Trauma-Informed Care Approach in Family Practice: Steps to Implementing

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Introduction
The traumatic experiences of living during the COVID-19 pandemic have had a massive impact on stress levels and overall mental health, not excluding our children (Zengin et al., 2021).Children experienced changes in school, home life, nutrition, sleep, and social interactions during the pandemic (Zengin et al., 2021).Children affected by these traumatic experiences and other adverse childhood experiences (ACEs) often experience chronic stress, increasing the risk of mental illness and negative coping behaviors such as alcohol abuse and tobacco use as teens and adults (Esden, 2018).Chronic stress also affects the body's regulatory systems contributing to chronic diseases in adulthood, such as heart disease, diabetes, and chronic pain syndrome (Esden, 2018).Chronic diseases add burden to the patient, family, health system, and community.
Mental health concerns are often brought up in primary care family practice.However, family practice health care providers may not feel confident or competent enough to address mental health concerns, causing them to often brush over the topic.Improving health care provider knowledge and comfort level in addressing these issues is imperative since "75% of children see a pediatrician or primary care provider at least once a year, only 4% see a mental health provider" (Sala-Hamrick et al., 2021, p. 3).
Addressing ACEs and other traumatic experiences our children have experienced is needed.Confronting childhood trauma earlier improves outcomes, such as decreased long-term services and care costs (Hornor et al., 2019).So how can we address children's stress and trauma issues better in primary care family practice?Primary care family practice providers can do this with a trauma-informed care (TIC) approach.TIC is the framework developed to care for people with a history of adverse childhood experiences and other traumatic experiences (Esden, 2018;Cannon, 2020).TIC has long been utilized effectively in settings such as mental health, social services, and substance abuse treatment centers and has been shown to improve health outcomes in those settings (Stevens et al., 2019).
having experienced trauma and stress during their life.It changes the perspective from "what is wrong with you" to "what happened to you" (SAMHSA, 2014, p. 17).The new perspective helps the provider avoid making assumptions to better understand the patient and the family from their experiences.This approach builds trust and improves communication to encourage a cohesive relationship between the provider and the family.The TIC approach improves the health and well-being of the family and can assist families in breaking the cycle of abuse that often occurs with a history of trauma and ACEs (Champine et al., 2018).
The benefits of the TIC approach are evident, so why aren't primary care family practice care providers utilizing it more?Patients report they would answer trauma questions truthfully if providers asked, unfortunately, providers rarely ask (Hamberger et al., 2019).This is due to a significant gap in provider and staff clinical knowledge and training in assessing ACEs and other trauma and how to implement a TIC approach in primary care (Barnes et al., 2020;Horner et al., 2019;Stevens et al., 2019;Stokes et al., 2017).Healthcare providers are rarely educated or trained in the TIC approach; thus, implementation has been sparse.
A TIC approach can potentially decrease the suffering of the child and family and positively impact children's current and future mental and physical health.Utilizing a structured process to assist in implementation of a TIC approach can increase knowledge and comfort level.TIC can then become part of our daily healthcare practices, like other annual well-child screenings.There is little literature available on how to implement a TIC approach in family practice.This article aims to develop a structured, step by step process for implementing a TIC approach to the care of children in family practice primary care settings.

Method
The study utilized an integrative literature review to determine the best process of implementing a TIC approach in the family practice primary care setting.Peer reviewed articles, government websites, and professional association websites were reviewed.Search terminology included trauma informed care, children, primary care, family practice, best practice, and implementation.The literature led to further search of the referenced websites.Inclusion criteria was of materials related to TIC implementation primary healthcare settings.Exclusion criteria was of materials not related to a primary care setting.This excluded emergency departments and mental health facilities and non-medical settings such as criminal justice, and social services from the review.

Results
The data analysis included 18 articles and websites.Several themes emerged from the analysis of implementing a TIC approach.The first was the use of universal screening.Universal screening for ACEs and trauma in children annually was found to be essential (AAP, 2020; Barnes et al., 2020;Bendall et al., 2020;Brown et al., 2017;Bryant & VanGraafeiland, 2020;Chokshi & Skjoldager, 2020;Hamberger et al.,2019;Hornor et al., 2019;Menschner & Maul, 2016).Bryant and VanGraafeiland (2020) implemented an annual screening using the Center for Youth and Wellness (CYW-ACE) forms available free of charge.Screening is vital as ACEs and trauma are as common as other conditions screened currently, such as anemia and developmental delays (Barnes et al., 2020).The need to screen is necessary, even with the risk of re-traumatization, which is reduced with proper staff training and a referral system (Bendall et al., 2020).Barnes et al. (2020) also recommend screening for protective factors to help empower patients and families and increase resilience.
The third theme found in the data for implementing TIC in the primary care of children is the ability to connect patients and families with needed resources (Barnes et al., 2020;Bendall et al., 2020;Brown et al., 2017;Bryant & VanGraafeiland, 2020;Hornor et al., 2019;Menschner & Maul, 2016).Providers felt a lack of resources, such as mental health and community services, was a barrier to care, stressing the importance of having a referral system in place with TIC best practices.Developing an effective referral system for providers is key for successful implementation, as is the need to increase community awareness through public and community health education (Hornor et al., 2019;Menschner & Maul, 2016, Raja et al., 2015).
The fourth theme identified was the imperative to get organization leadership buy-in and support for TIC implementation (Menscher & Maul, 2016, SAMHSA, 2014).The SAMHSA (2014) guidelines provide the needed structure to accomplish this with the 10 implementation domains (a). governance and leadership; (b).policy; (c).physical environment; (d).engagement and involvement; (e).cross-sector collaboration; (f).screening, assessment, and treatment; (g).training and workforce development; (h).progress monitoring and quality assurance; (i).financing; and (j).evaluation (SAMHSA, 2014).The guidelines will help clinics to implement TIC into practice efficiently and effectively.If problems arise, clinics can refer to the guidelines to get back on track with implementation.

Discussion
Proper planning is essential to ensure the success of implementation.The following best practice steps break down the process to ease the transition of implementing a TIC approach.

Steps to Implementing a TIC Approach
 Step 1: Seek support from the organization and community stakeholders.Meet with leadership and community stakeholders, such as public health, community health, mental health providers, and schools, to determine needs of the community and learn what resources are currently available.Working together will reduce duplicate services and create a cohesive community in action.Some talking points for the meeting include discussing the risks vs. benefits of implementing a TIC approach.Risks include the possibility of re-traumatization and increased provider and staff time.Benefits include decreased short and long-term mental/physical health issues, decreased health costs over time, and improved community health and well-being.Another point of discussion is the costs involved and the determination of funds available for implementation.State grants or other local funds may be available to help cover the costs.Public health is an excellent resource for locating these opportunities.Some costs to consider in the implementation include training sessions for providers and staff, screening tools, time to screen, and time to make referrals.An additional point of discussion is developing a policy to implement a universal TIC approach to care for children in the primary care family practice primary care setting with the goal of screening all children for ACEs and other trauma annually at well-child visits.Screening all children avoids stereotyping and provider assumptions.

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Step 2: The next step is providing TIC approach training to all; "from receptionist to nurses, from physicians to learners and other allied health professionals" (Purkey et al., 2018, p. 170) (Barnes et al., 2020;Bendall et al., 2020;Bryant & VanGraafeiland, 2019;Cannon et al., 2020;Horner et al., 2019;Pletcher et al., 2019).Periodic evaluation and training of best practices of TIC will keep providers and staff up to date and on track.The SAMHSA (2014) guides staff training with the four key assumptions: 1. realization and understanding the effects of trauma; 2. recognize and assist staff in noticing signs of trauma; 3. respond and apply the principles; and 4. resist re-traumatization to patients and staff.

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Step 3: Begin the universal screening of ACEs and trauma in all children annually (Barnes et al., 2020;Bendall et al., 2020;Bryant & VanGraafeiland, 2019;Horner et al., 2019).Feeling heard and cared for may be all the patient and family need.Barnes et al. (2020) also recommends screening for protective factors to empower patients and families and increase resilience.The Center for Youth and Wellness (CYW) (2022) has resources available at no cost, including screening tools.The tools include a user guide with easy-to-follow steps and scripting for clinic staff and providers.The facilities may use this in paper form, embed it into the EMR, or use a similar document in the current system if available.

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Step 4: Connecting patients and families with needed resources ais best practice in implementing a TIC approach in children's primary care (Barnes et al., 2020;Bryant & VanGraafeiland, 2019;Horner et al., 2019).Developing an effective referral system for primary care family practice providers is vital for successful implementation, as is the need to increase community awareness through public and community health education (Horner et al., 2019).Facilities should utilize available services, like Healthy Families America and the Bounce Back Project.Contact information for these services, local mental health services, and online resources such as the CYW (2022) website, and the Aunt Berthas findhelp.orgwebsite should be developed for the provider and for the patient and family to have readily available for reference and referral.There are many online resources that the patient or the family can easily access at home to learn more about mental health.Gaining knowledge helps to empower the patient and family to manage their mental health better.Feeling supported and knowing they matter can be the catalyst for the change needed.

Implications
Confronting childhood trauma earlier improves outcomes, such as decreased long-term service needs and care costs (Horner et al., 2019).Implementing TIC best practice approach in the primary care family practice setting can improve the health of our children, families, and communities.Increasing health care providers knowledge of TIC is key.Continuing education and teaching a TIC approach must be incorporated in nursing and medical school programs.Pletcher et al. (2019) states it is "imperative that health care providers receive training on ACEs as a health equality topic" (p.2).Cannon et al. (2020) propose adding TIC education to nursing programs as well.
Nursing "is the largest professional healthcare workforce…in a unique position to provide TIC and impact the quality-of-care patients receive" (Cannon et al., 2020, p. 4).This will improve knowledge and comfort level to address trauma as universal patient care.
More research on the TIC approach of children in nursing and primary care family practice is needed.Much of the current research on TIC is related to adults in the mental health, substance abuse, social services, and justice systems.Another area of study for TIC is pertaining to the effects of the COVID-19 pandemic on children's health.Lusk (2020) explains, "Anxiety, lack of peer contact, and reduced opportunities for stress regulation are main concerns and children and teens with lack of resources and history of ACEs and social complex needs are at greater risk for poor outcomes" (p.185).

Limitations
The findings of this study need to be seen considering the limitations.Limitations include the lack of current research on the use of TIC in primary care family practice settings.Because much of the current research on TIC is related to mental health, substance use, and emergency care, this limited the research data available for analysis in determining the best practice steps to implement in primary care settings.Much was relied on governmental and professional websites rather than peer-reviewed journal articles.The future is open for more research on TIC implementation, utilization, and effectiveness in primary care family practice.Other areas open for future studies include training nursing students on TIC in undergraduate and graduate nursing programs and examining the effectiveness of continuing education training of practitioners and staff in primary care settings.

Summary
The evidence shows the detrimental effect of ACEs and other traumatic experiences on health outcomes.These effects contribute to an increased risk of chronic disease, adverse coping behaviors, decreased productivity, increased healthcare costs, and shortened life expectancy.Addressing trauma earlier in life can improve care and health outcomes.TIC is the framework to guide care for people with a history of ACEs and other trauma.The research supports the need for provider readiness and implementation of the best practice TIC approach for children in primary care, though more research is needed.The barriers to implementing a TIC approach for children in primary care are lack of knowledge, time constraints, and decreased awareness of resources that can accept referrals.The barriers are addressed with the steps outlined including provider and staff training, universal screening for ACEs and trauma at all well-child exams, and a referral and resource process in collaboration with local mental health providers, public health, and social services.Current guidelines assist in planning the implementation of TIC in primary care family practice.Knowledge and training of TIC best practices ensures proper care of children and families.TIC implementation with children in family practice primary care can potentially decrease the short-term and long-term effects of ACEs and other traumas on children and the family, decrease suffering, and create more resilient and healthier communities now and in the future.

Declarations
The author did not receive support from any organization for the submitted work.The author has no relevant financial or non-financial interests to disclose.