Trauma Ambulances in NRW

Dr. Michaela Czeranski

LWL-Klinik Hemer

Hans-Prinzhorn-Klinik

Institusambulanz

LWL Für die Menschen.

Für Westfalen-Lippe.

Schwerte, 31th, .May 2011

Statutory Basis

• The state has a statutory duty to protect citizens from the effects of violence and crime against the person. If following an act of violence or crime, a person has new needs, the state is responsible to compensate the individual.

• The Victim Compensation Law or Opferentschädigungsgesetz (OEG) aims to ensure that the victim’s mental and physical health is restored as far as possible, so that the victim is able to continue to work and live within their community.

• Compensation and services granted will be in line with the statutory guidance of the Bundesversorgungsgesetzes (BVG)

• In Nord Rhein Westphalen, the Regional Councils Landschaftsverbände Westfalen-Lippe (LWL) und Rheinland (LVR) are responsible for the approval of any claim by a victim including the nature of the compensation to be provided.

In which cases is s.b. entitled for benefits according to the OEG?

• It must be a clear act of violence and the vic suffers from it.• The act must be committed after 15th May1976 in federal territory.• In cases of acts commited before this cut off date aid can be

received in form of “Hardship allowance provisions” if there is an degree of injury consequences at least 50 % and is experiencing financial hardship.

• Since the 1st July 2009 financial aid can also be received in case of violence committed abroad (one off payment and medical treatment)

• Eligible are also dependents (include 3rd degree since 1st of July 2009) an also foreigners residing in Germany (special rules and criteria)

Scope of Aid OEG

• Medical treatment including residential or ambulant psychotherapy

• recovery aid

• aid with participation in a working life

• temporary family/maintenance aid/aid for the eldery

• assisted living

• residential rehabilitation measure (also with kids)

• nursing aid

• provisions for dependents for widows, orphans and parents

• disability pensions

• death benefit and funeral allowance

• lump-sum payment/severance payment

Additional Aids For Children

• Private tutoring/school or home education• after school care center /educational aid • Psychotherapy also at therapists who are not

cowered in health insurance • Ergotherapie, Logopedics und Physiotherapy/body

therapy• residential rehabilitation measure with accompanying

person• recreational holiday for the family

Why Project “Trauma Ambulances”?

• Low-threshold (there must not exist an disorder)• OEG with its aids was hardly known• the act don’t have to be proved• the cost absorption for the first 5 appointments is

guaranteed• near time (within 3 workday we arrange an appointment)• attainable within an hour car by the patient• treatment by special qualified therapists• networked with the Victim Protection Officer, the White Ring

and regional medical and social care providers of the health care system

Network Trauma Ambulance - Adds of Patients

Victim Protection Officer

Practitioner/ Specialist

Counselling centres for women

emergency pastoral care

Employers/ job center/special service for integration/employer`s liability Insurance Association

Trauma AmbulanceOther:• employee• former patients•relatives/friends

Association “White Ring”

Regional authorities LVR/LWL

Application - post card sufficient

Framework of the Trauma Ambulance

Framework Conditions of the Trauma Ambulances

• An Application must have been submitted• 5 appointments at once possible • The ambulance sends a report to the LVR/LVA• 6-15 appointments possible in all (acute treatment)• Payment of travel cost possible • duty to cooperate required including the attendance of

the victim at a formal meeting to clarify facts in relation to the offence, examination, duty to participate in professional development and learning or in residential care treatment

• The act must be reported to the Police with the exception if this would pose a danger to the health of the victim, prosecution fails due to time lapsed since offence

What Symptoms do patients suffer from?

• Symptoms of intrusion/avoiding/arousal/dissociation

Intrusion: flash-backs, nightmares, triggers, feelings.

Avoidance: of thoughts, people, places.

Arousal: Agitation, nervousness, lack of concentration

Dissociation: numbing, depersonalisation, derealization.

• Symptoms of depression

• Symptoms of panic attacks

• Symptoms of Agoraphobia

Intervention Methods of the Trauma Ambulances

� Psychoeducation (80%)� Diagnostics (89 %)� Stabilisation techniques (63%)� EMDR (16 %)� Exposition (16 %)� counselling of people close to the patient, such as carers

or family members (27 %)� cognitive restructuring (23 %) � counselling about suitable forms of Treatment (28 %)� Support in changing to a different or further therapy

(20%)

1. session:

Patient arrives – relationship building

What has happened to her and how has she experienced the event/s?- empathy

From which symptoms does she suffer?

How is he/she being supported and is more help required?

Intervention: Psychoeducation, counselling of the relatives,

diagnostics including,

management of symptoms

Give written notes of intervention

Principle: Safety first - outer safety before inner safety!

Aim: “I feel unterstood.” “I’m reacting in a normal way”

“Now I know why I’m reacting this way” “I’m not to blame for

the act” “I’m able to protect myself in a better way”

Course Of Treatment

2. session:

Who is she doing?

What has worked?

How has life been?

What worked during a crises?

What are her competencies?

How is the social situation?

How does the social environment react

Intervention: Psychoeducation with management of symptoms and resource activation (to offer things which were helpful to others, remind patient of positive experiences in her life), Diagnostics with safety check, Stabilisation techniques (The Safe Place), consider contacting partners/carers to offer more support

Course Of Treatment

3. session:

evaluation - What has worked?

What is she avoiding and why?

Intervention: like session 2 plus

Diagnostics (Trauma land scape), Psychoeducation and resilience building/ EMDR,

Consolidation of stabilisation techniques (CIPOS) ,

Couse Of Treatment

4.sessions/and following ones

evaluation like session 2 and 3

Intervention: Consolidation/ perhaps Trauma confrontation

Counselling about further forms of treatment/aids

recommendation of contact addresses of community therapists/offer of treatment in the community

last session:

Reflection: What positives can I take from this crisis?

Ending

Aim: “I lived through something terrible, but now it’s over”

“It was good for something – I learned something about myself... “I can learn to live with it”

“I know what help I can get and where”

Course Of Treatment

Evaluation Of The Trauma Ambulances 2007 Gender Aspects Ivonne Schürmann

No significant gender difference concerning age, time of claim, numbers of appointments,severity of the symptoms exept severity of depression, outcome

Gender and Age

Evaluation of the Trauma Ambulances 2007 Ivonne Schürmann

Participation of 17 Ambulances with 241 cases

Measurements befor the 1., after the 5. Session and after 6 months after end of treatment (BDI, IES-R, SCL-27 und GAF)

Age: 2-81 30,2 J.

Gender: 80 % female (<14 J. 1:1)

Offences : 39% against sexual self-determination (sexual attacks)

32% a physical attacks

18 % robbery and extortion

Evaluation Of The Trauma Ambulances 2007 Ivonne Schürmann

Diagnosis:

Posttraumatic Stress Disorder : 49,2 %

acute stress disorder: 20,6 %

Adaptive Disorder: 2,7 %

Other Reaction of severe stress: 3,0 %

normal 2,6 %

Results- Evaluation OF The Trauma Ambulances 2007 Ivonne Schürmann

The averages of all instruments after the 1st and after the 5th session declined for all groups of symptoms as well as for an calculated aggregate figure in a highly significant way. And this is valid both for the self assessment and for the external assessment intruments.

The decline of the averages was also consistent after 6 months.

For the group of patients whose mental health suffered most (most damaged) the extent of positive change was highest.

Approximately 41% of patients showed improved results across all instruments, which are similar to a healthy persons indicating that their mental health improved to that of an average healthy person

Results - Evaluation Of The Trauma Ambulances 2007 Ivonne Schürmann

The treatment in the ambulances was succesful.

For most patients the development of a disorder or chronification following the trauma could be prevented.

A very small minority of patients experienced a worsening of their condition/mental health.

The evaluation shows that different groups of patients with different symptoms of mental ill health benefited after different lengths of treatment and different methods of intervention.

Costs - Evaluation der Traumaambulanzen 2007 Ivonne Schürmann

500 Euro/per patient with on average 5,5 sessions. For 400-500 Patients – total costs are 200.-250.000 Euro per year. (Total costs 40-50 Mill. Euro/Jahr equal to <o,5%)

Savings and Benefits

50% reduction in appeals amongst people who applied for the first time (16,8 vs 7,3%)

End diagnosis – 10% increase of patients treated successfully with no further action required

50% reduction in patients with an End diagnosis with GdS unter 25%

“The money is invested well” Möllering 2006 – An invest to Save