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Promo%ng  a  Universal  Design  to  Recovery-­‐oriented  and  Trauma-­‐informed  Care  in  Hospitals  and  Medical  Home  Se?ngs    

January  7,  2016  1:00-­‐2:30  PM  Eastern  Time  

 

BRSS  TACS  Webinar  

Webinar  Moderated  by  

 Robert  Sember  

Center  for  Social  Innova1on  

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BRSS  TACS  Major  Goals  

•  Engage  &  promote  leadership  of  people  in  recovery  at  all  levels  of  state  &  local  systems  &  services  

•  Disseminate  state-­‐of-­‐the-­‐art  informa1on  on  recovery  supports  &  services  

•  Through  cross-­‐sector  collabora%on,  implement  Recovery  Support  Ac1on  Plans  for  States,  Territories,  Tribes  &  communi1es  

•  Promote  peer-­‐driven,  recovery-­‐oriented  supports  and  systems  

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Webinar  Instruc%ons  

•  Webinar  will  last  approximately  90  minutes  •  Submit  ques1ons  at  any  1me  in  the  box  labeled,  “Submit  Ques1ons  Here”  

•  Access  to  the  recorded  version  of  this  webinar  will  be  available  in  about  a  week  

•  Download  presenta1on  slides  and  other  resources  in  the  box  labeled,  “Download  Presenta1on  Materials  Here”  

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Today’s  Presenters  

•  Rachel  LaTa,  Center  for  Social  Innova0on  •  April  Kyle,  Southcentral  Founda0on  •  Shane  Coleman,  Southcentral  Founda0on  •  Sharon  Morrison,  Boston  Health  Care  for  the  Homeless  Program  

•  Q&A  Session  •  Closing  Remarks  

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Promo%ng  a  Universal  Approach  to  Recovery-­‐oriented  and  Trauma-­‐informed  Care  in    Hospitals  and  Medical  Home  Se?ngs  

Rachel  LaTa,  Ph.D.,    Director,  Trauma  and  Violence  Preven%on  Center  for  Social  Innova1on    

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Tes%monial  

 

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In  the  ER…  again!  For  weeks  my  chest  pain  kept  coming  on  strong.  Just  when  it  appears  to  subside,  it  gets  going  again.  Usually,  a\er  I  get  injec1ons  of  Lasix  and  Lovenox,  the  treatment  winds  down  with  oxygen  or  breathing  treatments  that  alleviate  my  symptoms.  When  I  ask  what  is  wrong  with  me,  I  usually  get,  “Wait,  the  doctor  will  come  back  to  see  you.”  Then  the  next  thing  I  know,  I  am  discharged  and  told  the  doctor  le\  for  the  day  or  is  too  busy.    I  think  about  how  my  doctors  respond;  they  seem  to  think  my  inten1ons  are  to  overuse  services  and  burden  them…The  dismissive  a`tudes  leave  me  feeling  like  an  alien  devoid  of  any  ability  to  make  human  contact.  When  I  have  given  voice  to  my  need  to  be  respected,  it  has  only  fueled  the  fire.  There  is  never  any  pretense  of  caring  for  me  in  this  hospital.  All  the  appropriate  words  like  “pa1ent-­‐centered  care”  and  ‘individualized-­‐treatment”  wa\  like  flimsy  bubbles  through  the  air.  There  is  no  substance,  no  ac1ons,  and  no  kindness  to  transform  these  words  into  reality.    –Gloria  Dickerson,  “Looking  for  the  Borderline  Pa1ent”  

Behavioral  Health  Condi%ons  

•  Mental  illness  and  substance  use  disorders  •  1  in  5  adults  annually  (CDC,  2011)  •  1  in  2  adults  over  their  life1me  (CDC,  2011)  

•  Co-­‐occurring  behavioral  and  physical  health  disorders  •  1  in  6  annually  (Druss  &  Walker,  2011)  

•  7  in  10  over  their  life1me  (Druss  &  Walker,  2011)  

•  Increased  risk  of  mortality  (Parks  et  al.,  2006)    

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Trauma  Exposure:  Childhood  

•  1  in  6  children  experience  physical  or  emo1onal  neglect  (Stoltenborgh  et  al.,  2013)  

•  1  in  3  children  experience  physical  abuse  (CDC,  2014)  •  1  in  4  girls  and  1  in  5  boys  experience  sexual  abuse  (CDC,  2014)    

 

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Trauma  Exposure:  Adulthood  

•  3  in  5  people  experience  the  sudden,  unexpected  death  of  a  loved  one  (Breslau  et  al.,  1998)  

•  1  in  3  adults  have  been  in  a  serious  car  accident  (Breslau  et  al.,  1998)  

•  More  than  1  in  3  women  and  1  in  4  men  have  experienced  rape,  physical  violence,  or  stalking  (Black  et  al.,  2011)    

•  1  in  3  women  experience  mul1ple  forms  of  violence  in  their  life1me  (Black  et  al.,  2011)  

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Yet  our  healthcare  system  is  too  o]en  unresponsive.  

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If  we  can  design  a  system  that  works  well  for  people  with  behavioral  health  condi1ons  and  trauma  histories,  it  will  work  beker  for  everyone.      

That  is  what  universal  design  means.  

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Principles  of  Universal  Design  

Three  frameworks  • Person-­‐centered  care    • Recovery-­‐oriented  care  •  Trauma-­‐informed  care  

 

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Person-­‐centered  Care  

•  Collabora1ve  rela1onships  •  Context  considered  •  The  needs  and  preferences  of  people  using  services  are  gathered  

•  Documenta1on  in  medical  record  •  Built  within  integrated  healthcare  teams  which  include  primary  and  behavioral  health  prac11oners  

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Recovery-­‐oriented  Care  

•  Peer  integra1on  at  all  levels  of  organiza1on  including  leadership  posi1ons  

•  Recovery  is  possible  and  achievable  •  Many  pathways  •  Emerges  from  hope  •  Understanding  of  behavioral  health  condi1ons  

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Trauma-­‐informed  Care  

•  Training  on  trauma  and  its  impact  •  Respect  people  seeking  services  •  Promote  trauma-­‐informed  policies  and  procedures  •  Establishing  healing  rela1onships  •  Foster  trauma-­‐informed  service  delivery  

 

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18   ©2015.  The  Center  for  Social  Innova1on.  

Prac%ce  Guidelines:  Philosophy  and  Vision  

Core  principles  underlining  universal  design  •  Disseminate  person-­‐centered  standard  of  care    •  Place  the  person  using  services  at  the  center  of  care  •  Establish  a  collabora1ve,  mutually  respecmul  rela1onship  

between  prac11oner  and  service  user  •  Ensure  safety,  trustworthiness,  choice,  collabora1on,  and  shared  

decision  making  •  Respect  diversity  •  Understand  the  impact  of  trauma  and  mental  health  and  

substance  use  condi1ons  •  Promote  the  belief  that  recovery  is  possible  and  achievable  •  Ensure  that  person-­‐centered  care  is  customized,  transparent,  

and  documented    19  

Prac%ce  Guidelines:  Mapping  to  Prac%ce  

Service  level      

•  Establish  mutually  respecmul  rela1onship  between  people  using  services  and  prac11oners    

•  Expand  assessment  process    •  Iden1fy  the  priori1es,  needs,  and  goals  of  person  using  services    •  Encourage  shared  decision  making    •  Nego1ate  service  plans  with  people  using  services  and  their  

families  •  Document  in  the  electronic  health  record  the  narra1ve  and  

stated  goals  •  Ensure  that  informa1on  systems  and  health  records  are  

transparent  to  people  using  services    20  

References  

Black,  M.C.,  Basile,  K.C.,  Breiding,  M.J.,  Smith,  S.G.,  Walters,  M.L.,  Merrick,  M.T.,  …  Stevens,  M.R.  (2011).  The  Na0onal  In0mate  Partner  and  Sexual  Violence  Survey  (NISVS):  2010  Summary  Report.  Atlanta,  GA:  Na1onal  Center  for  Injury  Preven1on  and  Control,  Centers  for  Disease  Control  and  Preven1on.  

Breslau  N.,  Kessler,  R.C.,  Chilcoat,  H.D.,  Schultz,  L.R.,  Davis,  G.C.,  &  Andreski,  P.  (1998).  Trauma  and  poskrauma1c  stress  disorder  in  the  community:  The  1996  Detroit  Area  Survey  of  Trauma.  Archives  of  General  Psychiatry,  55(7),  626-­‐632.  

Centers  for  Disease  Control  and  Preven1on.  (2011).  Public  health  ac0on  plan  to  integrate  mental  health  promo0on  and  mental  illness  preven0on  with  chronic  disease  preven0on,  2011–2015.  Atlanta,  GA:  U.S.  Department  of  Health  and  Human  Services.  

Druss,  B.  G.,  &  Walker,  E.  R.  (2011).  Mental  disorders  and  medical  comorbidity  [Research  Synthesis  Report  no.  21].  Princeton,  NJ:  The  Robert  Wood  Johnson  Founda1on.  

Parks,  J.,  Svendsen,  D.,  Singer,  P.,  &  Fo1,  M.E.(Eds.)  (2006).  Morbidity  and  mortality  in  people  with  serious  mental  illness.  Alexandria  VA:  Na1onal  Associa1on  of  State  Mental  Health  Program  Directors  (NASMHPD)  Medical  Directors  Council.  

Stoltenborgh,  M.,  Bakermans-­‐Kranenburg,  M.  J.,  &  van  Ijzendoorn,  M.  H.  (2013).  The  neglect  of  child  neglect:  A  meta-­‐analy1c  review  of  the  prevalence  of  neglect.  Social  Psychiatry  and  Psychiatric  Epidemiology,  48(3),  345-­‐355.  

     

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Southcentral  Founda%on  Nuka  System  of  Care  

April  Kyle,  Vice  President  of  Behavioral  Services,  Southcentral  Founda1on  Shane  Coleman,  Division  Medical  Director  Behavioral  Services,  Southcentral  Founda1on   22  

Customer  Ownership  

•  Indian  Self  Determina1on  and  Educa1on  Assistance  Act  (638)  •  Inpa1ent  and  outpa1ent  services  •  We  care  for  60-­‐160K  Alaska  Na1ve  and  American  Indian  people  •  Mixed  payer  system:  IHS  funds,  private  insurance,  Medicaid,  

Medicare  23  

Nuka  System  of  Care  

•  Customer  Ownership  •  Rela1onships  as  the  core  of  healthcare  •  Mul1dimensional  wellness  24  

Customer  Owner  Driven  

•  Alaska  Na1ve  customer  owner  driven:  employees,  focus  groups,  gatherings,  etc  

•  Facili1es:  gathering  areas,  talking  rooms,  natural  products  •  Family  Wellness  Warriors  Ini1a1ve,  Tradi1onal  healing,  Na1ve  

Men’s  Wellness  Program  25  

Rela%onship  and  team  based  care  

•  Primary  care  is  basis  of  health  care  rela1onship  •  Focus  is  Customer-­‐Owner  partnership  and  whole  person  care  •  Mul1-­‐disciplinary  team  with  common  working  space    •  Integra1on  of  behavioral  health  consultant  with  same  day  access  26  

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•  Who  drives  change?  •  Improvement  vs  whole  system  redesign  •  Leading  with  vision  

Key  to  Success:  Leadership    

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•  Core  Concepts:    o  Rela1onal  styles  o  Basics  of  safe  listening    o  Basics  of  safe  story  telling  

•   The  Right  “Fit”  (hiring  prac1ces)  

Challenges:  Team  dynamics  

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•  Clinical  leadership  that’s  flexible  and  willing  to  work  with  one  another  

•  Apprecia1on  of  difference  between  culture  of  medical  and  behavioral  health  services  

•  Difference  in  Customer-­‐Owner  engagement    

Challenges:  Merging  Treatment  Cultures  

It  Takes  a  Community:  A  Collabora%ve  Approach    

to  providing    Office  Based  Opioid  Treatment  

Sharon  Morrison,  RN,  MAT    

Boston  Health  Care  for  the  Homeless  Program  Clinic  within  the  New  England  Center  and  Home  for  Veterans  

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The  Pa%ent  at  the  Center  of  Care  

Patrick    •   28  year  old  male  Veteran  Marine    •   Served  2  tours  of  combat            Iraq:  2005  -­‐  2006  -­‐  18  y/o            Afghanistan:  2008  -­‐  2009  –  21  y/o    •   Assigned  to  an  Explosive  Ordinance              Disposal  (EOD)  unit    

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The  Problem  at  the  Community  Level  

•  Opiate  use  and  overdose  fatali1es  are  at  epidemic  propor1ons  

•  The  number  of  veterans  with  opiate  use  disorders  is  unknown  

•  The  NECHV  is  located  in  a  building  that  abuts  City  Hall  Plaza  

•  The  NECHV  is  located  in  heart  of  the  financial  district  of  Boston  and  visible  to  businesses  and  tourists  alike  

•   Mul1ple  stakeholders  found  their  way  into  the  discussion  

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The  Problem  at  the  Center  Level  

 •  The  Center  has  a  zero  tolerance  policy  for  substance  use  

•  The  Center  staff  felt  overburdened  by  the  increased  demands  placed  on  them  by  the  opiate  use  by  veterans  and  felt  unqualified  and  understaffed  to  respond  to  the  demands  

•  The  Center  is  currently  undergoing  a  31  million  dollar  renova1on  that  has  resulted  in  disrup1on  to  the  sleeping,  bathing  and  daily  rou1nes  of  the  veterans  

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•  Mul1ple  mee1ngs  took  place  between  State  and  City  officials  and  BHCHP  and  NECHV  staff    

 •  The  Governor  endorsed  plans  to  assist  the  State  with  efforts  to  combat  the  epidemic  

 •  The  Center  had  increased  calls  to  respond  to  overdoses  

 

It  All  Came  Together  

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The  Ongoing  Challenges  for  the  Clinical  Staff  

•  Designing  the  prac1ce  to  encourage  pa1ents  honesty  when  presen1ng  their  histories  

•  Finding  a  way  to  accommodate  pa1ents  as  they  move  out  of  the  center  into  permanent  housing  and  the  return  to  work  

•  Taking  just  one  step  at  a  1me  in  this  prac1ce  

•  Resis1ng  the  tempta1on  to  meet  each  anomaly  with  1ghter  controls  instead  of  expansive  thinking  

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Remembering  the  Pa%ent  at  the  Center  of  Care  

•  While  not  our  first  pa1ent,  Patrick  remains  at  the  center  of  focus  as  return  each  day  to  address  the  needs  of  veterans  with  opiate  use  disorders    

•  He  returned  from  the  intensity  of  his  combat  tours  with  both  seen  and  not  seen  injuries  

•  He  came  to  us  asking  for  help  to  stop  using  heroin  that  he  had  been  using  a\er  he  was  cut  off  from  pain  medica1on  prescribed  to  him  by  the  VA  for  his  physical  injuries  

•  He  con1nues  to  struggle  to  talk  about  the  specifics  he  witnessed  in  combat  

   

Q  &  A  Session  

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Announcement  

$40,000  Available  to  Support  2016  Peer  Educa%on  Efforts  Regarding  the  Implementa%on  and  Support  of  the  Affordable  Care  Act  (ACA)    •  Download  official  announcement  from  the  box  to  the  right  

•  Capabili1es  statements  must  be  received  by  8:00pm  EST  (7:00pm  CT,  6:00pm  MT,  5:00pm  PT)  on  Friday,  January  22,  2016.    

•  Submit  ques1ons  to  Rebecca  Stouff  at  rstouff@center4si.com    

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Announcement    

$40,000  Available  through  2016  Collegiate  Wellness  and  Recovery  Capacity-­‐building  Opportunity  Download  official  announcement  from  the  box  to  the  right  •  Capabili1es  statements  must  be  received  by  8:00pm  EST  (7:00pm  CT,  6:00pm  MT,  5:00pm  PT)  on  Wednesday,  February  3,  2016.    

•  Submit  ques1ons  to  Rebecca  Stouff  at  rstouff@center4si.com    

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For  More  Informa%on  

•  Check  out  the  BRSS  TACS  Webpages  at  hkp://www.samhsa.gov/brss-­‐tacs  – Learn  more  about  other  training  and  technical  assistance  opportuni1es!  

•  Join  the  BRSS  TACS  listserv!  Send  an  email  to  brsstacs@center4si.com  to  start  receiving  regular  project  updates  

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 Thank  You  

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