Elisseou’s framework fits into a wider scope of practices that create a trauma-informed environment within an organization, many of which occur outside of the exam room. “In a trauma-informed primary care setting, we know that all staff are equipped to identify and address trauma among the people they’re working with. They understand, recognize, and respond to all types of trauma and they always avoid re-traumatizing anyone,” the National Council’s Karen Johnson says. “People understand and embrace cultural competence and humility.” But this requires buy-in from all employees at a care center: custodians, receptionists, medical assistants, nurses, case managers, and physicians. The criteria for and implementation of these practices is not yet uniform, which has hindered their widespread adoption. The National Council is assembling a “change package” to guide primary care organizations seeking to become trauma informed, Johnson says, and she’s considering including Elisseou’s physical exam guidelines. “The goal is to create this tool that is actionable, usable, and consumable that primary care providers and everyone working in that setting will be able to take and use to move forward trauma-informed primary care,” she says.
Such comprehensive organizational change is not without its challenges. In primary care settings, “staff are often overwhelmed, and may feel ill equipped to meet the needs of people with long-term complex health issues,” Johnson says. “How do we create a tool that people can take and use and not put on the shelf? That’s our biggest challenge. We want it to be as usable as and as relevant as possible.” In her mind, a major component of overcoming this obstacle is the collection and analysis of data that prove that this slow and complicated process can lead to tangible impacts on patient health outcomes.
Recently, small studies have shown such benefits. In December 2016, the McSilver Institute for Poverty Policy and Research released their evaluation of the Trauma-Informed Primary Care Initiative (TIPCI), a small pilot program sponsored by Kaiser Permanente and the National Council. TIPCI tested the implementation of comprehensive trauma-informed practices at 14 federally qualified health centers using small Core Implementation Teams, each composed of employees in various positions at each site. After 10 months of on-site implementation, the 10 sites that responded to organizational self-assessment questionnaires at the beginning and end of the trial period all showed improvement, with the greatest progress associated with the largest time investments in data collection, patient screening, and workforce development. Critically, patients who received care at the centers participating in this brief trial showed some improvements in health outcomes, most impressively in management of diabetes. In one clinic, 75 percent of people categorized as having “high-risk” diabetes at the beginning of the trial were classified as having it “controlled” by the end.
“It’s very difficult for organizations to take the long view, to understand this is baby steps. This is years in the making—I would argue decades in the making,” Johnson says. “Some of the work is about making sure we do have the data to prove that this is what providers need to invest in.”