Trauma informed care has become an area of focus for Post Acute Care providers and survey agencies. Organizations are required to provide trauma-informed care that meets “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” (p. 433, CMS, 2023).
The State Operations Manual (SOM), Appendix PP, identifies the Substance Abuse and Mental Health Services Administration (SAMHSA) as a resource when discussing caring for residents with trauma. Also discussed in the guidance is a “direct correlation between trauma and physical health conditions” (p. 434, CMS,2023). The SOM, Appendix PP, provides further guidance on assessment, care planning, and monitoring delivery of care and services. The following is a peak into the Minimum Data Set (MDS) when assessing a resident with trauma.
MDS Sections Impact Trauma Informed Care
The Resident Assessment Instrument (RAI) is one of the screening and assessment tools mentioned in FTag 699, Trauma Informed Care, to be used when assessing residents. This tool may be used with other screening and assessment tools specific to trauma mentioned in the guidance. As part of the RAI, a MDS is completed on all residents living in the nursing home on admission and at routine intervals. We therefore must ask ourselves: Have we correlated sections of the MDS that may require further investigation when completing the section and data element as it relates to trauma and trauma-informed care?
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- For example, Section A, Identification Information, addresses social determinants of health (SDOH), race/ethnicity, and preferred language to be considered when setting a resident’s care plan. A resident may request no care givers as a cultural preference or prevention of re-traumatization.
- Another example: if a resident is responding yes to data elements in Section D, Mood, have we further explored why? Is there a known traumatic history? Is there a concern that a resident with a traumatic history needs additional care and resources to address the mood indicators in this section? Is the resident socially isolating due to a history of trauma events?
- Looking further, we find Section E, Behavior. If someone is having behaviors noted in section E have, have we looked to understand if there is a history of trauma in the resident’s background and ensure our care planning has addressed triggers and potential behaviors?
- Section F, Preferences, begins reviewing the important daily activities of a resident.
- Accuracy of Section I, Active Diagnoses, stimulates involvement of the resident’s physician in care and attends specifically to psychiatric/mood disorders – including post-traumatic stress disorder (PTSD).
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These examples highlight a few sections of the MDS that can assist care givers when caring for residents with trauma.
What Should We Be Doing Now?
Each team of care givers must review the MDS, CAA, and care planning practices in relation to trauma-informed care so they can provide training and guidance on how the RAI system strengthens care practices of residents with a history of trauma. We recommend facilities:
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- Ensure protocols and processes are in place for the MDS team to review for trauma informed care
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- Monitor residents’ assessments for trauma
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- Incorporate areas for improvement in QAA/QAPI related to trauma informed care
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Ultimately, the RAI system (MDS section/data element completion; care area assessment (CAA) process; care planning development, implementation, and evaluation) provides an opportunity to take a closer look at residents with a history of trauma and enhance established care practices.