Improving primary care by addressing trauma
Recognizing that patients' experiences of childhood and adult trauma are common and have a direct impact on their health, UCSF clinical researchers and Positive Women's Network-USA have developed and are reporting a new primary care model.
"In our clinic where we treat women with HIV, we are able to deliver lifesaving anti-HIV medications, but we still lose patients far too often. Looking back over the last ten years, only 16 percent of our patient deaths were due to HIV/AIDS. Most deaths were due to events such as depression, suicide, murder, drug overdoses and lung diseases that are directly related to adult and childhood experiences of trauma. We also realized that trauma is having a devastating impact on the health of a broad spectrum of the U.S. population, regardless of someone's HIV status. We need a new model of care that addresses this key social determinate of health," said the paper's lead author, Edward L. Machtinger, MD, director of the Women's HIV Program at UCSF.
The paper presenting the new model will be published in Women's Health Issues on May 6, 2015.
Trauma can be defined as an event, series of events, or set of circumstances (e.g., childhood and adult physical, sexual and emotional abuse; neglect; loss; community violence; war; and structural violence such as racism) that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects.
Research demonstrates that trauma affects large numbers of U.S. men and women, regardless of HIV status. For example, the Centers for Disease Control and Prevention (CDC) estimates that 25 percent of women and 16 percent of men report childhood sexual abuse and that over one-third of women experience stalking, physical violence and/or rape from an intimate partner during their lifetime. The CDC also reports that childhood and adult trauma are strongly linked to the most common causes of adult illness, death and disability in the US.
"Understanding the link between trauma and health is an epiphany for clinicians. Many of us have spent years struggling to help our patients improve their health but did not realize that there was a missing ingredient in our model of care. Trauma affects health not only through psychological and behavioral factors, but also biologically, through neuroendocrine and inflammatory changes in response to trauma. By understanding the central role that trauma plays in illness, we can use this new model to reengineer clinical practice around trauma-informed principles to better serve our patients and save lives," said Machtinger.
The model represents a fundamental paradigm shift in how primary care is delivered. It is composed of four components—environment, screening, response and foundation.
"For patients who have experienced trauma, the healthcare environment can seem quite frightening. Some of our current healthcare practices may even trigger patients' memories of past traumatic events. Because trauma is so common, we need to critically examine how the healthcare environment affects not only patients but also providers and staff. By adopting trauma-informed practices and policies, healthcare providers and staff promote increased safety, reliability, trust and empathy to create a more healing environment for everyone, said paper co-author Leigh Kimberg, MD, UCSF professor of medicine at San Francisco Hospital and Trauma Center.
In the trauma-informed primary care model, the healthcare team routinely inquires about trauma, ideally in the context of an ongoing provider-patient relationship. Patients are educated about the ways that trauma affects health. Screening includes assessment for recent trauma including intimate partner violence, lifetime trauma, and/or the emotional and physical consequences of trauma such as depression, post-traumatic stress disorder (PTSD), substance use and chronic pain.
"Response to trauma disclosure should be empathetic and supportive, validate patients' experiences, choices and autonomy, get them immediately to safety if needed, and build on their strengths. Providers need to make an effort to understand where a patient is coming from, why they engage in unhealthy behaviors and what they get out of those behaviors," said paper co-author, Naina Khanna, executive director of Positive Women's Network-USA.
To help patients heal from past trauma and prevent re-victimization, the researchers say clinics will need to develop onsite trauma specific programs and/or link to community organizations that provide services such as trauma-informed mental health, PTSD reduction and interventions to enhance resilience and coping mechanisms.
"In addition, it is absolutely critical to do lethality assessments of patients at risk of violence and ensure that they get to safe places," said Khanna.
The foundation of this new primary care model begins with a reexamination of the healthcare setting, starting with the adoption of a core set of values. These values include safety, collaboration, trustworthiness, empowerment and respect for patient choice. In addition, the model includes partnership with community organizations and government agencies, genuine support for providers and staff, and ongoing monitoring and evaluation.
To develop this new paradigm, Machtinger along with other UCSF collaborators partnered with Naina Khanna and the Positive Women's Network-USA to convene a national working group of leading policy makers, trauma experts and advocates from the government, military, academia, and community organizations. The group, the National Strategy Group to Develop a Model of Trauma-informed Primary Care for Women Living with HIV identified evidence-based building blocks to create the model presented in the paper.