Initiative to Advance Trauma‐Informed Practice to Support Policy and Systems‐Level Culture Change

Abstract

Research ObjectivePennsylvania has announced an initiative to prioritize state‐level action to become trauma informed, affecting culture, policy, and practice. The present study investigates support for the implementation and sustainability of trauma‐informed organizational, clinical, and milieu practices among rural behavioral health care providers.Study DesignA trauma‐informed care learning collaborative (TLC) following the Institute for Healthcare Improvement's Breakthrough Series Model was developed and implemented by a behavioral health managed care organization as part of a larger initiation to change organizational culture to become trauma informed. Innovative strategies to support trauma‐informed practice adoption and sustainability include an organizational self‐assessment and rubric guiding designation of organizations as Trauma Informed Care Centers. Aims of this initiative include monitoring consumer screening rates for exposure to trauma and increase staff confidence over the 15‐month TLC, provide training in evidence based practices, and implement the organizational Trauma Informed Care Center designation strategy.Population StudiedTwenty‐two mental health and/or substance use disorder provider organizations of outpatient, ambulatory care in rural Pennsylvania to Medicaid‐enrolled adults and children; initiative participation requires the involvement of organizational leadership, clinical staff, non‐clinical staff, and consumers and family members.Principal FindingsBy the fifth quarter of the initiative, over two thirds (68%) of participating organizations self‐assessed as either showing sustainable improvement or demonstrating outstanding sustainable results. Consumer trauma screening rates improved markedly over time, from 39.2% in the first quarter to 76.5% of consumers screened by the fifth quarter. Over half of agencies (55%) report screening rates better than 90%. Staff training scaled up rapidly, with over 2900 staff educated in trauma informed care in the first 15 months of the initiative (e.g. Trauma Focused Cognitive Behavior Therapy, Cognitive Processing Therapy, Trauma 101, Seeking Safety). Supervisors monitored 3–77 staff members each month depending on provider organization; the percentage of staff reporting high confidence in delivering trauma informed care rose from 18.6% in the first quarter to 68.0% in the fifth. After 3 years, there are currently 17 provider organizations designated as trauma informed Care Centers, of which all 17 meet exemplary center standards.ConclusionsThe trauma informed initiative has yielded positive changes in both process and outcomes with sustained improvement indicating trauma informed culture change on a systems level. This initiative has improved quality of care and access to trauma informed care for consumers.Implications for Policy or PracticeA learning collaborative framework can support the practitioner‐level and organizational‐level changes necessary to disseminate and implement a set of aligned clinical and organizational practices such as trauma‐informed practices. A specialty center designation rubric can further bolster this adoption process by providing organizations with additional incentive and with a structure to advance practice implementation and sustainability.