Defining Trauma in Complex Care Management: Safety-Net Providers’ Perspectives on Structural Vulnerability and Time

Insights Results

Overview of article

• This article delineates how staff of 2 complex care management (CCM) programs in urban safety net hospitals in the United States understand trauma. This article seeks to 1) Describe how staff in CCM programs talk about trauma in their patients’ lives; 2) Discuss how trauma concepts allow staff to understand patients’ symptoms, health-related behaviors, and responses to care as results of structural conditions; and 3) Delineate the mismatch between long-term needs of patients with histories of trauma and the short-term interventions that CCM programs provide.
• Overall, CCM programs have been implemented with private insurance and Medicare patient populations, and more recently in settings that serve Medicaid recipients. They typically enroll patients for a limited period, provide team-based care and health coaching for symptom management, and “graduate” patients back into standard primary care when CCM providers deem them able to self-manage their health. Reviews of CCM best practices do not discuss an optimal length of the time for enrollment. Across CCM programs serving Medicaid patients, high levels of substance use, mental illness, and childhood trauma have been reported

Methods of article

• This paper emerges from a longitudinal study that seeks to understand how the interactions, processes, and organizational arrangements of two CCM programs contribute to patients’ use of health care services and fulfilment of their social and medical needs. The authors focus on 2 programs located within county-run health care systems in the Western U.S.
• This study analyzed data from ethnographic observations and in-depth participant interviews with patients and staff using a grounded theory approach

Results

• The study found that CCM providers defined trauma expansively to include 3 broad categories, as illustrated in the 3 cases below: 1) Individual experiences of violence such as childhood abuse and neglect or recent assault; 2) Structural violence; and 3) Traumatization in the course of accessing health care
• The authors argue that CCM staff understood their patients’ symptoms, health-related behaviors, and responses to care as embedded within structural conditions, and used available resources to provide care that at times went beyond treating mental and physical symptoms to addressing patients’ social position and circumstances. When asked to describe their patients, nearly all CCM providers emphasized social and structural determinants of health
• The authors would have liked to include multiple interviews with the patients whose stories are discussed in this paper, and to review our findings with CCM patients; however, it was difficult to engage many patients in interviews due to their poor health, and would have been quite challenging to ask through them to participate in an additional element of research
• Despite the authors best efforts to interview patients at times when they would be fully able to participate, the majority struggled continuously with fatigue, mental health symptoms, active substance use, and other barriers to participation, rendering it difficult to carry out extensive, in-depth interviews. Their poor health (a substantial number of patients also died during the course of data collection) also precluded participation in a process of validating our interpretation of patient interview data

Key takeaways/implications

• Compared to most health care providers, CCM staff had a great deal of flexibility in how they used their time, which allowed them to screen and respond to trauma alongside other patient needs. Nurses, community health workers and social workers were able and expected to have frequent, sometimes lengthy interactions with patients. They had flexibility to accommodate patients’ constraints; for example, staff in 1 program provided transportation vouchers, and made frequent home visits
• Trauma-informed care and structural competency approaches complement each other. A structural competency approach would also examine the structural racism of a system that leaves many people in the area we are studying homeless with little possibility of finding affordable, permanent housing. Nascent efforts to use a structural competency framework seek to address both individuals’ health and the community circumstances in which individuals live, yet there are few examples of how such an approach could be used to address patients in the later stages of complex illness such as those cared for by CCM teams