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Trauma-Informed Care: What It Is—and Isn’t

Effective this November 28, trauma-informed care will take center stage in the survey process for nursing facilities (NFs) and skilled nursing facilities (SNFs) as the Centers for Medicare & Medicaid Services (CMS) completes the final stage of rolling out the revised requirements for participation in Medicaid and Medicare. CMS will implement new trauma-informed care regulations under F699 (trauma-informed care), which is a quality-of-care F-tag; F659 (comprehensive care plans/qualified persons); F741 (sufficient/competent staff‐behavioral health needs); and F949 (behavioral health training).


These new or revised F-tags will come on top of two already implemented tags that address trauma—F742 (treatment/service for mental/psychosocial concerns) and F743 (no pattern of behavioral difficulties unless unavoidable)—giving surveyors a full suite of trauma-informed care tags to guide their investigations. Note: Read the Code of Federal Regulations citations that underpin the trauma-informed care requirements for each F-tag at the end of this article.


At press time, CMS has not yet issued an advance copy of the revised Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” in the State Operations Manual. However, while directors of nursing services (DNSs) have to wait for Appendix PP to learn the basic requirements for avoiding citations related to trauma-informed care, they can still lay the groundwork for an effective trauma-informed care program, starting with understanding what trauma-informed care is.


In the simplest terms, trauma-informed care is a paradigm shift, says Kathleen Weissberg, OTD, OTR/L, CMDCP, education director at Select Rehabilitation in Glenview, IL. “It is a shift from ‘What is wrong with you?’ to ‘What happened to you?’”


“Trauma-informed care is not so much a program as it is an organizational culture,” adds Jill Schumann, MBA, president and CEO of LeadingAge Maryland in Baltimore and co-author of the Foundations of Trauma-Informed Care Toolkit and Implementing Trauma-Informed Care: A Guidebook. “So it needs commitment from the top.”


Similar to the way that cultural insensitivity typically is much more subtle than, for example, refusing to provide services to people of different cultures, staff often may not outright blame or accuse traumatized residents for their trauma, says Weissberg. “However, their attitude and mannerisms nevertheless may be perceived as negative, stigmatizing these residents without staff even realizing it.”


Thus far, CMS has steered providers toward guidance developed by the Substance Abuse and Mental Health Services Administration (SAMHSA): SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. SAMHSA, which like CMS is part of the U.S. Department of Health and Human Services, has developed a concept of trauma based on the three “E’s”: event(s), experiences of event(s), and effect.


“Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being,” the administration notes.


SAMHSA has identified six key principles of a trauma-informed approach:

  1. Safety;
  2. Trustworthiness and transparency;
  3. Peer support;
  4. Collaboration and mutuality;
  5. Empowerment, voice, and choice; and
  6. Cultural, historical, and gender issues.


Those six principles should align across the following 10 implementation domains, according to SAMHSA:

  1. Governance and leadership;
  2. Policy;
  3. Physical environment;
  4. Engagement and involvement;
  5. Cross-sector collaboration;
  6. Screening, assessment, treatment services;
  7. Training and workforce development;
  8. Progress monitoring and quality assurance;
  9. Financing; and
  10. Evaluation.


Note: See the “Additional Resources” box below to find more educational materials.


Prior to crafting an implementation plan using these six principles across the 10 implementation domains, DNSs and other members of the executive team need to have a firm grasp of the following four do’s and don’ts:


Do understand the point of trauma-informed care


Certainly, one reason to implement trauma-informed care is because CMS will require it effective November 28, says Schumann. “However, probably a more important reason is that you want to help people—both residents and staff—to heal, to create safe environments, and to avoid triggers and retraumatization.”


Operationalizing SAMHSA’s six principles of a trauma-informed approach also will make the facility a better place to work, she points out. “There is some data that it may help with staff retention.”


Do realize the broad scope of trauma


Often, post-traumatic stress disorder (PTSD) receives the most attention. However, providers should be careful of defining trauma too narrowly, suggests Weissberg. “Trauma is different for everyone. What is traumatic for me may not be traumatic for you, and often people may not even be aware of some of their traumas. For example, people can be traumatized by going through a natural disaster, such as a flood or hurricane; a man-made disaster, such as a fire; childhood or adult sexual assault or domestic violence; or drug or alcohol addiction. So trauma is much more than PTSD.”


It’s important to think broadly about trauma, agrees Schumann. “The landmark ACE (adverse childhood event) study identifies 10 different kinds of childhood trauma that are more likely to have lasting effects. However, trauma also happens in adulthood, and some traumas specifically link to the aging process, such as the loss of a child, the loss of a spouse, loss of function, or the need to move into a dependent living situation.”


Don’t confuse trauma-specific treatment and trauma-informed care


Most nursing homes will not implement trauma-specific treatment, stresses Schumann. “Rather, they will implement trauma-informed care—and there is a difference. For the most part, only nursing homes that are specifically designated to work with populations that have higher rates of trauma (e.g., veterans, Holocaust survivors, or victims of elder abuse) will provide trauma-specific treatment. The majority of nursing homes will not. The expectation is not that you will become behavioral therapists.”


However, all providers will need to be able to refer residents for trauma-specific treatment, says Schumann. “As required under the currently implemented long-term care requirements of participation, you already should have behavioral health resources you can refer residents to, such as geriatric psychiatrists or psychologists. For trauma-informed care, you should make sure that these behavioral health resources are knowledgeable about—and can treat—trauma. It’s a specialty, so not everyone can. If you identify trauma issues that need to be treated, then you must be able to refer the resident to a specific, very well-trained behavioral resource.”


Don’t implement trauma-informed care in a vacuum


“Trauma-informed care goes hand in hand with both cultural competence and health literacy,” says Weissberg. “If you are going to do staff training on trauma-informed care, I believe that you have to train on these other two areas as well.


Cultural competence will help facility staff connect with residents, she explains. “For example, one culture may consider something to be incredibly traumatic, and another culture may not. You may look at a resident and ask, ‘You lived your whole life like that?’ And they respond, ‘Yes, that is what’s expected of my culture.’ If you don’t consider cultural differences, you may show biases and stereotypes that you don’t intend to, and the resident may be retraumatized by the very person who is trying to help them.”


Weissberg offers this example of how a lack of cultural competence can negatively impact trauma-informed care: At one nursing home, managers decided to pair a female resident who was German with a male nurse who was also German, thinking that the fact that they shared a language and a culture would benefit this resident. When this German man came in and asked this woman to go “to the shower,” she had behaviors.


“At the time, the management team didn’t realize that this resident was a Holocaust survivor, and they never thought about the potential impact of a large German man asking a Jewish German woman to go to the shower,” says Weissberg. “So while they tried to provide person-centered care, they misfired without cultural competence.” Note: Find cultural competence resources at the Health Resources & Services Administration’s Culture, Language, and Health Literacy page. Also see the resources at the National Center for Cultural Competence, which include the online learning course, Conscious and Unconscious Biases in Health Care.


Health literacy is the other piece of the equation, says Weissberg. “Health literacy doesn’t correspond to a person’s educational level. According to the literature, 90 percent of Americans do not have adequate health literacy. So when you try to discuss trauma-related resources or opportunities, the information you provide may go over people’s heads if you also don’t address health literacy.” Note: Find out more about health literacy by reading the Agency for Healthcare Quality and Research’s case study, Connecticut Rehab Facility Boosts Health Literacy Skills with AHRQ Toolkit.



Additional resources




Trauma-Informed Care Regulations and F-tags


The regulations and F-tags that apply to trauma and trauma-informed care fall into camps: those that will implement this November 28 and those that are already in effect. Providers have to wait for an advance copy of the revised Appendix PP of the State Operations Manual to obtain surveyor guidance on the new F-tags, but current Appendix PP guidance is available for the ones already in play. Here are the relevant F-tags and the citations from the Code of Federal Regulations that back them up:


* Newly implementing regulations


New regulations related to trauma-informed care will implement this November 28 under the following F-tags and sections of the Code of Federal Regulations:


§483.25 (Quality of Care)


F699*, §483.25(m), trauma-informed care


The facility 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.


§483.21 (Comprehensive Resident-Centered Care Plans)


F659, §483.21(b)(3)(iii), comprehensive care plans/qualified persons


The services provided or arranged by the facility, as outlined by the comprehensive care plan, must—

(iii) Be culturally-competent and trauma–informed.


§483.40 (Behavioral Health Services)

F741, §483.40(a)(1), sufficient/competent staffbehavioral health needs


(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with §483.70(e). These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for:


(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 … Note: As linked to history of trauma and/or post-traumatic stress disorder, this will be implemented beginning November 28. Otherwise, this regulation is currently in effect.


§483.95 (Training Requirements)


F949, §483.95(i), behavioral health training


A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at §483.70(e). Training topics must include but are not limited to— …


Behavioral health. A facility must provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.70(e).



* Existing regulations


Existing regulations related to trauma are already in place under the following F-tags and sections of the Code of Federal Regulations:


§483.40 (Behavioral Health Services)

(b) Based on the comprehensive assessment of a resident, the facility must ensure that—

F742*, §483.40(b)(1), treatment/service for mental/psychosocial concerns

(1) 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;

F743*, §483.40(b)(2), no pattern of behavioral difficulties unless unavoidable

(2) A resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post-traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident’s clinical condition demonstrates that development of such a pattern was unavoidable; and; …


* These F-tags can contribute to a substandard quality-of-care finding if the survey team finds one or more deficiencies with scope/severity levels of F, H, I, J, K, or L.


Sources: Subpart B, Requirements for Long-term Care Facilities, in Part 483 of Title 42 of the Code of Federal Regulations, and Appendix PP of the State Operations Manual.


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