Meryl Schulman, MPH and Alexandra Maul, MPHJuly 10, 2018
Earlier this spring, the Center for Health Care Strategies (CHCS) convened nearly 100 health care providers, payers, researchers, and leaders from the health, education, and philanthropic sectors in New York City to explore opportunities for accelerating the adoption and integration of trauma-informed care across the health care system. The meeting was the final convening for Advancing Trauma-Informed Care (ATC), a national pilot-site demonstration led by CHCS and made possible by the Robert Wood Johnson Foundation. Following are key themes that emerged from the meeting as priority areas for advancing the field of trauma-informed care.
1. Identifying Quality Measures to Assess Trauma-Informed Care Implementation and Outcomes
Finely tuned measures that assess an organization’s progress toward becoming more trauma-informed and the impact of those efforts are still in nascent stages. Establishing consistent, concrete implementation and outcome measures is critical both for ensuring the quality of trauma-informed care programming and making the business case with payers such as managed care organizations (MCOs). However, while some tools exist — such as the Attitudes Related to Trauma-Informed Care Scale, Creating Cultures of Trauma-Informed Care: A Self-Assessment and Planning Protocol, The Missouri Model: A Developmental Framework for Trauma-Informed, and the Trauma-Informed Organizational Capacity Scale — there is no agreed upon set of standards for measuring an organization’s “trauma-informed” capacity.
The Substance Abuse and Mental Health Services Administration has led a number of recent discussions in the field focused on establishing a measurement strategy and metrics for trauma-informed care. In the interim, a number of leading organizations have adopted a variety of approaches for evaluating the implementation and impact of trauma-informed care. For example, the San Francisco Department of Public Health (SFDPH) is assessing how well the health department reflects six core principles identified by its Trauma Informed Systems initiative: (1) trauma understanding; (2) safety and stability; (3) cultural humility and responsiveness; (4) compassion and dependability; (5) collaboration and empowerment; and (6) resilience and recovery. The Women’s HIV Program at the University of California, San Francisco’s (UCSF-WHP) is conducting a multi-year, prospective analysis of the effects of the clinic’s transition to trauma-informed primary care; quantitative and qualitative evaluations of staff wellness; and ongoing assessments of select trauma-informed care interventions. Future contributions from these and other ATC sites will focus on identifying outcome measures and proposing a logic model related to the implementation of trauma-informed care.
2. Exploring Financing Strategies and Opportunities to Sustain Investments in Trauma-Informed Care
Participants noted that paying for cross-disciplinary services (e.g., integrating behavioral health and primary care services) and two-generation approaches to care are especially challenging for providers due to the lack of payment mechanisms that exist. In particular, providers operating in fee-for-service environments often struggle to find time and resources to train staff, fearing that the time spent out of the clinic will result in financial losses. While philanthropic dollars are often critical to seed trauma-informed care efforts, participants highlighted the need for sustainable funding sources after pilot demonstration funding ends. To begin to address this issue, an increasing number of state-issued managed care request for proposals are beginning to require trauma-informed care implementation at the MCO level, but more financing strategies are needed. Payers and providers can work together to identify sustainable funding sources to spread trauma-informed care, whether through embedding it within MCO contracts, or incentivizing implementation through value-based payment arrangements.
3. Cultivating a Trauma-Informed Workforce: Training and Supporting Staff
Participants discussed the importance of training both clinical and non-clinical staff in trauma-informed care as well as supporting employee wellness through organizational practices and policies. Many organizations, however, grapple with how to begin. Attendees noted that changing organizational culture to prioritize staff wellness is challenging, as it is often subject to competing priorities and can be resource-intensive. Yet, participants agreed that promoting wellness and providing staff with opportunities to address their own trauma histories are critical components of a trauma-informed approach to care. For example, Stephen and Sandra Sheller 11th Street Family Health Services in Philadelphia described their experience spreading mindfulness practices throughout its health center. Montefiore Medical Group shared portions of its trauma-informed care training program, which includes modules on behavioral manifestations of trauma, techniques for universally screening for trauma, compassion fatigue, and burnout prevention.
4. Integrating a Racial Equity Lens to Advance Trauma-Informed Care Efforts
Many organizations stressed the need to acknowledge racial inequities when creating a trauma-informed environment as current and historical racism are often the underlying causes of trauma for people of color. Approaches to promoting racial equity include: facilitating conversations about race, culture, and the impact of historical trauma on health and behavior; and updating organizational policies and principles to reflect issues of equity and promote cultural and racial humility. The Greater Newark Healthcare Coalition described its recent multi-day Undoing Racism and Community Organizing training led by The People’s Institute for Survival and Beyond that focused on understanding racism and its different forms, how it is perpetuated, and how it can be undone. The SFDPH includes “cultural humility and responsiveness” as a guiding principle for its Trauma-Informed System initiative. The health department coordinates staff trainings on cultural and racial humility involving staff champions and leadership.
5. Supporting a Family Unit Across the Lifespan to Promote Prevention and Resilience
Beyond the above “real-time” strategies, participants also discussed the need for a focus on upstream approaches to prevent early adversity, and opportunities to adopt multi-generational trauma-informed treatment approaches to support families across the lifespan. This includes facilitating collaboration between pediatric and adult providers to support a continuum of care so that all generations, infants through grandparents, have continuous access to treatment. Ensuring that both the child and caregivers are treated offers the family more opportunities to thrive. Montefiore Medical Group, for example, offers mental health services for mothers as part of its Healthy Steps program that provides integrated primary and behavioral health care for children. In addition, the Center for Youth Wellness offers trauma-informed parent-child dyadic therapies and views the caregivers and children as a family unit.
As research continues to identify the negative effects of exposure to early adversity on the brain, as well as the impact on physical, social, and emotional health later in life, providers and policymakers are beginning to focus on preventing trauma early in life. At the same time, advocates are urging health systems to consider resilience, or protective factors that mitigate the effects of early adversity and toxic stress across the lifespan, and exploring ways that providers and communities can promote resilience-based frameworks.
The ATC final convening enabled thought leaders across multiple sectors to discuss challenges, identify trends, and forecast priority areas related to trauma-informed care implementation and sustainability. As trauma-informed care continues to evolve and gain traction, health care payers, providers, researchers, and patients should continue to converge around these issues. In particular, there are key opportunities to embed trauma-informed care into health systems’ strategic priorities to move closer to making it a standard practice.