Violence is recognized nationally as a social and behavioral determinant of health and increases the risk for mental and physical illnesses. Adversity in childhood results in a dose-response association with chronic conditions including cardiovascular disease, type 2 diabetes, and psychiatric disorders. Trauma and abuse present at higher rates in patients from lower socioeconomic environments and raise important public health concerns across the U.S., including Massachusetts. Mirroring national trends, violent crime in our state disproportionately impacts minorities, where homicide is the third leading cause of death for Latino and African American males ages of 15-24, and “nearly one-sixth of adult women and 5% of adult men endorsed experiencing sexual violence at some time in their lives.” Moreover, the racial disparities that occur in the context of violence significantly contribute to post-traumatic stress symptoms and health inequities overall." High-quality healthcare delivery and access depends on “finding providers who meet the needs of patients and facilitate meaningful relationships”. Despite the Quality Chasm's call to action more than a decade ago (IOM 2001), patient-centered care still is not the norm, and users continue to find the healthcare system uncoordinated and stressful to navigate. Those who have experienced trauma therefore may forego seeking care because of the risk of re-traumatization during healthcare encounters. This gap in care has prompted a call for a trauma-informed Culture of Safety that embraces cultural sensitivity and compassionate care to engage survivors as active allies in their own care.
The Substance Abuse and Mental Health Services Administration (SAMSHA) has taken the lead in defining a trauma-informed framework by addressing how systems may be oriented to recognize and respond to patients using a universal approach. A trauma-informed approach requires integration across the healthcare organization. Efforts to operationalize trauma-informed care (TIC) to date have primarily occurred in the pediatric and behavioral health settings, with program goals often limited to increasing awareness and attitudes. Yet the adult population, often without the supports provided to minors, continues to face the consequences of lifetime and acute experiences with trauma.
Wicked Problem Description:
Our hospital system recognizes that trauma, both individual and collective, forms a wicked problem that is deeply interconnected with health outcomes, and that trauma disproportionately occurs amongst the most marginalized, impoverished and vulnerable people in our community. Despite this recognition of trauma’s overt and insidious role in creating barriers to healthcare access, there is currently an absence of systems-based responses in adult populations. This chasm must be bridged to support coherent and effective mobilization of resources already available across health sectors. Importance of resolving the downstream effects of traumatic exposures range from significant economic burden on individuals, communities and the healthcare system, to measurable increases in medical and mental health burden across the lifespan. Medical evaluations and treatment themselves can be unintentionally triggering and traumatizing. A TIC approach is grounded in a universal understanding of the intersection of trauma and health consequence ensuring a Culture of Safety and Equity.
We plan to:
- Develop, test and evaluate the feasibility of ‘tiered’ trauma inquiry by engaging stakeholders from within our hospital setting, including members of our local community, patients and patient advisors and clinical providers.
- Support a Universal Trauma Precautions strategy by providing educational lectures and materials developed for both hospital staff and patients. For clinicians, the focus will be on integrating the TIC approach to engage patients in meaningful ways, inquiry and intervention and development of individualized TIC care plans. For patients we seek to understand what meaningful engagement means to them and assure they have a “voice in choice/s.”
- Implement and evaluate a “Wicked” Warm Handover (WWH) from the ED to continuity services (Primary Care, Advocacy, Violence Intervention, Social Services) utilizing a TIC Care Plan in the electronic health record that would inform the clinical care team on the individualized care plan. The WWH handover strategy will assure the voice of the patient is heard and that the transition of care is significantly improved.
Overall our short-term goals are to advance TIC practice, policy and research Our short term goals are to:
- Explore the feasibility of ‘tiered screening” for adverse or traumatic exposures with key informants (patients and providers) using an iterative process around acceptability of the trauma-informed care framework
- Implement and evaluate an educational campaign that will increase the application of TIC in the ED and primary care settings, y by increasing competence and resilience among providers and patients
- Increase patient engagement with primary care by using a “Wicked” Warm Handover that includes development of an individualized TIC Care Plan (uploaded to electronic health record).
Our long-term goal is to advance a sustainable model of Culture of Safety and Equity for vulnerable populations across their continuum of care within the health care system.
- Identify key stakeholders and develop communication plan (1-3 months)
- Scope areas for TIC education and develop core curriculum (1-3 months)
- Develop education surveys (1-3 months)
- Develop podcast content (1-6 months)
- Develop strategy for org. education campaign (1-6 months)
- Explore ‘tiered’ screening (3-12 months)
- Conduct TIC education sessions w/ surveys and analyze results (9-15 months)
- Develop and pilot wicked warm handovers and TIC plan (9-15 months)
- Conduct and analyze survey on provider burnout/compassion fatigue (9-15 months)
- Ongoing education with new and existing staff (>13 months)
- Implement and evaluate tiered trauma screening (13-30 months)
- Implement and evaluate wicked warm handovers and TIC care plan (13-30 months)
- Develop sustainability plan (18 months)
- Continue with staff education, wicked warm handover, and TIC plan (>25 months)
- Implement and evaluate sustainability plan (>25 months)
- Resurvey staff using PROQOL (>25 months)
We will build upon our current relationships within our internal community and build closer relationships with our external community via the Trauma Teams in place in our local community. Extended team members to include interdisciplinary ED team, Primary Care Providers, Community Violence Intervention Specialist, Local Trauma-Informed Teams (Community Based).
Our vision of success includes:
- Improved educational strategies and clinical practice related to trauma inquiry in the emergency room, informed by key stakeholder input. This would include an expanded, nuanced understanding of barriers to overall access and successful care transitions for patients from our priority communities. Increased accessibility of a TIC intervention to the most vulnerable patients identified in the ED would support overall efforts to deliver equitable access for community members.
- Develop and implement operational guidelines that support patient resilience by optimizing engagement in the emergency department to set the stage for successful continuity of care thru the utilization of a “Wicked” Warm Handover and Trauma-informed Care Plan.
- Improved health engagement and resource utilization, as measured by increased “show” rates at primary care follow-up appointments, as well as decreased ED visits.
- Improved staff wellness by increasing resilience and decreasing compassion fatigue and burn out.