Fostering Resilience and Recovery: Change Concept 5

December 15, 2019

Finance and Sustain Trauma-Informed Approaches in Primary Care

Identifying and developing a sustainable financing strategy is critical to effective implementation and maintenance of a trauma-informed approach in primary care. To do this, an organization must secure adequate financial and organizational resources including identification of relevant policy, reimbursement processes and opportunities within existing service incentive programs. The alignment of workflow and staffing with reimbursement options is paramount to success.

Change Concept 5 Goals

  1. Our primary care service’s budget includes funding for structural and administrative resources specific to comprehensive integration of trauma-informed approaches.
  2. Our primary care service’s budget includes funding for ongoing cross-sector training regarding trauma-informed approaches.
  3. Our primary care service’s budget includes funding for the maintenance of a safe physical environment.
  4. Our primary care service recognizes that finances are not our only resource. Equip staff to support patients in engaging with community social resources that align with their care.
  5. Our primary care service identifies desired outcomes of the trauma-informed primary care initiative.
  6. Our primary care service actively monitors patient-level outcomes of trauma-informed interventions for a target patient population.
Identify all planned, new and existing activities and procedures resulting from implementation of trauma-informed approaches

Organizations need to identify activities, procedures, staffing, spaces and equipment related to trauma-informed care. Understanding what exists currently or what will in the future, will enable an organization to plan for funding and reimbursement options.

Measure trauma-informed activities

Tracking processes and outcomes related to trauma-informed initiatives and activities helps develop a value case for your services. Each organization’s scope of services and data collection, management, analysis, reporting and interpretation capabilities are unique and will shape the ability to understand the effect of trauma-informed primary care efforts at the organization.

Existing activities and funding streams may inform or drive data collection efforts, particularly for patient level health metrics. By identifying activities, procedures, staffing, spaces and equipment, your organization can decide what kinds of clinical encounters are reimbursable by funders and payers under current agreements versus creating agreements in the future. The Trauma-Informed Care Quality Outcomes Crosswalk is a tool that organizations can use to help assist in this process.

Choosing Data to Track

The CIT and staff responsible for quality improvement should explore available data indicators to track over time. The tools provided throughout the Change Package to assess safety, staff and patient satisfaction and training evaluations provide CITs an opportunity to track implementation progress specific to their goals and action steps. The OSA Workbook provides a list of indicators to help assess your implementation. The CIT should also track readily-available information about engagement, such as staff turnover and number of personal and sick days taken. As you integrate trauma-informed care into your organization, these values should decrease and will likely be among the first metrics that change as a result of your initiative.

Eventually, the CIT and staff responsible for quality improvement should identify key health metrics among patients to track over time. The goal of trauma-informed primary care is to improve the quality of care and the health of patients. While it may take time for implementation to settle in before you see demonstrated improvement in these metrics, it is important to capture and track them over time to inform your service provision and action planning.

Organizations can track their data at the patient level by using the Patient-Level Outcomes Data Collection Template. The full chapter contains examples of common patient- level process and outcome measures. Research suggests these chronic health indicators will improve as you adopt trauma-informed care.


Use billing mechanisms to finance trauma-informed approaches

Adequate resources are critical to long-term sustainability of trauma-informed practices in primary care settings. Because there are very few direct payment or reimbursement mechanisms specifically indicated for trauma-informed activities, it is important to incorporate trauma-informed practices into existing services that receive reimbursement from payers. Organizations will not see billing codes that read “trauma.” To finance trauma-informed activities, organizations should focus on larger shifts in health financing, including the movement toward integrated behavioral health and primary care, value-based payment mechanisms and bundled rates for services.

There are a growing number of value-based and other alternative payment models to support integrated behavioral health services within primary care settings. These include integrating behavioral health outcomes within value-based managed care contracts, pay-for-reporting and pay-for-performance within fee-for-service contracts, shared savings and condition-specific population-based payments.

Organizations should also strive to use billing codes strategically to support trauma-informed services. Because there are no billing codes specifically for trauma-informed services, organizations need to understand how trauma-informed services fit into the existing services they provide and bill for. The full chapter provides a list of common billing codes used to support trauma-informed services. Additionally, specific guidance regarding financing trauma-informed practices is found in the Financing Trauma-Informed Primary Care resource.

Identify nonfinancial resources for support

Not all aspects of sustainability are directly related to financial support. There are other resources that are critical to embedding trauma-informed practices, including patients, individuals with lived experience and the community itself. Establishing robust partnerships with existing community services and supports and including a range of community stakeholders on advisory and governing boards are examples of ways to leverage nonfinancial resources to support trauma-informed efforts. By continually involving the community, your organization recommits to the principles of trauma-informed care, particularly empowerment, voice and choice. Increasing community-wide understanding of trauma and resilience increases the capacity of your referral partners to provide relevant and responsive services to advance trauma-informed approaches across systems of care.

Analyze policy landscape and select an advocacy goal to support financing and sustainment

In addition to looking at an organization’s internal policies, it is imperative to assess the current and potential external policy landscape to align support and maintain trauma-informed practices and set an advocacy goal based on that assessment. Legislators, regulators and funders make decisions every day that will either help improve access to care for those who need it or make it more difficult for your organization to serve your community. Ensuring that these stakeholders have current information on the prevalence and impact of trauma and the relevance and effectiveness of trauma-informed approaches will ensure you don’t miss opportunities to financially support and sustain this work.

Develop and tailor advocacy messaging for identified stakeholders

Organizations need to create advocacy messaging that aligns with its trauma-informed practice efforts. The Trauma-Informed Care Advocacy Handbook is a guide you can use to develop a plan and approach to speak to legislators, regulators and funders. Part of the process includes getting to know your legislators, regulators and funders and their positions on your issues; introducing yourself and your organization via email or in-person; and attending upcoming community events or town halls or inviting your legislator to visit your agency.

Sustain a trauma-informed approach

Sustaining trauma-informed practices in primary care requires ongoing financial and operational support. In addition to financial resources, ongoing clear and consistent leadership, engaged staff buy-in and a commitment to continuous quality improvement are factors for sustainability. The Trauma-Informed Care Sustainability Guide contains detailed organizational considerations for sustaining a trauma-informed approach.

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