Understanding Trauma-Informed Care, Communication

What Is Trauma-Informed Care?

According to Christie Hahn, the manager of Behavioral Health, Complex Product Development for Aetna Medicaid, a CVS Health Company, there isn’t a standard definition or accreditation for trauma-informed healthcare.

“The interesting thing about trauma-informed care, and especially as it has to do with providers and their practices and how they work with their patients and consumers and clients, is that there's no single nationally recognized accreditation body or certification body that says, "You, provider, are trauma-informed,’" she explained in an interview with PatientEngagementHIT.

That lack of an industry standard can be challenging because it leaves payers and providers with no yardstick against which it can assess its trauma-informed care efforts. But for Hahn and her team at Aetna Medicaid, this also meant they could build out their own definition, which she boiled down to the four Rs:

• Realize
• Recognize
• Response
• Resist re-traumatization

Clinician and payer organizations that are able to realize that trauma exists in their patient or member populations, are able to recognize that trauma during the individual encounter, and accurately respond to it will be successful at delivering trauma-informed care, Hahn said.

“That means being able to either provide trauma treatment, or refer to trusted providers that can provide trauma treatment and trauma treatment modalities,” she explained.

“But it also means understanding that folks that come through, because somebody has experienced trauma does not necessarily mean that they have a behavioral health condition,” Hahn continued. “It's also understanding that we're not here to pathologize trauma that people have experienced, but we're here to account for it, address it, and to help that person navigate their healthcare journey, taking that into respect.”

For resisting re-traumatization, healthcare organizations will need strong care coordination, clinician-to-clinician communication, and health IT interoperability. Trauma-informed care means a patient should not have to recount her trauma multiple times as she is being seen by various clinicians, meaning the link between in-person and digital communication must be strong.

According to SAMHSA, both organization leaders and individual clinicians have responsibilities for trauma-informed care. Organizations are in charge of training clinical staff in trauma-informed care, incorporating the patient voice into organization decision-making, creating a physically and emotionally safe environment, and hiring a trauma-informed workforce.

Clinicians need to be in charge of screening for trauma and then avoiding re-traumatization, share decision-making with patients, and engaging referral resources.

Building Patient Trust for Trauma-Informed Care

A good sense of patient trust is intrinsic when dealing with patient trauma. In fact, building that trust with the patient is a key goal of delivering trauma-informed care. But it’s also a continuous loop; healthcare providers can’t always deliver trauma-informed care if they do not know the patient has experienced a past trauma.

A good rule of thumb is to always deliver care assuming a patient has experienced a trauma.

“Think about it as universal precautions; they're the same universal precautions that anyone in healthcare has been taught related to making infectious disease management,” Hahn advised.

“Not to say that trauma is an infectious disease at all, but it's the same concept,” she acknowledged. “You assume that folks coming through your door may have experienced some sort of trauma in their lives and in so making that assumption you practice those behaviors, those four Rs within, both at the practitioner level as well as at the organizational level.”

Per SAMHSA, it is also effective to screen for trauma as a part of patient intake, similar to how many organizations have begun social determinants of health screenings.

However, debate remains about when clinicians should screen for trauma. For some, upfront screenings provide an opportunity to screen any and all patients for trauma, getting to the heart of challenges early and reducing any bias in later screenings.

But other schools of thought assert that delayed screening allows patients to establish rapport through traditional patient-provider communication before disclosing traumas.

Although SAMHSA does not advocate either way for upfront or delayed screening, it did suggest that upfront is better in primary care offices and delayed for behavioral health.

Additionally, the agency said screenings should:

• Always benefit the patient
• Only happen once, when possible, as to avoid re-traumatization
• Be accompanied by strong clinician communication training that is culturally competent

Scripting for Trauma-Informed Care

As part of their endeavor to avoid re-traumatization, healthcare providers should consider their patient-provider communication skills for trauma-informed healthcare, according to Anita Ravi, MD, MPH, MSHP, FAAFP- CEO, Co-Founder of the PurpLE Health Foundation in New York City. Ravi is known on social media for her cartoons depicting trauma-informed care and how clinicians can rethink communication for patients of all backgrounds.

For example, one of Ravi’s cartoons depicts the many reactions a patient might have upon learning she is pregnant, including panic about being able to support a baby or bring a baby home to a dangerous household. Ravi suggested clinicians who are trauma-informed will consider those factors when delivering results.

In another example, Ravi noticed patients apologizing for not wearing underwear upon arriving to exams or other situations patients perceived as embarrassing. But Ravi didn’t think those patients needed to be embarrassed—maybe they only had one pair of underwear that needed to be cleaned. Maybe it was bothersome, or the patient didn’t have access to undergarments.

“Now I change the language in how I talk about it with people,” Ravi told PatientEngagementHIT in a previous interview.

“I say, ‘Okay, and if you just want to undress from the waist down, and you can put everything on the side.’ I don't want to imply societal pressures anymore. I'm trying to be as respectful or sensitive as possible, and you just have to learn and do better each time.”

Scripting for trauma-informed care does require healthcare providers to slow down, as it might not always align with how they are used to communicating. However, it is a muscle that they can build to ensure a positive interaction with the patient to avoids embarrassment or retraumatization.

Avoiding Workforce Trauma, Burnout

In pursuit of better trauma-informed care, healthcare providers may begin to experience burnout.

That’s what happened with Aetna Medicaid, as it rolled out trauma-informed care initiatives with certain Medicaid managed care organizations it worked with, Hahn said.

“What we realized is that the staff that were working within those systems, child protection systems, child and family welfare systems, juvenile justice, and so on, were really hit hard with the day-to-day exposure to others’ traumas,” she explained.

For Aetna Medicaid, work with Dr. Chan Hellman, the director of the Hope Research Center at the University of Oklahoma Tulsa was crucial. In partnership with Hellman, Hahn and her team were able to employ the science of hope among MCO staffers and clinicians who were becoming burned out.

“Hope is more than wishful thinking; it's a cognition, it's a mindset, and it therefore can be taught, and it can be learned, and it can be measured,” Hahn stated. “And to be able to just embrace that idea of hope as a mitigating factor for trauma, both individual and collective was just so inspiring for us to learn about that.”

Tactically, SAMHSA recommended organizations employing trauma-informed care strategies also employ the following for staff:

• Providing trainings that raise awareness of secondary traumatic stress
• Offering opportunities for staff to explore their own trauma histories
• Supporting reflective supervision, in which a service provider and supervisor meet regularly to address feelings regarding patient interactions
• Encouraging and incentivizing physical activity, yoga, and meditation
• Allowing “mental health days” for staff

“Secondary traumatic stress can lead to chronic fatigue, disturbing thoughts, poor concentration, emotional detachment and exhaustion, avoidance, absenteeism, and physical illness,” SAMHSA says on its website. “Clinicians and other front-line staff experiencing these symptoms may struggle to provide high-quality care to patients and may experience burnout, leading to staff turnover — which can create a negative feedback loop that intensifies similar feelings in remaining employees.