Johns Hopkins Bayview Medical Center

Johns Hopkins Bayview Medical Center is one of six member institutions in the Johns Hopkins Health Systems. It is one of the oldest, continuous healthcare institutions on the east coast. It is home to a Level II Trauma Center and Regional Burn Center. Specialties include but are not limited to hip and knee replacement surgery, burn care, Geriatric/Primary Care Medicine. The hospital has been designated as a Comprehensive Stroke Center by Maryland Institution for Emergency Medical Service Systems. Rehabilitation Services offers acute/inpatient rehab, Myositis/POTS therapy, Stroke/Neurologic rehab and Geriatric rehab as well as other rehab programs.

Geriatric Medicine Clinic and Primary Care Physical Therapy

Physical therapists are trained to understand the social determinants of health and understand the impact of previous trauma on the healing process. Knowing patients’ social and psychological context can aid in the treatment and recovery of patients. Knowing one’s patients promotes trusting relationships. Why does this build trustworthiness: Knowing one’s patients is an essential part of good communication and builds trusting relationships between patients and therapists.

How It Works

The trust practice focuses on screening older adults that come into the Geriatric Medicine Clinic for fall risk and other age-related neuromuscular issues, such as postural problems, core strength, and rotator cuff impairments in addition to balance and overall physical activity using a Trauma-Informed Care (TIC) approach. TIC is strength-based. “Grounded in an understanding of and responsiveness to the potential impact of trauma, TIC emphasizes physical, psychological, and emotional safety and creates opportunities for patients to rebuild a sense of control and empowerment.”¹ Educational sessions between the PT and patient introduce the long-term effects of adverse childhood experiences (ACEs) on health and the TIC orientation to health care.

Baltimore city residents, and those in Baltimore County that live on the east side of our hospital, face challenges to incorporating physical activity into their daily routines due to socio-economic disparities.

Physical therapists’ knowledge of disease and physical activity positions them as an integral partner with the Geriatric Medicine Clinic to transition from an emphasis of treating chronic diseases to disease prevention and a culture of health and wellness, moving from reactive to proactive. Physical inactivity is a modifiable determinant of health. Between 6-10% of non-communicable disease deaths worldwide are related to physical inactivity. Physical activity level needs to be looked upon as a “vital sign.” Understanding social determinants of health implies that every person should have the right to a healthy quality of life. As physical therapists, we have a responsibility to find ways that allow individuals to achieve this. This is especially needed within Baltimore City, given the low socio-economic and racial inequity.

Skills and Competencies

Physical therapists are required to have an understanding of “psychologically informed practice” and use a “universal precautions” approach based on trauma-informed care principles to reduce the risk of re-traumatizing patients, given the built environment of Baltimore City. Training for physical therapists is provided via mock interviewing using an interview protocol, through which physical therapists learn how to ask patients about ACEs using positive questions and not solely focus on negative questions, so as not to re-traumatize or make patients feel like these events are their fault.

The concept of “re-traumatizing” is based on the conscious or unconscious reminder of past trauma that results in a re-experiencing of the initial trauma event. It can be triggered by a situation, an attitude or expression, or by certain environments that replicate the dynamics (loss of power/control/safety) of the original trauma. The risk of re-traumatizing applies to our own interactions with our clients with a history of trauma, likely unknown to the therapist, in which we may inadvertently trigger a negative reaction.

Origins

Having been a PT for 28 years and as a recent public health graduate, I began to wonder about the Adverse Childhood Experience (ACE) study done by Anda and Felitti. Reading more on this topic made me begin to reflect on many of my patients who did not benefit from PT for their acute or chronic pain. As I developed relationship-centered care, some of my patients would provide me with more life experiences. Many of these stories related to home or community violence, both when they were young and as adults. From these stories, I began to assume many of my patients likely had these experiences and I should approach trauma as a “universal precaution.” These experiences in childhood might be the reason why some have their pain resolved and others not, and why pain perception may be altered just as their risk of chronic medical conditions is significantly increased.

Effectiveness

The qualitative evidence used is the Health-Related Quality of Life measure in addition to the Fear of Falling questionnaire. Additional measures to be explored are Patient-Reported Outcome Measure, narrative-based approaches looking at symptom burden, and functional impact, being mindful that “providing care that is respectful of, and responsive to, individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” Other measures that would be interesting to track would be hospitalizations from chronic diseases.

Scalability

This trust practice is in development and its inception occurred before the pandemic. During the initial months of the pandemic, ambulatory clinics were closed, and I was redeployed to a different non-direct patient care position. We are returning to this project currently. Adoption of this project into a scalable form of health promotion and intervention would need further investigation into effectiveness, reach and adoption; human, technical, and organizational resources; costs; intervention delivery; contextual factors and appropriate evaluation approaches. Addressing these issues would likely develop better acceptance to expand this promising project into larger practice within the Hopkins Health System, such as expanding into Internal Medicine, Orthopedics, and Mental Health.

Footnotes:

¹ Harris, N. B. (2018). The deepest well: Healing the long-term effects of childhood adversity. Houghton Mifflin Harcourt.