As we wrote last week, trauma-informed care in health care delivery settings is most effective when systems move beyond the “one-day training for employees” approach and have widespread organizational culture change to support it. Policy changes within health systems are instrumental in bringing trauma-informed care practices to the forefront. A growing body of research within implementation science demonstrates that organizational culture, organizational climate, leadership, organizational support for the intervention, as well as provider-level attitudes and beliefs all contribute towards the uptake of any intervention, program, or policy. The Substance Abuse and Mental Health Services Administration (SAMHSA) has identified ten implementation domains to guide the organizational implementation of trauma-informed care, which is a helpful way to move beyond the “one-day training” approach. We will briefly highlight considerations within each of these implementation domains.
Governance and Leadership: Any organization-wide culture change needs broad-based leadership support that will lead and oversee the work of transforming the culture. Governance and leadership also include providing adequate resources to support the changes.
Policy: Administrative policies within a health care delivery system should be reviewed and potentially modified to align with the principles and practice of trauma-informed care. Health care organizations also may need to adjust patient policies to be more flexible and less punitive. One example of this is changing practices that discharge patients after a set number of “no-show” appointments.
Physical Environment: Physical spaces within health care delivery settings may need to be altered to be more welcoming and confer a sense of safety and calmness. Health care can learn from the discipline of human factors engineering in this regard. Many health care delivery systems have brought on human factors engineers in full recognition of the fact that physical environment can help or hinder patient interactions.
Engagement and Involvement: Understanding patient experience and incorporating family voice has tremendous value and impact in differentiating service delivery. Shared decision-making practices involve patients and families in their plan of care. How do we know what patients and families want in their health care? Simple. We ask them.
Cross-Sector Collaboration: A true system approach would facilitate collaboration across departments within the health care system, but also with community partners in outside service areas. For example, primary care practices, as part of being a patient-centered medical home, are often initially charged with identifying and addressing trauma-related problems. One model of improving cross-sector collaboration within the primary care space is integrating mental health professionals within the medical home which builds upon the trusting relationship that is built between patients, families and the primary care provider. These types of collaborative partnerships should not be limited to within the health care delivery system, however. Health care systems that are trauma-informed recognize that many community-based services, often in the social sector, are a critical part of helping children and families with trauma experience. Effective partnerships, including sound referral mechanisms, between health care delivery systems and community-based services only serve to improve child and family outcomes through a true wraparound approach.
Screening, Assessment and Treatment Services: Much research on the value of screening for social determinants of health and adverse childhood experiences has been ongoing in recent years. It is important for pediatric health care delivery systems to adopt “two-generation” approaches to screening for trauma, and adverse childhood experiences. Child health is inextricably linked to parental health; and therefore, understanding parental trauma is key. Incorporating such screenings into health care delivery should use validated questionnaires that are appropriate for the patient populations they serve. As with any screening, careful planning should also be made to determine what referrals and resources will be made for any indicated needs.
Training and Workforce development: While initial in-depth trainings for all employees within a health system are a great start to build recognition of the widespread nature of trauma, on-going training is needed to refresh on concepts and hold everyone accountable to the practices. Structured peer support groups are one way to prevent and address vicarious trauma and burnout among providers and staff. Policies for employees (providers and staff) to have opportunities to debrief and release stress from interacting with patients with trauma experience. Strategies to address provider burnout is a growing area of concern within health care delivery systems as we learn more about the science of trauma. We know that vicarious trauma has a real and profound effect on staff and providers in health care settings. How can organizations factor in downtime and self-care practices for providers and other staff members?
Progress Monitoring and Quality Assurance: A quality improvement approach, or rapid Plan/Do/Study/Act (PDSA) cycles, is one way to assess the effectiveness of organizational practice changes while building an improvement-oriented culture. PDSA cycles allow teams to have a data-informed approach to where recent changes to workflow and protocol are working, and where improvements could be made.
Evaluation: Health systems that set measurable goals for change and track their performance over time are much more likely to be effective stewards of change and drive improved outcomes for their patients. Setting goals and strategy around work in the trauma-informed care space requires some mechanism to evaluate outcomes related to these goals, and clear accountability for ownership.
Financing: As mentioned in leadership, investing in trauma-informed care is a steady investment over time. Health care organizations should consider how they will make initial and sustained investments in training, service delivery, and reinforcement. Although there is growing momentum to incorporate screening and referral for adverse childhood experiences and social determinants of health into value-based arrangements, it is also likely that systems will supplement direct reimbursement with system revenues.
Genesis Health Consulting has significant experience coaching organizations on how to successfully facilitate change within their business, and to work across sectors to manage change within their industry or community. We welcome the opportunity to learn about your particular challenge, and to share more about our experiences. Please contact us at: email@example.com