The Substance Abuse and Mental Health Services Administration (SAMHSA) outlines three criteria for trauma informed services, programs and organizations:

• Awareness: Realizes the widespread impact of trauma and understands potential paths for recovery
• Detection: Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system
• Integration: Responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist retraumatization.

The Agency for Healthcare Research and Quality (AHRQ) defines integration as a process unifying care across different

providers and sites. In our case, it specifically means breaking down barriers between primary care, mental health services, families, and communities (Figure 2). If viewed from a family perspective, integration also includes unifying services for children and other members of their families, especially caregivers For us, trauma-informed integrated care refers to services that unite primary care, mental health, families, and communities while also integrating knowledge of the impact of trauma on all aspects of care. Trauma-informed integrated care seeks to understand the origins of trauma faced by members of communities, to aid efforts to prevent trauma, and to help those who experience trauma flourish despite it. The first step to trauma-informed integrated care is bringing together all members of the team representing primary care, mental health, families, and community services. Only once these key players are “at the same table” can care be transformed using a trauma-informed lens. In the next sections we will explore models of pediatric integrated care. In the following chapters we will outline how services for children and families can be integrated and trauma-informed.

Medical Home Model

In the 1960s, the American Academy of Pediatrics proposed the idea of the “medical home” for children as “a cultivated partnership between the patient, family, and primary care provider in cooperation with specialists and support from the community.” Though the idea has proven more difficult to implement than initially thought, medical homes are now more widely established. Many states and agencies have sponsored medical home learning collaboratives, from which we have drawn valuable lessons. More information is available at www.medicalhomeinfo.org.

Chronic Care Model

The chronic care model (CCM) (Wagner 1996) has provided a way of thinking about how to integrate primary and specialty care for conditions that need treatment and monitoring over time. The CCM outlines roles for patients, primary care providers, staff, and specialists as well as principles of collaboration between generalists-specialists and providers-patient-community.

The CCM provides the following guidance for specialist-generalist collaboration:

• Systematic monitoring: Generalists should routinely look for common problems faced by their patients so that they can intervene early or try to prevent the problems altogether.
• First-Line Intervention: Generalists should have the tools and assistance to provide first-line care for the problems right away.
• Follow-up Systems: Systems should be in place to follow-up the first-line treatment and decide if it has been successful.
• Collaboration: When more treatment is needed, generalists should be able to work closely with specialists to assure that patients get the added care they need, and that the added care fits with the patient’s other medical needs (this is often referred to as “stepped care”).

In addition, the CCM emphasizes provider-patient-community collaboration. The CCM is a model of behavior change, and one of its goals is to help providers partner with patients to develop and nurture over time the skills required for “self management.”

In our case, that means helping families feel more in control of their lives and develop the skills and knowledge to navigate the stressful circumstances that they face.

Each primary care office has a unique structure in place to work with their mental health affiliate – and vice versa. At the level of health care organizations, different services might be provided by the same organization (possibly even the same location) or require coordination across sites. Scheduling and medical record systems might be unified or separate. Clinicians caring for a family might meet regularly as teams, have protocols for talking with each other one-to-one, or have little or no communication with each other. The following table sets out some of the possible combinations and assigns each a “degree of integration,” with close and full integration theoretically being better.

We will now take a moment to explore three specific models of integrated clinical services that can effectively facilitate collaboration between primary care providers and mental health providers: (1) co-location (2) screening, brief intervention, and referral to treatment and (3) task shifting. In practice, elements of all three of these models are often combined.

Co-location

Co-location refers to the placement of a specialist physically in a primary care office (or the opposite – placing a general medical provider at a site that mostly provides mental health services). There is some evidence that co-location increases the proportion of patients who are able to complete a mental health referral. However, there are a number of potential pitfalls, and not all co-location efforts have been successful.

Below are a few suggested best practices for those interested in co-locating services:

Develop a work plan

Start off by developing a shared understanding between generalists and

specialists about how they will work together. What will the specialist help the

generalists learn? What criteria should be used to trigger informal

consultations, team discussions, and referrals? The specialist may need to

learn how the generalists work, too. Before starting, he or she may need to

“shadow” the generalists and spend some time understanding how patients

flow through the site.

Benefits Pitfalls

•! “One stop shopping” Reduces the number

of places clients have to visit, and sometimes

allows more than one type of care to be

delivered back-to-back in the same place

•! Reduce stigma: May reduce some of the

stigma or visibility associated with obtaining

mental health or trauma services – the facility

is not associated uniquely with mental health

or trauma care

•! Personalized referrals: Offers the

opportunity for personalized referrals –

specialist and generalist providers can meet

together with a family to jointly plan how they

will work together

•! Increase consultations: May increase the

chance that specialists and generalists can

informally consult with each other or work as

a team – they are in the same place and more

readily find each other

•! Does not ensure communication: Being in

the same building does not mean that

generalists and specialists will meet each

other or understand each other’s jobs. This

usually requires additional work

•! Diverts responsibility: The presence of the

specialist can lead the generalist to take even

less responsibility for knowing about mental

health or trauma care – the responsibility can

just be shifted

•! Overload specialists’ capacity: The colocated

specialist can be swamped with

referrals, creating delays in treatment that

discourage patients from returning (the same

as when the specialist is located somewhere

else)

•! Budget: No one business model will work

across all sites – in some places the

specialist can bill separately for her services,

in others there will have to be ways of

factoring specialist costs into an overall

budget

Table 4: Benefits and Pitfalls of Co-located Services

!

! 23!

􀀁􀀁Make a communication plan

Both generalists and specialists should set up rules for how they will

communicate with each other and how their “native” work style will be

modified to fit the shared environment. For example, mental health workers

typically do not interrupt visits for telephone calls or knocks at their door, while

primary care providers frequently break visits up into segments and, in some

settings, may actually be seeing more than one patient simultaneously. How

will these styles mesh, especially when there is a perceived need for a quick

consultation or introduction of the patient and co-located therapist?

􀀁􀀁Set up mechanisms for sharing information

How will referrals be made, what information should they contain, and how will

the specialist communicate their findings and suggestions back to the

generalist? Can both specialist and generalist access the same medical

record? How will families be able to control and consent for the exchange of

information? Will mental health or substance treatment notes be kept

separately from general medical records?

􀀁􀀁Develop a business plan

With different types of funding, reimbursements, and billing allowed, how do

the generalists and specialists work in ways that are financially sustainable in

the practice? How are their varying types of work and workload supported?

How does the practice pay for some of the non-reimbursable activities, such

as cross-education, consultation, and care management?

[Note that all of the above points are discussed in greater detail later in the

toolkit, including strategies, since they apply to nearly all forms of integration,

not just to co-location.]

SBIRT (Screening, Brief Intervention, Referral to Treatment)

SBIRT is a model originally developed to identify individuals who could benefit

from alcohol and substance abuse treatment and link them to care. The SBIRT

model might be seen as a special application of the Chronic Care Model as the

two models have very similar elements. The core components of SBIRT are

discussed in Table 5.

! 24!

Table 5: Core Components of SBIRT

1)! Universal screening in primary care

2)! Identification of a specific problem

a)! Provider and patient agree that there is an issue

b)! They work to develop a shared understanding of why the issue requires help and why now is a

good time to act

3)! Brief counseling specific to the problem

•! What might the patient do about the problem now – including seeking more specialized

treatment

4) Long-term tracking of the issue since

a) Many patients may not immediately want to seek care

b) Even those who seek additional care may give it up

c) Many problems are recurring, even if successfully addressed in the short term

Task Shifting

Task shifting (or sharing) is a term for strategies that try to move tasks usually

delivered by specialists (who are in short supply) to less-specialized health

workers who are more easily accessible. For example, in some systems, mental

health professionals deliver all depression care. A task-shifting plan would move

some first-line depression treatments to primary care. Ideally, task shifting always

involves sharing – the specialist and generalist are really sharing responsibilities.

Specialists support generalists by providing training, advice to specific patients,

and by collaborating in the care of patients with greater levels of need. The main

motivations for task shifting are listed in Table 6 below.

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