Despite an increasing recognition and surge of evidence that trauma is pervasive and has significant negative health consequences, the traditional healthcare system has not yet been configured in a way that is adequately responsive to this knowledge. Conversely, the system creates barriers to implementing upstream prevention efforts and relies on costly treatment interventions when predictable healthcare issues emerge. As Dr. Robert Anda, Co-Principal Investigator of the Adverse Childhood Experiences (ACEs) Study at the CDC, says, “What’s predictable is preventable.”
While the healthcare system can do its part by routinely screening for ACEs, recognizing signs of trauma, and treating the subsequent health issues, it’s not enough to wait until the need for treatment arises, particularly when we understand the root causes. If we recognize that a calcium deficiency contributes to osteoporosis and that osteoporosis often results in costly surgeries and decreased quality of life, we expect the healthcare system to support reimbursement structures for prevention (i.e., calcium supplementation). This approach not only improves outcomes but reduces overall costs. The disconnect the healthcare system must find a way to disrupt is that prevention methods for toxic stress are often not medical in nature; there is no vaccine for trauma and toxic stress. But, given that there are significant, long-term health outcomes associated with toxic stress, it makes sense that the healthcare system would invest in efforts to prevent it.
Health and behavioral health care providers have experienced the frustration of this disconnect, as traditional reimbursement structures have not supported provider incentives to implement this type of whole-person care. A provider working with a pregnant woman, who is living in unsuitable housing, experiencing food insecurity, and exposed to interpersonal violence will be reimbursed for vaccinations and routine healthcare, essential components of the maternal/prenatal health. However, the community-based organization (CBO) that addresses the family’s poverty and safety has also provided services that will significantly impact the healthcare outcomes without that same reimbursement support. Moreover, similar scenarios often play out in areas where a CBO is inadequately funded or doesn’t exist at all. This example, one of the countless ways in which alarming racial, disability-related, and economic health disparities emerge, highlights how crucial it is to prioritize health equity measures at a systemic level.
New York State is poised to address these disparities associated with the delivery of care through the 1115 Waiver, which would transform Medicaid payment structures to support the integration of social care and health care. One of the four subsidiary goals of the waiver is to build a more resilient, flexible, and integrated delivery system that reduces racial disparities, promotes health equity, and supports the delivery of social care.1 The proposed waiver includes an explicit focus on increasing health equity amongst the most vulnerable and underserved populations. The state has a structured plan for implementation, with a significant role for providers and CBOs in making the work happen.
With the intent of improving the overall health and wellbeing of individuals and families that have been marginalized and traditionally underserved, an equity-focused, trauma-responsive approach must be woven through every aspect of the service delivery system. Approaching the work through the lens of trauma-responsiveness will provide the ideal foundation for meeting the stated goals, integrating what we know about trauma’s impact with prudent action steps. As the system moves to support this integration, providers can strengthen this foundation in preparation. We know there are ways in which the traditional policies and payment structures created a disincentive to implementing some aspects of a trauma-informed, equity-focused approach. If we look at these challenges and can reframe them as opportunities, innovation can flourish.
It is well documented that disparities in health outcomes exist for members of racial and ethnic communities, people with disabilities, members of the LGBTQ+ community, individuals with limited English proficiency, members of rural communities, and those impacted by poverty. This became even more glaring during the COVID-19 pandemic, as rates of death and illness were higher amongst non-White individuals.2 Promoting health equity requires that we understand the root causes of this type of disparity and remove obstacles to achieving better outcomes. An equity-focused approach requires a foundation of trauma-awareness, just as a trauma-informed approach requires an emphasis on equity. They are not competing initiatives, but rather interconnected conceptual frameworks that dig beneath the surface to understand how community and environmental factors contribute to harm amongst marginalized segments of the population.
Trauma-responsive, equity-focused organizational change is an endeavor that is ongoing, seeking to understand and respond to all the factors impacting both those receiving care and employees. It is an approach that acknowledges that the healthcare system has and continues to re-traumatize individuals by removing choice, power, and safety, and then makes transparent efforts to prevent this re-traumatization. Though much of this information is not novel, it can be overwhelming for organizations to determine where to start. Using a standardized assessment measure, such as the Trauma-Responsive Understanding Self-Assessment Tool (TRUST), can provide a snapshot in time of how well organizations are implementing trauma-informed care practices across SAMHSA’s 10 implementation domains. The TRUST allows organizations to view aggregated survey results from their leadership and staff, as well as receive reports and recommendations for Trauma-Informed Care practices. Organizations in NYS can access the tool and associated recommendations at no cost.3
The most important factor in addressing and preventing trauma is the presence of supportive, nurturing relationships. As such, CBOs have a strong track record in building these relationships with the individuals and families they serve and have an opportunity before them to prepare for meaningful engagement and participation in meeting waiver goals. There is no pathway to success without this, as we need to resist reverting back to the medical model that prioritizes treatment over prevention and social care. Simultaneously, provider organizations need to be strengthening their partnerships with CBOs, creating an alignment of goals and objectives, be prepared for regional health planning, and be responsive to market changes in the system. Ensuring that there is a voice at the table for CBOs and their constituents highlights the trauma-informed principles of collaboration and restoring power.
Adopting a trauma-informed approach positions organizations to remain adaptively flexible and responsive to their staff and consumers’ needs amidst a system that is persistently in flux. Approaching this current transformation with an eye toward equity means intentional restoration of power to the communities that have historically been disenfranchised, not just understanding, but responding to the voices of those with lived experience. Achieving the goals of this waiver demand this paradigm shift.
Jenna Velez, LCSW, is Sr. Consultant of System and Practice Transformation and Tricia Williams is Director of 1115 Waiver Planning and Technical Assistance at Coordinated Care Services, Inc.