pointed to statistics indicating that what customers might consider good service could actually result in poorer clinical care. (Think: I’m so happy they gave me that opioid I wanted.)
Workers fumed that their own opinions weren’t solicited. They were also concerned about superficial fixes such as pushing employees to plaster smiles on their faces without investigating and correcting the reasons that they weren’t smiling in the first place.
My take is that while workers have valuable information regarding the patient experience, they’re not always in a position to reveal it and management isn’t generally receptive to worker commentary. If the leadership team uses the information gleaned from the brief deception of a secret shopper to make underlying changes that positively impact patients and employees, then the strategy is a valuable tool.
Application to LTC
Those interested in the idea will note, however, that it’s easier to pose as a hospital patient than it is to be a mock nursing home resident.
For the entire article, visit: Secret shoppers in LTC
If toileting were a billable service …
If toileting were a billable service …
The other day over lunch a colleague said to me, “Imagine how things would change if toileting were a billable service.” I laughed, briefly considered that fanciful notion and continued eating my meal.
As I gave the idea further reflection, however, it might not be as laughable as it first appears.
Consider the following:
Funding
Remuneration for toileting would mean that aides would hold income-generating positions. We’d expect that nursing departments would become fully staffed in order to take advantage of this new funding stream and that compensation for aides would increase.
Respect
We might also anticipate that CNAs would become more highly valued for their services by others in the facility.
Philosophical shift
Direct payment for the tasks of aides would strengthen incentives for employers to support ways for employees to manage their jobs around their lives, which often entail demanding family caregiving responsibilities.
Retention programs/employee benefits
The funds could be used to develop retention efforts such as flexible schedules, onsite daycare, financial contributions to staff education and other employee benefits.
Training
Increased remuneration for personal care would lead to more resources for training and for creating programs that promote the development of CNAs, such as peer mentorships.
For the entire article, visit:
If toileting were a billable service …
Enhancing resident independence
Enhancing resident independence
It’s the week of Independence Day and freedom is on my mind. Residents frequently speak to me of their dissatisfaction with the limitations on their liberty, from being told to sit in a communal room when they want to be alone, to needing a family member to sign them out on pass.
“Me and the other inmates,” they say, trying to use humor to cope with their confinement.
Constraints on residents are generally due to a combination of factors, first and foremost being the physical and/or cognitive impairments that led them to require rehab or nursing home care. Psychotherapy often addresses residents’ feelings about having become ill through aging, accidents, life choices and other circumstances and it can reduce some of the blame of the nursing home for curbing their freedom.
It must be acknowledged, however, that there are many aspects of long-term care itself that limit residents, including the facility’s desire to protect residents from harm and themselves from litigation, regulatory requirements, risk-avoidance policies and routines (because “that’s the way it’s always been done and we keep passing surveys”) and inadequate staffing.
As we celebrate our freedoms in the country this week, perhaps we can consider ways in which to create a better balance between the need to provide a safe environment for residents and their right to make their own choices.
Below are just a few of the many aspects of care that could be adjusted for increased autonomy:
- Reevaluate practices that restrict residents as a matter of routine and consider instead ones that are based on their capabilities. For example, rather than disallowing all motorized wheelchairs, offer the opportunity to residents who are found to be physically and cognitively capable, pass a periodic “driver’s test” and follow established guidelines for use.