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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,
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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,
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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 [email protected]
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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 [email protected]
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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 [email protected] to start receiving regular project updates
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Thank You
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