Upper Northeast TIC Regional CollaborativeNovember 7, 2014

Northcoast Behavioral Healthcare

What is Trauma ? The Three E’s

Individual trauma results from an event, series of events, or a set of circumstances

that is experienced by an individual as physically or emotionally harmful or

threatening and that has lasting adverse effects on the individual’s functioning and

physical, social, emotional, or spiritual well-being

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Prevalence of Trauma

Exposure to trauma is widespread• Trauma can occur at any age• Trauma can affect individuals from all

walks of life

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Prevalence of Trauma

Exposure to trauma is especially common among individuals with mental illness, substance use disorders and developmental disabilities

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Trauma Affects…

Over one out of three females with mental health disorder; and

About one out of five males with mental health disorder in Ohio

Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Trauma Affects…

Over one out of four females with a substance use disorder; and

About one out of ten males with a substance use disorder in Ohio

Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Trauma Affects…

Over one out of three females with co-occurring mental health and substance use disorders; and

Over one out of ten males with co-occurring mental health and substance use disorders in Ohio

Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Trauma Affects Ohioans with Developmental Disabilities…

Neglect

1116366

Physical Abuse

310

Verbal Abuse

83

Sexual Abuse

CRN Validation Cube. Ohio Department of Developmental Disabilities 2013.

Ohioans with Developmental Disabilities…

Increased risk for abuse as compared to the general population (Gil, 1970; Mahoney & Camilo, a998; Ryan, 1994)

Over four times as likely to be victims of crime (Sobsey, 1996)

Two – ten times more likely to sexually abused than those without disabilities (Westat Ind., 1993)

Often experience rejection and loneliness (Pitonyak)

Trauma Affects Ohio’s Children…

29600

Neglect

Physical Abuse

2750012600

Foster care

12100

Multiple Allegations

10600

Sexual Abuse

1800

Emotional Abuse

PCSAO Fact Book: 11th Edition, 2013-2014, Public Children Services Association of Ohio

• In 2013, 15,000 Ohio children of a substance-abusing guardian entered the county child-welfare system

• At least half of these children remained in the county’s custody for more than 300 days compared with the average 70-day stay

• Child abuse and neglect reports in which heroin was listed as a factor increased from 4.9% of total reports in 2010 to 8.9% 2013

Trauma Affects Ohio’s Children…

Ohio Department of Job and Family Services, Office of Families and Children

Trauma Affects Ohioans with Domestic Violence…

Arrests (41,000)

Barbara Warner Committee on Workplace Domestic Violence -2013 Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012,

Ohio Domestic Violence Network HealthDay, Copyright © 2013

Trauma Affects Ohioans with Domestic Violence…

Of families who experience intimate partner violence:

• Four out of five adult children commit violence against partners

• Three out of four adult children become victims of domestic violence

Children exposed to domestic violence may develop a widerange of problems, including interpersonal skill deficits,psychological and emotional problems such as depression andPTSD, and externalizing behavior problems.

Barbara Warner Committee on Workplace Domestic Violence -2013 Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012, Ohio Domestic Violence Network HealthDay, Copyright © 2013 Carlson, B. E. (2000). Children exposed to intimate partner violence: Research findings and implications for ntervention. Trauma, Violence and Abuse, 1(4), 321-342.

Ohio ranks fifth among all US states in human trafficking

1000 Ohio children are estimated to become victims of human trafficking each year

NOT FOR SALE

http://humantrafficking.ohio.gov

Trauma Affects Ohioans Who Are Victims of Human Trafficking…

Trauma Affects Women . . .

• Interpersonal violence is a major source of trauma in the United States, particularly for women• While men are most likely to experience violence from strangers, women and girls are most likely to be hurt by people they know. • For women in the military, the greatest risk of harm is from fellow soldiers; for adolescent girls, it is from the people they love.

Trauma Affects Older Ohioans . . .• Ohio’s population age 60 and older is

projected to grow by 13.7 percent to 2.6 million between 2010 and 2015

• Around 15,000 cases of elder abuse are reported in Ohio every year but the actual number of cases is much higher

• A 2010 statewide assessment of family domestic violence in Ohio estimated that about 115,000 seniors experience abuse, neglect or financial exploitation at the hands of a caregiver

• In the general population, approximately 70% to 90% of adults aged 65 and up have been exposed to at least one potentially traumatic event during their lifetime

Policy Matters Ohio, May 2014Journal of Consulting and Clinical Psychology, 60, 409-418

Trauma Affects Older Ohioans . . .• Gender differences exist in regard to trauma

exposure. Based on a community sample of older adults, about 70% of older men reported lifetime exposure to trauma; older women reported a lower rate, around 41%

• In a large sample of older adults, greater lifetime trauma exposure was related to poorer self-rated health, more chronic health problems, and more functional difficulties

• Among a community sample of older women (average age = 70), 72% had experienced at least one type of interpersonal trauma during their lives (e.g., childhood physical or sexual abuse; rape) and higher rates of interpersonal trauma were related to increased psychopathology

Creamer, M. C., & Parslow, R. A. (2008). American Journal of Geriatric Psychiatry, 16, 853-856.Krause, N., Shaw, B. A., & Cairney, J. (2004) Psychology and Aging, 19(4), 637-648.

Higgins, A. B., & Follette, V. M. (2002) Journal of Clinical Geropsychology, 8, 215-226.

Adverse Childhood Experiences Study

Collaboration between Kaiser Permanente and CDC

17,000 patients undergoing physical exam provided detailed information about childhood experiences of abuse, neglect and family dysfunction (1995-1997)

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ACE Categories

Abuse• Emotional• Physical• Sexual

Neglect• Emotional• Physical

Household Dysfunction• Mother Treated Violently• Household Substance Abuse• Household Mental Illness• Parental Separation or Divorce• Incarcerated Household Member

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ACE Score and Health Risk

As the ACE score increases, risk for these health problems increases in a strong and graded fashion:

• Alcoholism and alcohol abuse• Chronic obstructive pulmonary

disease (COPD)• Depression• Hallucinations• Fetal death• Health-related quality of life• Illicit drug use• Ischemic heart disease (IHD)• Liver disease

• Risk for intimate partner violence• Multiple sexual partners• Sexually transmitted diseases (STDs)• Smoking• Suicide attempts• Unintended pregnancies• Early initiation of smoking• Early initiation of sexual activity• Adolescent pregnancy• HIV

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Cost of Trauma

Trauma is a major driver of medical illness, including cardiac disease and cancer

Addressing trauma can positively impact the physical, behavioral, social and economic health of Ohio and Ohioans

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What is “Trauma Informed”?

A program, organization or system that is trauma-informed:• Realizes the widespread prevalence and impact of

trauma • Understands potential paths for healing• Recognizes the signs and symptoms of trauma and how

trauma affects all people in the organization, including:• Patients• Staff• Others involved with the system

• Responds by fully integrating knowledge about trauma into practices, policies, procedures, and environment.

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Core Principles

• Safety

• Trustworthiness and transparency

• Peer support and mutual self-help

• Collaboration and mutuality

• Empowerment, voice, and choice

• Cultural, historical, and gender issues

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Outcomes with TIC

• Improved quality of care and impact of care• Improved safety for patients and staff• Decreased utilization of seclusion and restraint• Fewer no-shows• Improved patient engagement• Improved patient satisfaction• Improved staff satisfaction• Decreased “burnout” and staff turnover

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Ohio’s Trauma Informed-Care (TIC) Initiative

• Many mental health and addiction treatment agencies, inpatient facilities, child-serving agencies and other community partners, have already provided training and consultation in trauma informed practice

• Many clinicians are trained in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Eye Movement Desensitization training (EMDR); Dialectical Behavioral Therapy (DBT) and other treatment modalities

• ODYS has embarked on the development of a universal trauma screening tool for youth in detention centers

• Trauma Informed Care is not the same as PTSD treatment25

Ohio’s Trauma-Informed Care (TIC) Initiative

• There continues to be a need for training for staff/facilities and community system partners

• The ability of all communities and providers to organize trauma

trainings internally is often beyond their finances, time and capabilities, yet the need of persons served has not changed

• The initiative will seek to provide additional resources for agencies and programs in Ohio who may need this support

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Ohio’s Trauma-Informed Care (TIC) Initiative

• Since Summer of 2013, an interagency workgroup comprised of leaders from Ohio MHAS and Ohio Department of Developmental Disabilities (DODD) has been meeting to formulate plans to expand TIC across the state

• A portion of the “Strong Families, Safe Communities” funds from the Governor’s Office have been earmarked for this purpose

• The National Center for Trauma-Informed Care (NCTIC)/SAMHSA and Ohio Center for Innovative Practices (CIP) have also consulted formally

• Additional conversations and advice from Ohio Hospital Association, OACBHA, Ohio Council, PCSAO, and many others (thanks!)

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Ohio’s Trauma-Informed Care (TIC) Initiative

Vision:To advance Trauma-Informed Care in Ohio Mission:To expand opportunities for Ohioans to receive trauma-informed interventions by enhancing efforts for practitioners, facilities, and agencies to become competent in trauma- informed practices

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Ohio’s TIC InitiativeTrauma-Informed Care • The TIC model assesses a service delivery system and makes

modifications based on the basic understanding of how trauma affects the life of an individual seeking services

• TIC means that every part of an organization or program understands the impact of trauma on the individuals they serve and promotes cultural and organization change in responding to the consumers/clients served

• This is not a service; rather it is an approach to interpersonal interactions that takes into account the potential scars of a person’s past experience

• The TIC Initiative is not about endorsing particular trauma-informed practices, treatment models, screening or assessment instruments or processes and takes an across-the lifespan approach

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Trauma-Informed Care (TIC) Promotes Cultural Change

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“What’s wrong with you?”

“What has happened to you?”

TIC Planning Framework

Interdepartmental Team(OhioMHAS and DODD)

Statewide Trauma Informed (TIC) Propagation PlanFor MH, DD and AoD

TIC Training/Summit for Clinical and Administrative Leaders

Regional TIC Collaboratives

Community AgenciesCO Partners , Specialty Groups

(Children, older adults, DD)

Internal Departmental

Implementation(Hospitals/community

support network, developmental centers,

therapeutic communities)

Collaboration with other departments

and agencies

Technical Support

Organization(s)

Advisory Committee

TIC Project Coordinator

OhioMHAS and DODD Leadership

Ongoing communications/Training for Regions, Boards, Agencies and

Providers

Interdepartmental Leadership Team

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• Dr. Mark Hurst, OhioMHAS, Co-Chair

• Kathy Coate-Ortiz, OhioMHAS

• Jody Lynch, OhioMHAS• Angie Bergefurd,

OhioMHAS• Trudy Sharp, OhioMHAS• Dr. Lisa Gordish, Twin

Valley RPH• Dr. Kraig Knudsen,

OhioMHAS• Latonya White, OhioMHAS

• Pam Berry, DODD, Co-Chair• Sarah Lawson, DODD• Angela Sausser-Short, Ohio

MHAS• Patrick Kanary, CIP, Case

Western Reserve University• Joyce Starr, OhioMHAS• Dr. Tammy Collins, OhioMHAS• Jackie Doodley, OhioMHAS• Dr. Afet Kilinc, OhioMHAS• Rob Robbins, DODD• Kim Kehl, OhioMHAS

Framework for Ohio’s TIC InitiativeProgress so far—Hospital Services:

• June 2013: Initial training of ODMH/MHAS Central Office and Regional Psychiatric Hospital (RPH) leadership in TIC

• On site training of clinical and support staff at all RPHs, with participation of DODD Developmental Centers, as available

• Consultation from NCTIC on next steps in Hospital Service• Each RPH has identified specific TIC project(s)• Establishment of staff and patient safety initiative in RPHs• Plans for subsequent visits and consultation from NCTIC• Launch of TIC research study in collaboration with OSU

College of Social Work• 2014 Spring Conference – “Why The Need For Trauma-

Informed Care?”33

Framework for Ohio’s TIC Initiative

Progress: Statewide

• TIC Project Coordinator • Statewide Advisory Committee• Meets monthly• Endorsed “Fundamentals of TIC” approach• Serve as “ambassadors” of TIC

• Partnership with National Center for Trauma-Informed Care NCTIC • Train-the-trainers model• System infrastructure and infiltration

• Updated TIC Website (in progress):http://mha.ohio.gov/traumacare

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TIC Advisory Committee:

• Survivors of Trauma• DODD• Ohio Hospital Association• Medicaid• PCSAO• OACBHA• Ohio Council• OACCA• ODH• Hamilton County Board of DD• ODE• ODJFS

• Wright State University: MI/DD CCOE

• Depart of Aging• Human Trafficking

Commission• CIP• ODYS• Ohio Women’s Network• Board of Regents• Center for the Treatment and

Study of Traumatic Stress• Ohio Provider Resources

Association (DD)

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Framework for Ohio’s TIC Initiative

TIC Summit - June 26, 2014Creating Environments of Resiliency and Hope• Thematic fundamental training for clinical and

administrative leaders• AM session: Didactic by leaders from NCTIC• PM session: Regional breakouts to advance TIC locally• Identify strengths, weaknesses, needs, champions• Identify initial plan to proceed, with support from

departments for communication, facilitation, etc.• Sustainability

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Framework for Ohio’s TIC Initiative

Regional Collaboratives• Progressively transmit TIC and increase expertise within

regions• Facilitate cultural change within organizations,

addressing gaps and barriers and taking effective steps based on the science of implementation

• Topical workgroups (prevention, DD, child, older adult, etc.)

• Department(s) continue to support, facilitate, communicate

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Athens Region

Lawrence

Meigs

Gallia

Washington

Monroe

SciotoAdams

Brown

Hamilton

Butler WarrenClinton

Highland

Jackson

RossVinton Athens

Preble

Greene

Fayette

Madison

Clark

Miami

Darke Champaign

Franklin

PickawayFairfield

Hocking

Mercer Auglaize

ShelbyLogan

Union

Hardin

Allen

Van Wert

Paulding

PutnamHancock

Wyandot

Marion

Delaware

Morrow

Seneca

Sandusky

Ottawa

LucasFultonWilliams

Henry WoodDefiance

Erie

Huron

Lorain

Wayne

Medina

Cuyahoga

Summit

Knox

Holmes

Licking

Coshocton

Muskingum

Tuscarawas

Guernsey

PerryMorgan

Noble

Belmont

Harrison

Carroll

ColumbianaStark

Portage

Mahoning

Trumbull

Ashtabula

Geauga

Lake

Crawford

Twin Valley

Region

Lawrence

GalliaScioto

Adams

Hamilton

Pike

Jackson

Vinton Athens

Madison

Miami

Darke

Fairfield

Hocking

Mercer Auglaize

Shelby Union

Hardin

Allen

PutnamHancock

Wyandot

Marion

Delaware

Seneca

Sandusky

Ottawa

Lucas

Wood Erie

Huron

Holmes

Guernsey

Perry MorganNoble

Belmont

Harrison

Clermont

Jefferson

RichlandCrawford

Ashland

Montgomery

Lower Northeast

Central

Southeast

Upper Northeast

Southwest

Northwest

Trauma-Informed CareRegional Collaboratives

Framework for Ohio’s TIC Initiative

Sustainability:

• Based on the passion of those involved in the initiative• This can be launched and maintained with fairly little

infusion of resources• Encourage use and repurposing of existing resources• Technical support: NCTIC and deliverables of CCOEs• Encourage regions and states to develop internal expertise

and learning communities to transmit, maintain and advance our ability to respond to those with trauma needs

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TIC: Why is this important?

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TIC: Why is this important?

“What Happened to You?”

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Contact Information

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Dr. Mark Hurst, M.D., FAPAMedical Director, OhioMHAS

30 East Broad Street, 36th Floor, Columbus, OH 43215(614) 466-6890

Mark.Hurst@mha.ohio.gov

Pamela BerrySenior Policy Advisor, Ohio Department of Developmental Disabilities

30 East Broad Street, 12th Floor, Columbus, OH 43215(614) 301-2992

Pamela.Berry@dodd.ohio.gov

Kim KehlTIC Project Coordinator, Office of the Medical Director

OhioMHAS30 East Broad Street, 36th Floor, Columbus., OH 43215

(614) 644-8442Kim.kehl@mha.ohio.gov