Trauma centers and emergency rooms have always focused on physical life-saving measures, and improvements in acute care access and quality continue to lower mortality rates.
But these advances, while positive overall, have failed to address a longstanding gap in full-spectrum care in the initial days and weeks following a patient’s discharge from the hospital, according to Ken Ruggiero, Ph.D., clinical psychologist and director of the Trauma Resilience and Recovery Program in the College of Nursing at MUSC.
With over 3 million nonfatal injuries in the U.S. per year, critical care is a crucial aspect of recovery. But Ruggiero says that over 20% of hospitalized patients in the country develop post-traumatic stress disorder (PTSD) or depression in the first year following injury, so caring for mental health following a severe injury is also important. Unfortunately, it is often overlooked.
A New Program
When MUSC Health became a Level I trauma center in 2011, Ruggiero and his team saw an opportunity to develop a program targeting mental health after severe injury where licensed psychologists are more deeply incorporated into patient care in the hospital. The team had started to notice that their only patients with PTSD and depression were those who had been experiencing symptoms for years and came into MUSC clinics of their own accord. Ruggiero knew there was more he and his colleagues could do to help patients if they could start at the bedside.
He credits the leadership of trauma surgery chiefs Samir Fakhry, M.D., and Bruce Crookes, M.D., who saw the value in addressing the mental health needs of their patients and opened the doors that the team needed to have an impact.
In a coordinated effort to reach that goal, he and colleagues Tatiana Davidson, Ph.D., associate professor, clinical psychologist and codirector of the program, and Leigh Ridings, Ph.D., assistant professor and associate director for child and family services in the program, launched the Trauma Resilience and Recovery Program.
Leigh Ridings, Ph.D. (left), Hannah Espeleta, Ph.D., Ken Ruggiero, Ph.D., and Tatiana Davidson, Ph.D. (right), are all part of the Trauma Resilience and Recovery Program. Not pictured: Olivia Bravoco, who is the team's program manager. Credit: Scott Garrand
“From the start, we’ve focused on simplicity, efficiency and scalability,” said Ruggiero. “We knew that if we could create a model that is not only evidence-based and effective for patients but also manageable from a resource standpoint, then this may not only be a solution for MUSC patients but for those across the state and maybe even nationally.”
They started by asking trauma patients what they would find most useful and which communication styles worked best for them. The resulting program is now in 16 different hospitals across five different states in addition to Washington, D.C.: South Carolina, North Carolina, Alabama, Indiana and Massachusetts.
Two grants led by Davidson, both awarded by The Duke Endowment, have allowed for program adoption in 11 trauma centers in the Carolinas alone.
The program consists of three main steps. Initially, a member of the mental health care team meets the patient at their bedside to provide an introduction. The team members invite the patient to enroll in a 30-day text messaging program as well as a telephone check-in 30 days after discharge. That check-in serves as an opportunity to evaluate the patient for possible additional treatment recommendations. Approximately 98% of patients enroll in the program.
The Trauma Resilience and Recovery Program consists of a team of licensed clinical psychologists, program coordinators and managers as well as an internship program that includes predoctoral clinical psychology trainees and postdoctoral trainees. It also includes a partnership with the Citadel where students enrolled in the master’s program in clinical counseling can rotate at MUSC for their internship. Volunteers from the College of Charleston School of Public Health also help staff the program.
The text messaging aspect was borne out of a strategy to have continuity of care by reaching patients at home during the start of their recovery and providing wellness tips and ways to lower anxiety. Texts ask patients to rate their mood or their success in getting a good night’s sleep, for example. And depending on their answers and need, patients will then receive information on ways to improve their symptoms. This helps patients pay attention to changes in their mood over the course of the month and allows the health care team to know if their patients are at risk for developing PTSD or depression.
“After a patient reports a symptom, tips can include different relaxation strategies like mindfulness exercises, diaphragmatic breathing or progressive muscle relaxing,” Ridings said. “And even different audio clips, videos and games can accelerate their recovery and provide coping strategies.”
Ruggiero says that two-thirds of patients they meet with accept enrollment in the text messaging aspect of the program, and half of those patients actively engage with it.
“It helps increase continuity of care,” he said. “When people are prompted to monitor their mood and anxiety, it can help improve outcomes, too.”
With support from the South Carolina Telehealth Alliance, the Trauma Resilience and Recovery Program offers telehealth options to patients as well. If further care is indicated, patients can continue that in person or via telehealth video conferencing, which helps with transportation drawbacks, stigma, time and even physical mobility issues following their injury. When asked, 80% of patients requested telehealth in addition to the opportunity for in-person care. And by using technology to assist, the program can stay less resource-intensive, which gives it the opportunity to work in hospitals without enough staff to implement it otherwise.
Expansion for Children & Caregivers
The program started with adults but grew to include pediatric patients. With a grant from the National Institute of Child Health and Human Development, Ridings was able to expand and recreate the program to encompass younger children as well as their caregivers. Studies have shown that children with untreated mental health issues can have social, cognitive, and emotional development issues as well as issues with academic functioning.
Caring for both the child and the caregiver is important for Ridings. Initially it was complex to add children because with younger patients, much of the care needs to go through the caregiver or parent, but then the child’s caregiver is also likely to experience their own PTSD, anxiety or depressive symptoms depending on their child’s recovery or the nature of their child’s injury.
Ridings is currently piloting a change in the text messaging system where the caregiver receives two texts each day: one geared towards assessing their mood and providing tailored tips and the second aimed at assessing their child’s mood and anxiety levels. An app for the program is also under development to provide cognitive behavioral coping strategies, relaxation techniques, symptom tracking and psychoeducation using interactive tools, videos and audio clips.
“With the help of the Duke Endowment grant and the National Institute of Child Health and Human Development, I’m able to test the feasibility of a technology-enhanced intervention like this, which we’ve called CAARE.” CAARE stands for Caregivers Aid to Accelerate Recovery After Pediatric Emergencies.
Ridings says the program aims to normalize the symptoms that patients and caregivers are experiencing. For instance, parents often feel guilt after an accident, or their children could become more likely to act out. Knowing that their symptoms happen to others can provide comfort, and feedback has been positive.
Davidson says her patients have also liked the check-ins via text message. “I have memories of calling patients at the end of their first month of recovery,” she said. “And they thank me for following up and admit they had no idea they were feeling a certain way until prompted or that they had no idea their child could be having certain feelings. And we were able to connect them to services that could help. That’s the best part.”
Growth & Equity
From the beginning, the team involved in the Trauma Resilience and Recovery Program wanted to develop a program that could be implemented in other hospitals as well as at MUSC. Davidson says they wanted a program that was both cost-effective and sustainable, so they initially partnered with Trident Medical Center, Prisma Health-Midlands and Prisma Health-Upstate to embed a full-time program coordinator at each location with funding from the Duke Endowment.
Over the course of 3 years, they learned what changes could be made to the model to fit into each hospital’s infrastructure and workflow. The results were so promising that by the end of each coordinator’s time at their respective locations, the trauma centers themselves saw the benefit to their patients and funded their own permanent positions.
Davidson says it was a really rewarding experience. “I loved seeing that the program we had spent years developing could actually stand on its own at other hospitals,” she said.
While most research can take decades to reach patients, if not longer, Ruggiero points to the uniqueness of this program. He feels it went in the opposite direction of traditional research in an effort to help patients sooner. “We started with a base of research,” he said. “And we took it straight to the clinic to expand upon and grow. The practice started first and then led to all of these really important research questions about how to optimize and scale the model.”
Ruggiero, Davidson and Ridings are currently investigating these questions through large-scale studies with George Washington University Hospital in D.C. as well as hospitals in Boston, Alabama and South Carolina. “Normally you’re testing and testing and testing to eventually see something that might one day impact practice,” Ruggiero said. “It feels good to be doing it the other way around for once and having immediate impact with patients who need services.”
Equity is another important aspect of the program for Ruggiero, Davidson and Ridings. The program partners with groups like Turning the Tide, which is a new initiative that prioritizes the needs of underserved patients who experience violent injury. “We’ve seen in our samples that there are higher levels of distress at the bedside and a higher likelihood of meeting the criteria for PTSD and depression after violent injury compared to nonviolent injuries such as serious car crashes,” Ruggiero said. “And yet, it’s harder for us to stay in contact with these patients. The highest-risk patients seem to be the hardest ones to follow up with over time, and programs like Turning the Tide have a broader range of services to offer.”
He says they’re partnering with health equity experts to look at social determinants of mental health in an effort to improve equity in the services provided within the program.
“We designed this program to help people recover on an emotional level and behavioral level more quickly than they otherwise would have on their own,” said Ruggiero. “And to reduce the prevalence of PTSD and depression among patients who experience severe injury.”
“We can leverage things like technology to reach more patients and reduce barriers,” said Davidson. “And the growth and success of this program has just been incredible. I’m just so excited because this is what we do, and it’s really for the patients at the end of the day.”