Trauma-informed health care

Trauma-informed care (TIC) is a framework that requires change to organizational practices, policies, and culture (AIR-DeCandia 2014) that reflect an understanding of the widespread impact of trauma and potential paths for recovery, and actively seek to prevent re-traumatization (SAMHSA-Trauma 2014). In health care, TIC usually includes universal trauma precautions and practice changes for patients with a known trauma history. Universal trauma precautions emphasize patient-centered communication and care, often with careful screening for trauma (Raja 2015*), safe clinical environments (e.g., quiet waiting areas), and shared decision making for all patients (CWF-TIC 2016). Under a trauma-informed clinical approach, providers collaborate across disciplines, use streamlined referral pathways, and remain aware of their own trauma histories and stress levels when they know patients have experienced trauma (CWF-TIC 2016, Raja 2015*). TIC can also be implemented in oral health settings (Raja 2014*).

Expected Beneficial Outcomes (Rated)

  • Improved quality of care

  • Improved health outcomes

  • Improved mental health

  • Reduced post-traumatic stress

Other Potential Beneficial Outcomes

  • Reduced substance abuse

Evidence of Effectiveness

Trauma-informed health care is a suggested strategy to improve quality of care and health outcomes for patients who have suffered trauma (CWF-TIC 2016, Raja 2015*, SAMHSA-Trauma 2014, Ko 2008*). Available evidence suggests that trauma-informed care (TIC) may reduce use of seclusion and restraints in inpatient mental health settings (Muskett 2014*, Azeem 2011*, Borckardt 2011*), and improve mental health and reduce substance abuse when implemented as part of an integrated social services and health care model (Suarez 2014, Cocozza 2005*, Domino 2005*, Morrissey 2005*). Additional evidence is needed to confirm effects.

Results from the Women, Co-occurring Disorders and Violence Study (WCDVS) suggest TIC can improve post-traumatic symptoms and mental health, reduce drug use problem severity (Cocozza 2005*, Morrissey 2005*), and may also improve physical health (Weissbecker 2007*), particularly with intensive counseling that addresses substance abuse, mental health, and trauma-related issues together (Cocozza 2005*, Morrissey 2005*), at a cost similar to usual care (Domino 2005*). Initial results from Project Kealahou, a Hawaii-based TIC model for at-risk female youth, also suggest improvements in both clinical and functional domains with minimal cost increases (Suarez 2014). A Massachusetts pilot project that adapts the Attachment, Regulation and Competency (ARC) framework in two youth residential treatment settings indicates decreases in trauma-related symptoms, particularly PTSD symptoms, and  use of restraints (Hodgdon 2013*).

Experts suggest that organizations that adopt trauma-informed practices communicate about the transformation process, engage patients in organizational planning, train clinical and non-clinical staff, work to create safe environments for patients and staff, and engage with referral sources and partnering organizations (CHCS-Menschner 2016). Screening approaches that help patients understand the link between traumatic experiences, unhealthy behavior, and health outcomes are also recommended (CWF-TIC 2016), and organizations that screen for trauma should have resources available to address it, on site or by referral (Raja 2015*).

Impact on Disparities

No impact on disparities likely

Implementation Examples

Trauma-informed care (TIC) is being introduced in health care organizations and clinics across the country. In December 2015, the Center for Health Care Strategies launched the Advancing Trauma-Informed Care initiative at 6 health care organizations to understand how trauma-informed approaches can be implemented across the health care sector. Pilot sites reflect a range of health care settings, including the Montefiore Medical Group in Bronx, NY, and the San Francisco Department of Public Health in CA (CHCS-Menschner 2016).

TIC models such as Sanctuary and Risking Connection can support the transition to trauma-informed practices in health care organizations (CEBC). Risking Connection has been adapted into a continuing medical education course called Trauma-Informed Medical Care (Green 2015).

Implementation Resources

ACEsCN-TIC Toolkits - ACEs Connection Network (ACEs CN). Trauma-informed care (TIC) toolkits: Education resources.

SAMHSA-NCTIC - Substance Abuse and Mental Health Services Administration (SAMHSA). National Center for Trauma-Informed Care (NCTIC).

SAMHSA-NCTIC TIP57 - Substance Abuse and Mental Health Services Administration (SAMHSA). National Center for Trauma-Informed Care (NCTIC). (2014). Trauma-informed care in behavioral health services. Treatment Improvement Protocol (TIP) Series 57. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA); 2014 HHS Publication No. (SMA) 13-4801.

CPTS-Health care toolbox - Center for Pediatric Traumatic Stress (CPTS). Health care toolbox.

Citations - Evidence

* Journal subscription may be required for access.

CWF-TIC 2016 - Hostetter M, Klein S. In focus: Recognizing trauma as a means of engaging patients. Transforming Care: Reporting on Health System Improvement. New York: The Commonwealth Fund (CWF); 2016.

Raja 2015* - Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma informed care in medicine: Current knowledge and future research directions. Family & Community Health. 2015;38(3):216-226.

SAMHSA-Trauma 2014 - Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA); 2014.

Ko 2008* - Ko SJ, Ford JD, Kassam-Adams N, et al. Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice. Professional Psychology: Research and Practice. 2008;39(4):396–404.

Muskett 2014* - Muskett C. Trauma-informed care in inpatient mental health settings: A review of the literature. International Journal of Mental Health Nursing. 2014;23(1):51-59.

Azeem 2011* - Azeem MW, Aujla A, Rammerth M, Binsfeld G, Jones RB. Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing. 2011;24(1):11–15.

Borckardt 2011* - Borckardt JJ, Madan A, Grubaugh AL, et al. Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital. Psychiatric Services. 2011;62(5):477–483.

Suarez 2014 - Suarez E, Jackson DS, Slavin LA, Michels MS, McGeehan KM. Project Kealahou: Improving Hawai’i’s system of care for at-risk girls and young women through gender-responsive, trauma-informed care. Hawai’i Journal of Medicine & Public Health. 2014;73(12):387–392.

Cocozza 2005* - Cocozza JJ, Jackson EW, Hennigan K, et al. Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of Substance Abuse Treatment. 2005;28(2):109–119.

Domino 2005* - Domino ME, Morrissey JP, Chung S, et al. Service use and costs for women with co-occurring mental and substance use disorders and a history of violence. Psychiatric Services. 2005;56(10):1223–1232.

Morrissey 2005* - Morrissey JP, Jackson EW, Ellis AR, et al. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services. 2005;56(10):1213–1222.

Weissbecker 2007* - Weissbecker I, Clark C. The impact of violence and abuse on women’s physical health: Can trauma-informed treatment make a difference? Journal of Community Psychology. 2007;35(7):909–923.

Hodgdon 2013* - Hodgdon HB, Kinniburgh K, Gabowitz D, Blaustein ME, Spinazzola J. Development and implementation of trauma-informed programming in youth residential treatment centers using the ARC framework. Journal of Family Violence. 2013;28(7):679-692.

CHCS-Menschner 2016 - Menschner C, Maul A. Key ingredients for successful trauma-informed care implementation. Hamilton, NJ: Center for Health Care Strategies (CHCS); 2016.

Citations - Implementation Examples

* Journal subscription may be required for access.

CHCS-Menschner 2016 - Menschner C, Maul A. Key ingredients for successful trauma-informed care implementation. Hamilton, NJ: Center for Health Care Strategies (CHCS); 2016.

CEBC - California Evidence-Based Clearinghouse for Child Welfare (CEBC). Information and resources for child welfare professionals: List of programs.

Green 2015 - Green BL, Saunders PA, Power E, et al. Trauma-informed medical care: A CME communication training for primary care providers. Family Medicine. 2015;47(1):7–14.

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