By Bonnie P. Arons
It’s hard for those in the senior care business to argue with the thinking behind trauma-informed care protocols in the Phase III rule reforms issued by the Centers for Medicare and Medicaid Services (CMS). The CMS protocols are part of the well-intended shift to patient-centered care that has been underway in all healthcare disciplines for the last 20 to 30 years.
Compliance with this particular set of reforms, however, may be one of the most complex regulatory challenges the industry has faced to date – and that’s saying a lot given that senior care is a highly regulated business.
It’s not just that an overwhelming number of moving parts must be brought together to comply successfully with the protocols and resulting surveys assessing compliance. The challenge is also how to start preparing for a rule that is final on November 28, 2019.
CMS directs surveyors to “use this protocol for a sampled resident exhibiting physically or verbally abusive behaviors, socially inappropriate or disruptive behaviors, including resistance to care; psychosocial adjustment difficulties after admission, symptoms of depression and/or presence of delirium.”
As such, the protocols require that the facility speak with the resident/family/responsible party to provide insight into why the noted behavioral reactions might occur, and to identify underlying (possibly traumatic) causes of the resident’s symptoms in order to provide specific-patient centered care. The approaches and goals must reflect gained insight into why the behaviors or mood reactions might occur and to ensure that interventions reflect choices and preferences of the resident – as is feasible.
Under the rules, the nursing home’s staff must comprehensively assess the resident’s physical, mental and psychosocial needs and devise a care plan that includes measurable objectives and timetables, as well as specific interventions/services to manage and treat the symptoms presented. The intent is to avoid “re-traumatizing” residents, hopefully preventing or defusing the negative behaviors that impact their quality of life. While nurses and aides are not expected to act as therapists, they are expected to help create therapeutic environments where the triggers for prior traumas are neutralized.
Survey guidelines are a starting point
The CMS recently issued survey guidelines that outline exactly what it is looking for in gauging a facility’s compliance with the Phase III protocols. Found in two separate documents (here and here), the guidelines cover everything from staff interview expectations to requirements for documentation and management of resident records. These should be the basis for every organization’s policy on trauma-informed care.
However, there are very specific requirements that facility administrators must prepare for. These include specific determinants for resident assessments and care plans (with an eye on behavioral and emotional conditions). Documentation is key, too. It’s not enough to do everything required in the protocols. The documentation must be there in writing to attest to it, reflecting any changes between shifts, which, by the way, also must be communicated effectively to relevant staff.
And finally, there are staffing considerations. Facilities must assign one individual to oversee the implementation process. Staff must be trained to perform fact-based resident assessments for trauma-related behaviors, which takes finesse and sensitivity when simply asking about traumas can spark negative reactions. In addition, the facilities must become more sensitive to staff members who work with traumatized residents as they themselves may become stressed while working with traumatized residents.
How to prepare strategically
Facilities that haven’t already should immediately start developing their strategies to position themselves for what lies ahead:
- Review the CMS survey guidelines for requirements of trauma-informed care.
- Use the guidelines to develop trauma-informed care policies and procedures.
- Appoint a champion to lead these efforts.
- Teach and train staff to advance their capabilities and sensitivities for trauma-informed care, including trauma screening and assessment, and trauma-specific interventions.
- If not available internally, create an effective referral system for appropriate treatment of trauma.
Given the widespread uncertainties among facilities over how to interpret the requirements, now is the time to start developing your approach.
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