Trauma-Informed Care for Veterans

By Kate Hendricks Thompson and Sarah Plummer Taylor

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An increase in trauma-informed care leads to more efficient and effective response at every level of patient care, and thus, a reduction of wait times at VA Hospitals.

Rebecca served nine years as a Marine Officer, and had relied upon the Veterans Administration Medical Center (VAMC) for her health care since departing active duty.  She was a devoted runner trying to get back in shape, but a few months into this well-intentioned effort she found herself calling the VAMC appointment line.  Her Achilles tendon was swollen and painful, and she found herself limping through busy days. The first call to the appointment line resulted in a referral, a message taken, and the promise of a call back. The nurse who called back wasn’t authorized to book anything beyond 24-hours out, and the promise of a return call was again offered. A week later, the phone had not rung, and Rebecca was still limping along without an appointment.

Military veterans consistently report access problems with Veterans Affairs (VA) hospitals and outpatient clinics.  Patients in Phoenix reportedly died while waiting for slow cancer care.  The issue is an administrative and ethical conundrum; veteran satisfaction rates and overall patient wait times must be improved.

The solution is not entirely structural, though more infrastructure and staff would directly reduce wait times because more providers are available.  The answer to date has been the bandage of increased oversight – stipulating tighter regulation and monitoring of recorded wait times. The intention of such accountability measures is consistently undermined by employees incentivized to modify the numbers, and it is a rare whistle-blower willing to call attention to the statistical maneuvering.

If adding more directives to reduce wait times has been met with maintenance of the defunct status quo, how can we improve accountability while working within the current system reality?

The answer involves expanding the standard of care and embracing holistic wellness. First and foremost, we need to make the process of receiving care easier, more effective, and more efficient, and one of the best and most empirically validated ways to do so is to offer trauma-informed care. Trauma-informed means knowing the history of past and current abuse or trauma in the life of the consumer with whom one is working and to understand the role that violence and victimization play in the lives of most consumers of mental health and substance abuse services, thereby utilizing that understanding to design service systems that accommodate the vulnerabilities of trauma survivors and allow services to be delivered in a way that will facilitate consumer participation in treatment. With trauma at the center of understanding, all parties – clients, providers, clinicians, and programs – will benefit.

We must begin providing trauma-informed care at all levels of care, from point A to point Z in the care cycle for our veterans, working with existing VA employees, staff, and providers. Our veterans are coming from a place of trauma, be that trauma combat or simple transition.

VA hospitals are not public hospitals. Therefore, trauma-informed care must be a requirement for any person in the VA.

 Research has convincingly shown that it is not just mental health care providers who need a trauma-informed approach, and sadly even many of those providers do not have this background. For instance, psychiatrists are not taught to account for cultural, environmental, economic, gender, or trauma history differences among clients. Social workers, for example, are exclusively trained and educated from this perspective of the prevalence of trauma and the impact of environmental factors.

How does this impact wait times?  Education of the entire staff is required, not just the person the veteran encounters after the 5th stage of waiting (multiple phone calls, an employee they encounter in the parking lot, the volunteer at the front desk, employees inside the building, the receptionist at the clinic office) because all of those stages of interaction impact how care is sought, followed up with or not, or perceived by the patient.  Part of wait time computation involves the actual time but some of it is the perception of time – sometimes a 2 hour wait can feel worse than a week long wait; it depends on how the person who is addressing you talks to you. Veteran perceptions are important and impact how they feel about care received.

  • Improving the staff’s trauma-informed perspective improves wait times by improving and tailoring the environment. Frankly, this trauma-informed paradigm can be used as an incentive to the care provider because the whole process becomes more humane to them. As they are trauma-informed they address people differently.
  • Trauma-informed personnel are more likely to address issues more effectively and efficiently. As empathy and understanding increase, so does efficiency because veterans come in to be treated, feel safe doing so, are being treated one time, versus becoming overwhelmed and leaving, necessitating another visit. For instance, if a veteran enters the hospital and is yelled at by the person behind the desk, or harassed by a janitor, he or she very well may turn around and leave. The veteran will then have to call in again, make another appointment, likely be perceived as disrupting the system and be chastised for not showing up for their appointment. The whole process not only may be re-traumatizing, but will add to the backlog of appointments.
  • Trauma-informed care creates safer environments. Feelings of safety are fundamental to effective health care, especially effective mental health care. Thus, veterans are more likely to feel comfortable coming in for proactive and preventative care versus waiting until they find themselves in a most extreme case which then often requires more resources for a longer amount of time, resulting in more pressure on the system again.
  • Trauma-informed care creates better-informed clients. Veteran patient clients, when treated with the respect a trauma-informed model demands, are well-informed at every stage of care, from administrative matters to the care itself. Lack of information leads to confusion and threatens the basic need for feelings of safety. Waiting for return phone calls that never come, or waiting in a waiting room for hours on end well after their scheduled appointment time, are re-traumatizing (and common) occurrences for veterans seeking care at VA hospitals. Trauma-informed care standards would mandate that appointment times be honored, that waiting room facilities are safe and comfortable, and that a patient is communicated to regularly and with respect about the process required to receive care.

Every single employee at a VA hospital needs some trauma-informed education and training, not just psychiatrists. Through a trauma-informed lens, any staff member can see issues more clearly and solve problems where they occur. This would mean, for instance, having a person at the entrance of the VA Hospital who is calm, clear and helpful; not an untrained, random volunteer. Having staff members who are trained in harm reduction and de-escalation techniques is also critical to trauma-informed training, education, and care provision. To shift culture, you cannot just train the leaders. All employees at the VA should receive at least a basic level of training of trauma-informed care. This absolutely also includes care providers.

We do not need more regulations and stipulations on time-frames, which are already in place and already not being followed. Veterans and the families who support them are calling for a true cultural shift in care, one that can be achieved with training and standard of care expansion.

Editor’s note: This article was jointly authored. Sarah Plummer Taylor, MSW is an established leader in the field of resilience building, holistic wellness, and leadership training. Learn more at SEMPER Sarah®. Kate Hendricks Thomas, PhD is an Assistant Professor of Public Health at Charleston Southern University. 

Back on Capitol Hill, Different Day, Not Much Has Changed

I’m back on Capitol Hill in the office of Congresswoman Marcia L. Fudge. Rep. Fudge represents Cleveland and Akron, Ohio and currently serves as chairperson of the Congressional Black Caucus. Rep. Fudge sits on the Committee on Agriculture and the Committee on Education and the Workforce. Both are areas of great interest to social workers. It’s a wonderful office to be in these days as spirits are riding high with the return of LeBron James to the Cleveland Cavaliers and the prospects of a “Johnny Football” Manziel-led Cleveland Browns going to the NFL playoffs. On top of that the Republican National Committee (RNC) recently selected Cleveland as the site for their 2016 presidential nominating convention and the Rock and Roll Hall of Fame just opened a fashion exhibition of Beyoncé’s personal collection. Cleveland is on the rise!

So what’s happening on the Hill? Not much. This, the 113th Congress is on track to be the least productive in history with 128 laws passed to date. You don’t have to go too far back to find the least productive Congress before this—it was the 112th Congress which passed a total of 284 laws. With 30 working days left, there is minimal probability that this Congress will pass 200 laws. You have to go back to the 93rd Congress (1973-1974) which passed 772 laws to find the most productive Congress in the past 20 years. The average number of laws passed during the last 20 sessions of Congress was 564. Enough said.

Keep in mind that many of the bills that pass both the House and Senate and are then signed into law by the President are ceremonial—that is they are laws that name a post office, courthouse, or airfield after prominent individuals or award medals to distinguished people or organizations. Many of the laws passed are extensions of previously enacted legislation. Many important bills are stalled.

So what gives? Why are Republicans in the House so consumed by parsimony that they refuse to invest in things that are vital to the social and economic health of the country? Their dislike for President Barack Obama is well documented so their opposition to Obamacare—a term they coined in disdain is expected if not defensible. You would think Republicans would welcome the fact that 8 million people have purchased health insurance through the Affordable Care Act another 6.7 million have signed up for Medicaid. Yet, the House has voted more than 50 times to repeal all or some part of the ACA while not being able to present an alternate plan.

It was a struggle for the House to agree to a consensus on the Farm Bill passed earlier this year. Ultimately House Republicans and the Democratic-led Senate settled on a bill with an $8.6 billion reduction in the Supplemental Nutrition Assistance Program (SNAP) that issues food stamps to eligible households. This, at a time when the Department of Agriculture reported more than 47 million Americans had difficulty putting adequate food on their tables in 2012.

Legislation currently stalled in the House includes the reauthorization of the Moving Ahead for Progress in the 21st Century Act (MAP-21) which is the comprehensive transportation and infrastructure bill that funds highways, mass transit, bridges and other projects related to transportation. Despite the fact that many of the nation’s bridges, airports and highways are crumbling, lawmakers cannot find a compromise to provide adequate resources to rebuild America’s infrastructure. The Highway Trust Fund will run out of money before Congress returns from its five-week recess that begins Friday if it fails to pass stopgap legislation this week. A 10-month, $11 billion patch is expected to be voted on by the Senate before week’s end.

Congress has not figured out what to do with the thousands of immigrant youth coming across the border to seek asylum in the U.S. It appears no action will be taken on President Obama’s request for $3.7 billion to address the problem. A 2008 law protecting trafficking victims makes it difficult to send youth back to their home countries other than Mexico and Canada. Of course a comprehensive immigration bill is needed but may not get a hearing until after the 2016 elections.

Monday, the House and Senate agreed on a $17 billion bill to reform the Veterans Administration with $10 billion set aside for veterans to use at non-VA medical facilities. The bill was almost a no-go as House Republicans sought to offset spending with cuts to other programs. You know things are out of control when it is difficult for lawmakers to agree on providing adequate healthcare for veterans.

The bottom line is this is the only government we’ve got so we need to be involved in trying to make it better. More social workers are needed in politics and policy.

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