Ohio Association of Common Pleas Judges December 3, 2015 Mark Hurst, MD, FAPA

The Science on ACEs... 2 New lens through which to understand the human story Why we suffer How we parent, raise and mentor our children How we might better prevent, treat and manage illness in our medical care systems How we can recover and heal on deeper levels

Prevalence of Trauma Exposure to trauma is especially common among individuals with Mental illness Substance use disorders Developmental disabilities 3

How does ACES affect our society?

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 5

What can be done about ACEs? These wide-ranging health and social consequences underscore the importance of preventing ACEs before they happen Safe, stable and nurturing relationships can have a positive impact on a broad range of health problems and on the development of skills that will help children reach their full potential Strategies that help address the needs that children and families have include: 6 Home visiting to pregnant women and families with newborns Parenting Training Programs Intimate partner violence prevention Social support for parents Parent support programs for teens And teen pregnancy prevention programs Sufficient income support for lower income families Early childhood programs and environments Mental illness and substance abuse treatment

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 7

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 8

Ohio’s Trauma-Informed Care (TIC) Initiative 9 Infiltration of TIC in Regional Psychiatric Hospitals (RPHs) Goal: RPH infrastructure will support cultural and environmental changes that support effective care and excellent outcomes. RPHS will be recovery-oriented; trauma- informed; culturally and linguistically competent; and address health and wellness. Progress to date: June 2013: Initial training of MHAS Central Office and Regional Psychiatric Hospital (RPH) leadership in TIC On-site training of clinical and support staff at all RPHs Continued consultation from the National Center for Trauma-Informed Care (NCTIC) on next steps in Hospital Services Launch of TIC research study in collaboration with OSU College of Social to explore implementation of TIC at two psychiatric hospitals and focusing on two implementation variables: readiness for change and implementation climate Clinical Safety Initiative

Ohio’s Trauma-Informed Care (TIC) Initiative 10 Infiltration of TIC in Department of Developmental Disabilities (DODD) Developmental Centers (DCs) Goal: DCs become trauma aware, knowledgeable and responsive to the impact and consequences of traumatic experiences for residents, families and their communities. Progress to date: Initial training of all Developmental Centers completed in FY 2015 Plans for subsequent visits and consultation from NCTIC Consultation being planned on the impact of secondary/ vicarious trauma on staff at Montgomery and Youngstown Developmental Centers scheduled to close June 30, 2017 Community provider outreach and training – Spring 2016

Ohio’s Trauma-Informed Care (TIC) Initiative 11 Infiltration of TIC in Ohio communities Goal: Expand opportunities for Ohioans to receive trauma-informed interventions by enhancing efforts for practitioners, facilities and agencies to become competent in trauma informed practices. Progress to date: Train-the-trainer model – 170 trainers available throughout the state Content focused on system infrastructure and infiltration o Understanding trauma o Trauma-informed approaches o Principles of trauma-informed approaches o Guidance and implementation o Healing and recovery

Ohio’s Trauma-Informed Care (TIC) Initiative 12 TIC Communication Plan/MHAS/DODD organizational and administrative commitment to TIC Goal: Develop an educational and communication campaign on trauma and its association to health that encourages the adoption of trauma-informed practices among facilities, agencies and practitioners to support both their customers and their workforce in achieving better health. Progress to date: MHAS website developed as a “clearinghouse” for information related to TIC distributing up-to-date information about TIC to the field, including materials for clinicians and health professionals, those who may have experienced trauma and other interested individuals Combined TIC training for Central Office staff of OhioMHAS, DODD, and Attorney General – Spring 2016

Ohio’s Trauma-Informed Care (TIC) Initiative 13 Third Annual Trauma-Informed Summit Goal: Identify promising practices and share feedback and continuous learning and form the basis for more advanced work in developing trauma-informed environments and practices. Progress to date: Creating Environments of Resiliency and Hope in Ohio June 2016 o Two day Summit o Day One – TIC and exemplary Ohio programs o Day Two – Clinical Best Practice Institutes

Ohio’s Trauma-Informed Care (TIC) Initiative 14 Alternatives to Seclusion and Restraint (S/R) Initiative Goal: Initiate a statewide quality/performance improvement and trauma-informed strategy in responding to, reducing and eliminating the use of seclusion and restraint incidents in children’s residential facilities. Progress to date: June 18, Alternatives to Seclusion and Restraint Forum ODJFS children’s residential and/or OhioMHAS children’s residential centers, licensed inpatient facility or a facility providing services to young persons with developmental disabilities World café model used to identify: What accomplishments do agencies have to build upon? What can be accomplished together that agencies cannot accomplish alone? What policy challenges exist? Trauma-Informed Approach Training for combined ODHFS and OMHAS Licensure and Certification Training

Ohio’s Trauma-Informed Care (TIC) Initiative 15 Partnership Work Goal: Support the implementation of trauma-informed care systems and trauma-specific services across Ohio’s social services systems. Progress to date: Formation of a Statewide TIC Advisory Committee by coordinating existing experts on a state and regional basis Partner with the Ohio Department of Health on their Early Childhood Comprehensive Systems (ECCS) Grant – MHAS, Bureau of Children and Families Understanding Toxic Stress: Protecting Infants and Young Children From the Life- Long Impacts of Prolonged Adversity Partner with Attorney General’s Office VOCA (Crime Victim’s Fund) programming

Regional Trauma-Informed Collaboratives Goal: Expand opportunities for Ohioans to receive trauma-informed interventions by enhancing efforts for practitioners, facilities and agencies to become competent in trauma informed practices, and facilitate cultural change within organizations, addressing gaps and barriers and taking effective steps based on the science of implementation. Progress to date: Six Regional TIC Collaboratives formed Staffed by MHAS and DODD personnel – (DODD Regional Liaisons) Transitioning to local leaders 16 Ohio’s Trauma-Informed Care (TIC) Initiative

Trauma-Informed Care Regional Collaboratives

What we CAN do... Slide 18 Treat everyone with universal precaution: Assume that the person has experienced trauma even if you don’t know their personal history. Create a welcoming environment that promotes a feeling of safety and non-violence – pay attention to physical space, tone of voice, loudness of music or side conversations and eliminate anything that could be intimidating or anxiety provoking. Be very aware of personal space. Realize that some painful memories may be triggered by touching, hugging, behaving authoritatively, standing over the person or blocking their exit in a closed space, etc.

What we CAN do... Slide 19 Recognize that certain practices (e.g., seclusion and restraint) may create trauma and trigger traumatic memories. Make a commitment to non-violence in words, actions and policy/practices. Support meaningful power-sharing and decision-making – Voice and Choice! Use tools/approaches that help calm fear/anxiety/anger/defensiveness as a preventative and healing method rather than engaging in confrontational approaches that focus on coercion or control of external behavior.

What we CAN do... Understand that troubling behaviors that we may find uncomfortable likely helped the person cope/survive under extreme circumstances. Seek to understand their experiences and identify a path to healing. Show genuine concern and be sensitive to physical or intellectual barriers, gender and cultural issues. Slide 20 Help link the person with trauma responsive services and ensure continuity of care between organizations and across systems. Ask “What happened to you?” instead of “What’s wrong with you?”

What we CAN do... Slide 21 Recognize that certain practices (e.g., seclusion and restraint) may create trauma and trigger traumatic memories. Make a commitment to non-violence in words, actions and policy/practices. Support meaningful power-sharing and decision-making – Voice and Choice! Use tools/approaches that help calm fear/anxiety/anger/defensiveness as a preventative and healing method rather than engaging in confrontational approaches that focus on coercion or control of external behavior.

TIC: Why is this important? TIC: Why is this important? 22

TIC: Why is this important? “What Happened to You?” 23

24 Dr. Mark Hurst, M.D., FAPA Medical Director, OhioMHAS 30 East Broad Street, 36 th Floor, Columbus, OH (614) Tina Evans Regional Liaison Team Lead, Division of Policy & Strategic Direction 30 East Broad Street, 12 th Floor Kim Kehl TIC Project Coordinator, Office of the Medical Director OhioMHAS 30 East Broad Street, 36 th Floor, Columbus., OH (614)