Research on the impact of trauma has exploded over the past 40 years, showing a clear link between traumatic experiences and overall health and well-being. CareOregon, the state’s largest Medicaid managed care plan, established HRP to provide trauma-informed care management for Medicaid and dually eligible Medicare-Medicaid beneficiaries with complex health and psychosocial needs. The program is designed to address the bio-psychosocial needs of this population using a strengths-based, trauma-informed approach to advance client-identified health goals.

Guiding principles of CareOregon’s trauma-informed approach include:

• Reducing barriers: Avoid lengthy assessment processes or asking for personal information before a relationship is built.
• Remaining client-centered: Meet the client/medical staff ‘where they are;’ collaborate on client and programmatic goals.
• Embracing transparency: Be open about intentions and do not withhold information from clients or providers.
• Building a relationship: Be honest and transparent, offer clients choices, and collaborate with them. We do not operate on a billable hours model, which means we can build a relationship at the client’s pace.
• Avoiding judgment and labels: Classifying someone a “drug abuser” or “non-compliant” makes it difficult to form a trusting, unbiased relationship with clients.
• Staying community based: Reach out to clients in their own environments and ensure meetings take place in a non-hierarchical setting.

Why Develop a “Trauma-Informed” Workforce?

Many of the individuals served by the HRP have experienced adverse childhood experiences, such as abuse or neglect in early childhood, setting them on a course for increased marginalization and vulnerability. Traditional approaches to care that do not take into account history and life experiences are typically not effective for this population. A trauma-informed care approach supports accountability and responsibility by recognizing the limitations that traumatic experiences have on one’s ability to make decisions, communicate, and process information.

Individuals who have experienced trauma may have difficulty trusting authority figures and tend to fare poorly within traditional health care structures. To engage this group, it is critical to develop a workforce that is aware of the effects of trauma and potential behaviors related to past trauma. For instance, labeling someone as “non-compliant,” “drug seeking,” “borderline,” or ”personality-disordered,” may negatively affect how providers perceive and deliver services to that person.

By using a trauma-informed lens, health resiliency specialists can recognize certain socially unacceptable or “noncompliant” behaviors as an indicator that someone may have a history of trauma. This prompts the specialist to ask: what happened to this person, rather than what is wrong with this person. Health resiliency specialists replace judgment with curiosity, and work to build trust by listening, collaborating, and being transparent.

What Do Health Resiliency Specialists Do?

CareOregon’s health resiliency specialists engage in trauma-informed care with clients from their very first contact. This process begins with listening, then asking if a client wants help and, if so, what kind of help with their health goals. Health resiliency specialists model communication skills, healthy behavior, self-advocacy, and planning for the future. They also provide information on health literacy, social services, and what to expect at a doctor visit, eliciting client input throughout their interactions. These specialists provide the foundational steps to build future healing, which include collaboration, empowerment, choices, transparency, focusing on strengths rather than weaknesses, skill building and providing hope.

How Do We Hire?

Building HRP’s trauma-informed workforce begins with screening potential candidates who are committed to and familiar with trauma-informed care principles, including the importance of resiliency. HRP uses “behavioral interviewing” techniques, where candidates are asked to provide examples of how they have handled challenging situations, such as working with someone who did not want to follow a doctor’s treatment plan. Interviewers hope to hear something like “I would sit down with the client and ask them what they think is going on, and what they understand about the plan.”

Most HRP staff have master’s degrees in either social work or psychology. They are trained in trauma-informed care principles, motivational interviewing, case management in the community, safe home visiting, understanding the social determinants of health, setting boundaries, self-care, mental health and addictions issues, and working with people living in poverty. HRP staff work both in the field and in the primary care setting, and must have the ability to make informed decisions on their own.

Challenges

Given the traumatic stories encountered daily, staff burn-out is a key challenge for HRP, which engages its specialists in ongoing discussions about how to stay motivated. Besides encouraging time off whenever needed, HRP is also looking at the potential of rotating specialists to other positions for some months as a way to step back. We encourage self-reflection, open discussion of the hard work, and asking for support from all. While the challenges may sometimes seem overwhelming, the rewards of helping individuals find resiliency in their lives is empowering – not only for our clients, but also for our staff.