Trauma-Informed Population Health Management

©️ 2024 Kaiser Foundation Health Plan, Inc.

Defining Trauma

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. Examples of trauma and toxic stress include but are 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]

Defining Trauma-Informed Care

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]

Overarching recommendation: Practices should strive to provide care throughout the patient journey in trauma-informed ways.

This guide is a brief sketch of a broad and nuanced field. It includes recommendations directly relevant to population health management. People can build trauma-informed healthcare organizations that create “safe, caring, inclusive environments for all patients.”^[4] A number of trauma-informed strategies exist that organizations can adopt to avoid traumatizing or retraumatizing patients; better understand the connection between trauma, toxic stress and health; and help people overcome the effects of trauma and toxic stress. These strategies range from “organizational changes in the culture and atmosphere of a health care setting to full adoption of practices to address trauma at the clinical level.”

Cultivating TIC entails:

• Ensuring patients are warmly welcomed on the phone or in person.
• Training all staff and providers in universal empathic communication to convey respect, dignity and compassion to patients.
• Ensuring that staff maintain healthy interpersonal boundaries and manage conflict appropriately.
• Striving for consistent patient scheduling and informing patients when appointments are running late.
• Offering sufficient apology and repair when scheduling or other changes are necessary.
• Maintaining communication that is consistent, open, respectful and compassionate with patients and between the healthcare team.
• Being aware of how an individual’s culture affects how they perceive trauma, safety, resiliency and privacy.
• Enhancing staff and provider skills in administering and responding to sensitive screenings, such as those for adverse childhood experiences (ACE), Substance Use Disorders and others.
• Informing patients that they have the option to complete or abstain from screenings (e.g., ACE and other behavioral health, developmental or social needs screenings) and being connected to relevant, trustworthy resources as needed.
• Ensuring staff competency in skills to prevent and intervene early in escalations to ensure a safe atmosphere.
• Providing a safe environment, including ensuring parking lots are well lit and security measures are supportive and adequate.^[5]
• Providing 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.
• Providing care that is sensitive to the patient’s racial, ethnic and cultural background as well as their sexual orientation and gender identity.

The Center for Health Care Strategies and the SAMHSA offer detailed guidance on successful TIC implementation.

Menu of Strategies to Implement TIC Across the Patient Journey

1. Tie TIC to strategic priorities and build awareness and generate buy-in for a trauma-informed approach.

There are many ways organizations can continually expand their capability to provide TIC. The process does not have to be a burden to work toward; it can propel the organization’s strategic priorities. Foundational steps organizations can take to move toward deepening a trauma-informed approach to care include:

• Using existing strategic priorities and initiatives to build awareness and generate commitment toward continual improvement of a trauma-informed approach.
• Supporting a trauma-informed workplace through a focus on employee wellness.
• Hiring a workforce that embodies the values of TIC.
• Creating a safe and trustworthy environment, both physically and emotionally.

The Trauma-Informed Care Implementation Resource Center, Center for Health Care Strategies and 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 recruitment, selection and hiring protocols, as well as new hire orientation and training. Training sessions should be experiential and practice based. They should include patient and family testimonials as well as reflection by staff members. Include examples of trauma-informed approaches in all staff roles and discuss how missteps may hinder patients and families’ resilience. Include a focus on team members’ own well-being. The practice’s quality improvement lead should include pre-/post-training feedback, including questions on staff confidence in implementing TIC practices.

See the appendix for a suggested outline of TIC training.

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

The practice’s human resources lead should periodically remind all staff of the array of confidential employment assistance available to them, as staff may experience the impacts of ACE, current difficulties or toxic stress, which will affect their health and well-being and 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 support and supervision to all staff.

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

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

Going deeper, your practice can work with experts, patients and families on eliminating ways of working that create or reinforce trauma, replacing them with trauma-informed practices. The Center for Care Innovations offers guidance on becoming a healing organization and the Trauma-Informed Care Implementation Resource Center offers this analysis of a host of tools to assess an organization’s uptake of trauma-informed practices.

6. Universally assess patients for trauma.

Select one or more validated, standardized screening instruments to use and establish how screening results should be documented. Establish a workflow for screening and referrals.

Pick standardized screening tools that fit your organizational environment and the context of your patient population.

• Consider using the Pediatric ACEs and Related Life-events Screener (PEARLS) for children and adolescents ages zero to 19 years and the ACE questionnaire for adults.

7. Improve the clinic’s physical environment.

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.⁵ Partnering with patients and caregivers to assess the current state of the clinic’s physical environment, identify improvement opportunities and shape improvements will build relevance and ownership of the changes.

This set of resources from EM Consulting provides considerations for the waiting room.

8. Track the results of implementation.

Patient experience surveys should include questions about the patient and family’s level of comfort at the practice, how much empathy they feel from the healthcare team, 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; responses also could be segmented to identify groups of patients and families who respond negatively or less positively than others.

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

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.

With patients, feedback loops might include:

• Reviewing patient experience data, such as the Consumer Assessment of Healthcare Providers and Systems (CAPHS) or other surveys.
• Providing follow-up calls with a subset of patients to understand what has been going well and what could be improved.
• Hosting patient focus groups.
• Soliciting guidance and feedback from the practice’s patient advisory board.
• Reviewing patient complaints and grievances for themes and patterns that relate to a lack of TIC.
• Educating Medi-Cal patients about their rights to submit a grievance to the Medi-Cal managed care plan and submit complaints about discrimination to the Department of Health Care Services’ 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.

With the care team, feedback loops might include:

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

10. Align TIC and equity efforts.

TIC 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 health and social care systems. TIC efforts that are aligned with organizational equity efforts – such as diversity, equity and inclusion work as well as efforts to eliminate health disparities – will strengthen both. Strategies include:

• Aligning and cross-supporting the TIC task force aims with the diversity, equity and inclusion committee aims.
• Including anti-bias training for staff and providers within TIC training.
• Framing cultural humility as a central part of TIC.

Resources

Appendix

A potential list of introductory TIC training topics could include the following.