Children - Key Activity 10

KEY ACTIVITY #10:

Implement Trauma-Informed Care Approach Across the Patient Journey


 

This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; behavioral health integration; address social needs.

Overview

This activity provides guidance on concrete actions that practices can take to embed trauma-informed care into their daily workflows and interactions with patients.

Individual trauma is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as follows: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual well-being.”[1] Toxic stress is similar: significant stress that is frequent or prolonged without adequate buffering protections. Many experiences may be traumatic, including but not limited to: physical, sexual and emotional abuse; childhood neglect; living with a family member with mental health or substance use disorders; sudden, unexplained separation from a loved one; poverty; racism, discrimination and oppression; and violence in the community, war or terrorism.”[2]

Trauma-informed care (TIC) is defined by the National Child Traumatic Stress Network as “medical care in which all parties involved assess, recognize and respond to the effects of traumatic stress on children, caregivers and healthcare providers. In the clinical setting, TIC includes the prevention, identification and assessment of trauma, response to trauma, and recovery from trauma as a focus of all services.”[3]

People can build trauma-informed healthcare organizations that create safe, caring, inclusive environments for all patients. A number of trauma-informed strategies exist that organizations can adopt to help people overcome the effects of trauma. These strategies range from organizational changes in the culture and atmosphere of a healthcare setting to the full adoption of practices to address trauma at the clinical level.[4]

Of note, the Pediatric ACEs and Related Life-events Screener (PEARLS) includes the following factors in its assessment:

  • Abuse (e.g., physical, emotional, sexual).
  • Neglect (e.g., physical, emotional).
  • Dysfunction in the household among parents and caregivers (e.g., caregiver separation or divorce, domestic violence, substance misuse, incarceration, mental illness).
  • Hardship (e.g., food insecurity, housing instability).
  • Other significant life events (e.g., caregiver’s serious physical illness or death, community violence, bullying, discrimination).

Actions that support cultivating trauma-informed care include:

  • Ensure patients are warmly welcomed on the phone or in person.
  • Train all staff and providers in universal empathic communication and conveying respect, dignity and compassion to patients.
  • Ensure that staff maintain healthy interpersonal boundaries and manage conflict appropriately.
  • Strive for consistent patient scheduling and inform patients when appointments are running late.
  • Offer sufficient apology and repair when scheduling or other changes are necessary.
  • Maintain communication with patients and between the healthcare team that is consistent, open, respectful and compassionate.
  • Be aware of how an individual’s culture affects how they perceive trauma, safety, resiliency and privacy.
  • Enhance staff and provider skills in administering and responding to sensitive screenings, such as adverse childhood experiences, substance use disorders, and others.
  • Inform patients that they have the option to complete or abstain from screenings (e.g., ACEs and other behavioral health, developmental and social needs) and connection to relevant, trustworthy resources, as needed.
  • Ensure staff competency in skills to prevent and intervene early in escalations to ensure a safe atmosphere.
  • Provide a safe environment, ensuring well-lit parking lots and supportive and adequate security measures.
  • Provide a warm and calm environment from the waiting room to the exam room, with low noise levels and decor with warm colors and gentle images.
  • Provide care that is sensitive to the patient’s racial, ethnic, and cultural background and sexual orientation and gender identity.

See more in Key Activity 7B: Develop a Screening Process for Social Needs and Adverse Childhood Experiences (ACEs) that Informs Patient Treatment Plans.

As the American Academy of Pediatrics acknowledges, pediatricians and other pediatric care providers (e.g., family physicians, pediatric nurse practitioners) are likely to be the first, and often only, professionals who encounter the 68% of American children who have experienced trauma, and have the greatest potential for early identification and response to childhood trauma. TIC is fundamentally relational health care – the ability to form safe, stable and nurturing relationships (SSNRs). Pediatric care providers can support the caregiver/child relationship, the context in which there can be recovery from trauma and the restoration of resilience.”[5]

Additionally, using a trauma-informed approach benefits not only patients but also providers and staff. For patients, TIC offers the opportunity to engage more fully in their health care, develop a trusting relationship with their provider, and improve long-term health outcomes. It may also help reduce burnout among healthcare providers, potentially reducing staff turnover.[6]

Racism, bias and discrimination are pervasive forms of trauma.[7][8] Providing TIC supports equitable outcomes and limits effects of racism, bias and discrimination in multiple complementary ways. For example, people affected by trauma may develop coping mechanisms to help alleviate the emotional and/or physical pain they feel as a result of trauma. Sometimes, these strategies involve maladaptive behaviors, such as unhealthy eating, tobacco use, or drug and alcohol use. These coping mechanisms may provide some relief, but they can also simultaneously contribute to anxiety, social isolation and chronic diseases.”[9] Of note, there is evidence to support the potential benefits of racial concordance between patient and provider; ensuring concordance, when possible, may be one strategy to support patients who disclose trauma related to racism and/or discrimination.[10][11][12]

Additionally, regardless of the type of trauma a person has experienced, traumatic experiences impact relationships. This includes, but is not limited to, relationships between people, communities, and the delivery systems that support individuals’ health and social needs. When a person experiences trauma, they may feel unsafe, betrayed, and/or have difficulty trusting others. This can lead to heightened emotions, such as anger or aggression, or a tendency toward shame, numbing and/or isolation. Within the context of healthcare, this can negatively impact the bond between a patient and their provider, and thus a patient’s engagement in care.[13]

Providing trauma-informed care is likely to boost care participation by patients and caregivers with social needs, since TIC practices are designed to welcome people into care by supporting them and avoiding retraumatization. Certain social needs may be an ongoing source of trauma. The more access people have to trauma-informed preventive care, the more opportunities practices will have to identify unmet social needs and connect patients and caregivers to needed supports and resources.

Consider how a trauma-informed approach applies to patients of different ages (e.g., young children, youth, young adults) and to parents or caregivers. All groups will benefit from recognition of trauma and the practice of trauma-informed care.

Technology can support trauma-informed care by delivering structured guidelines, protocols and clinical decision support to care team members responsible for carrying out assessments and incorporating standardized screening tools into EHRs and care management/care coordination applications. These screening tools can also be made available directly to patients through patient outreach and screening technologies. Recording information regarding trauma exposures in standardized ways is important in assessing their prevalence. Understanding their prevalence will assist in program and resource development to track impact on health outcomes and to incorporate into risk stratification. Health information technologies used to track referrals are also important in care management.

Action steps and roles

1. Build awareness and generate buy-in for a trauma-informed approach.

There are many ways to become a trauma-informed organization, and the process does not have to be a burden to adopt. Foundational steps that organizations can take to move toward fully adopting a trauma-informed approach to care include:

  • Using existing meetings and initiatives to build awareness and generate buy-in for a trauma-informed approach.
  • Supporting a culture of staff wellness.
  • Hiring a workforce that embodies the values of trauma-informed care.
  • Creating a safe physical, social and emotional environment.

The Trauma-Informed Care Implementation Resource Center, Center for Health Care Strategies, and the California Academy of Family Physicians provide a range of guidance and tools for getting started.

 

2. Provide TIC training to all staff.

Incorporate TIC training into new hire orientation, and require all staff to complete TIC training. Training sessions should include role play, patient and family testimonials, and reflection by staff members. Include examples of trauma-informed approaches in all staff roles, and discuss how specific practices may hinder patients’ and families’ resilience. Include focus on team members’ own well-being. The practice’s QI lead should include pre- and post-training feedback, including questions on staff confidence in implementing TIC practices.

The California ACEs Aware website has online access to free trainings.

A potential list of introductory topics could include:

  • Introduction to trauma-informed care:
    • What is trauma? Definition, types, and prevalence.
    • The physical, emotional and psychological effects of trauma.
    • Design principles and core values of trauma-informed care.
    • How patients and the care team benefit from trauma-informed care.
    • Trauma-informed care at a Community Health Center.
  • Recognizing and responding to trauma:
    • Trauma-sensitive communication: Effective ways to interact with trauma survivors.
    • Signs and symptoms of trauma.
    • Link between trauma and physical health conditions.
    • Recognizing potential triggers for trauma survivors.
  • Creating a trauma-informed environment:
    • Establishing a safe and trusting atmosphere.
    • Strategies to prevent retriggering trauma.
    • Understanding the impact of cultural differences on trauma experiences.
    • Ensuring patients have a say in their care.
  • Trauma-informed practices at our practice:
    • Screening for trauma.
    • Trauma-informed intake.
    • Trauma-informed care planning with patients.
    • Linkage and referrals to experts on trauma-informed care.

 

3. Provide ongoing support to promote resilience among all staff.

Suggested team member(s) responsible: Human resources.

The practice’s human resources lead should periodically remind all staff of the array of confidential employment assistance available to them, as staff may be experiencing the impacts of childhood ACEs or ongoing sources of trauma, which will affect their health and well-being, as well as likely impact their ability to approach patients in a trauma-informed way. Likewise, personal development, team building, and practices aimed at boosting joy in work, if leveraged in trauma-informed ways, are all likely to support staff and limit the effects of trauma.

 

4. Provide ongoing supervision to all staff.

Suggested team member(s) responsible: Director.

Ideally, each staff member should have supervision time (perhaps twice monthly) with a TIC-trained direct supervisor to surface bright spots and challenges and work through questions toward professional development. Behavioral health and human resources leaders should assess supervisors’ ability to engage with patients, families and staff in trauma-informed ways, as well as guide others to do the same.

When one-on-one supervision time is lacking, explore ways to develop other supports around TIC implementation. This could include devoting portions of regular staff meetings to surface TIC implementation challenges and bright spots, leveraging and highlighting standout workers’ skills and capacities to support the wider staff’s ability to implement TIC, or incorporating short training modules during staff meetings.

 

5. Partner with patients and families to identify trauma-informed practices that support your patient populations and improve existing practices, including eliminating practices that reinforce trauma.

Suggested team member(s) responsible: QI lead.

As a foundational step, clinic leaders should invite families to shape TIC training topics and practices, with attention given to making it easy to participate in these sessions. This may mean scheduling after-hours, offering refreshments and childcare, and paying family representatives for their time.

Going deeper, your practice can work with experts, patients and families on eliminating practices that create or reinforce trauma and replacing them with trauma-informed practices. The Center for Care Innovations (CCI) offers guidance on becoming a healing organization. Consider using the capacity assessment tool for trauma and resilience-informed pediatric care. The Trauma-Informed Care Information Resource Center also offers an analysis of a host of tools to assess an organization’s uptake of trauma-informed practices.

 

6. Improve the clinic’s physical environment.

Suggested team member(s) responsible: Director, human resources staff, caregiver representatives.

The American Academy of Pediatrics recommends creating a safe environment using engagement strategies to build trust, focusing on strengths to empower patients and families, and having brief office-based approaches to promote a growth mindset.

Ensure that the clinic offers well-lit spaces from the parking lot to the examination rooms, that noise levels are low in the waiting room and all patient areas, that security is sufficient, and that decor integrates warm colors and gentle images.[14]

Partnering with caregivers to assess the current state, identify improvement opportunities, and shape improvements will build relevance and ownership of the changes.

 

7. Track the results of TIC training and implementation.

Suggested team member(s) responsible: QI lead, director.

QI leads should include pre- and post-training feedback, including questions on staff confidence, in their ability to recognize signs of trauma and implement TIC practices. Patient experience surveys should include questions about the patient’s and family’s level of comfort at the practice and their ability to get the care and support that they want and need when they want and need it. Rather than creating your own survey, consider implementing an existing survey.

Consider how you will track results. One option is to track the percentage of respondents who respond favorably, and responses could be segmented to identify groups of patients and families who respond negatively or less positively than others.

 

8. Develop formal and informal feedback loops with patients and the care team to understand the effectiveness of your approach to TIC.

Suggested team member(s) responsible: QI lead, director.

To help ensure that your approach is meeting the needs of patients and is consistently feasible for the care team, it is important to have both formal and informal feedback loops.

For patients, feedback loops might include:

  • Patient satisfaction surveys (or similar).
  • Follow-up calls with a subset of patients to understand what has been going well and what could be improved.
  • Patient focus groups.
  • Feedback from the practice’s patient advisory board (or similar).

Having an accessible, safe and robust patient complaint process is also a critical dimension to practice learning about TIC opportunities in conjunction with formal patient experience surveys. At the minimum, educate Medi-Cal patients about their rights to submit a grievance to the Medi-Cal managed care plan and submit complaints about discrimination to the DHCS Office of Civil Rights. However patients choose to express dissatisfaction, it is important to assure them that they will not experience any retaliation from their providers or health plan.

For the care team, feedback loops might include:

  • Daily huddles.
  • Existing or new staff satisfaction and feedback mechanisms.
  • Supervisors and managers eliciting feedback and experiences from staff during one-on-one meetings.
  • Regularly scheduled meetings and calls to get staff feedback on processes, methods and tools.

 

9. Align trauma-informed care and equity efforts.

Trauma-informed care and a trauma-informed culture must, by definition, also be equity-informed. Racism and discrimination are risk factors for toxic stress and have long-term health consequences. Additionally, through implicit bias and systemic racism, people of color have often been harmed in healthcare and social care systems. TIC efforts that are aligned with organizational equity efforts, such as diversity, equity and inclusion (DEI) work, and efforts to eliminate health disparities will strengthen both. Strategies include:

  • Align and cross-support TIC task force aims with the DEI committee’s aims.
  • Include anti-bias training for staff and providers within TIC training.
  • Frame cultural humility as a central part of TIC.

 

Integrating trauma-informed care across care delivery

Coordinated care delivery that is trauma-informed may include:

Importantly, there is no one workflow for implementing a TIC approach in the patient care journey within a practice. Rather, this endeavor requires proactively and intentionally integrating a TIC approach across all activities and interactions in patient care. While the awareness, training and support efforts may look similar across different sites of care, the starting place for implementing a TIC approach – and the subsequent opportunities for implementation – will likely be different across sites. For example, one clinic may choose to start by first implementing a TIC approach in their check-in process, whereas another clinic may choose to start with their newborn WCVs.

Endnotes

  1. Menschner C, Maul A. Key ingredients for successful trauma-informed care implementation [Internet]. 2016 Apr. Available from: https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf 
  2. Trauma-Informed Care Implementation Resource Center. What Is Trauma? [Internet]. Trauma-Informed Care Implementation Resource Center. 2018. [accessed 2023 Aug 27]. Available from: https://www.traumainformedcare.chcs.org/what-is-trauma/ 
  3. Trauma-Informed Care [Internet]. [accessed 2023 Aug 17]. www.aap.org. Available from: https://www.aap.org/en/patient-care/trauma-informed-care/ 
  4. Centre for Health Care Strategies. What is Trauma-Informed Care? [Internet]. ]. Trauma-Informed Care Implementation Resource Center. 2021. [accessed 2023 Aug 17]. Available from: https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/3 
  5. Trauma-Informed Care [Internet]. ]. [accessed 2023 Aug 17]. www.aap.org. Available from: https://www.aap.org/en/patient-care/trauma-informed-care/. 
  6. Centre for Health Care Strategies. What is Trauma-Informed Care? [Internet]. Trauma-Informed Care Implementation Resource Center. 2021. Available from: https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/ 
  7. Survey on Racism, Discrimination and Health [Internet]. KFF. 2023. Available from: https://www.kff.org/racial-equity-and-health-policy/poll-finding/survey-on-racism-discrimination-and-health/ 
  8. Tong JKC, Akpek E, Naik A, Sharma M, Boateng D, Andy A, et al. Reporting of Discrimination by Health Care Consumers Through Online Consumer Reviews. JAMA Network Open. 2022 Feb 28;5(2):e220715. 
  9. Trauma-Informed Care Implementation Resource Center. What Is Trauma? [Internet]. Trauma-Informed Care Implementation Resource Center. 2018. Available from: https://www.traumainformedcare.chcs.org/what-is-trauma/ 
  10. Takeshita J, Wang S, Loren AW, Mitra N, Shults J, Shin DB, et al. Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open. 2020 Nov 9;3(11):e2024583. 
  11. Jetty A, Jabbarpour Y, Pollack J, Huerto R, Woo S, Petterson S. Patient-Physician Racial Concordance Associated with Improved Healthcare Use and Lower Healthcare Expenditures in Minority Populations. Journal of Racial and Ethnic Health Disparities. 2021 Jan 5; 
  12. Frakes MD, Gruber J. Racial Concordance and the Quality of Medical Care: Evidence from the Military [Internet]. National Bureau of Economic Research. 2022 [cited 2023 Oct 13]. Available from: https://www.nber.org/papers/w30767 
  13. Trauma-Informed Care Implementation Resource Center. What Is Trauma? [Internet]. Trauma-Informed Care Implementation Resource Center. 2018. Available from: https://www.traumainformedcare.chcs.org/what-is-trauma/ 
  14. Schulman M, Menschner C. Laying the Groundwork for Trauma-Informed Care [Internet]. 2018. Available from: https://www.traumainformedcare.chcs.org/wp-content/uploads/Brief-Laying-the-Groundwork-for-TIC_11.10.20.pdf