This text is being provided in a rough draft format. Communication Access Realtime Translation (CART) is intended to facilitate realtime access to oral and aural communication. It is not meant to produce a verbatim record of the proceedings. Let the coordinator know if a more verbatim transcript is required. Red text indicates poor quality audio feed. ⇒ >> ROARA: Good afternoon everyone and welcome to the SAMHSA-HRSA Center for Integrated Health Solutions webcast. Titled impact of ACEs and Adoption of Trauma Informed Approaches in Healthcare Settings. My name is Roara Michael, the senior associate and your moderator for today's webinar. I am also joined by Linda Ligenza who is a clinical services director for the National Council for Behavioral Health. As you may know, the SAMHSA-HRSA promotes the development of integrated primary and behavioral health. Including mental health and substance abuse services to better address the needs of individuals with mental health and substance abuse conditions. Whether seen in specialty behavioral health or primary care provider settings. In addition to national webinars designed to help providers integrate care, the centers continually posting practical tools and resources for the website providing phone consultations, providers and state groups been working directly with the primary and healthcare integration grantees to find a safety net provider and training/education program. Before we get started, a couple of housekeeping items. To download the presentation slides, please click on the drop-down menu labeled "Event Resources" on the bottom left of your screen. The slides are also available on the CHS website which is located under the tab "about us/webinar". During today's presentation the slides will be automatically synchronized with the audio, so you will not need to flip through any slides to follow along. You will listen to audio through your computer speakers, so please ensure that they are on and the volume is up. You may also submit questions to the speakers at any time during the presentation by typing a question into the ask a question box in the lower left portion of your player. >>> Finally, if you need technical assistance, please click on the question mark button at the top right corner of your player to see a list of frequently asked questions and contact info for tech support if needed. >>> Just a quick disclaimer: the view, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), or the U.S. Department of Health and Human Services (HHS). Now I would like to kick it off to Linda Ligenza to introduce todays speakers and also discuss the objective, Linda. >> LINDA: Thank you. Welcome everyone to today's webinar. We are so pleased so many of you could join us today. We are as you know, we are going to be speaking about adopting

approaches within primary care and integrated settings. I wanted to start by introducing myself and Karen Johnson, we are both clinical social workers. I have been with the national Council for about the past eight years. Working within the trauma informed services department as well as the Center for integrated health solutions. The national Council has really been at the forefront of advancing trauma and forced care across the country. Karen has been a major player in this work. A lot of the work started out with behavioral health organizations, we have moved into working with schools, communities, and for the past three years, really through Karen's efforts we have been working very closely with Kaiser, Kaiser foundation to advance trauma informed care within health and integrated health settings. So, Karen and I come with this background and experience and we also are joined today by Patty who is going to who is a nurse and she is going to be able to bring to this conversation, her experience of actually working over these past several years to integrate trauma informed services into her organization. We are so pleased to have all of our speakers join us today. And all of you listening in. >> LINDA: What we want to make sure that we cover, is a range of topics. We know also that it's very difficult to try to gear a webinar to so many people and be able to really address the kind of things that you are interested in, for the place that you are in, along your via adoption continued care continuum. We recognize that, we hope that you are going to get, we recognize everybody is at different stages of implementation. But we hope that all of you are going to be able to come away from this webinar today with something new, something important that you be able to adopt in your organization. We want to make sure that we are talking about some of the basics, in case that is where some of your at. We will talk about trauma, its impact and prevalence. We also want to talk about why it is important to adopt trauma into informed approaches within healthcare settings. We want to define what we mean by trauma informed approaches and talk about what it looks like to implement trauma informed care. Because that is not an easy task as many of you who are working on, the know. Then I am going to have the pleasure to introduce you to Patty and we will get a chance to hear from her. We will have time for questions and answers. Please explore and type those into the box anytime and we will get to those at the end. We want to also make sure that we cover some of the resources that we know many of you are looking for in doing this work. At this point, I am going to turn it over to Karen to get us started. >> KAREN: Thank you so much, Linda. Welcome to everyone who has joined us today on this webinar. >> LINDA: Karen, would you do the polling question, please? >> KAREN: Certainly would be happy to. We are going to start today just trying to get a better sense of who has joined us. Where you might be in relation to your work to become trauma informed. If you could respond to the question. The polling question that is on your screen.

How much do you know about becoming a trauma informed organization? A we have been fiercely working on becoming trauma informed. B we have been working on becoming trauma informed to a limited degree or C we have not looked at doing this work at. If you could enter your answers and Roara will give us the results. >> ROARA: I will give you a few more seconds. We have about 43 percent to say that they have been working on trauma informed. 44 percent we have started working on becoming trauma informed to a limited degree. 13 percent is we have not looked at doing this work yet. >> KAREN: Thank you so much, Roara. That is a healthy split. What we often see and what Linda noted for the folks joining us today are all on the continuum of this work. The good news is there is room for everyone. It is an evolution and people again across the country are in different stages and if you're just joining us, if you're part of the 13 percent you're very welcome. We are so glad you're here. For those that have started or further along, we hope you will also benefit from the information shared today. We believe you will. Certainly, when you hear both from Linda about trauma informed approaches. Then from Patty about her work at the center, we hope that that will inform your knowledge on this work. Thank you so much for sharing and joining in that polling question. Now, we want to move to the first section of the webinar. Which is an overview of trauma, its prevalence and impact. We want to provide this foundation information so that we are all working for the same level of knowledge as we move into talking about trauma informed approaches. We know from a large body of research that adverse experiences are prevalent in our world. These events have a significant impact on individuals across the lifespan. It is important also to note the trauma impacts organizations, communities and systems as well. Trauma is not easily observed or identified and often without foundational knowledge about the impact of trauma, it can be easily overlooked. Thus in our health care settings, we need to know how to recognize it and know how to respond. In fact, in our work we often talk about using universal precautions when striving to be trauma informed. This means we are always looking to infuse trauma informed principles into all of our interactions. With everyone we serve and with everyone we serve next two. All of our colleagues, staff, community partners, everyone who is engaged in our processes and our work. The informed approaches about culture shift, changing our perception, our thinking, our beliefs. Changing your language, looking at our relationships and changing our environment and attitudes. This is not about adding new things so much as doing what we are already doing in a better way. It is about infusing principles of trauma informed care to guide our work and everything that we do. Very good news is that trauma informed care perfectly and lines with our work to become integrated healthcare setting. It is critical for all staff in our settings to understand trauma and its impact because many current chronic health conditions may be related to events that have happened in someone's life. In fact, our work is often about helping connect the dots between

life events and current health challenges. Also, people have experienced trauma are often very sensitive to reminders of the original event, set of events or circumstances. These reminders or triggers may cause a person to relive the trauma within our settings. They may see our services as stressful instead of places where they can come to heal and get better. The first goal of trauma informed care is to not re-traumatize individuals seeking our services. That is why it is so critical for us to make sure we understand trauma and its impact. Let's talk in a minute talking about the definition of trauma, we know that especially in our primary care settings that were trauma has always been used to describe injury to the physical body say a brain injury or something that might've happened in a car accident and requires major surgical intervention. That kind of trauma. Over time, you know we needed to come to an agreed-upon definition of what trauma is in the context of this work. SAMHSA-HRSA brought together the administration brought together a panel of experts to answer this is question. This is the definition of trauma. Their definition is, it is called the three ease. An individual trauma results from an event, the series of events or a set of circumstances that is experienced. That is the second E. By an individual is physically or emotionally harmful or life-threatening and that has lasting adverse effects. It has the effects on the individuals across multiple domains including mental, physical, social, emotional, spiritual. All of those areas. Two important things to take away from this, it might not be readily evident in that definition, is one in individual to find their experiences related to their trauma, they tell us as caregivers and providers what they have experienced and we do not dictate to them what are they have experienced trauma. We also don't read as a level I trauma etc. All that information comes from the individual that we are working with. Two, an individual who witnesses an event or a set of circumstances that is traumatic also can be impacted in a life-threatening way. Or in emotionally harmful way. You don't have to be the direct victim of an event or directly. You can witness it also and you can be traumatized in that way. These, one by one. Very good. Here's on the screen, we have a collection of types of trauma that are experienced by individuals. It's not a complete list, but many of them can cause trauma in these categories. We have child maltreatment and complex trauma. Child abuse, physical, sexual, emotional abuse and neglect. We have medical traumas, so we know anyone who experiences a medical issue that can be stressful. It can often become traumatic if it's a chronic illness. For the many procedures that result from that, also, from interfacing with the health system that could often be traumatic for an individual. We have serious illness, natural and man-made disasters, clearly we have had a long list of those that have happened over the last many years including multiple hurricanes this summer. The fires in California, all of those events that impact people in a profound way. Our next one is trauma that impacts that takes place within war zones, everyone who is in those war zones that is impacted in a profound way often. We have terrorism and political violence. We have witnessing a domestic community and

school violence. This picture here is representing traumatic grief separation after a significant loss so those events such as divorce or incarceration of a parent or involvement with a foster care system. This is three examples of grief separation and loss that fit the definition. Of a traumatic event. Then, this next one is historical trauma. I wanted to talk a little bit about this. We use different words to describe this, we can talk about historical trauma in generational trauma or a cumulative trauma. Really, what it is is cumulative emotional and psychological wounding over the lifespan and across generations emanating from massive group trauma experiences. It is a set of catastrophic events that has happened to a group of people in one generation that is not healed with that generation that is passed down to future generations. Certainly, the picture on this slide represents or shows us children from boarding schools in which Native American children were removed from their home, removed from their families and forced to go to boarding schools where they were forced to simulate to the Western culture. That is one example of historical trauma. We also of course have slavery and how that has impacted the African-American population. We had the Holocaust, many other examples. It's important incredibly important in our work to always understand trauma within the context of culture. In this case understand how these events, these historical events continue to impact people today. We use the word cumulative trauma to make sure that we understand these traumas are not overpaid many people that we serve are experiencing these ongoing events right now. Yesterday, this morning, etc. What are some common signs of trauma. These are some of the things that we see as a very short list and the list is very long. Isolating behaviors, behaviors in which individuals who struggle to seek or make healthy social connections. Often confusion or difficulty concentrating. We know that trauma impacts the neural paths in our brains. I will talk a little bit about that in a minute. When we are in the survival mode we have a difficulty using our cerebral cortex and concentrating and not getting distracted, etc. Trauma can cause individuals to react to situations in ways that are hard to understand by observers. Reacting quickly to something that might be happening to others not see as a concern. Certainly people that we serve in our health centers may cancel or not keep appointments or have a diminished level of engagement because of a trauma history. We know this trauma can result in frequent visits to the emergency department. Sometimes it can be caught right away with multiple medical and/or psychiatric diagnosis is. Diagnosis that have no clear etiology. It relates to suicide, we know that there is a strong correlation between individuals who attempt suicide and a trauma history. Whatever we are doing, suicide prevention and screening for suicide, we need to be paying attention to the potential trauma history. Then as it relates to these last diagnosis is, attention deficit hyperactivity disorder, we know that trauma is often mirrored symptoms that are the same as ADHD and in borderline personality disorders in adults. In children the ADHD pieces are unfortunately when we diagnosed children without a trauma lens we may be missing the cause of

their symptoms. We may miss diagnosed with ADHD. When we do that, we prescribe the wrong medicine and the wrong treatment. It doesn't address the root causes. Unfortunately it doesn't help children to improve or heal. The stresses of a normal part of life and our response to it. This is responses to stress that is hardwired in all of us. It's evolution's way of keeping us alive. When we are stressed out, our heart beats faster, blood pressure rises, adrenaline and cortisol which is a stress hormone service our system to make us stronger, faster, more alert. In short these changes that come with stress give us difficult resources to deal with when wherever we are seeing. Cortisol, the stress hormone that is present can help us perform at our peak. In a chronically stressful environment however, the body stress responses are always on. There's little relief from the certain chemical increase with heart rate, blood pressure, when this happens the stress becomes toxic and can cause dramatic changes in the brain and body. This picture here highlights the common noticeable effects when in fact we are in that fight/flight or freeze mode or the survival mode. When we are facing toxic stress. Again, this picture indicates a long list of how our bodies impact by trauma. We also know that when we look across a person's life our beliefs are impacted by trauma. It's a view on an individual who may experience trauma that does not believe the world is safe and everybody is going to hurt me. It leads to identity and individuals who have had a traumatic history may believe things like I am broken, damaged, a leak. I'm no value. Obviously these thoughts and that type of worldview make it difficult for people to navigate or interface with the world. As it relates to spirituality common for trauma patients to ask God why me, if God is so good or the higher power whatever word we use is so good, then I must not be worthy of that. It is also important to know the spirituality and faith is an amazing resource also for people who have experienced trauma. I reference at the beginning of my comments why research that we are using to inform our understanding of trauma. It really is going on in the study in the late 1990s. This study that ACEs study is to understand trauma informed care. It was conducted by the Center for disease control and Kaiser Permanente. The principal investigator, Dr. Vince Felitti, basically what they were doing is striving to answer the question. Is there a relationship between childhood, poor health, into adulthood. What they found is that there is a strong correlation between the two that adverse childhood can result in a long raising risk for a long list of things that come into adulthood. This pyramid represents the findings from the study. How those average experience is play out in our lives, so we have a foundation of ACEs. There is an event, disrupted neurodevelopment, the brain can be changed. Which can lead to social, emotional and cognitive impairments. Adoption of health risk behaviors. Disease, disability and social problems. Unfortunately, early death. What they did was screened over 17,000 adults, mostly college educated individuals. 10 average childhood experiences, asking everyone to fill out a skill noting if they had any of these experiences. This is a list of those trauma events that were part of the original study. We know our list of events

that can be traumatic is long beyond this list as I shared earlier. But these are the 10 questions that were included on the adverse childhood experience study. What they found was they found both that there was a high prevalence and a high impact. Only two thirds of participants reported at least one average childhood experience in their life before the age of 18. Over reported ⅕three or more ACEs including abuse, neglect, other types of childhood trauma. Major links were identified between early childhood trauma and long-term health outcomes. Here is our list of the long lifelong physical mental and behavioral health outcomes linked to ACEs. The list will be provided to you but many many, all of the chronic concerns that you and your staff in your Health Center deal with show up on this list as outcomes that can happen if someone has a history of adverse childhood expenses. I will leave that for you to look at. Just note the variety of outcomes that can result from ACEs. So we are left with noting that this is profound and really ACEs is what many people are starting not starting to but really embracing and understanding is that ACEs is the number one health condition in our world today. Now that we know this information, now that we have the experiences to inform the understanding of how people are impacted by their histories, we are compelled to take that information and move forward. He is a quote from Vince flitted the principal investigator, we are just as likely to develop heart disease from an ACE as you are from high blood pressure, high cholesterol or family history. Thank you very much. I will now turn it over to Linda. >> LINDA: Thank you. >> KAREN: The last slide is just a reminder that ACEs are not destiny. The good news is that all the work we are doing in trauma healthcare across the country and private sectors including health settings, Linda and Patty will talk to you to address both to mitigate their impact. >> LINDA: Thank you, Karen. I wanted to move now from giving that kind of understanding about trauma and its impact on prevalence to making the case for why it is important to adopt informed approaches and integrated care settings. So one of the reasons it's really important is because often times, the persons first encounter is in healthcare settings. That could be children as well as adults. So, you may be or that primary care service may be the first way to contact. It is really important to use that opportunity to understand that person to possibly screen for a history of trauma and of course to provide healing, helpful environment for that person. It is also in integrated settings an opportunity to address and prevent adverse childhood experiences both in adults as well as children. It is also trauma informed care is not only a benefit to the patient. It is also a benefit to the staff as well as everyone in the organization. We are really talking about creating safe compassionate and healing environments. That really affects every single person who is walking in your door who continues to work within your setting. Trauma informed care also offers a framework, a way of working with people that we really think allows you to get better outcomes than the ones he may have been getting all along. We like to talk

about seeing everything we do through a trauma informed lens. If you think about that as a framework, seeing the work that you're doing with patients, the interactions that you have with staff, families. If your board members, really using that trauma is going to be so helpful. It also helps to address what we refer to as the quadruple aim. That improves health outcomes, lowering costs, greater satisfaction with care. But we also at an improved clinical experience. As I mentioned it's not just about healing for the patient but also creating healing and helpful environments for the staff and supporting staff as well. When staff feels supported they are in a better position to support the patient population. So what we know about trauma informed approaches within primary care and its integrated care settings is, the environment that is one that is set up to really minimize those reactions to triggers. I have been working a lot with folks in health centers through an innovation community that I'm working with and so many of them are talking about encounters with a patient or the patient's need to be de-escalated. So what we need or hope is through creating trauma informed environments, training all staff including front desk staff about the impact and prevalence of trauma and what it means to be trauma informed, in their role, they would be better skilled at working with people in a way that it doesn't promote escalation at all. So that is really the aim. It also is an opportunity to improve adherence, to treatment, whether it's medical, primary care treatment or being able to take medications regularly. Reduce visits to an emergency department, we are going to talk in a moment about the importance of the relationship with being able to really get to these places. Adopting trauma informed approaches also helps not only the staff but it really helps the staff to help the client to connect. The trauma experience with what is going on in their life today. It is a really wonderful opportunity because so many times, patients don't know that what they have experienced really does affect the way that they have gone through their life. They don't understand the connection to the stress or the connection to something with issues. Other kinds of behavioral issues, mental health issues, there is a real opportunity there for primary care staff, behavioral health staff to make that connection. It's also an opportunity to connect people with the services that is going to help heal them. Preventing possibly prevent ACEs in the next generation. I wanted to share with you one doctor's view of addiction and the experience of ACEs. I think it is a really helpful way of seeing this issue. Addiction shouldn't be called addiction. It should be called ritualized compulsive comfort seeking. Ritualized compulsive comfort – seeking what traditionally is called addiction is a normal response to the adversity experience in childhood just like bleeding is a normal response to being stabbed. The solution is to address a person's adverse childhood experiences and this comes to us from Doctor Daniel Sumrok from the University of Tennessee. It is really so profound, really and we talk about that experience of the adverse childhood experiences and the trauma, as a reaction to those experiences. A lot of the diagnoses that we give to people really are there way of trying to cope with very very difficult life experiences. It's

a different way really for us to look at a persons life and experiences, the symptoms that we are seeing. Another really helpful quote comes from Doctor Nancy Hardt who is with the University of Florida College of medicine. She talks about the most important thing, she didn't learn in medical school is about adverse childhood experiences. She mentioned if she had understood, then the way she does now, she would have had a better and more compassionate, she would have been a better and more compassionate physician avoiding mistakes. My mistake was to try over and over again to get people to give up certain things like cigarettes, alcohol, pills or overeating without addressing the reasons for why they were doing that in the first place. As I mentioned, these are, we have such an amazing opportunity to be able to recognize these symptoms, these signs and people that we are working with. To see those signs and symptoms really as a reaction to vary very difficult life experiences. I wanted to move into really helping us to understand what we mean by trauma informed approaches. I just want to mention also, it is so helpful to understand based on our polling earlier, so many of you are really have or already moved into this realm. Which is very very exciting for us. This is a slide where I guess the pictures going to, here we go. Sometimes they show up. We talk about what's important and what really drives the work of trauma informed care in our organizations. Karen mentioned earlier, this committee that SAMHSA worked with to define trauma, they also worked with that same advisory group to define the principles and values that really support all of the work. These really consist of safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice, cultural, historical and gender issues. Obviously when we talk about trauma as Karen described earlier, there are such major issues around safety and trust. So when we are working with people, we may not want to or we may know that this person needs to change the medication for example. But we may want to take time to develop that relationship. The trust. Before we move into doing something that we know. The issue around safety and not just patients safety but staff as well. We are talking here about relationships as well as the environment. Looking at everything we do to ensure there is a safe way of doing it. Peer support, looking to the clients that we are working with, the patients we are working with. Asking them to I know that probably all of you have peers or recipients of just services involved in your board or on your board. We will talk later about limitations and ways you can really bring the voice of peers into the work that you're doing especially trauma work. It could be extremely helpful. Collaboration and mutuality is really all about leading the patient where they are at, informing that connection. So that they really become the expert in their care. Using techniques like motivational interviewing can be really helpful there. Empowerment, voice and choice. Again, really allowing people to have a voice in their treatment. In the treatment processes it is so healing and important. Karen talked earlier about the cultural, historical and gender issues that we really need to be very aware of. In terms of our values and

principles. Seeing everything we do through the cultural lens as well. The other thing that SAMHSA did with this expert panel as they wanted to really get a definition of what we mean by a trauma informed approach. So they came up with the four R's. In defining trauma and now they talk about the four R's. They are referring to the realizing, widespread impact we talked earlier about the prevalence of trauma. The impact the trauma has on the patient population we are working with. Understanding that healing does happen, it can and does happen. In our environment. We want to make sure that we have a hopeful perspective that we can share with patients. We want to make sure that every single person in our setting has that hopeful environment and realizes the impact. Recognizes signs and symptoms of trauma in clients, families as well as the staff that we are working with. Also others involved in the system. There really needs to be this very important recognition that trauma is prevalent and we need to be able to recognize those signs and symptoms. We need to also be able to respond in a way that allows us to fully integrate what we know about trauma, not just in the work that we are doing. Through the practices, but also looking in our policies and procedures. How can we see our policies, procedures and practices through that trauma informed lens so we can make a change we need to make. To promote healing. Of course we want to make sure that we resist, resist re-traumatizing people. That is certainly involves looking at our practices. Improving in the exam room. I am surprised, another very important issue is not just to look at trauma, what is wrong or what are the ways that we can think about someones experiences but what are the strengths as well. So, easily thinking about not just the impact of trauma in a negative way, but also thinking about it in a very positive way because the people that we work with are often so very resilient. Given the experiences that they have had, they come to us within amazing resilience. So what we know about these resilience is that it's all about the relationship. The connections to others in their world, in their families, friends, but also in our environment so think about how we can strengthen the relationships inside and outside of our organization will be extremely helpful. The way that we can really help people to build on the resilience is through teaching. Helping them to become more self-aware and taking responsibility for their actions and their behaviors. Really, really recognizing their strengths. How to build on those. Another thing about promoting trauma informed approaches within healthcare settings really has to do with looking at where are the places that we can really change the way we practice. This information comes from a handbook that was developed specifically around people who have experienced sexual abuse but really it cuts across all healthcare areas. These are simple and important values again. Be respectful, take time, we know that in your kind of settings in healthcare settings, time is of the essence. Often times we can get further when we spend more time with people that we are working with when that is needed. Build rapport, I mentioned the relationships. Share information, often times people come to us very stressed, it's very difficult to listen, hear what is

going on. Making sure that we are sharing information in a way that they can hear is important. I think that you will have access to these slides and will be helpful to look at the practices that you're involved in. Think about how they can become much more sensitive. A trauma informed healthcare environment really emphasizes the importance of the relationship as I mentioned. Respect, physical, emotional respect. It creates opportunities to engage patients in very meaningful ways. It considers trauma whenever we see people who are missing appointments, have difficulty adhering to the treatment or showing up often for appointments who are frequently going to need emergency departments. Those are the times we want to be thinking about does this person have a trauma history. So I wanted to move into how we start to adopt these trauma informed approaches. Certainly, we talk about this as being a culture shift. It's really a paradigm shift that moves us from asking what happened to you or what is wrong with you to what is strong. It's actually not what is wrong with you but what happened to you. Also, what is strong rather than what is wrong. I'm sure many of you heard that message before. Karen talked earlier about universal precautions, making sure we are looking at everything we do through this trauma informed lens. At the Council we really focus on five domain areas when we talk about how to teach people about trauma informed care and how to adopt trauma informed care. We talked about early screening and comprehensive assessment of trauma, patient choice and collaboration. Workforce development to using best practice approaches. A safe, creating the safe and secure environment. Of course we want to also make sure that we are collecting data and using that data to improve our performance. I know all of you probably are looking at these different areas and these are the ones that we think at the national Council are really critical in terms of adopting the approaches in healthcare settings. We at the national Council have relied a lot on the work that comes to us from John Kocher. Looking at the eight stages of change. Based on these eight stages of change, we developed these nine steps in the implementation process. Gaining commitment from leadership, developing implementation team, build consensus along with the team members. Help team members to create a shared vision around what you want your organizations to look like. We will hear more about this from Patty. Communicate for buy-in by educating everybody about trauma and trauma informed care. Assess your organization in terms of where you are at right now and where you want to go. Develop a plan. Create a monitoring or data system. Just move ahead. I want to reference to important resources, one is 10 implementation domains that come to us from the SAMHSA concept paper as well as the healthcare strategy advancing trauma and informed care. At this point I want to introduce you to Patricia Gerrity, a nurse with a PhD. She is the director of the Evans Street family health services at Drexel University. She is a nurse led federally qualified center at Northern Philadelphia. Patty focuses on trauma informed care and building community resilience in her work. It is a pleasure for me to turn this over to Patty.

>> PATRICIA: Thank you so much. Thank you for this opportunity to share our work. What I'm going to be doing is as Linda asked me to bring it to light, I'm going to take all of the things you have heard so far or most of them and give you examples of how we try to put this into action. Based on what you heard. Just a very very brief introduction to our health center. It is a comprehensive nurse health Center, a partnership between Drexel University and a federally qualified health center. We have been operating for about 20 years and we started out with the focus on people who lived in public housing, the areas that going to gentrification. It's causing many of the public housing residents to be fairly culturally isolated sometimes. Our mission and the reason why I wanted to point this out is the reason why we changed our mission from a more usual mission of providing comprehensive quality care, for Philadelphia's opportunity to try by providing comprehensive integrated health services. Then we added to the explicit part of our work providing community members and allied organizations to advocate for health equity and sustainable change. We have been doing this but we really wanted to put into our mission statement. If we don't do this, we will end up for the next 30 or 50 years giving the same old type of care with people's chronic illnesses if we don't change the community and work on the social determinants of health. I think this comes out rather small, but this is a sketch of the services we have. We very much try to not separate the mind and body, so the departments shown here in circles, they are not necessarily discrete. They operate together and they are supported by integrated services team. So for instance, look at the bottom right, we have creative arts therapies which are so important. We have music, art and dance therapy. We have a full program of oral health and we have medical, dental integration, you can start your dental care rate in primary care. We have a social work department and the social work department also includes attorneys, medical legal partnerships. To look at anything about criminal laws that might affect your health. We have our law school that comes in directors, power of attorneys and wills. We have a faculty and student physical therapy practice. We have the more traditional outpatient behavioral health. We have community health and wellness which helps us work with our larger communities because we are interested in all of those who need services, not just those who come in. We have a nutrition department that also looks at food access, we do farm to family boxes. We have farmers markets, we have our own garden. We have a mind and body department. The mind body department is the mind-body educator that works with both staff and patients. They do mindfulness, MBSR, yoga, reflexology, general stress reduction and also work with patients in the waiting room to introduce breathing and relaxation. Then we have primary care, any of the services I mentioned already can go in and be primary care. Primary care is a family nurse practitioner we also have behavioral health consultants, we have one just for children during their well exams that could be sick exams also who does screening for ASIS. We are using the program to screen for ASIS with the parents and children. Looking at their

growth and development referrals. We have a nurse practitioner, this is an awful lot going on in the center and we can do a lot of referrals to each other. One of the things about the creative arts therapy, not everybody is familiar with them. It really is a respected art form, a creative process which is within the psychotherapeutic relationship. It works on clients, behavioral health diagnostic systems. It offers a unique therapeutic opportunity for clients to nonverbally identify processes, strengths, challenges and memories. There are people who don't want to go to talk therapy there is a stigma related to it or crazy people go to that. Who will open up and go to creative arts therapies. Just to give you a little overview to see that many of the safety net providers probably have a similar somewhat similar patient population. 86 percent of our patients are African-American, seven percent Latino. Two thirds are female. 38 percent are between the ages of 25 to 44. About 20 percent are uninsured. That drops, has dropped a bit. 58 percent on Medicaid. 16 percent on private insurance. It's traditionally underserved and a challenged population to work with. That is to give you a background. I noticed that one of the questions that came up is can you tell us more about the quadruple aim. So I am just going to address that again right here for a minute. You are all familiar with probably the triple aim. This difficulty in rising expectations in primary care practice. There is so many increasing demands on primary care providers. There was a paper done in 2012 on safety net clinics that showed higher scores on patients with medical home assessments that could be associated with greater clinician burnout. In the safety net clinic. We are asking people to do more and more and more. We often don't realize that that can be so traumatic to the staff, it's not just the patients. It is the staff, the organization. They all have trauma history. Yet, often don't have the resources or the skills to address this. That is why we look at the triple aim of improving the clinician experience. We think that is really important. It's a major part of what we do is looking at trauma. We know that burnout leads to lower levels of empathy. We want to provide services to reduce the burnout. We have essentially these three models of care at 11th Street. The first is the partnership for community-based care. That is how we work with people outside of the center. The schools, community-based organizations, resident groups as we have worked with them on all of this work that I am describing with you with trauma. They really help us expand our initiative to strengthen and to sustain healthy families in our community. It builds on mutually beneficial relationships to promote health is very much based on principles of social justice to help improve the quality of life for everyone. The second model is the integrative healthcare model when I showed you the circles, where all of these departments, we are not totally there yet but very much working in integrated manners. All you have to do is get yourself into one of the services at the center and start to build a relationship. Get you the help you want. Then the model I'm going to talk about today is the sanctuary model. It is the model we chose to use for our trauma informed program. Our journey to trauma informed began long ago probably

2006 when staff recognized although patients were screened and treated for depression in primary care, many weren't making significant process in managing their illness. We knew having many of these patients had experienced trauma. But they didn't have the data on our panel of patients. As a result, in 2008 I worked with one of my faculty colleagues Doctor Burda Waite, we worked with the CDC and did a complete replication of the ASIS study at the 11th Street center. It was interesting because quickly in comparison to the original ASIS study where 12.5 percent of the original study participants had four or more ASIS, hours was 49 percent. In the original study where 36 percent had zero ASIS, we had 6.3. It was sort of flipped. What we saw was really half of our patients had four or more ASIS. It gave us some data, and we sort of had an idea of what we were working with and had to take an all-out organizational approach to this. And that is the sanctuary model. The sanctuary model represents a theory based trauma informed, trauma responsive evidence supported whole cultural approach because that was mentioned before to do trauma informed care it requires a culture shift. How do you make a culture shift if you are not looking at the whole culture. It gave us a structured methodology for creating our organizational culture. The sanctuary model started in its way and some people are reluctant to use the sanctuary model because it started in psychiatric hospitals. Then in residential facilities. But the principles are universal no matter what kind of practice you are. Some people were reluctant to do it and we were at first also. But we find that it really works. The sanctuary model is based on these four pillars. That is the theory or the knowledge, the things that were talked about today, understanding, theory. Then it is based on the values and those are the seven commitments. Our staff agreed to abide by and we help support these seven commitments within the center which are nonviolence, emotional intelligence, social learning, democracy, open communication, social responsibility, growth and change. Then we have the self which is the language we use which is safety, emotional management, loss and future. Then there are also the sanctuary tools which are community meetings, everybody has a safety plan including the staff. Self-care plans, again going also back to the staff. Anyone can call a red flag meeting to say something is going on that needs attention. Team meetings and psychoeducation. These are the four pillars of sanctuary that really address how does one realize recognizing, respond and resist. This is the model we chose. It starts with the staff. What we did, was we had a steering committee that went to the initial training and came back, they formed a core team. The core team is made up of people who were across all of the departments in various levels of departments. Some of our biggest champions in this our medical assistance and they are tremendous leaders in this work. Also, one of our dental assistants is a major leader. They help spread this knowledge and educate the staff. The core team is responsible for teaching all of these things and embedding them within our practice across the center. We have learned to use the sanctuary tools and use the shared language. It was challenging because we needed to get

everyone trained and on the same page. There is 70 people who work at our center. So they need initial training and it's not a one and done kind of thing. We are continually striving to get better and some people come and go, you need ongoing training for new staff. There's a lot that has to be put in place. Safety was mentioned before, I want to talk about one of the things we did with safety, it was one of our themes of the month and we post these all over that the center for patients and staff. The important thing about safety is that there is these different components of safety. Physical safety, psychological safety, social safety and moral safety. Really, for any of us to thrive and grow we have to feel safe. Most people were many people have been victims of violence and abuse and so this is very important. We want to make sure we are not re-traumatizing anyone with our policies and procedures. And we want to be able to know how to react to any perceived threats. We want to ensure that hopefully real threats don't exist. We are always looking at nonviolent conflict resolution. It is interesting because when we really talk about safety, we spent a great deal of time with our staff and with our patients on safety. This understanding and this is sometimes challenging for the staff. That there is a difference between being safe and being uncomfortable. Initially some staff if we are looking at open communication, they would say I'm not going to speak up because I don't feel safe. What they really meant is they are not comfortable. People have to start to understand that some change requires being uncomfortable. Not hiding behind I am not safe. It requires tremendous support from the leadership, if the leadership wasn't on board then this wouldn't happen. The leaders need to model these behaviors. To make sure there is time and resources available to do this. If you look at, you can get certified in sanctuary, some people say why don't you just do this and why are you going for certification. What we find is, so many places try to do trauma informed care and as soon as they get busy it's often the first thing that dropped. We don't have time for that. The leadership also has to be open to what comes out of the discussions because as you are promoting open communication with the staff, all kinds of things are going to come up. One of the things that came up for us early on was racism, power and privilege. We were very much trying to get through the implementation guide for sanctuary and kept saying that we will put that in the parking lot. We certainly couldn't do that. We actually started a national program called undoing racism. We have in addition to the sanctuary group that undoing racism group. It looks closely at things such as hiring policies, where do we advertise for our jobs, who is deciding who gets interviewed for jobs and things like that. The leadership has to be open to whatever emerges through this. It takes a lot of time to do this training and it can be challenging when providers have billable service times, they meet and they need time out from this. We have given after the initial trainings which are extensive, all of our staff, no matter who they are, given two hours a month to attend sanctuary workshops and undoing racism. Their supervisors make sure they have that time so they can do it. It's the same problem getting time for the core

team to meet. It very much takes a commitment from the leadership to do this. One of the things we did was provide staff with these to promote their safety. One of the opportunities to relax, to get away sometimes from what is happening to reduce the stress. We have quiet spaces, we have self groups and I will give an example of the self safety in the future. We have staff lost groups with the dance moves and therapy. We very much have put a lot of effort into mindfulness of the staff. This then allows the staff to be prepared to provide whole person care for our patients. Let me give you an example of self, this is the language of sanctuary it stands for safety, emotion, loss, future. The self is really sort of a compass on the road to healing. You can start anywhere in these four key domains. You can start with safety and emotional, management, loss, or future. We do this for patients but I want to give an example of how we have used this for staff and how it helps especially identifying emotion and things that are happening. We had to dismiss a medical assistant and you know that because of HR roles we can't say why somebody left but people who work with them no. We have done this many times. What happens if somebody leaves, there is the talk in turmoil, trauma, problems within that area of the practice. What we do is we say okay we are going to call a self group or a self meeting. For instance, that M.A. says safety, she was let go. In my next? Are the budget cuts? What is happening? So we really provide a place for safety and open to medication to talk about these things. It is also letting people identify their emotions and talk about them. She says I'm going to miss her and I was just becoming friendly with her, then there is the loss. We are missing one person, what is going to happen? Who is going to pick up the work? In the future, what is going to happen? Is this position being cut? Are we going to hire another person? You can start anywhere in this discussion where people feel comfortable but what it does is really talk about these traumatic experiences and give a framework for processing this with staff. We also note that in order to do this staff has to be present and be able to listen. It can also be challenging with financially driven models of what is happening with healthcare. We are really looking at how can we promote safety and all of these things in the staff and also, provide the integrated care. I mentioned that we really put a lot of time, money, effort into developing these practices. It is very much the same way that our sanctuary did. We started with the staff. We have gone off-site and again this is all level of the staff. They learn to be more present. It allows for better and clear thinking. It creates a more compassionate provider. We feel that in along with sanctuary, the mindfulness was an important way to continue to deepen and embed our practices, I will give you an example. We'll have safety plans on our badges that we wear but we also have these that are called shift notice and rewire. We have stars around the center and when somebody sees the start at any time, they can stop and it takes 15 seconds to notice to become aware of where your intention is. To redirect your attention to the present moment. Bringing any object and focus, perhaps sounds around you, sensations. Take the 15 or 30 seconds to say what this experience is

and reinforce the shift that you just made with neurobiology. The patient sees this as well, they love it. I can't keep up enough of these in. These are examples of how we put into practice that tell me about that, how did you use that. There are things like mindfulness minis that we use. Before you go into the exam room, put your hand on the door. On the doorknob to the room. Stop for a minute, take a breath, leave whatever else is going on outside so you can enter the room and really be compassionate. Available to your patient, they notice it. In our exam rooms, we have mindfulness toolkits for the patients, children, pinwheels and bubbles to teach them how to breathe. We have squeezy things, rocks, our own sound cloud with relaxation. So we try to spread this throughout the center. A lot of it was centered on staff but now they are able to provide this care for the patients. We have a share the care model which is a team model. We have open access, if you call today and want to be seen. In the morning, with the team with all these different practitioners get together and they have a huddle. They discuss who is coming in. Who needs what, who needs to see a health consultant. The child, have they done yoga, what is happening, how to support what they're doing, what else they might need. It really re-allocates the responsibilities of all of the team members share the responsibility for the people who are coming in. In addition, referrals can be made to the on-site groups which is behavioral health. The mind-body therapist. Or creative arts therapy. I think I am out of time. But this is one of the signs we have up to help people understand what we are trying to do. We try to talk a lot about healing, I am not sure if I heard the word yet today but I know it is always talked in bottles creating whole health. But you can't have whole health if you don't have healing. So many of our patients don't know healing is possible. In addition to this, we have cards that we worked with the Philadelphia ASIS task force information that they can take and encourage them to talk to their providers. Some of this successful approaches and outcomes we have is this no wrong door approach. You saw the services we have, get yourself into a service. We will work with you and eventually get you the care. We find the integrated teams really help with trauma. We also do trauma informed care in dental departments. They screen for depression and the behavioral health consultant and creative arts therapy works with dental as do the mind, body therapy. The well-child care as we look at this perspective is where we put the emphasis on pregnant women, we screen for ASIS and discuss what happened in their life. What they want to see for the children. We work on that. There is so many things that we can do. I am out of time, Linda. >> LINDA: I was on mute. I want to thank Karen and Patty so much. We do have several questions here that I want to get to. Let me get to a couple of those questions before I go to the last polling question. Patty, there were a number of questions related to screening. This is a very it has to be a thoughtful process. In terms of screening patients. One question could you answer

both of these, what tools have you found is the best tool to use for screening and assisting for trauma. Secondly, what language to use to help a patient connect the trauma with their health. >> PATRICIA: No problem, we have these services but we also are educating the community something we call patient ambassadors. They help spread the word so that it is not totally new to people. But a lot of it is depending on the person, age, situation is, the screening. So the way of screening for children which is using the ACEs questions without looking at the number of the individual once so the parents aren't afraid of being referred somewhere. Depending on the age of the child and what is happening, we also ask if anything has happened that upsets your child since the last visit. With pregnant women we use the ACEs screening tool because we do a lot of group work with them. We talk about it. We don't use that for all of the adults, a lot if that is a series of questions with using the nurse practitioners or the behavioral health consultants. I am talking about what happened and using this series of sensitive questions about things that happen to them before. Upsetting things and explaining how that can affect their health. Because we can do ongoing work, they start to understand. A lot of people say it means something, it happened to me years ago. It could be affecting blood pressure, diabetes. That's the opening. Some people don't know it. >> LINDA: Absolutely, thank you so much Patty. Another question has to do with approaching staff about their own trauma. How have you gone about that? >> PATRICIA: When we start the sanctuary training, we give all staff a trauma questionnaire. The ASIS questionnaire to fill out. We also have people available because many of our staff has been through trauma especially some of our sometimes lower paid staff, they are exposed to these things all the time. Once they learn about trauma they are more likely to talk about it. Get them into services, our mindfulness work has been wonderful. For the staff because they start to identify how they are reacting and identifying their emotions and have tools to do something about it. I don't know if that is totally answering the question. But we recognize that we all have trauma. The organization as well, we did a full trauma history of the organization. That is the leader and director, that was challenging for me to listen to. >> LINDA: Thank you, Patty. I know this is one thing that you had wanted to talk about and I don't think you mentioned it. But how do you pay for some of the interesting things that you do and is there any reimbursement for any of the services that you are providing trauma related? >> PATRICIA: It is built into the care, there are reimbursements for primary care, behavioral health consultants, the one for children. Right now the diagnosis is not reimbursable. We are working with the local behavioral health group and the state to right now create therapy to be billable. We are working on getting that changed and working on all types of things for the creative therapy because it is so valuable and so important. We have also gotten funding for this to pay for the and initiative sanctuary. We have had grants from the child coordinators who gets

a grant from charitable trust. The independents, Blue Cross foundation has given us money to work on our mindfulness. Life course perspective, we are a part of the Center for healthcare strategy national collaborative. >> LINDA: I mentioned them earlier, that is great. I also wanted to I see that a lot of you are answering that polling question if you would all continue to do that as I go to some of your other questions. As a result of this webinar, is there one thing you plan to stop doing, start doing, or continue doing? Thank you so much, I know a lot of you have already started to answer that. I think there are, let's see. Roara is there an announcement about how people can access these slides were this recorded webinar? >> ROARA: Yes, you can access the slides on our website at Integration.SAMHSA.gov and you can hit the tab about us \webinars. You can also download the slides via the event resources. >> LINDA: Great, thank you. There are a lot of people that are interested. It is okay with us if you download these slides or use them to train your own staff. That would actually be a very nice complement to us. Let's see. Karen, you talked earlier about the impact on the brain, can you say just a little bit more about how trauma affects the brain. >> KAREN: The brain is such a complex organ in the most complex structure we have on the planet actually. Social workers, healthcare providers and primary care may be are able to speak to it much better than a social worker. But we talk about it in more simple terms, in talking about different parts of the brain. The lower brain where the stress response system is housed and where all our stimuli, screened first. We decide what to do about it. Any stimulus we have internal external comes through the responses through the lower brain. What happens if we experience adverse events or in early childhood for short or childhood is those neurons are impacted in ways we see fault to the flight or survival mode. Again, the neural pathways cause us to people who have experienced trauma and been impacted and that we cannot be able to think process or grow. In the ways that our traditional exciting is expected to. When we have kids in school were expected to sit and fill out worksheets or do whatever a long list of things we ask them to do. If you are in survival mode as a child and you are being activated by internal and external simulators going through the stress of bounces getting you to think I might be in trouble here. You're going to struggle to do any of those things. That is really helping us understand how kids and adults struggle to manage and do well in our traditional settings. In many ways, healthcare is a traditional setting where we expect people to be able to engage, process and work with us in ways that we are very used to. But may not work for people who have brains that have been affected in this way. There are ways to heal the brain for sure, a lot of ways to heal. Healing is the piece of this work that we always have to be talking about. We do things like mindfulness and we learn how to self regulate, how to come down our brain that is on fire. People who have experienced trauma so that you can engage and manage these really intense

emotions, really intense trauma responses. To create safety for yourself and individuals who have safety for her or himself. Also than to be able to engage in the world and the ways that we so often expect. I'm not sure if that answers the whole question but the brain is impacted in many ways. The biggest nugget that we as providers need to learn more about so we can change our services and our interactions appropriately. >> LINDA: Thank you so much, Karen you did an unbelievable job in such a short amount of time. It is really critical to understand that there are actual changes that are taking place in the brain during the time that someone is going through that trauma experience. Then of course that leads to the area of signs and symptoms that we see later on in adulthood. Thank you so much to both of you for answering those questions. Let me tell you that there are many many questions that have come in. We will do our best to answer those questions. We will email you because we have your contact information listed there. Hopefully Patty will join us because some of those questions might be specifically to her. I want to mention just a couple of things. Before I get to resources, wanted to let you know that some of the responses we got are really amazing and wonderful to hear in terms of what you guys do following this webinar. A lot of it has to do with being more aware of language like saying what is strong more often. You want to call attention to staff trauma and well-being. Looking into the possibility of looking into the sanctuary model, you are looking into doing more mindfulness and a number of you said that. Which I think is an extremely helpful technique for both staff and patients as Patty mentioned. Just wonderful responses, we hope that you have gotten a lot out of this webinar today. I want to mention some resources to you that we think it could be very helpful as you continue this work. SAMHSA trauma resources, these resources are at one of the trauma sites which is national Center for trauma informed care. This is a site that will have multiple resources related to your trauma work. I encourage you the concept is a paper that has all the definitions that you will find there. You will also find those kind of resources at our website the Center for integrated health solutions trauma website. Many many resources there including resources on related topics like suicide into violence. Please check those out. Another resource that we wanted to bring to your attention is the ACEs connection, this is kind of a chat box or a listing of lots and lots of different information, they are always updating the information that's coming through there. For instance we recently did a segment on 60 Minutes. You can find that segment there at ACEs connection. It's something you can get signed up to receive on a regular basis. I mentioned earlier, the Kaiser project that Karen is doing through the national Council. There is a poster there called hope beyond hurts. It could be very helpful in you are putting them up in your organization. It really sends a message to both patients and staff. It's okay to talk about trauma here and this is a safe and healing place. Please check out those resources as you have a moment to do so. I just want to also mention that we have resources also at the SAMHSA CIHS integration website right

there. I want to especially thank our speakers today, Karen Johnson from the national Council. Patricia Gerrity from 11th Street Hope Center. Roara for help facilitating this webinar. I want to thank mostly all of you for spending this time with us this afternoon. I think we have had a really amazing turnout today. At the end of this webinar, there will be a survey. We would really appreciate your feedback through that survey. Again, thank you so very much. For joining us and we will do our best to get to all of your questions. Have a great afternoon, everyone!