Trauma-Informed Care:An Innovative Partnership

CACHC Conference 2015

Linda Dawson Kiri Shafto

Overview

• Upstream Thinking

• Klinic (Then & Now)

• PHAC and the Canadian Public Health ServiceService

• Klinic project - how it came about

• What is Trauma?

• What does it mean to be Trauma-informed?

Discussion throughout!2

Upstream Thinking @ Klinic

The Project…

1. Develop and implement a strategy to help Klinic become a trauma-informed organization

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The Project…

2. Develop and implement a decision support tool for new projects/programs that addresses the social determinants of health and the root causes of disease health and the root causes of disease using a community development lens

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The Project…

3. Create a framework using principals of trauma-informed care and social determinants of health to inform programming, policies and inform programming, policies and practices

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The Project…

4. Share learnings

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Klinic (Then & Now)

The Story of Klinic

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https://www.youtube.com/watch?v=rHU6MCgXTSc

Klinic – 1970s

• Takin’ it to the streets

• Student docs start seeing people on the street and in the park – sex, drugs and rock n’ rollrock n’ roll

• Move into the crypt (church basement)

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Klinic

Crisis

Response

Acute Medical

Care

Klinic – 2015

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Klinic Service Delivery

• Medical services – Community*

• Counseling services – City

• Crisis lines & education – Province

• Manitoba Trauma Information and • Manitoba Trauma Information and Education Centre - North America

• Calm in the storm app – World

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Klinic Innovation

• Calm in the Storm - http://calminthestormapp.com/

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Discussion Points

• Show of hands – have you seen/used the Calm in the Storm app?

• How does your CHC remain current?

• How does your CHC assess and address • How does your CHC assess and address need?

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The Public Health Agency of Canada and the Public Health OfficerOfficer

History

• Created in 2004

• Focal point for managing public health emergencies

• Post SARS (Naylor report)• Post SARS (Naylor report)

• Response to concerns about capacity of Canada’s public health system

“The record of the last several decades is depressingly clear… Governments

have steadily committed virtually all new health spending to areas other than

public health.” – The Naylor Report16

What is the Canadian Public Health Service?

• Created as part of the 2006 Avian and Pandemic Influenza Preparedness Treasury Board Submission, intended to:

–Build a federal public health workforce across Canada

–Provide public health capacity to respond during a –Provide public health capacity to respond during a public health emergency

• Focus on surveillance (infectious/chronic), EPR and health promotion

• Work on specific projects in jurisdictions across Canada, for short-term (1-4year) placements

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CPHS Accomplishments

15 –Active federal Public Health Officers (PHOs) across Canada

6 – Currently placed with northern and/or First Nations organizations (40%)First Nations organizations (40%)

63 –Different projects across Canada since 2006 (F/P/T/local and NGOs)

49 –Co-op students

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Who are the PHOs?

• Qualified public health employees, trained in epidemiology, policy analysis and public health nursing

• PHOs offer a variety of expertise:– Infectious disease

– Chronic disease– Chronic disease

– Vaccine preventable disease

– Injury prevention

– Health promotion

– Public health policy

– Environmental health

• Not involved with delivery of front-line patient care

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Show of Hands

• Have you heard of the Canadian Public Health Service or Public Health Officers?

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Partnership

Klinic

Engaged and healthy communities

Shared Visions?

PHAC

Healthy Canadians and communitiesin a healthier worldcommunities in a healthier world

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Klinic and the Public Health Officer

• PHAC annual call for placements

• Klinic proposal

“…community health centres face the challenge of transferring knowledge

of trauma and the social determinants of health into policy and practice”

• Klinic proposal

– Develop a strategy/framework to become

a trauma-informed organization

– Integrate knowledge of trauma and SDH

into policy, procedures, practices, and

settings

– Share learnings23

Benefits of the partnership

• PHAC strengthens its public health capacity by building: – workforce

– Infrastructure

– knowledge & networks– knowledge & networks

• Klinic– Time

– Naivety and Curiosity (new eyes)

– Deadline

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Discussion Points

• Are partnerships (other than simply financial) with governmental agencies part of your CHC?

• Do these partnerships enhance the work?• Do these partnerships enhance the work?

• How does your CHC partner with external agencies?

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What is Trauma?

What is Trauma?

“…out of control, frightening experience that

has disconnected us from all sense of

resourcefulness or safety or coping or resourcefulness or safety or coping or

love”.

- Tara Brach

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What is Trauma?

• Common elements:

– The event was unexpected

– The person was unprepared

– There was nothing the person could have – There was nothing the person could have

been done to stop it

• Psychological impacts for all

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Types of trauma

1. Single incident trauma

2. Developmental trauma

3. Complex trauma

4. Intergenerational trauma4. Intergenerational trauma

5. Historical trauma

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The Effect of Stress

“…the effects of early stress or

adverse experiences directly

shape both the psychology and

the neurobiology of addiction in the neurobiology of addiction in

the brain.”

Gabor Mate

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Adverse Childhood Experiences Study

• Kaiser Permanente and Centers for Disease Control

• Over 17,000 participants (1995-1997)

– Mostly middle-class, employed, educated, – Mostly middle-class, employed, educated,

insured

• Ten yes or no questions

• Discovered that childhood trauma (ACEs) connected to long-term health and social outcomes

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Toxic stress

• Result of high levels of stress over time, without support

• Weakens the architecture of the developing brain

• Increases the likelihood of developmental • Increases the likelihood of developmental delays and later health problems

• Supportive, responsive relationships with caring adults can prevent or reverse the damage

• Evidence that mindful awareness practices are protective

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“Difficult” patients

• Difficulty remembering appointments

• Reluctant to make changes

• Abuse(d) medication

• Become overwhelmed by what others would consider a minor setback

• Become overwhelmed by what others would consider a minor setback

• Continue to engage in high risk behaviours even when they recognize the negative effects.

• Exhibit frequent mood changes ranging from anger to resignation in the space of minutes

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“Strategic” patients

• Strategies that “almost work”

– Disordered eating, risk taking, promiscuity,

etc.

• Difficult to counter despite evidence to the • Difficult to counter despite evidence to the contrary

– Smoking to relax

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Discussion Points

• Wordplay – Trauma

• Do different professions within your organization look at this word differently?

• Have you had any conversations about • Have you had any conversations about this?

• Do you define physical and psychological trauma differently?

• Do we need to apply a different lens?

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What does it mean to be Trauma-Informed?Trauma-Informed?

So why trauma-informed?

• Shift “What’s wrong with you” to “What happened to you”

• Practical ways to engaging a patient with high ACE score:high ACE score:

1. Build patient-centred approach

2. Identify strategies to help calm the patient’s

sympathetic nervous system

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What is Trauma-Informed

• Trauma-Informed Staff

– individual practice

• Trauma-Informed Space

– environment– environment

• Trauma-Informed Organizations

– policies and procedures

– plus individual and environmental

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Case study

• Patients dropping out of weight loss program as they approached target weights

• Interviews identified high amounts of • Interviews identified high amounts of childhood abuse and neglect

• Complex and multidetermined disease

• Not simply mismatch between caloric intake and energy expenditure

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What do people want?

• Talking about ACEs brought sense of consolation

• Pleased that HCP looked beyond presenting health issues

• Want to be seen holistically (strengths and challenges)

• Will asking the hard questions re-traumatize patients?

• “How do these experiences impact your life now?”

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Trauma-informed –Caregivers

Communication tips

• Be curious about people

• Become vulnerable with patients and their families

• Listen compassionately

• Learn the therapeutic value of touch• Learn the therapeutic value of touch

• Make meaningful connections as an act of self-care

• Appreciate silence

• Tolerate uncertainty

• Develop mindful presence

• See the patient as a person

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Self-care and protective factors

• Burnout

• Emotional fatigue

• Mindfulness

• Self-compassion• Self-compassion

• Social supports

• Exercise

• Trauma exposure response

• Eating and sleeping well

• Communities of practice43

https://itunes.apple.com/us/app/calm-in-storm-stress-management/id966020512?mt=844

Self-Care / Client-Care

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More Stress…

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More Stress…

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More Calm…

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More Calm…

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Calm for everyone…

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Trauma-Informed – Space

Physical space?

• Calming and welcoming

– Waiting and treatment rooms have space

for people to move

– Confidential space available for intake– Confidential space available for intake

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Safety inside the building

• The space inside the building is safe

– Common areas are

well lit

– Bathrooms offer

privacy

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Safety outside the building

• The space around the building is safe

– Parking lot and

sidewalks well lit

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Trauma-informed –Organizations

What is a Trauma-Informed Organization?

• Commitment to providing services in a manner that is welcoming and appropriate to the special needs of those affected by traumatrauma

• Integrating an understanding of the impact of trauma and violence into the organization’s policies, procedures, and interactions.

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Trauma Process Plan

• Evaluate current literature / tools

• Create checklists / tools

• Evaluate current TIP (checklist evaluation)

• Share checklists / tools / presentation with • Share checklists / tools / presentation with external agencies

• 6 month post evaluation

• Create infographic of progress

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Checklist

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Checklist Specifics

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Discussion Points

• Has your workplace considered trauma-informed principles when:

– Using space?

– Implementing programs?– Implementing programs?

– Developing policy and procedure

• Is this another buzzword?

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Next Steps

Part 3 - Goals

• Create a framework using principals of trauma-informed care and social determinants of health to inform programming, policies and practicesprogramming, policies and practices

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Where do Trauma and the Social Determinants of Health Meet?

• Phase 1 – 50% of work

– safety (emotional & physical), housing,

biological needs (food) & relationships

• Phase 2 – 25% of work• Phase 2 – 25% of work

– Remembering and mourning – includes grief,

recognizing impact of trauma &

acknowledging the loss

• Phase 3 – 25% of work

– Resolution and reconnection

– Trauma is in the past63

Discussion Points

• How to begin the work? – Trauma informed has to start somewhere

• How to sustain work? – Trauma informed can’t be static can’t be static

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Information Sharing

Part 4 - Goals

• Share learnings

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Discussion Points

• What, if anything, would you want us to share?

• How would you like us to share it?

• What do you see as the value add for you • What do you see as the value add for you and for your workplace?

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Summary

Project Summary

• What is Klinic left with when Kiri leaves?

– People understand the tool and the process

behind the tools

– People know what a Logic model is– People know what a Logic model is

– Klinic Quality lead is left with a structured

evaluation plan

– Somehow share information broadly

– Hope to integrate Trauma Informed with

SDOH into one tool

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Linda DawsonDirector of Health Services

Klinic Community Health Centre (204) 784-4063

ldawson@klinic.mb.ca

Kiri ShaftoPublic Health Officer

Klinic Community Health CentrePublic Health Agency of Canada

204-784-4207 kshafto@klinic.mb.ca

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