Studies show that the prevalence of trauma is ubiquitous and can create adverse health outcomes for individuals. As the first HIV/AIDS organization in Brooklyn, New York, Bridging Access to Care (BAC) works with high-needs individuals in New York City who have trouble coordinating their healthcare. Established in 1986, BAC is a community-based organization providing an array of services to low-income individuals, families, and communities of color throughout New York City, including the homeless, substance users, mentally ill, and previously incarcerated.
Behavioral health organizations like BAC continue to address systemic challenges – homophobia, racial discrimination, stigma, and other social injustices – that persist and retraumatize the clients we serve. Although BAC has been adaptive and responsive to their varying needs through expanding our scope of services, BAC leaders recognize the effect of trauma on our clients’ overall wellbeing and the struggle of our staff in reducing barriers as a result of trauma. Moreover, many staff and clients had trouble understanding how trauma-informed care connects to better health outcomes. These findings motivated BAC to embark on a remarkable journey in 2014 to reset the organizational culture through a trauma-informed care (TIC) lens.
Defining the Purpose and Plan
BAC’s initial organizational culture change had the overarching goal of routinizing trauma-informed care using trauma-sensitive approaches to deliver daily service and augment care plans with trauma-specific objectives. BAC leaders determined that using the measurement-based care (MBC) approach would allow us to measure the realized value of health outcomes—How well the client is doing. MBC systematically uses standardized, validated symptom assessment tools and behavioral health functional rating scales to drive clinical decision-making (The Kennedy Forum, 2015). According to The Kennedy Forum, rating scales optimize the accuracy and efficiency of symptom assessment to improve the detection of patients or targeted populations not responding to the current clinical interventions.
Using the MBC framework, BAC began to connect the dots from symptoms, diagnosis, and function to the effects of the social determinants of health on individual wellness outcomes. MBC empowers providers to change or fine-tune treatment plans more quickly when patients are not improving. In addition, patients who regularly complete rating scales are more likely to increase their knowledge about their disorders, become attune to their symptoms, and be mindful of the warning signs of relapse or reoccurrence. Thus enabling them to better self-manage their symptoms or illnesses and seek treatment earlier.
Innovate, Test, and Evaluate
The implementation of TIC at BAC has required an enormous amount of research, testing, training, re-training, and evaluation. BAC leveraged technology to create a systematic approach. One of our desired outcomes was to develop a system for sharing information in real-time to facilitate access and retention in care. We also wanted to design a system that would enable trauma-informed care routinely across our agency.
Our strategy was to incorporate best practices and various screening and assessment tools in the electronic health record (EHR) system to help inform and guide staff in delivering trauma-sensitive activities. The EHR could capture specific data and trend changes in our clients’ health outcomes. Specifically, BAC identified validated screening and assessment tools that were easy to use, have met industry standards, and were recognized by payors. In collaboration with our EHR vendor, TenEleven, BAC designed and created an electronic trauma-informed care module known as the Treatment Wizard, which uses a decision tree structure to determine the workflow based on individual scores from the screening and assessment tools.
Simultaneously, we conducted an organizational assessment for trauma readiness and offered all providers and managers training and re-training in trauma-informed care, screening and assessment tools, workflow, and documentation. BAC also ran a pilot test with the harm reduction program to examine the validity of delivering trauma-informed care using MBC. The work done in the pilot was worthy of semifinalist status in Healthcare Informatics’ 2017 Innovator Awards Program.
Creating a trauma-informed culture is a journey involving continual training, reevaluation, and modification of current practices. In 2018, BAC joined the National Council for Behavioral Health (NATCON) learning community, which focused on resilience-orientated trauma-informed approaches to client services. Subsequently, BAC developed a Steering Committee and various subcommittees using NATCON’s Wellness-Oriented Trauma-Informed Care instrument as a guide.
The positive outcomes of the pilot demonstrated that routinizing trauma-informed care and using a standardized trauma-informed approach has positive effects on clients’ overall wellness. In our experience, the value of MBC is improved wellness = reduced cost + decreased symptoms. The plan was to use the pilot test results to inform the rollout of TIC in the rest of the BAC programs. To measure wellness outcomes over time, a client would need to be accessing services for at least three months to allow BAC to capture baseline and follow-up data. Because BAC is a complex organization offering multiple services, workflows could vary by programs and program departments. Looking back, these variations in workflows have posed a significant challenge for TIC implementation, and BAC is currently addressing the areas identified for improvement.
Re-Evaluating Implementation and Capitalize on Lessons Learned
In the fall of 2020, BAC had the opportunity to begin working with Cicatelli Associates, Inc. (CAI) Trauma-Informed Care (TIC) Initiative funded by the New York State AIDS Institute and Amida Care through our membership with the EngageWell IPA. Participation in the CAI TIC Project has allowed BAC to complete a second cultural assessment (including environmental), re-train staff, and re-evaluate our current practices. It has also deepened our understanding that transforming organizational culture to one of TIC is a continual process, not a one-time project. While our experience in implementing TIC has been rewarding – opportunities to explore new ideas, learn new skills, create new partnerships, and improve our infrastructure, it has also presented challenges we did not fully anticipate.
BAC has learned that regular communications, check-ins, and re-engagements are quintessential to a successful organizational culture transformation. To ensure members of our teams understand the implementation of TIC as an agency priority, BAC leaders provide updates on this subject in all-staff and monthly management team meetings. In addition, BAC has incorporated a TIC introduction as part of the onboarding process and modified all job descriptions to include staff responsibilities to be knowledgeable about the TIC approach and principles.
BAC is investing much time in providing skill-building training to improve staff delivery of trauma-informed care. However, one of the missing links is direct observation of the team and incorporating TIC principles in staff supervision. Our work with CAI has allowed us to build capacity in this area. It has also allowed us to learn new tools, including providing brief psychoeducation to clients, a component that was missing from our original implementation plan.
Although technology advancements augment the workflow, data integrity plays a crucial role in producing valuable information to demonstrate client progress. Incomplete data collection and inconsistent documentation, lack of buy-in, and staff turnover have affected the number of clients screened and assessed and caused failures in translating trauma objectives into the care plan. BAC has begun re-engaging and re-training existing staff on screening and assessment tools, strength-based language, and the Treatment Wizard in our EHR to address these issues.
A cultural change requires buy-in from the top down, including the Board of directors. TIC has not only changed our relationships with our clients but also our relationships with our staff. Notably, the TIC approach fosters a community of leaders who lead by example. To be successful, BAC leaders need to model the behaviors we want to see in all relationships—managers, staff, and partners. Using wellness as an example, a shared goal of TIC and MBC, promoting wellness among our teams is as important as promoting wellness among our clients, and we must do both.
The COVID-19 pandemic has left an indelible mark on behavioral health services. During the last year, trauma has been exacerbated, especially in our client population, with marked increases in substance use and mental health issues, making TIC an even more critical need than before.
We are very grateful for the generous support from the New York State AIDS Institute and New York Community Trust for helping us build on our successes, strengthening our infrastructure, and improving our TIC model of care. BAC envisions becoming a national thought leader in trauma-informed care by helping organizations transition to a TIC agency through sharing our experience with them, actively cultivates partnerships, and seeking funding to replicate our TIC approach.
BAC recently convened a strategic planning retreat where our Board of Directors approved the provision of trauma-informed comprehensive care as the agency’s strategic direction. As we begin a new fiscal year in July, we are excited about supporting our Board’s commitment to learning more about TIC. We are also committed to providing our clinicians and managers the environment and opportunities to improve their skills. With this in mind, BAC has created a new learning space where our staff meets monthly to share, practice, observe and reflect on applying TIC principles in their work. We are looking forward to learning with them.
Issue Brief – Fixing Behavioral Health Care in America. https://thekennedyforum.org/app/uploads/2017/06/KennedyForum-MeasurementBasedCare_2.pdf