Delivering Trauma Informed Care is Vital in Long Term Care<p><span class="rollup-image"></span>Trauma Informed Care (TIC) is an approach to care that requires specific staff competency and a system of care delivery that provides the necessary support to care for nursing facility and assisted living residents who may suffer from trauma.</p><div aria-labelledby="ctl00_PlaceHolderMain_ctl01_label" style="display&#58;inline;"><div>TIC also is a regulatory requirement for skilled nursing facilities. At least eight CMS F-tags cover various aspects of TIC making compliance with this critical form of care vital to nursing facility survey success and quality care.&#160;</div></div><span class="rollup-image"></span><p></p><div aria-labelledby="ctl00_PlaceHolderMain_ctl02_label" style="display&#58;inline;"><div>The recently released <a href="https&#58;//educate.ahcancal.org/products/trauma-informed-care-training#tab-product_tab_overview" data-feathr-click-track="true" target="_blank" style="text-decoration&#58;underline;">Trauma Informed Care Training</a> contains simple foundational steps and practical recommendations for implementing a TIC program that can help improve resident outcomes. Individuals will learn how to screen and assess for trauma and incorporate TIC into the discharge process. There also is a focus on building awareness of TIC among staff to help them deliver appropriate care and deliver meaningful activities and other services from a TIC perspective.</div><div><br></div><div>This nine-module online course was developed through a joint collaboration between AHCA/NCAL and the American Association of Post-Acute Care Nursing (AAPACN).&#160; The training is designed to educate long term care providers and nurses about how to implement TIC in their facilities with staff who are appropriately trained and competent to care for residents who are at risk for re-traumatization.&#160;</div><div><br></div><div>TIC is an important aspect of care given that 62 percent of adults have had at least one traumatic event and 25 percent have had three or more traumatic events.&#160;&#160;&#160;</div><div><br></div><div>The cost of the program is $350 for AHCA/NCAL members and $650 for non-members. The program is approved for 5.75 NAB CEs for administrators and 5.10 AANC continuing education hours for nurses.<br></div><div><br></div><div>Members will need to login to <em>ahcancalED </em>with their AHCA/NCAL usernames and passwords to <a href="https&#58;//educate.ahcancal.org/products/trauma-informed-care-training#tab-product_tab_overview" data-feathr-click-track="true" target="_blank" style="text-decoration&#58;underline;">register for the course</a><span style="font-size&#58;11pt;">.</span><span style="font-size&#58;11pt;">&#160;</span><span style="font-size&#58;11pt;">For assistance obtaining usernames and passwords, members should e-mail <a href="mailto&#58;educate@ahca.org" data-feathr-click-track="true" target="_blank" style="text-decoration&#58;underline;">educate@ahca.org</a> with their name and facility contact information.&#160; <br></span></div></div>2022-01-12T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/senior_hands_cane.jpg" style="BORDER&#58;0px solid;" />Caregiving;WorkforceTrauma Informed Care (TIC) is an approach to care that requires specific staff competency and a system of care delivery that provides the necessary support to care for nursing facility and assisted living residents who may suffer from trauma.
The Difference Makers<p>​There’s a reason why some skilled nursing facilities have one star and others have five, or why some struggle to maintain census and others are nearly full and selective about which patients they admit. Some are just better than others.</p><p>In several decades of providing care in skilled nursing facilities, I’ve learned a lot about balancing the need for better care with the need to earn a profit. Most important, I’ve learned that improved care and improved profits are not concepts that are at odds with each other. On the contrary, they are essential and totally complementary. Facilities that accomplish this are the ones with all the stars, the full census, the selective admissions counselors, and yes, the most impressive profits.</p><p>When I pioneered telemedicine in nursing homes, the goal was to reduce hospitalizations. If a doctor could see the patient at 1 AM and determine if they could be safely stabilized at the facility until morning, then the patient would be kept safe, the facility would save on staff and transportation costs, census would be maintained, and a lower hospitalization rate would help improve their reputation. That service continues today, and is expanding to other levels of post-acute care and even into private practices.</p><p>The big change in telemedicine is the extent to which providers have embraced technology, how aggressive they have been about innovation, and how well they balance profitability and care. Most don’t. They continue to provide a valuable but limited service. Let’s start with this premise&#58; Patients that are treated regularly by their own primary care physician will fare better than those who are not.</p><p>No one really disputes that, but the cost is prohibitive. Enter innovation. At TapestryHealth, we started with this premise and then figured out how to accomplish it through technology, business savvy, a deep understanding of all aspects of the skilled nursing environment, and a desire to see our patients get what they need. What we realized, is that technology actually lets us take a step back to a time when doctors still made house calls. </p><h2>Build Around the Clinician, NOT Around the Technology</h2><p>There is no better alternative to a patient seeing their own clinician, which is why we build our services around the clinician. Technology is a tool; a very valuable one, but it is not the care provider. That is still the domain of doctors, nurses and nurse practitioners. The shortcoming of traditional telemedicine is that it is built around the technology. At TapestryHealth, each facility is assigned its own trained clinician with geriatric and behavioral care experience. That clinician gets to know and build a relationship with each patient. They work closely with the facility staff, helping to train them on examination, evaluation and treatment techniques, and even meet with family members. The result is the kind of trusting doctor/patient relationship that is missing for so many nursing home residents. <br></p><p>Now, enter technology. In some cases, the most efficient delivery is for our clinician to work on-site in the facility, but typically, especially in smaller, rural facilities the clinician works remotely. And it’s common for facilities to utilize a combination of both to provide complete 24/7 coverage. <br></p><p><img src="/Topics/Special-Features/PublishingImages/2022/Rosie%20art.jpg" alt="Rosie" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;280px;height&#58;280px;" />Technologically, we’ve come a long way from the early years of telemedicine. Our clinicians have access to multiple hi-def cameras to closely examine wounds down to the smallest skin tear. An integrated digital stethoscope provides crystal clear transmission of blood flow, breathing and an integrated otoscope allows for examinations of the ears, nose and throat. Digitally recorded vital signs are guaranteed accurate and uploaded in real time to the facility’s Electronic Medical Records system. <br></p><p>Assigning a dedicated clinician to a facility, including a dedicated after hours support team and providing them with the most advanced technology in the business are three things that separate leading telemedicine providers from the legacy providers. But there’s more, and it’s equally valuable. A dedicated clinician means daily rounds, wellness check-ups, appropriate follow-up, even admissions intake and transition-to-home care.</p><h2>Specialists Can’t Help You If You Can’t Get in to See Them </h2><p>Seeing a specialist is one of the most difficult appointments to get. If you’re a Medicaid patient in a suburban or rural SNF, your chance of seeing a specialist while there’s still time to take effective action is slim. Yet this is a population that needs the attention of specialists maybe more than any other. So, we bring specialists right to the bedside whenever needed. Cardiologists, pulmonologists, urologists, endocrinologists, even psychiatrists can all be brought to the patient’s bedside by their clinician, who also coordinates all specialist visits and oversees medication reconciliation. This doesn’t just enhance our service, it saves lives, and it’s all made possible – and profitable – through technology.</p><h2>What’s Next?</h2><p>What’s next is already making an appearance. The traditional telemedicine treatment cart is evolving to support remote medical technology that allows us to measure vital signs and upload them to the EMR in about one-third the time it would take a nurse. But we don’t stop there. Our clinicians look at any anomalies on every patient’s vitals and can immediately alert the facility if one or more readings indicate a possible problem. Potential disasters, like an outbreak of flu or Covid-19 can often be see coming days in advance of visible symptoms, allowing the facility and staff to prepare. Testing is already underway on our newest remote technology, robotic treatment carts, which will enable remote clinicians to navigate the facility and see patients without the assistance of a staff nurse.</p><p>Using today’s technology efficiently and effectively, helping to innovate tomorrow’s technology now so it meets the changing needs of post-acute care facilities, establishing a familiar clinician as the central point of care to oversee and coordinate a patient’s care&#58; these are the difference makers that have elevated independent care far beyond what was expected when telemedicine began. Today telemedicine is a vital tool in post-acute care and a major contributor to increasing reimbursements, reducing hospitalizations and stabilizing census, improving CMS star ratings, and enhancing reputations with local hospitals, all of which provides the balance between improved care and improved profitability. Not every provider can promise all this. Can yours?<br><br><em>Dr. David Chess is a geriatrician who pioneered the original concept of telemedicine. He has spent much of his career since then advancing the use of technology to improve both patient care and profitability in SNFs. He is the founder of TapestryHealth, one of the nation’s leading providers of healthcare in skilled nursing facilities. <br></em></p>2022-01-03T05:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2022/DavidChess.jpg" style="BORDER&#58;0px solid;" />Caregiving;TelemedicineDavid Chess, MDThere’s a reason why some skilled nursing facilities have one star and others have five, or why some struggle to maintain census and others are nearly full and selective about which patients they admit.
Picking Up the Pieces Post-Trauma<p>In &#160;many ways, trauma is like snowflakes. It looks different for each person, and everyone experiences it in their own unique way. How someone responds to a traumatic event—such as a pandemic—depends on their history, beliefs, values, and other factors. Addressing trauma may seem like reconstructing a shattered vase, but putting the pieces together, even when it doesn’t look perfect, can result in something strong and beautiful.<br></p><p>The American Psychological Association (APA) defines trauma as an emotional response to an accident or natural disaster. Immediately after the event, APA says, shock and denial are typical. Longer-term reactions include “unpredictable emotions, flashbacks, strained relationships, and even physical symptoms like headaches or nausea.”</p><h2>Identify, Acknowledge Trauma</h2><p>While trauma and grief are different, they are intertwined. As Trish Childress, LCSW-S, ACHP-SW, a long term care social worker and director of supportive services, says, “Grief is a natural emotional process we go through after a loss, whereas trauma is an emotional response after a horrific event. But grief can be impacted by trauma, and trauma can be complicated by grief.”<br></p><p>Identifying trauma can be challenging, as people can respond in different ways. But there are signs to watch for, such as someone who was always a pleasant, cheerful person is now angry and short-tempered, or someone becomes preoccupied with death. <br></p><p>As with grief, ignoring signs of trauma isn’t healthy. Instead, Childress suggests, “Try to identify where the person is. Acknowledge that their mood, attitude, approach, etc. has changed, and support them through it.” She stresses that a person can’t receive information about someone’s trauma and just do nothing.<br></p><p>“If you open the box, you have a responsibility to help, and that can be challenging; knowing your boundaries and professional limits with co-workers is important,” she says. An option could be referring them to the Employee Assistance Program. “We don’t want to be passive, but we don’t want to be intrusive either,” she says.</p><h2>Check in With Co-workers</h2><p>After a situation such as a pandemic, natural disaster, or violent event, Childress says, “It is important to check in with team members and co-workers. HR [Human Resources] or other leaders can meet with team members and talk to staff. They can watch for shifts in attitudes, behaviors, or company culture and simply ask people if there is anything they need to do their jobs.” </p><h2>The Role of Control</h2><p>“Two of the greatest predictors of trauma are whether we feel like we had adequate support and how well we were able to take action on our own behalf after the traumatic experience,” says Carla Cheatham, MA, PhD, founder of the Carla Cheatham Consulting Group.<br></p><p>“I know of nurse leaders who when the pandemic began had team members who were terrified, and understandably so,” she says. “They were struggling with lack of information, understanding, and support. I suggested&#58; Go be present with them; walk them through it.” <br></p><p>These leaders were concerned about their teams and took actions such as providing detailed written instruction on how to put on, take off, and dispose of Personal Protective Equipment, how to wash up, and how to protect their families when they went home. However, Cheatham observes, “Their presence gave their teams comfort that written memos and training programs couldn’t. This took time, but the impact was tremendous. It bonded teams and reassured frontline workers that they were cared for.<br></p><p>“Leaders who turn off their phones and listen to their people will build brand loyalty and connections and, ultimately, save much time, money, and energy in the long run.”</p><h2>Offer Options, Be There</h2><p>Giving people the option of initiating outreach for help is important as well. “We set up a call line where residents and employees could talk about their losses and their feelings,” says Jasmine Wadkins, LCSW, CDP, BF-CMT, CCTP, CEA, director of behavioral health services operations and education at Signature HealthCARE.<br></p><p>At the same time, it is important to realize that some people may not be willing or able to take that first step, she says. “If someone acknowledges feelings of trauma, you can say, ‘Would you like me to help you get assistance?’ or, ‘Can I make a call for you?’”<br></p><p>The personal touch is essential. For instance, instead of having corporate HR handle everything, Signature has HR people who deal with just a few buildings so they can get to know staff and communicate with them one-on-one. “We promote the Employee Assistance Program and do many referrals. We connect with area clergy and form other partnerships. As a result, we are able to make sure that employees get what they need.”<br></p><p>Encouraging self-care is important, especially after people have experienced a trauma or crisis. However, Cheatham stresses the need to realize that this isn’t a panacea. “We can’t tell people to exercise, eat right, take a vacation, or something else and expect everything to be okay. We need to look at what aspects of the workplace contribute to or trigger trauma and address them head on,” she says.</p><h2>Trauma Beyond Disease and Death</h2><p>There is no doubt that COVID has been responsible for much trauma, but there are issues beyond the illness that have negatively impacted many in long term care. The battles and controversies about vaccinations and masking, as well as conspiracy theories about the virus itself, have affected many people at all levels.<br></p><p>“When what we believe about the world gets smacked by reality, we hit an existential crisis,” Cheatham says. To let go of the belief that people will stop doing something that will hurt others when you find that this isn’t necessarily true, you first have to grieve, she says. “Once you do that, you can find a new place to come to. You can accept the reality of the world while understanding that when people are afraid, they’re not always their best selves.” </p><h2>Post-Trauma&#58; PTSD</h2><p>With post-traumatic stress disorder (PTSD), which is not uncommon for people who have experienced traumas, specific triggers (such as loud noises) take them back to the event and make them feel fear, terror, or helplessness. Symptoms may include flashbacks, recurring dreams or nightmares, feelings of detachment, problems sleeping, and/or an exaggerated startle response.<br></p><p>Researchers have found that PTSD affects many COVID survivors, as well as those who have been impacted by the virus in some way. One contributor to this is economic stress, something that many people—including a number of frontline workers—experienced during the pandemic. <br></p><p>COVID-related PTSD can be challenging to treat. In “COVID-Related Post Traumatic Stress Disorder&#58; What It Is and What To Do About It,” William Haseltine, PhD, said, “Building resilience is an important part of overcoming trauma, yet the ambiguity surrounding it makes it more difficult to build resilience. People can’t always resort to typical methods such as goal setting and shifting the focus away from the trauma and toward the future.”</p><h2>So Many Starfish</h2><p>It may be tempting to assume that once the worst of COVID is over, trauma will ease. However, this isn’t likely to be the case.<br></p><p>“When people have time to come up for air and reflect on what they’ve been through, we can anticipate that burnout and trauma rates will go up,” Cheatham cautions. In addition to trauma, there may be widespread compassion fatigue, the physical and emotional exhaustion that leads to diminished ability to empathize or feel compassion, and moral distress, which results when people are prevented from taking or are unable to take the correct response to a situation.<br></p><p>Even the best, most caring, and conscientious of leaders and organizations are likely to see these kinds of issues arise. In addition to dealing with the Delta variant and new outbreaks and infections, says Cheatham, many staff members are confronted by pushback on vaccinations and masking, as well denials of COVID’s existence or severity. <br></p><p>“When there are that many starfish on the beach, you can only pick up so many,” she says. “It will take time, effort, and patience to deal with the traumas resulting from the pandemic and other crises we’ve faced in the past few years.”</p><h2>Person-Centered Care for Staff, Too</h2><p>“We pride ourselves as an industry for doing person-centered care, but it’s not enough to do it for residents. We need to take what we do for our residents, like trauma-informed care, and do it for our staff as well,” says Cheatham, adding, “The best leaders I’ve seen understand this.”<br></p><p>Paige Hector, LMSW, national speaker and clinical educator, suggests encouraging staff to have an “empathy buddy.” An empathy buddy can be a colleague or co-worker or someone outside of the work setting. Engaging with an empathy buddy is an intentional practice that is different from usual conversation, one in which the individuals can share their feelings and explore underlying needs.<br></p><p>“This doesn’t have to be a formal arrangement or involve structured meetings,” Hector says. It could mean a &quot;check-in,&quot; where each person has the opportunity to share while the other person listens deeply instead of typical back-and-forth talking or problem solving. It can be helpful to agree upon a set time, for example, five minutes each (or longer if the situation allows). <br></p><p>“It lays a foundation to help people understand and practice empathy, and it encourages mutually supportive relationships,” Hector says. Of course, she notes, “Participating in this type of practice is voluntary, and some staff may choose to not participate.”<br></p><p>It’s important for leaders to create a culture where everyone understands that trauma is an injury, and not a weakness, illness, or character flaw, says Hector.<br></p><p>“Few of us will get though life without being traumatized by something at some point,&quot; she says. “Infusing trauma-informed care in the facility fabric of daily interactions is the beautiful opportunity we all have to support each other in healing.” <br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.​</em></p>2021-12-01T05:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2021/1221/CF1-Truama.jpg" style="BORDER&#58;0px solid;" />Caregiving;Behavioral HealthJoanne KaldyIdentifying trauma can be challenging, as people can respond in different ways. But there are signs to watch for.
Coming to Terms With Grief<p>Grief is a complex issue. It doesn’t follow a straight trajectory or timeline, and people don’t all grieve in the same way or for the same losses. The key is to understand the big picture of grief, determine how to create an organizational culture that honors and supports those who are grieving, and plan how to help people as individuals through their grief.<br></p><p>Start by understanding that there are many misperceptions about grief. For instance, Trish Childress, LCSW-S, ACHP-SW, a long term care social worker and director of supportive services, says, “People sometimes think that if they talk about someone’s loss, it will only make them sadder. I hear this a lot.” However, she says, “In reality, they are already sad. We need to give them an opportunity to talk about their loss if they want to.”<br></p><p>Another myth is that grief is the same for everyone—that there is a set timeline for grieving or that people go through predetermined <a href="/Topics/Special-Features/Pages/Stages-of-Grief.aspx" target="_blank" title="Stages of Grief">stages of grief</a> and then are “done grieving.”<br></p><p>Paige Hector, LMSW, national speaker and clinical educator, says, “People tend to think that grief is something we should experience briefly and move on.” This “just get over it” mentality, she says, is common in health care.<br></p><p>“We don’t allow people the time to reflect and experience all of their emotions,” she says. “As a result, they get bottled up inside, and [it affects their] entire being.”<br></p><p>People often think that grief is only an emotional experience. However, Hector notes, “Grief is a whole-body issue. We experience grief in all sorts of ways, and our bodies aren’t hardwired to get over it quickly. It’s about building capacity around grief and mourning, instead of getting around it.”</p><h2>COVID Grief Looks Different</h2><p>“The landscape of grief looks different in the COVID world,” Childress observes. For one thing, people are grieving many losses beyond deaths. They are suffering from the loss of social norms, activities, interactions with families and friends, traditions, and more. People may not even realize they are grieving these losses until something triggers a reaction.<br></p><p>For instance, says Childress, “A colleague told me how, in the middle of the pandemic, she broke a dog food dish she had bought for her first dog 20-some years ago. She said she sobbed for an hour and thought something was wrong with her. In fact, the dish actually represented all of the losses she had experienced—lost work, lost connections with friends and family, lost holidays—and she was grieving for all of those things.”<br></p><p>Once the colleague understood this, she was able to acknowledge her grief and begin to deal with it.<br>Many healing traditions, such as viewings or memorial services, have had to be skipped or postponed during the pandemic. People even had to forgo simple gestures such as bringing someone a meal or a gift. “These are important rituals and gestures for many people, and not being able to participate in them has delayed the grief process for some,” Childress says.<br></p><p>The pandemic took everyone off guard, and “none of us was completely prepared to deal with the amount of loss and level of grief we’ve experienced,” says James Wright, MD, CMD, a multifacility medical director in Virginia. “I think we’re actually still gritting our teeth. We’re imagining the light is at the end of the tunnel and figuring we’ll grieve when we get there.”<br></p><p>In the meantime, he suggests, everyone is still putting one foot in front of the other to make it through. However, it still is important to take the time to stop and grieve, he says.</p><h2>Daunted by Discomfort</h2><p>Even when they have the best of intentions, some people don’t know how to help someone who is grieving or even how to address their own grief. “In general, we have a dislike or fear around vulnerability,” Hector says. “We have this idea that vulnerability isn’t acceptable or worry that we’ll get stuck if we let ourselves be vulnerable.”<br></p><p>People may hesitate to reach out when they are grieving because they don’t want to bother others, she suggests. “We need to help people understand that part of being human is to grieve and mourn when you experience a loss.”<br></p><p>When people don’t know how to help others who are grieving, they may just avoid them. “People in my [grief support] groups say that it’s so lonely, that others are avoiding them ‘like the plague,’” Childress observes. Those feelings of isolation are one reason such support groups are so important.<br></p><p>“I think grief groups are the best thing anyone ever came up with,” says Judi Crick, a family caregiver who has lost three close relatives in the past year. “You come together with others who are grieving, and you start to share your feelings. Before long, you realize you’re not alone, that you’re okay,” she says. Someone will tell a funny story about a loved one and “you find yourself laughing and that it’s okay.” <br></p><p>In truth, just reaching out and expressing a willingness to be there for the person can be helpful. Childress suggests offering something specific, such as bringing the person dinner, taking their dog for a walk or their kids to a movie. </p><h2>Take Time for Tears</h2><p>“When someone is in grief, create a safe place for them to express their feelings,” says Hector. This means, for example, letting people cry, instead of saying, “Please don’t cry. Don’t be sad. Everything is going to be okay.” Shedding tears is a perfectly normal human reaction and can provide much-needed release.<br></p><p>“Take your cues from the person,” Hector says. “Don’t jump in, offer advice, reassurance, or consolation. Instead, offer an empathic presence, which may include warm silence as the individual experiences their emotions.”<br></p><p>An empathic presence conveys a message of caring, listening, and spaciousness, not problem-solving, she says. “If you sense an urge to say something, keep it simple and focused on the other person&#58; ‘This really hurts,’ or ‘I hear you and will stay with you as long as you’d like.’”<br></p><p>When people cry, she adds, “It’s often a knee-jerk reaction to give them a tissue. But this can look like you’re encouraging them to stop crying.” Instead, wait for them to look around for a tissue or ask for one.</p><h2>Some Steps Toward Healing</h2><p>There is no panacea for grief, but there is much facility leaders can do to help residents, families, and staff who are grieving. <br></p><p>For instance, Childress says, “We do a 12-minute virtual memorial online every month, and we encourage people to take the time to feel and acknowledge their emotions. They can take a minute to think about people they’ve lost, reflect, and smile at a happy memory.”<br></p><p>Wright stresses the importance of openness. “We need to recognize loss, not cover it up or ignore it. At one of my facilities, we had a memorial service at the end of the January 2020 outbreak that was attended by family and staff. It brought us together respectfully,” he says.<br></p><p>“There was a recognition that we were going through something that was unprecedented. Our chaplain was very involved, and we offered grief counseling and opportunities to vent and be there for each other.”</p><h2>A Long Road to Healing</h2><p>Addressing grief isn’t one and done. Childress suggests, “Make sure your Human Resources department is putting out tips and tools all year long to help people deal with grief. For instance, have teaching sheets to put out in monthly newsletters or promote local bereavement groups they can participate in.” <br></p><p>It’s not just enough to say that the company supports efforts to grieve and mourn. “Even when facilities say it’s okay to grieve, staff may not feel that it’s safe to express their feelings if there are no formal processes or structure for them,” Hector says. “Everyone needs to know where they can turn if they want counseling or other help.”<br></p><p>Judi Crick and her husband Rob suggest a few ways staff can help families with grief. Judi says, “When my mother was dying, I didn’t know what to expect. The facility staff were so good about telling me what was happening with her physically; they walked me through the dying process. This helped me to have feelings of peace when she passed away.”<br></p><p>Rob recommends that staff keep the rooms of residents who are in the dying process as neat and free of clutter as is possible. “Creating a comfortable environment to spend time with a loved one really helps, and it demonstrates for family members how much respect the facility has for the resident and those who love them.”<br></p><p>It’s important to remember that grief is unpredictable and can pop up unexpectedly long after the loss. When this happens, Childress offers, “Think about the basics. Is the person safe? If not, how can I get them to a safe space? What was the trigger?” She adds, “It’s best to just sit with them and encourage them to talk if they want to. You don’t have to know what to say or ask a lot of questions,” she says. “The best gift is to be present.” <br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.​</em></p>2021-12-01T05:00:00Z<img alt="" src="/Topics/Special-Features/PublishingImages/2021/1221/CF2-Grief.jpg" style="BORDER&#58;0px solid;" />Caregiving;Mental HealthJoanne KaldyGrief is a complex issue. It doesn’t follow a straight trajectory or timeline, and people don’t all grieve in the same way or for the same losses.