Workshop: Trauma- I - PowerPoint Presentation

Workshop: Trauma-Informed Integrated Care for Families and Children August 9, 2016

Workshop Objectives Participants will be able to:Define trauma-informed integrated care and identify core components and functions present across different modelsIdentify strengths, challenges, and areas of focus for implementing trauma-informed integrated care in your communityPropose next steps to create trauma-informed integrated care programs in your community

Agenda Welcome and Introductions (I hr.)Overview of trauma-informed integrated care (45 min.)Identify challenges/success (15 min.)Smaller group discussions (1.5 hrs.)What is a PDSA? (15 min.)Action planning (1.5 hrs.) Discussion (I hr.)

Welcome Jerry Waukau and Diane Hietpas

Building a Culture of Health Imagine living in a community making sure the health of all of our children is a matter of fact and not a matter of chance. Imagine knowing that all of our employers, our mayors, our educators and our faith leaders were working together to give everyone the tools and the opportunities they need to make responsible choices. A Culture of Health means living in a society that not only believes but also insists that every person has the chance to be as healthy as they can be.Risa Lavizzo-Mourey, MD, MBA, President & Chief Executive Officer, RWJF (in an interview with AARP, Sept. 2014)

Wisconsin’s oldest continuous residentsOnly WI Tribe inhabiting ancestral lands Treaties reduced Tribal lands from 10 million acres to the current 235,523 acresMenominee Nation Maintains the country’s largest sustainable forest 9,000 Tribal members, 4000 residing on the reservation Tribal members have shown tremendous resilience Ranked 72 out of 72 WI counties in Public Health Outcomes

Finding key stakeholders

Health strategies

Lessons Learned It’s difficult to do prevention when patients are in the crisis modePatient Relationship + Trust = ChangeVoice = Ownership and AccountabilityNeed Community Partners – The clinic and school district could not do this alone Embracing traditions & cultures will lead to more accountability, healthy choices & healthy lifestyles

Start with What’s Simple and Safe

Vietnam Combat Veteran taught us to “Connect the Dots” Community Engagement Workgroup including 90 day plans of action Increase community awareness of trauma Training and workforce development with a trauma focus AccountabilitySuccesses

“Trauma-informed care doesn’t take a lot of planning. It doesn’t take extra time. It’s about getting to know your kids.”

https://youtu.be/WOpewNNwwiI

IntroductionsJen Agosti

Welcome and Introductions Around your table…..

What Is Trauma? Maegan Rides at the Door

Exposure to and Experience of Trauma: Our Usual Thinking

Complex traumaVictim of violence (physical, sexual, emotional) from caregivers, peers, othersNeglect (insecurity with regard to emotional and concrete support from primary caregiver)Witnessing violence within and outside familyLiving in situation of sustained adversity with threats to safety, security and other basic needs

The “dark matter” of social neuroscience. Insell, Neuron, 2010;65:768.

Related symptom clusters in complex trauma Problem categoryCommon presentationsDevelopmental issues: language and learning, attachment, social skills, emotion regulationDifficulty understanding or expressing emotions, school learning difficulties, problems forming secure relationships, Attentio n and behavioral self-regulation Distraction, poor problem solving, poor planning Negative valence – low mood Withdrawal, sadness, shame, anhedonia , passivity, focus on pessimistic information Negative valence – anxious Worry, avoidance, numbing or hyper-vigilance, focus on threats and conflicts Difficulty tolerating negative valence states Anger and aggression, impulsive or avoidant acts, suicidality Substance use and other compulsive or habitual behaviors related to neg. valence Drinking, drugs, cutting, sexual activity

How different from mild developmental/transient problems Multiple “modules” involved simultaneously involved that multiply vulnerabilities“Set point” or baseline outside usual level of homeostatic swings – don’t flip back to “normal” (high “allostatic load”)Much more pervasively negative world view and self-narrative

Definition Historical Trauma: “Historical trauma is the cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma” (MYHBH, 2003) Primary elements:1) Trauma or wounding (“soul wound”) or set of trauma’s (Duran & Duran, 1995, Duran, 2006, Mohatt, et al, 2014) 2) Trauma is shared by a group of people who share a specific group identity (Walters, et al. 2011) 3) Genocidal or ethnocidal intent (Walters, et al. 2011) 4 ) Spans multiple generations ( Mohatt , et al, 2014)

Definitions Race-based trauma: Injury can be a consequence of emotional pain that a person may feel after encounters with racism, which can be understood in terms of specific types of acts:racial harassment or hostilityracial discrimination or avoidance discriminatory harassment aversive hostility Ones experience depends on factors associated with ones background , health, and cognitive processing. Ones interpretation and appraisal of a racial encounter as extremely negative (emotionally painful), sudden, and uncontrollable, may exhibit signs and symptoms associated with the stress and possible trauma of racism . ( Carter, 2006)

Definitions Cultural trauma: “when members of a collective feel they have been subjected to a traumatic event that leaves indelible marks upon their group consciousness, marking their memories forever and changing their future identity in fundamental and irrevocable ways” (Alexander, 2004, P. 1)

What Is Resilience? The ability of an individual, family, organization, or community to cope with adversity and adapt to challenges or change.

Types of Resilience Definition Key Factors Individual Behaviors, thoughts, and actions that promote personal wellbeing and mental health. Cultural & economic background Life History and Experience Social supports Family Coping processes in the family as a unit. Belief systems Organization Communication Organization The capacity of an organization to withstand potential significant economic/systemic risk or business disruptions by adapting or recovering and resuming its core operations Resilient Leadership Safe and secure work environment Individual resiliency Community The sustained ability of a community to utilize available resources to respond to, withstand and recover from adverse situations Available resources Community supports Participatory decision-making

What Is Trauma-Informed Integrated Care? Larry Wissow, Maegan Rides at the Door, Jerry Waukau, and Diane Hietpas

What We Mean by Integrated Care

What Is the Pediatric Integrated Care Collaborative (PICC)? Goal of PICC: Improve access to trauma prevention and treatment services for families with young children Part of the National Child Traumatic Stress Network (NCTSN, www.nctsn.org), funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) NCTSN grant focused on: Integrated Care Collaborative (I-Care) One BSC + two LCs = PICC Toolkit

Overall Frame for PICC Collaborative Change Framework (CCF) Mission“…find practical, sustainable ways to integrate trauma/chronic stress prevention, detection, and early intervention into primary care for young children.”

PICC Themes (How the Mission Gets Achieved)

1. Create a Trauma-Informed Office The environment—both physical and human— fosters patient comfort and trust, promotes the health and effectiveness of staff, and facilitates improved staff-staff and staff-family communication. What does this look like? Staff trained on the impact of trauma Waiting room makes families feel comfortable Families are engaged in decision-making Staff have protected time for communication Focus on staff well-being

2. Develop Family-Informed Services Involve families in the planning, execution, and evaluation of programs to help ensure that services are responsive to family needs, culturally sensitive, appealing, and thus promoting long-term engagement in care and better outcomes What does this look like? Clinic has a vision for family involvement Multiple families are recruited and oriented to their role in the clinic Family advocates are supported

3. Enhance Collaboration Between Behavioral Health and Primary Care ServicesPositive relationships between primary care and behavioral health providers has the potential to promote engagement in treatment necessary for positive outcomes and create pathways across which information can flow safely and efficiently, so that services are most likely to meet patients’ needs and preferences. What does this look like? Identified partnership between behavioral health and primary care providers Integrated behavioral health partner into primary care practice Coordinated communication system

4. Prevent Trauma & Promote Resilience Assess strengths as well as possible vulnerabilities. While we often treat children and parents individually, it is also important to consider the family unit. What does this look like? Family assets and risks are routinely assessed Resources are provided to parents Active evidence-based home visiting programs are available

5. Assess Trauma-Related Somatic and Mental Health IssuesThe assessment of trauma-related problems among young children involves a balanced approach that incorporates screening and communication, with the goal of promoting dialogue about stressful circumstances that may impact health and well-being. What does this look like? Screening tool(s) are selected Process is developed to administer and introduce screener System is in place to document results Screening is used to engage in meaningful dialogue

6. Address Trauma-Related Health and Mental Health IssuesThere is a continuum of interventions: some occur in the primary care office visit; others follow a visit and occur offsite, either in specialty care or in the community. What does this look like? Providers make plans with families for needed care / monitoring Providers help families stabilize children’s routines Providers explain referral processes to patients Reminders and follow-up are provided

Reflecting on Where You AreJen Agosti

Theme Areas on the Self-Reflection

Self-Reflection Background and Instructions

Breakout SessionsSmall Group Facilitators

Breakout Session: Instructions

Breakout Session Group Facilitator Trauma-Informed Office Diane 2. Involving Families in Program Development, Implementation, and Evaluation Jen 3. Collaboration and Coordination with Mental Health Services Jerry 4. Promoting Resilience/Primary Prevention of Trauma Maegan 5. Assessing and Addressing Trauma-Related Somatic and Mental Health Issues Larry

Highlights from Breakout Sessions In 3 min (or less) share one or two highlights / pearls from the session

Accelerating ImprovementJen Agosti

Moving to PDSAs (Tool to Support SUSTAINABLE Improvement)Test hunches quickly (by getting & studying results)Multiple hunches can be tested simultaneously Identify problems while they have minimal impact Get buy-in as you go based on proof of success Always have the end in mind: What Am I Trying to Accomplish AND How Will I Ensure It Will Be Sustained? Adapted from © 2001 Institute for Healthcare Improvement

What in the World Is a PDSA? What can I test quickly? Try it out – small! What did I learn? How can I make it better?

An Example: Moving from Broad Strategy to PDSA (small test) What changes can we make that will result in improvement?Provide guidance that promotes development of resilience and wellness ENDLESS Number of Ideas to Test Share written information with parents during child well-being visits Use parent advocates / liaisons to talk with parents about positive parenting Offer parent coaching / parenting sessions during clinic hours Incorporate questions on positive parenting into well-being visits Use Talking Points to help staff talk about positive parenting and resilience And so on…..

Developing a PDSA: First Cycle PLAN: What are we going to do? (What is the change being tested?) Primary care provider on the team will give a written information sheet about positive parenting to one parent at the next well-child visit. (The information sheet will be developed by the family member on our team.) Who is going to do it? Family member (developing the info sheet); PCP – testing it with a parent When will it be done? Next week Hypothesis (What do we expect will happen?): Parent will express that the information is helpful. She will ask for some possible referrals or more information about community resources as a result. PDSA Title : Give parents information about resilience and positive parenting at well-child visit.

The S-A Is Always the Hard Part! STUDY: Did what we expect to happen actually happen? What was different than what we expected? What did we learn? Parent seemed to like it, although there were a few things she didn’t seem to understand. She had a lot of questions, which took more time than I expected. She also asked about resources in the community that I don’t know much about. ACT : What learnings will we apply to our next text cycle? What will our next PDSA be? Revise sheet to make more clear (areas where there was confusion). Hand it out earlier in the visit so I don’t feel quite as rushed for time. Need to learn more about community resources – maybe develop a community resource guide? PDSA Title : Give parents information about resilience and positive parenting at well-child visit.

A Real PDSA from Menominee Develop a screening tool for families:

One Small Test of Change… So What? First PDSA is just the first stepSmall so that it can be tested quickly, but…Small test does not equal small changeGoal is to apply learnings and continue to make tests bigger and broaderSweep in more people as you go – moving toward implementation as you continue to learn and refine tools/develop processes

90 Day Plan

Small Test of Change CHECKLISTIs intended to be an actual long-term change -- making something different Can be accomplished quickly No over-planning (Plan only as much as you can do) Consensus not required Adapt known results and tools Base on learning from prior cycle Is replicable and sustainable

Moving from Strategy to PDSA: What Teams Might Actually Test Possible PDSAs What changes can we make that will result in improvement? Objective: Provide guidance that promotes development of resilience and wellness. Framework Objectives

One More Note on Small Tests of Change Not just about changing thingsNot just about doing something smallNot just about doing things quicklyAll about replicable and sustainable implementation

Self-Reflection & Self-Care: Take a Moment Check in with yourselfLaugh (Tell jokes)Breathe (Head outside)Create (Sketch)Stretch (Do some yoga) Nourish (Snacks, water, and coffee)

Action PlanningJen Agosti

Action Planning Example Theme Area of Focus (see themes on pg. 1) Assessing Trauma-Related Somatic and Mental Health Issues Proposed Action Step and Goal (description of what you’ll do) Test out the SEEK screening tool with a few families and providers Evidence of/Data for Current Strengths   Many providers interested in identifying trauma Evidence of/Data for Current Need   No one to currently knows how How will you know if the action was a step in the right direction? What can you measure?   How many families screen “positive”; new conversations Team/allies collaborators – Who will you include?   Behavioral health therapists; teachers If things happen the way you expect, what might be the next step?   Combine with TI training – give tool with the knowledge

Small Group Sharing

Small Group Discussions

Large Group Sharing/Reflections Jen Agosti and Maegan Rides At The Door

Reflecting on What You Heard and Thought Today

THANK YOU!