Meryl Schulman, MPH and Lisa Dubay, PhD and Rachel Burton, MPP, Urban Institute

October 18, 2018

Trauma-informed care has emerged as a core competency to improve how health care organizations deliver services to people who have experienced adverse life events. Through the Advancing Trauma-Informed Care (ATC) initiative, and with support from the Robert Wood Johnson Foundation, the Center for Health Care Strategies convened innovators in the field to build on existing trauma-informed efforts and share lessons nationally. The Urban Institute conducted an implementation analysis to better understand how participating pilot sites adapted clinical and organizational practices to advance trauma-informed care. Following is a summary of key findings from the study, Early Adopters of Trauma-Informed Care: An Implementation Analysis of the Advancing Trauma-Informed Care Grantees.

Key Themes for Advancing Trauma-Informed Care

Interviews with staff and patients at ATC pilot sites revealed that successful trauma-informed organizations had key elements in common:

1. Prioritize organizational culture change.

ATC sites offer comprehensive training for staff on trauma and its impact on health and behavior to develop a common understanding around the concept. Some sites, like Stephen and Sandra Sheller 11th Street Family Health Services (11th Street) in Philadelphia, the San Francisco Department of Public Health, and the Women’s HIV Program at the University of California, San Francisco (UCSF-WHP), are focused on robust organization-wide culture change. To achieve this, some are using existing frameworks like the Sanctuary Model to guide trauma-informed organizational change, while others have developed their own guiding principles.

2. Incorporate patient voice to guide the process of becoming trauma-informed.

ATC sites agree it is important to solicit patient feedback early and often to guide the process of becoming trauma-informed. To ensure patient feedback is incorporated on an ongoing basis, many ATC sites have patient advisory committees. One interviewee noted that it might be beneficial to consult with patients regularly to determine the types of interventions the community needs. Another recommended that health care providers offer patients the opportunity to provide anonymous feedback to help patients feel protected in voicing their opinions. To ensure that new perspectives are incorporated into the group discussion, one ATC site shortened the terms for patients who serve on its advisory committee.

3. Train all staff and review hiring practices to promote a trauma-informed workforce.

Across the ATC sites, trainings, for both clinical and non-clinical staff, covered similar topics, including adverse childhood experiences (ACEs), vicarious trauma, and staff self-care. Many also included sessions on cultural humility — a respectful approach toward individuals of other cultures that challenges cultural biases — which is a critical yet often overlooked component of a trauma-informed approach. All sites relied on external consultants to develop curriculum, but the training itself was often led by internal staff. Some organizations used train-the-trainer approaches to maximize initial investments in training.

Organizations also recognized the value of using a trauma-informed lens for hiring, and noted that doing so impacted the type of people they hired. For example, one organization focused on restructuring its hiring process to try to eliminate racial bias, and another is considering hiring staff that better represent its patient population. Overall, many sites agreed on the importance of assessing whether a candidate would be supportive of trauma-informed care.

4. Encourage self-care to prevent burnout.

All ATC sites promote staff wellness to reduce the effects of secondary traumatic stress and vicarious traumatization, which is common among health care workers. The Center for Youth Wellness (CYW) and 11th Street offer trainings focused on topics such as emotional balance, mindfulness, and techniques to reduce stress. Overall, ATC sites promoted self-care at both the individual and organizational levels. For example, staff may be encouraged to vent to a colleague or do deep breathing exercises or go for a walk when working through a stressful situation. Some organizations also promote wellness by incorporating mindfulness or meditation into staff meetings, or reducing the number of patients providers are expected to see per hour.

5. Screen patients for trauma and its symptoms.

All ATC organizations agree on the importance of knowing whether a patient has experienced early adversity; however, they use various approaches to obtain this information. Some organizations, like CYW and Montefiore Medical Group, use ACEs questionnaires, which may ask patients to specify which types of traumas they have experienced, or simply the total number of experiences. Questionnaires are completed either by the patient or their provider during annual physicals/well-child check-ups. Others take a less formal approach, asking patients verbally, allowing them to disclose ACEs as their relationship with the provider develops, or only screening select patient populations (e.g., pregnant women). Still others do not screen for ACEs at all, and rather only screen for current symptoms (such as depression) and exposure to trauma.

6. Deliver trauma-specific services to patients.

Many ATC sites have behavioral health clinicians on staff or co-located on-site, which facilitates warm handoffs from primary care providers and allows patients to receive mental health services in a more seamless and timely fashion. Of interest, a number of patients interviewed expressed preference to see behavioral health clinicians at the same location as their primary care provider, even if it means delaying treatment. Pilot sites offer an array of treatments for trauma, including cognitive behavioral therapy. Several sites also offer alternatives to talk therapy, as patients may not feel comfortable reliving traumatic experiences verbally. For example, 11th Street offers a suite of creative arts therapies including dance/movement, art, and music therapy, and UCSF offers performance art therapy. For patients who need medication or long-term counseling, ATC sites have established referral networks of behavioral health providers, as well as care coordinators to connect patients to social services and manage referrals.

Facilitators and Barriers to Trauma-Informed Care Implementation

The ATC implementation analysis revealed both facilitators and barriers to pilot sites’ efforts to become more trauma-informed. Findings, summarized below, may inform other health care organizations interested in implementing trauma-informed care.

FACILITATORS
BARRIERS
  • Commitment from organizational leadership
  • Involvement of middle management in implementation efforts
  • Ability of staff to innovate, be flexible, learn from failures, and revise approaches to becoming trauma-informed
  • Availability of skilled therapists on-site to allow warm handoffs from providers
  • Creating protected time for providers to step away from clinical duties to participate in trauma-informed care trainings
  • Staff resistance to change
  • Organizational hierarchies that inhibit exchange of ideas
  • Few opportunities for patients to provide feedback regarding the services they want to use
  • Lack of accountability when staff fail to make good faith efforts to engage in new trauma-informed efforts
  • Pressure on providers to meet productivity targets
  • Reliance on grant funding for organizational transformation and lack of stable funding sources for select services (e.g., screening, alternative therapies)

Looking Ahead

The findings from the ATC implementation analysis offer valuable insight into how health care organizations are transforming organizational culture and clinical practice to support trauma-informed principles and practices. As trauma-informed care continues to gain traction in the health care field, these lessons will be particularly important for stakeholders to consider when piloting trauma-informed care and exploring opportunities to scale and spread existing efforts.


Be sure to bookmark CHCS’ upcoming Trauma-Informed Care Implementation Resource Center, which will serve as a starting point for anyone wishing to learn the “whys” and “hows” of adopting a trauma-informed approach to health care. Launch is slated for late fall!

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When I see anything about “Trauma-informed” services I always look for some attention to resilience as well. Seldom do I see it. If the lens of service providers and researchers is limited to trauma we are doing a great disservice to consumers of our services as well as distorting research analysis by the omission of an essential variable that shapes outcomes.

Meryl Schulman, Center for Health Care Strategies

Thanks for your comment and glad to hear you are engaged in this very important work. Many of the organizations we work with recognize the importance of protective factors that help foster resilience in children, families, and staff, and offer supports and programming centered around doing so.

I love that this continues to be in motion! We implemented trauma-informed services here at Tri-County Mental Health Services in Maine almost two decades ago under the mentoring of Maxine Harris and Roger Fallot (lucky us!). While we successfully made the paradigm shift to include all recommended components of the model, it has been critical to ensure ongoing discussion, training and accountability for maintaining such a culture. Thank you for your efforts and for maintaining the energy!