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.

Resources


Appendix


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

  • Introduction to TIC:
    • What is trauma (definition, types and prevalence)?
    • The physical, emotional and psychological effects of trauma.
    • Design principles and core values of TIC.
    • How patients and the care team benefit from TIC.
    • TIC at a community health center.
  • Recognizing and responding to trauma:
    • Trauma-sensitive communication – universal empathy.
    • How to be helpful to people who have experienced ACE.
    • 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 your practice:
    • Universal screening for ACE with adults.
    • Universal screening for ACE for children.
    • Trauma-informed intake.
    • TIC planning with patients.
    • Linkage and referrals to experts on TIC.
  • TIC and equity:
    • The impacts of the toxic stress of racism and other discrimination.
    • Amplifying resilience and positive cultural identities and experiences.
    • Countering bias, discrimination, stigma and judgment to enhance TIC.

Endnotes

  1. Menschner C, Maul A. Key ingredients for successful trauma-informed care implementation [Internet]. Hamilton (NJ): Center for Health Care Strategies; 2016 Apr [cited 2023 Dec 21]. 12 p. 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 [Internet]. Hamilton (NJ): Center for Health Care Strategies; 2024. What is trauma-informed care? 2022 [cited 2023 Aug 27]; [about 4 screens]. Available from: https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/  
  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. Trauma-Informed Care Implementation Resource Center [Internet]. Hamilton (NJ): Center for Health Care Strategies; 2024. What is trauma-informed care? 2022 [cited 2023 Aug 27]; [about 4 screens]. Available from: https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/  
  5. Schulman M, Menschner C. Laying the groundwork for trauma-informed care [Internet]. Hamilton (NJ): Center for Health Care Strategies; 2018 Jan [cited 2023 Dec 21]. 9 p. Available from: https://www.traumainformedcare.chcs.org/wp-content/uploads/2018/11/Brief-Laying-the-Groundwork-for-TIC.pdf