The effects of trauma have been in the headlines too much over the past few weeks. Most recently, trauma from mass shootings (see ‘Trauma By Proxy’: How To Cope With Mass Shootings and Mental Trauma From Mass Shootings – How Do We Cope?) to trauma from neighborhood gun violence (see Flint Activist Reflects On Gun Violence In His Community and For Some In Chicago, Gun Violence Is A Daily Reality, Leaving The Same Trauma As Mass Shootings). Likewise, the trauma from sexual assault (see Sexual Assault And Harassment May Have Lasting Health Repercussions For Women and Building Strength And Resilience After A Sexual Assault: What Works) and the trauma of childhood separation and mass incarceration (see The Time Is Now For Baltimore To Become A ‘Trauma-Responsive City and Congress Told Impact Of Immigrant Children’s Trauma May Be Lifelong) are also in the headlines far too frequently.
Most professionals in the health and human service field are aware of the Adverse Childhood Experiences (ACEs) study (see About the CDC-Kaiser ACE Study) and the long-term and lasting effects of trauma. The effects include mental health conditions (depression, anxiety, post-traumatic stress disorder), chronic physical health conditions (heart disease, stroke, cancer, COPD, diabetes, HIV, or sexually transmitted diseases), risky health behaviors (alcohol and drug abuse, unsafe sexual behaviors), and injury, among others (see About Adverse Childhood Experiences).
The question for health plan executives is how to best serve consumers who have experienced trauma—increasing their “wellness” and as a result decreasing their long-term use of more expensive care health resources. In a recent interview with Robert M. Atkins, M.D., MPH, Senior Medical Director, Aetna Medicaid, we learned about how one health plan is developing an evidence-based approach and standardized model to do just that. He explained:
We decided that since there was no standard model for identifying providers who are trauma-informed, we would create one. We are solving for the questions: How do we promote trauma-informed care in our network? And how do we have a network that is capable of providing trauma-informed care to the different populations that we serve?
Eighty percent of health outcomes are the result of factors other than health care. But we are overly focused on health care, somehow expecting that 20 percent contribution to create better outcomes. If you think about it, the best traditional health care can do is a perfect score on 20%. Trauma and adverse community experiences are a high proportion of the remaining. There is no way to separate trauma from other adverse community experiences that people face. I think organizations will continue to expand their scope as they become accountable for outcomes in the communities they serve.
And, sounding familiar, it’s important to recognize that trauma-informed care and social determinants of health (SDH) are intricately linked—Dr. Atkins noted that 80% to 90% of health outcomes are driven by common factors external and largely unrelated to health care. He shared that Aetna Medicaid’s Levels of Trauma-Informed Provider Practice model includes six levels of practice that provider organizations can aspire to. These levels include:
Level 1: Foundational awareness—Individual clinical professionals are aware of what trauma is and how common it is, and how sensitivity to it can affect outcomes.
Level 2: Enhanced routine clinical practice—Individual clinical professionals integrate Level 1 knowledge into routine clinical practice and the provider organization promotes trauma-informed universal supports.
Level 3: Basic trauma-informed care—Individual clinical professionals are qualified to deliver trauma-specific treatments, serve populations at high risk of trauma, and the provider organization performs universal trauma screening.
Level 4: Advanced trauma-informed care—Individual clinical professionals adopt a biopsychosocial model of care and provider organizations implement a trauma-informed center of excellence for at least one population.
Level 5: Collaboration in a merged practice—Provider organization include trauma-informed Individual clinical professionals on interdisciplinary care teams and maintain high levels of integration between behavioral health and physical health.
Level 6: Trauma-informed system of care—Provider organizations collaborate across sectors to meet the needs of consumers in a larger community context.
This is similar to the remarks of OPEN MINDS Advisory Board Member Richard Knecht about the importance of trauma-informed care and embracing the approach at all levels of the organization – through the organization’s culture, policy, procedures, staff, and screening tools (see How ‘Trauma-Informed’ Is Your Organization?). Managers of provider organizations should note that turning trauma-informed knowledge into practice is a complex endeavor but adopting an integrated approach can enhance the trauma-informed network in better supporting this under-served population.
While the Aetna model is still in development, Dr. Atkins explained that there are a few basic desirable features that needed to be part of the “final” model—prioritizing member experience, a level of physical health/behavioral health integration, and being agnostic about the approach provider organizations use to become increasingly trauma-informed. This will allow for flexibility in finding and incorporating tools that will help engage consumers better. When looking for provider organizations to fit into this work, Dr. Atkins noted:
We’re developing the incentives now. We have some for patient-centered medical homes and meeting cultural competency goals. And we have a whole set of things already that are incorporated into our contracts with states. We have a whole set of expectations, such as value-based reimbursement, wellbeing, and health care equity. Trauma-informed transformation is the frame that ties all of that together, and fully integrates trauma and community conditions where people live, learn, work, and play.
For health care to be effective, people must be engaged and committed to working collaboratively with their providers. They need to trust the people they meet in the provider organization and they need to feel safe when they go there. As a managed care organization we need to know how to identify those provider organizations. We need to know people will feel safe. We need provider organizations that are trauma-informed, and we need to know they understand what that means when delivering care.
We are concerned that providers gather meaningful data about peoples’ experience on a routine basis, analyze it, and do something when they find actionable opportunities for improvement. How is that experience distributed among the people you serve? Where are the disparities? Where are the opportunities to work cross-sector to address adverse community conditions? Can you identify a population at higher risk of trauma, and work together to mitigate those risks? It’s the ability to see how questions around trauma informed by lived experience shed light on issues around health care equity. We tell providers, here is what we are looking for. We want to know whether you’ve implemented and documented these evidence-based models. We want to see that. If you say you are a trauma-informed provider organization, that’s great, but we need to see that and here are the things we are looking for.
For more on trauma-informed care, check out these resources from the OPEN MINDS Industry Library:
- Making Trauma-Informed Care An Operational Reality
- Trauma-Informed Care In Action
- Care Delivery In A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based
- Making The Link – Trauma & High-Needs Consumers
- The Trauma Quandary
- Traumatic Consequences
- Judging, Not Judging: Trauma-Informed Courts
- What Is The Alternative To Restraint?
- ‘Person-Centered’ Health Care Records Take Center Stage
- Would This List Bend The Cost Curve?
For more, join me on September 10 at The 2019 OPEN MINDS Executive Leadership Retreat in Gettysburg, Pennsylvania for Dr. Atkins keynote, “Building A Trauma-Informed Provider Network: The Aetna Experience.”