Advancing Trauma-Informed Primary Care
Implementing trauma-informed approaches within primary care marks a fundamental shift in care delivery that supports improved utilization of services, improved patient outcomes, increased staff satisfaction and healthier work environments.
Trauma occurs in all populations regardless of socioeconomic status, race, ethnicity, gender and sexuality or geography and the impacts of trauma are long-lasting affecting development, wellness and stress response across the lifespan. There are effective strategies primary care providers can implement to improve the health and resiliency of individuals with histories of trauma resulting in better patient and provider outcomes.
What is a Change Package?
A Change Package is a practical toolkit that is specific enough for clinicians and practices to implement, test and measure progress on an evidence-based set of changes while being general enough that it is scalable in multiple settings.
To better address trauma in primary care, Kaiser Permanente and the National Council for Behavioral Health (National Council) launched the Trauma-Informed Care Primary Care: Fostering Resilience and Recovery initiative to develop, test, disseminate and scale a field-informed Change Package. An 11-member national Practice Transformation Team convened to develop the Change Package to provide information, action steps and tools to guide implementation of a trauma-informed primary care approach. Following the initial development of the Change Package, seven primary care organizations, the Primary Care Learning Community, worked with the National Council to pilot the tool and provided feedback to inform its refinement. This Change Package is a result of the generous efforts by the Practice Transformation Team, the Primary Care Learning Community, National Council project staff and partners.
Trauma-Informed primary care settings can help establish more appropriate and effective care utilization patterns among individuals with trauma histories. The benefits of creating trauma-informed environments include creating safer spaces for staff, improving clinical decision-making by equipping providers to identify and respond to trauma and building collaborative care networks to increase providers’ capacity to address holistic needs.
Implementing a trauma-informed approach also aligns with and supports existing health care transformation efforts, including integrating primary care and behavioral health services.
“The most important thing I didn’t learn in medical school is about adverse childhood experiences, also known as ACEs. To be sure, if I had understood them then the way I do now, I would have been a better and more compassionate physician. Importantly, I would have avoided lots of mistakes.”
Dr. Nancy Hardt, Professor Emerita, University of Florida College of Medicine
Organizations currently or planning to integrate behavioral health services are well-positioned to concurrently implement trauma-informed principles and practices. Payment mechanisms associated with integrated care practice can also help support the sustainability of a trauma-informed approach within primary care.
One of the most compelling reasons to implement a trauma-informed approach was documented by the Adverse Childhood Experiences (ACE) Study. The ACE Study revealed a 20-year life expectancy gap between individuals with high and low ACE scores demonstrating the profound impact trauma has on
morbidity and mortality. Recent research confirms that trauma leads to brain dysregulation and chronic stress that negatively affects development, health outcomes and life expectancy. A trauma-informed approach prioritizes understanding life experiences and their impact on psychological wellness, physical symptoms and outcomes, treatment adherence and other behaviors to deliver more effective care to patients.
In medical settings, trauma commonly refers to severe physical injuries that require immediate emergency response; however, when applied to trauma-informed care, it encompasses a range of physical, emotional and psychological events and effects across all domains of human functioning.
Trauma is “an event, series of events or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual well-being.” Trauma is experienced in multiple forms and ways including physical, sexual and emotional abuse; interpersonal violence; impacts from natural disasters; neglect; serious illness; surviving or witnessing violence; historical trauma; bullying; military trauma and war; racism; and forced displacement, among others. Pervasive and long-lasting, trauma can be experienced at any level, have community-wide effects and pass through generations resulting in historical or cumulative trauma.
- 2 times more likely to smoke
- 7 times more likely to misuse alcohol
- 10 times more likely to inject illicit drugs
- 12 times more likely to attempt suicide
Trauma is widely prevalent across populations in the United States. Public health surveillance data collected from 23 states over four years showed that approximately 61 percent of adults experienced at least one ACE and nearly 25 percent experienced three or more ACEs. In 2016, it was estimated that 46 percent of youth age 17 and younger experienced at least one traumatic event. While all populations are affected by trauma, certain groups experience trauma at higher rates than the general population, including individuals who identify as Black, Hispanic or multiracial; individuals with incomes of less than $15,000 per year; and unemployed individuals. Additionally, youth who identify as lesbian, gay, bisexual, transgender, queer and/or questioning (LGBTQ) experience trauma at higher rates than youth who identify as heterosexual. Urban populations show higher rates of trauma, with one study documenting that 83 percent of youth living in urban areas experienced at least one traumatic event. Populations that have suffered discrimination, racism, slavery, genocide, war, forced migration and other forms of oppression are more likely to experience cumulative trauma. An in-depth analysis of the research on trauma can be found in a literature review compiled by Kaiser Permanente and the National Council.
A trauma-informed approach that not only identifies traumatic experiences among patients but builds resilience by identifying and supporting protective factors at the individual and community levels.
Resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.” Most individuals can foster hope and strengthen resilience to “bounce back” after experiencing trauma. There are several factors that contribute to increased resilience and hope for adults and protective factors among children, including caring and supportive relationships, capacity to manage strong feelings and emotions and communication and problem-solving skills, among others. In addition to individual resilience, resilience occurs at the community level. Community resilience is a “measure of the sustained ability of a community to utilize available resources to respond to, withstand and recover from adverse situations.” Primary care organizations can identify and strengthen patient and community resilience factors, which are key components of a trauma-informed approach. Strategies, tools and resources to measure and build resilience exist throughout the Change Package.
A trauma-informed approach provides an organizational structure and treatment framework that embeds the six principles of trauma-informed care (see Table 1) into practice and services.
|Principle||Definition||Examples in Practice|
|Safety||Ensuring physical and emotional safety among patients and staff.||
|Trustworthiness and Transparency||Conduct operations and decisions with transparency with the goal of building and maintaining trust with patients, family members and staff.||
|Peer Support and Mutual Self-help||Promote recovery and healing by valuing and applying lived experience of peers and individuals with trauma histories.||
|Collaboration and Mutuality||Make decisions in partnership with patients and encourage shared power between patient and provider.||
|Empowerment, Voice and Choice||Patients retain choice and control during decision-making and patient empowerment with a priority on skill building.||
|Cultural, Historical and Gender Issues||The organization embeds principles of diversity, equity and inclusion to deliberately move past cultural stereotypes and biases and incorporate policies, protocols and processes that are responsive to the racial, ethnic, cultural and gender needs of patients served.||
This Change Package outlines a framework for implementing a trauma-informed initiative within your primary care organization. The framework includes guidance for adopting foundational change management strategies. Address these first to create optimal conditions for change. The framework also includes five trauma-informed areas for action or Change Concepts (see Table 2. Framework for Implementing Trauma-Informed Approaches in Primary Care) to address after initiating the change management strategies.
The five Change Concepts are generally addressed in the order they are presented; however, it is important to prioritize and implement the components of the Change Package in response to the result of your organizational self-assessment (OSA), internal and external priorities and market influences. Not all included recommendations will apply for every organization. As you read the Change Package, focus on each of the Change Concept Action Steps. It is likely that you will not fully complete one Change Concept before moving on to the next. This is a multi-step process implemented over time and Action Steps in one Change Concept may influence action in another.
|Step 1: Change Management Strategies: Create the Conditions for Successful Change|
|Step 2: Trauma-Informed Actions – Change Concepts 1 through 5|
|Change Concept 1||Help all individuals feel safety, security and trust.|
|Change Concept 2||Develop a trauma-informed workforce.|
|Change Concept 3||Build compassion resilience in the workforce.|
|Change Concept 4||Identify and respond to trauma among patients.|
|Change Concept 5||Finance and sustain trauma-informed approaches in primary care.|
Action Steps, Implementation Tools and Goals support each Change Concept (see Table 3). Within each Change Concept there are also Key Considerations to help assess if you would benefit from taking additional planning steps prior to implementing the Action Steps. Review the Action Steps within each Change Concept to assess what additional resources or steps your organization will need to take prior to acting. Tips, checklists and other resources throughout the Change Package will guide your implementation efforts. A complete list of resources is available in Additional Resources for Implementation and the Trauma-Informed Primary Care Action Items Checklist provides an easy reference for the Change Concept Action Steps. Leaders in primary care and behavioral health tested and shared these recommendations.
|Action Steps||Appear at the beginning of each section and detail planning and implementation steps.|
|Change Concept Goals||Appear at the beginning of each Change Concept section and outline the objectives for that action.|
|Implementation Tools||Guide the Core Implementation Team (CIT) to successfully implement the action steps and recommendations.|
|Key Considerations||Questions for the CIT to resolve to guide implementation efforts.|
|Checklists||Items that facilitate application such as Implementation Tools for each Change Concept.|
|Quick Tips||Quick insights into different approaches and ideas for implementation.|
|Sample Scripts||Examples of dialogue you may want to use in your organization.|
|Case Examples||Real-world examples of trauma-informed approaches.|
This Change Package is for a Core Implementation Team (CIT) in primary care organizations planning to implement trauma-informed approaches. The CIT will lead planning and implementation efforts and consists of members who represent the diversity of the organization and are motivated and empowered to implement change. See Change Management Strategies: Create the Conditions for Change for more guidance on CITs.
This Change Package recognizes the breadth of diversity across primary care related to organizational size, setting, populations served, level of behavioral health integration and staff composition and provides recommendations for primary care organizations that have onsite behavioral health clinicians and those that do not. All types of primary care settings can benefit from this guidance, regardless of their size, level of behavioral health integration or past progress in advancing trauma-informed approaches.