It's 1 or 2 as people are coming in. We want to welcome you. And to be respectful of everybody's time, we'll go ahead and get started. Hi, everyone, and welcome to ACPM's webinar on React and Respond, A Trauma-Informed Approach to Care. This webinar is conceptualized by ACPM Summer Policy Fellow Ariana Ali, who is a rising second-year medical student at George Washington University School of Medical and Health Sciences. My name is Anita Balan. I am the ACPM Director of Residency Engagement and Development. I have the privilege of working alongside Ariana. This is her labor of love and passion, and I'm just in her place. I hope I can do justice in moderating this webinar. I'm very honored today to present today's webinar and feature an incredible panel of speakers, each of whom will present different aspects of integrating a trauma-informed approach to care. Today's speakers include Dr. Alex Crosby, Dr. Victoriana Schwartz, and Dr. Elizabeth Tilson, and I will be introducing each of them throughout the webinar. Research shows that traumatic stress has physiological manifestations in patients, increasing the risk of numerous chronic and mental illnesses. By reshaping our care to be trauma-informed, we can take the necessary steps towards addressing and improving health outcomes at the patient and population levels. We also saw this manifest itself at the clinical and a population level during the COVID pandemic, which is why this is such an incredibly important topic, given the role that preventive medicine physicians have faced in the front lines and at systems level and a clinical level in addressing the pandemic as well. Our speakers have no disclosures. Throughout the webinar, please feel free to post the question and answers into the Q&A tab or the chat. I will be monitoring them and we will have time towards the end to answer your questions. Panelists will have time towards the end to answer the questions. These are the overarching learning objectives. Each of the speaker will also provide some additional learning objectives. Through today's webinar, we hope you get away with understanding the benefits of trauma-informed care and building a trauma-informed care organization within clinical and public health settings to advance patient and population health outcomes, identifying and applying best practices for developing coalitions to build a trauma-informed community and articulating how preventive medicine physicians can contribute to promoting a trauma-informed institution. Before I have the privilege of introducing Dr. Alex Rothby, our first speaker, I just want to set the stage and share with you that according to Substance Abuse and Mental Health Services Administration, SAMHSA, a U.S. governmental agency, a program, organization or a system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery, recognizes the signs and symptoms of trauma in patients, families, staff and others involved in the system, responds by fully integrating knowledge about trauma into policies, procedures and practices and seeks to actively resist re-traumatization. And we're gonna be learning a little bit more about each of these today from our speakers. So without further ado, it is my privilege to introduce Dr. Alex Crosby. Dr. Crosby is a professor at Morehouse School of Medicine. He has worked at the Centers for Disease Control and Prevention for 30 years, responding to various public health emergencies, including firearm-related injuries, coronavirus and much more. He completed his medical degree in Howard University and his MPH in Health Administration and Management at Emory University's School of Public Health. He went on to complete his residency training in family medicine and public health and general preventive medicine and received additional training in epidemiology. Without further ado, Dr. Crosby, over to you. Thank you very much and thank you for the introduction, Ms. Vailen and also wanted to say good afternoon or those of you who are on the East Coast this afternoon, some of you, it may still be part of the morning, but thank you. Thank you for the invitation from the American College of Preventive Medicine, Ms. Ali for setting this up and also Ms. Vailen. What I'm gonna talk about as you see is hospital community partnerships with trauma-informed care practices. Just one piece of what we'll be talking about this afternoon. And so as part of that, why is this an important topic for us to try to address that unfortunately, when you look across the United States and actually across the world, trauma is much too prevalent, if you will. And those who have been exposed to trauma, what can we do for those that may be suffering from the consequences of trauma? And how can we make that in terms of our systems, how we interact with those populations, those communities, what we do in terms of response, what can we do to better understand as well as better look for the future of what's happening in regards to trauma-informed care. And so the plan is, we can move on to the next slide. What I'll do in terms of learning objectives is I'll define trauma a little bit according to some of the definitions that we've seen as Ms. Vailen quoted from the Substance Abuse and Mental Health Services Administration, talk a little bit about trauma, describe some of the magnitude of suicidal behaviors and of course, how it relates to trauma and then cite some examples of hospital-based interventions for violence prevention. You can go on to the next slide. So how do we define what trauma is? And from one definition, it's an event or a set of events or a series of events or circumstances directly or indirectly experienced. As some of you may know, someone can be the direct victim of trauma or can witness a traumatic event and be affected in that way. It can be a child or an adult experiences and the sum of that event experience or the effects for each individual and it can be experienced differently by each person. So even though, for example, you might have two or three people that witnessed the same traumatic event, the effect can be very different on each of those individuals that saw them. Next slide, please. So here are some of the core values of trauma-informed care and you can see it just depicted here as this cycle. Safety as one, trustworthiness, that the individual has to trust those caregivers, choice, collaboration, and empowerment. Next slide. So in terms of lifetime exposure to traumatic events, exposure to traumatic events among U.S. adults, about nine out of every 10, 89.7% of adults in the U.S. experienced a traumatic event in their lifetime. This is according to the Diagnostic and Statistical Manual Version 3 in terms of a criterion A event. And you can see the resource down there. Some of the different types of traumatic events included exposure to a disaster, it can be a natural human disaster or a natural disaster, accident or fire, hazardous chemicals, combat or war zone, sexual or physical assault, a witnessed sexual or physical assault, witness dead bodies, family or a close friend that was threatened or injured, exposure to a death due to a violent event, an accident or disaster, or a work or a secondary exposure that's some way to have that. And you might think of someone that might work in firefighting or someone that might work as a paramedic or emergency medical technician or somebody in law enforcement that as part of their work, they might be exposed. Next slide, please. So in terms of a post-traumatic stress disorder, so we talked about almost 90% of U.S. adults have been exposed to some sort of traumatic event. However, when you look at post-traumatic stress disorder, which is one of the consequences of exposure to a traumatic event, it's only one out of every 20. So that's still a high number, but not as many as if you were thinking about the 90% that have had an exposure versus only one out of 20 having a post-traumatic stress disorder. So you see about five of every 100 adults in the U.S. has PTSD on any given year. In 2020, about 13 million U.S. residents had PTSD. And this came from some information from U.S. Department of Veterans Affairs, but it looked at veterans as well as civilians. Next slide, please. So there are some different approaches and some different resources for addressing the issue of trauma in different populations. One of the ones that I'll mention is the Centers for Disease Control and Prevention produced several documents called Resources for Action. They were formerly called technical packages, and they produced them under these several different topics that you see here on the side, about six different topics. One in terms of these resources for action were really some recommended or at least the best available evidence to address some of these particular issues in regards to violence. These all came from the Division of Violence Prevention there at CDC to address child abuse and neglect, to address sexual violence, youth violence, intimate partner violence, suicide prevention, as well as adverse childhood experiences. And we'll talk about the ones that address youth violence prevention in terms of what was some of the best or the most promising types of strategies, approaches, and programs. Next slide, please. So here are the six different approaches that were identified in terms of being the best available. And you can see kind of in the highlight, if you go down to the bottom, those strategies that intervene to lessen harms and prevent future risk. And you can see down at the bottom there, hospital community partnerships. And so we'll talk just a little bit about some of those hospital and community partnerships. Next slide, please. So here are a few of those in kind of in the general category of those programs or those strategies that intervene to lessen harms and prevent future risk. One is treatment to lessen harms of violence exposures. And so you can see trauma-focused cognitive behavioral therapy, cognitive behavioral intervention for trauma specifically in schools. Next, treatment to prevent problem behavior and further involvement in violence. And there's several different categories here, functional family therapy, multidimensional treatment in terms of foster care, implemented in the foster care situation, and then also multisystemic therapy. Next slide, please. And so here are some of the ones in regards to hospital community partnerships, one called Safer Teens and another called Caught in the Crossfire. I'll mention just one adaptation of Caught in the Crossfire, which has to do with ceasefire or violence interrupters, a program that was developed, I think, initially implemented in Chicago through Dr. Gary Slutkin that developed these violence interrupters that were trained community members, in some cases, those who had lived experience in regards to violence, to go out and to interrupt violence. Their approach was that in many cases, violence was like a contagious disease, that just like a contagious disease where it can spread from one person to another, what might happen with some violent events is that you would find people trying to engage in retribution or revenge. And so that violence that occurred for one individual might spread to others. And so with these violence interrupters, they had those trained in the community, they had trained community members that could go out and interrupt the violence because there was an individual that had been a victim of violence, that maybe their friends, maybe their family members wanted to go out and seek revenge. How could you interrupt that violence to provide alternatives so that those who were victims or who had been exposed to that violence would not go out and try to replicate that violence on someone else or those who they thought were responsible? We can go into the next slide. I wanted to describe a couple of specific programs that give examples of that community hospital partnership trying to address trauma-informed care. One is occurring in the city of Atlanta, Grady Hospital, which is the large public hospital that primarily serves Fulton County and DeKalb County, which are the two counties that incorporate the city of Atlanta. It's at Grady Hospital, it's called Grady's Interrupting Violence in Youth and Young Adults, the IVY Project, Interrupting Violence in Youth and Young Adults. Two of the primary investigators, Dr. Noor Bakash and then Dr. Randy Smith. We can go into the next slide, please. And so here are some of the components of that system, of that IVY interruption, that violence interruption project and kind of starting at the top and kind of going around clockwise that they have trauma surgeons that are involved. You also have credible messengers that work with the patients as well as work with the community members. You have criminologists that are able to look at the data, look at the forensic data, identify what's going on in terms of what might be understanding perpetrators as well as victims. You also have next public health professionals kind of looking at some of the issues from a public health approach, where especially is the opportunities for prevention, whether you're looking at primary, secondary, tertiary prevention. How can we also look at upstream versus midstream versus downstream types of interventions? Next is you're looking at how the clergy can be involved with that might be the chaplains in the hospital or also clergy in the community that might be involved with these activities. Next is emergency medicine physicians that might be the first ones to see the patient when they're admitted to the hospital or admitted into the emergency department. Next is nursing. So there's involvement with all of these as I kind of go through these different disciplines and different sectors that are involved. How do we make sure that we're doing training of all of these different professionals so that they know the best way to interact and communicate with the patients? So kind of dropping back to the nurses, also community health workers that can also be those that are ambassadors out into the community to talk about some of the issues regarding violence and violence prevention. Social workers. I mentioned social workers in this light, but they're not the only ones because oftentimes what we have found is that the social determinants of health are important risk factors in the occurrence of violence in communities. So social workers play a very critical role in terms of looking at things like housing, looking at things like employment, looking at things like finances as one of the aspects that play a role in violence prevention. And then lastly, up near the top, educators, understanding especially with youth that might be in school. How do we understand how they are functioning in schools? What are the school's role in trying to prevent violence prevention? You can move on to the next slide, please. This is some of the process of what might happen in regards to the intervention, arrival at the hospital. What is the golden moment in terms of the first providers or clinicians interacting with the victim, especially those who have been victims of the violence, doing a needs assessment that looks at not just the physical needs, but also what are some of the social needs, ongoing research focus. So how do we also understand what are those risk factors for the aggregate population, as well as that individual, a warm handoff to community case management, and then in-hospital case management so that we're addressing some of the problems even before the person is discharged. Next slide, please. All right, and then we will move on to one other one, less than a 1% in terms of re-injury rate of the IV participants. So they've been able to drastically reduce the number of patients that return because they've been re-traumatized. Next slide, please. This is another program that operates out of North Carolina Atrium Health, and then I will wrap it up here. It's a hospital-based violence intervention program called the Project Building Optimum Outcomes for Survivors of Trauma called BOOST. Here's some of the key goals of that program. Identify the needs of the participants, connect the patients to community resources, grow the community connections, and then reduce recidivism. One of the things that you might notice is that they're very similar objectives and goals and interventions with this program and also the one in Grady. Next slide, please. This is some of their violence prevention program, who it is that they serve. Got patients between 15 and 25, intentional injury mechanisms such as gunshot wounds, stabbings, and assaults, and their approach is identify the patients at multiple entry points into the system, whether that's emergency department trauma services, pediatric trauma services, orthopedics, do a comprehensive evaluation of those patients to identify health and social needs, connect those patients to tailored resources through referrals to a community resource hub, and then provide long-term follow-up with participants to ensure adherence to the plan. Next slide, please. And in conclusion for this, trauma does affect a major portion of the US population. It can result from many different sources, has wide-ranging consequences, but there are some successful programs that can lessen or eliminate the effects of trauma. In particular, we've talked about some of the hospital community partnerships and addressing trauma requires a broad community partnership. It's not just the clinicians in the hospital, but how they work with communities that can really make the difference. Thank you very much. Thank you, Dr. Crosby. Okay. I think it was incredibly beneficial to receive an overview of just a basic introduction to trauma and also learn about the critical role that community partnerships play in addressing trauma. I would now like to introduce our second speaker, Dr. Victoriana Schwartz. Dr. Schwartz received her medical degree from the Medical College of Wisconsin and is currently completing her residency in public health and general preventive medicine with Cook County Health and her MPH with Northwestern University Feinberg School of Medicine in Chicago. She's also a board certified lifestyle medicine physician. Prior to her preventive medicine residency, she trained at the University of Chicago in general surgery where she faced the exacerbated ethics of the COVID-19 pandemic on preventive and primary care access, gun violence rates and trauma services. This up close experience treating gun violence victims and Chicago's health disparities led her to match to working on upstream public health issues with a focus on underserved and disproportionately affected populations. Dr. Schwartz, just give me one moment as I share the screen. Thanks for controlling that for me. I need to... Absolutely. Just a moment. I'm having to navigate a couple of screens. Just give me one second. And take it away. I'm not sure if it changed for me. I can only see the conclusion side but hopefully it looks good for everybody else. But, um, I did. Should I start or. Yeah, please go ahead and start I think I think okay let me just go ahead and see if I can share one more time. So, um, yeah. Hi, I'm Victoriana Schwartz, I am finishing up my residency in public health and preventive medicine in Chicago. I have experience in general surgery, which has led to my experience in implementing programs at Cook County Health. And so, in my presentation, I'll be going through our experiences here at our institution with implementing, you know, our transformative change and trauma informed care, and what that looks like at a real place. And then, you know, I'll talk about like some of the steps that we followed. As soon as we get into it. One second I think I had to switch the screen I'm having a little bit of a technical issue. Oh, you have my words up. I think it should. I think you want to put it on presenter mode. So the notes aren't there. Yeah, that's what I'm trying to do just one second. Yay. Now, I think we have it now. Yes, please go ahead. I'll have to thank Anita for for doing all all this work you know, and also future Dr. Ali who put together this presentation, I mean, I think it's a wonderful topic that all of us should learn about. I'm obviously super biased. So, getting into it some of the learning objectives that are in my portion of the talk are here. So, we had a great overview of what trauma informed care means and what that kind of looks like in a setting of hospital based violence intervention programs. So I'll be talking about how to transform from an institutional level and what that means. So it's incorporating language in the practices in order for you to be able to advocate and make these changes at your own home institution. Next we'll talk about some of the practices the history and some of the rationale behind making institutions and communities trauma informed. Then we'll review some steps into how you can plan out your own program. What initiation looks like, as well as assessment. And finally, we'll briefly touch on how you can create policies at your home institution, and we'll review examples of what that looks like at my own institution and what we're doing here. So, what does trauma informed care mean, and why is this important, I think Dr. Crosby gave a really great overview of that. You can continue to click forward. Basically, there, there was this landmark study in 1998 called the ACES study by Feliti et al. And in that study they looked at the link between adverse childhood events, and the outcomes in adulthood. And they found that the more adverse childhood events, one had in childhood so the more traumatic experiences they had, the more likely they were to have chronic diseases such as liver disease cardiovascular disease, mental illnesses, and, and other things. And so there were a number of institutions that picked up on this, you know, how do we reduce re traumatizing folks. And so, SAMHSA is one of the governmental organizations that put together a trauma informed care approaches guide for how institutions can make their place more welcoming and have more of a feeling of safety for not only their staff but also the patients in the community members that they serve. At the end of this presentation that I have there is also a link that you can find these resources out if you would like to read more about this. And so the idea comes from evidence based practices in behavioral health, which looked at individuals who have suffered trauma. And how do you make them again feel more welcomed and safe. And so there are different ways you can do that, whether it's incorporating language or making physical changes to space. So there are some evidence based practices in the sense that I will touch upon in going through our own examples here in Chicago. So, in Chicago, we have a city wide initiative to make our entire city trauma informed. And so, at my institution Cook County Health. We are a large safety net hospital system for our region, and we have over 6000 employees to hospitals over a dozen ambulatory We also have our own county health department, and we also service external areas such as a jail and the juvenile detention center. So our employees and our staff are diverse their backgrounds are diverse and not not everybody is patient facing. So what does this mean to employ a trauma informed care approach to an entire system. And for us, and for all the hospital systems that are within this collaborative working group. dedicated ourselves to transforming the internal culture that we have at our institution. And that will be through policy changes through training individuals, and through making our environments feel more comfortable for our patients and our staff and again the community members. It's a lofty goal to train at Cook County over 6000 employees. So there's, we're not there yet, I will be honest, admittedly, this is a project that is has been years in the works. We have picked up an external partner to help us, because it is a heavy lift, you know, if you can imagine you know you're at your health department and you want to change the culture, and you know, have everybody learn the language. It does take materials to do that. And so for us, we partnered with an external organization that I'll mention later, and they were critical in helping us get this trauma informed care program off the ground. And so I'd like to say insert your city here, this is our city of Chicago, but of course you guys can also make the same changes and make that difference in your institution. So, I put together seven different steps that one can take when coming up with how to incorporate organizational change and change your policies. And these are derived not only from traditional public health practices but also basically how we undertook this transformation at our place. And so, when you're putting together a team. Maybe it just starts off with two folks that are very passionate about introducing trauma informed care into their institution. You want to define what your goals are. And so, SMART is an acronym that stands for specific measurable attainable realistic and timely. And so, when you're making a goal. Here's an example that you can think about our institution is committed to developing a user friendly interactive mandatory trauma informed care training program to pilot with small groups in one year and roll out for all employees to complete within two years following the pilot. So, it's specific in that this discusses a training program. This is measurable in terms of the years you know pilot in one year and a full rollout in two years. It's attainable, but that also depends on the size of your organization. It's realistic, and then it's also timely. Again, you want to set goals but you do have to be very flexible with your goals, because things could change funding could change for you, your leadership can change. And so you know the passionate folks that may have been there may leave. So, you do have to refine your approaches as you participate in again transforming your institution to be more trauma informed. Along with planning, you do have to not only make sure you have your goals, but you have to engage multiple stakeholders. And so, that includes patients of course that includes your community members, and that should include an advisory board made up of leadership at your institution So, at Cook County Health, we have our C-suite executives participate, and they have been wonderful resources in allocating things for us. And here I have a picture of a new consult room that was created based on the relationships that we were able to form through putting together our stakeholder groups. And so, a social worker brought up that, you know, there's no safe and quiet place to have the sensitive discussions with family members who are here waiting in the emergency department. And you know there's this room that's nearby that's currently being used as a closet. What do you guys think about that? And so trauma informed approaches is not only training your employees and staff to be to understand the language that's involved and understand how trauma can affect an individual, that's part of it but you also want to think about how you can transform your spaces volunteer social worker who was part of our group, our task force for trauma informed care, put together this initiative to change the space, and it did take some time. But eventually we were able to turn this closet space into this beautiful room that's next to the emergency department, where these sensitive conversations can take place, rather than corners or in waiting rooms, amongst other people. So, when you put together a plan you want to be able to determine how to assess your goals. So, how will you know if you're meeting them, you should probably make a chart that has short term intermediate term and long term goals. Many look at this as a logic model, you can put together a one page or logic model, which not only discusses your processes but also your outcomes that you hope to achieve, and how those are measured. And then, as you go along the way of implementing, you may need to modify the process, and that's also part of it. So, when you're ready to implement. You want to confirm your implementation team make sure all your members are there and ready to roll. And then you want to consider piloting your ideas. And so for us, again, we wanted to train all of our employees to be trauma informed. And so we started off with pilots. 90 minute training programs which introduced these, these new terms to folks, as well as provided a space where people could discuss their own experiences. And so we took those 90 minute sessions we gathered the data, and we incorporated that into our approaches going forward. And so 90 minutes ended up being a little bit too long. So we shortened it to 60 minutes, for example, with the caveat that this wouldn't be a one time one and done situation. This is our culture now, we are a trauma informed care organization. And so we hope to have multiple trainings for our employees. That will be mandatory. So everybody's on the same page because it's, it's not something that happens like in a vacuum, it has to be a cultural change where everybody is in the know. And as you are incorporating your feedback. You also have to be flexible. So, you know, it's so hard when you're putting together a presentation to get rid of slides and I helped organize a lot of the training program that we have here at Cook County. And, you know, it's, it's, it's, it's like torture like, oh, we have to delete this we have to shorten that. And you just hope your points get across but, you know, again, it's all about being flexible and improving your process along the way using an iterative approach. So we were able to do this, really, because of the health and medicine policy research group that's located in Chicago. It's a nonprofit organization dedicated to these transformative projects and trauma informed care is a program that they put together and used at the Chicago Department of Public Health. And so we saw that it was well received at that health department. And so we decided to take that into our own institution. And again, we do have a health department, but we wanted to make it make this idea spread to all of the departments. So this external partner was critical, again, because they were experienced, you know, they knew what to expect when it comes to a training program they had reliable resources. We are a safety net hospital so we don't have a limited funding. So grant funding really enabled this relationship to work. And for the other side, they were able to use some of the data learned from implementing it implementing this training program at our institution for their benefit, you know, because they were able to refine the different areas. And again, learn from the experience of working with us. And so I would say that external partnerships, they don't leave at that one consulting firm, you know, they don't they don't stop there. Because once your institution is able to develop wonderful materials that are well received by your staff and your patients. You may be able to share that with other community based organizations that do not have the same resources that you do. But perhaps you're already partnered with. So perhaps the Spanish speaking wellness clinic is looking to make their institution more trauma informed. having to do with the pandemic. So sometimes when we think about PTSD and trauma and stress, we think about that on that left-hand side, this traumatic injury, kind of like what Dr. Crosby was saying, some of our violence, gun violence, those very kind of high level, very intense traumatic injuries where there's a threat to life. That is certainly a really, really, really important part of stress and trauma. And one that I think people think about, but there's multiple other aspects of stress and trauma that we also need to pay attention to. Loss, so people who have lost family members, friends, as a result of trauma or disease or death, that's a really important piece. But there's also thinking through, especially in the pandemic, there's other grief and losses I think many of us experienced. Many of us were very used to being exceedingly competent in our fields. We knew exactly what to do. We knew what the lesson plans were. And then we just were getting hit with novel things over and over and over again. And to kind of lose that feeling of confidence and competence, and I know what to do in all situations. I think a lot of us really struggled with that, with feeling a loss of competence, professional competence. Then this idea of a moral injury, which many, many of us are facing as well, where you're put in a position where you have to do something that is not in line with your moral values that comes up in multiple different settings. And especially in the pandemic, I think two concrete examples, we're thinking about how do we do infection control in nursing homes, which then also meant shutting those nursing homes and not letting loved ones come into people in nursing homes. Boy, that was a big moral injury and moral conflict. And again, those of us who were involved in thinking about prioritization of vaccines and having to think, no, people are experiencing homelessness with chronic disease. You have to wait because I have to give it to these people. So even that idea of prioritization and rationing resources that weren't enough to go around, rationing resources that weren't enough to go around, that was really hard for many of us. And then I think just the universal wear and tear and this fatigue injury, I think we all experienced that as we were responding to COVID. So just thinking through and we talk about PTSD and we talk about trauma and stress to realize there's multiple different aspects that we can experience that. Next slide. Very, very quick. I think you heard some really, really nice detail descriptions and plans of how to do trauma-informed care, especially on that individual level in a more clinical setting. I like this little cheat sheet. It makes it easy for me to remember, but the first part is regulate. So making sure that people have a safe and quiet space that they can regulate their emotions. That was a great example about what's the nice room that we are using to allow people that ability to regulate. We have to get people to regulate in order for their frontal cortex to kick in and that their core brain isn't on overdrive. Second, this concept of relations. Humans need to feel relationship to other humans. That is a critical piece of our human condition. I think something also that made the pandemic so hard is that it was our feeding and our need for human relations was being strained. And then finally, once you have those two, you have your brain can regulate, you feel that you're in a trusting relationship, then that frontal lobe can kick in and you can really start that higher order thinking and how do I reason? How do I think about problem solving? And how do I think about building confidence and competence and start achieving and building those skills? So that's the kind of cheat sheet I think about trauma-informed care on an individual level. And again, this fundamental change in the question that someone comes in and they're very agitated and instead of thinking what's the matter with you as a person is really taking a step back and said, what happened to you and understand the context of that person. And that really, I think unlocks that compassion and that ability to think about trauma-informed care. Okay, next slide. So that's individual level. We think about organizational level. So many of those principles translate as we think about taking care of populations and not necessarily on the individual. And again, thinking about it purely individual solutions, that's not enough. It actually might cause harm as we're thinking about organizational resiliency and response. So saying, oh, you're stressed, you employ, well, then you should go exercise. You should go do meditation. Like putting the burden of resiliency and stress on the individual and not on the employer is not where that locus of control needs to be. You're gonna do harm for your employees because now they're stressed and now they're feeling like they're failing because they haven't gotten to that yoga class that they're supposed to do. So we really need to support the workplace. It really is about the setting up a workplace around the people, not trying to ask your people to do things on their own, which really requires this organizational intentionality, thinking about better data. What are the questions? What can we do to actually change that workforce? And really think through and incorporate these trauma-informed elements and stress reductions across our workforce. So we can't put this on the employee. This is the responsibility of the employer. Next slide. This is a really nice, I really like this toolkit in thinking about how to implement organizational elements of trauma-informed care. It's really nice. It comes from the VA and it is the, which in their National Center of PTSD and thinking about stress response. It's a really great organizational model. You have these hot links if you want to go in and look at those details. And I've pulled out a couple of tools from that, but I really like this model if you want to, if you're in charge of putting into elements of organizational trauma and stress elements. Next slide. This is a highlight or an example of some of the elements. And so this is kind of aligned with those three R's that I talked about in patient-specific trauma-informed care which was the regulate, relate and reason. These are the five C's in thinking about organizational trauma-informed care. Very similar, but the first ones is cover. Making sure that people know they're not in this alone and you have their back. Calm, so make sure that same thing, calm settings that people can regulate. Connect, this is that same thing as relations. People need to have that social connection to not feel they're isolated, to be brought in and to have that human connection. There's a quote that's attributed to Margaret Mead who's many of you know is a famous anthropologist who says, the first evidence of civilization is a healed femur. Because typically what would happen if someone broke their femur, an animal broke their femur, then they either die of starvation or dehydration or they get eaten because they can't move and they can't fend themselves. But seeing a healed femur said that someone was injured and so somebody else took care of that person. They brought them to shelter, they protected them, they gave them food, they gave them water. And it is that fundamental showing of that human connection and caring for each other is that first sign of civilization. So it's incredibly important when someone has been traumatized, someone is injured, you need to bring them in and not isolate them. And then as they, depending on the level of their injury, you have to start building up, especially in a professional setting, their sense of competence again. What do they do well, making sure they're feeling confident and competent professionally. And then that really then leads and it's a success but gets the sets and they can start feeling even more confident and then more competent. So those are the kind of organizational Cs to think about trauma-informed care. Next slide. But then we need to think about not just remediating disease and illness, but that concept that health is not just the absence of disease, but it is health in the full aspects of wellness as well. And so that next slide. There you go. Thinking about, again, not just the absence of disease, but really wanna promote wellness as a way to prevent and build resiliency or prevent trauma and build resiliency in our workforce. So thinking about the emotional wellbeing, a lot of that we talked about within trauma, thinking about spiritual, giving people a sense of purpose and mission, intellectual, building their confidence and competency, making sure that our environments are productive for physical health, environmental health, thinking about our financial, occupational, and social health. So going beyond just remediating disease and making sure that you are building that workforce or that occupational environment that's really promoting all those elements of wellness. Next slide. And this is my last one so that we will be under time and have a little bit of time for questions. So again, I think preventive medicine physicians are the perfect physicians because we sit really by definition and by training at the intersection between clinical settings, public health settings, individual medicine, and caring for populations. And we have to think about trauma in all of those pieces. So for those of you who are working in a healthcare setting, like Dr. Schwartz, and really in charge of thinking about how do I put together trauma-informed care settings and clinical settings in order to take care of my patients? That's a really important part and many of our preventive medicine physicians are in there. And I think Dr. Schwartz highlighted perfectly how to think about implementing trauma-informed care in clinical settings. And again, many of us are also in charge of our own employees, our organization, either in healthcare setting or public health setting or an employer setting, but we are in charge of the health and wellbeing of our own workforce. So understanding those elements of trauma-informed care and stress reduction as part of an employee workforce is incredibly important. And again, I gave you some of those five Cs and some tools to that. But then again, we are preventive medicine physicians, so we don't wanna just treat injury once it happens. We wanna think about how do we upfront and promote resiliency as a way to prevent some of that damage, some of that harm, some of that trauma, and really think about how do we put into place those elements that promote whole person health, whole employee health and promoting wellness. So I hope you see yourself in this picture, regardless of where your setting is. Trauma is pervasive and we are the perfect workforce to think about implementing the elements of this regardless of where our specific job duties and responsibilities lay. So with that, I'm gonna stop and I'll turn it back over to Anita, I guess, to maybe do some of our Q&A. Perfect, thank you, Dr. Totson. I think we've already gotten a couple of really good questions and maybe we can take one more if another one comes up. But we have a question here. Thank you, Dr. Crosby, very much for your comprehensive presentation. As you know, excessive drinking, specifically binge drinking is a significant risk for both suicide and violence. Could you please discuss the role of public health interventions to reduce excessive drinking, example, regulating alcohol outlet density in helping to reduce trauma at the individual and community levels? Thank you. All right, I will definitely do that. I typed in a part of the answer there into the chat, but also wanted to address it. That's a very good point that I think that's Dr. Brewer, Rob Brewer, I used to work with there at CDC made in terms of looking at some of the risk factors that could contribute to trauma and to violence. One of those being alcohol misuse, and he particularly points out binge drinking. There are a number of different successful interventions that have tried to address that, whether that's at the individual level. Again, many in preventive medicine will be aware of the US Preventive Services Task Force that talk about screening, especially some of the brief intervention screening that deals with the individual and alcohol misuse. But there are also a number of strategies that have been reviewed and approved of by the Guide for Community Preventive Services, including one of the ones that Dr. Brewer mentioned in terms of reducing alcohol density, alcohol outlet density, which is basically talking about the number of alcohol stores or bars that exist within a given community, the more that you have, the more likely it leads to alcohol misuse. So there are things in which they've been able to show some of these policy-related, community-related, as well as individual-related interventions can reduce alcohol misuse and actually show that they have an impact on reducing suicidal behavior, self-directed violence, as well as interpersonal violence. So definitely a good point in terms of looking at some of the interventions that have been shown to demonstrate that they work. Thank you, Dr. Crosby. For our next question from Dr. Brewer, Dr. Schwartz, thank you very much for your presentation. Given how common exposure to trauma is among youth and adults in the U.S., and I'm sure in Chicago and Cook County too, do you think it is particularly helpful to frame some of the changes in patient care that you're discussing to trauma, or shouldn't these approaches to patient care be universal, whether there's a specific reference to trauma or not? Thank you. Yeah, I think that's a great question because it initially started off with us touching base with our trauma team, and that was our first pilot. How will this program, this training program, be received by the people who are actually getting in all of these acute trauma cases? But when you think about it, you can't really just train one department. It has to be the entire institution. And so that includes accounting who may not be patient-facing. And I think that the importance is that you have staff relationships too. And as Dr. Crosby pointed out, over 90% of us have had a trauma in our lives. So it's being more empathetic to your fellow working man or fellow working colleague and their situations. And I think about it as what if one of your employees is coming in late regularly? Maybe it's not, hey, let's put them on a probation plan. Maybe it's asking them, hey, is something going on? And really having that heart-to-heart and providing them that space. It's thinking about safe spaces too. And as a resident, we are in this hierarchical system where you don't always feel comfortable speaking your mind on things. And so I am very fortunate that in my group, we do have a safe space that is made up of not faculty, but administrators. And they are the safe people that we can talk to about our concerns. And so that's a way of thinking about how to introduce trauma-informed care into your practice. But it should be ubiquitous. It should be for everybody to be knowledgeable about this language so it can be a shared experience for all. Thank you, Dr. Schwartz. Dr. Crosby? Yeah, I just wanted to add on. I absolutely endorse what Dr. Schwartz was talking about. And just as a reminder, one of the programs that I mentioned in terms of that Grady program had all of those different kinds of disciplines and all of those different kinds of professionals that they had to train in order to make their program successful. From nurses to the trauma surgeons to the emergency department, to the community workers, to clergy, to educators, all of them being educated on some aspect of trauma because they all interact with those that may be victims or those who may be witnesses. The other thing that Dr. Schwartz mentioned, and again, I'm basically just endorsing what she said, is in terms of thinking about those that might have secondary exposure. You know, when she talked about residents, when she talked about other kinds of individuals that may have witnessed it or been exposed to trauma, that we also have to address some of their needs too, because they may have some of the consequences, mental health, emotional, even physical manifestation. So definitely we've got to do some broad-based training across different kinds of sectors in order to be as successful as possible. It is 2.02, and if it's okay with you, Dr. Chilton, I want to be able to end on a question with you. Do you have just one moment to take a- Sure, yeah, yeah, that's okay. So, you know, obviously Dr. Crosby and Dr. Schwartz talked about the importance of community partnerships and how ubiquitous it should be. And as the chief medical officer and the health director of a state health department, I know it's a loaded question, so I want you to have the final word here as to what role do you think as a state health department chief can play in making sure these practices are ubiquitous and ensuring the critical community partnerships start and continue to function? Yeah, and one, I just want to say, I totally agree with Dr. Schwartz and Dr. Crosby was saying, I think we're all on the same page in talking about this ubiquitous experience. I think multiple ways. One, we need to take care of our own house, right? And so thinking through our own workforce, our public health workforce, you know, about 50% of public health workforce in the pandemic report at least one, if not two symptoms of PTSD. So we got to take care of our own house, our own people, you know, put our oxygen mask on first. So that's a really, really important piece. Second is work through, and we've already done this thinking about it with our local health departments. And we think about upstream of behavioral health and resiliency, what's the role of local public health, not just in their own employees, but also in promoting this in our community. So thinking about helping to facilitate trauma-informed care training out across our stakeholders and in our communities as well. And same thing with us thinking through what's the components of trauma-informed care and making sure we're disseminating that out to our partners as well. So our house first, and then making sure we're getting it out to our communities as well. It's a key piece of our health, key piece of behavioral health and resiliency, key piece of the human experience. Wonderful. Thank you all so much, Dr. Tilson, Dr. Schwartz, and Dr. Crosby. This webinar is being recorded and we will share the recording and we will send email out to all those who are seeking CME credits for this webinar. Thank you very much, everybody, for staying the extra few minutes and have a wonderful afternoon. Thank you all.

trauma-informed care

ACPM

webinar

clinical settings

public health

hospital-community partnerships

employee training

organizational resilience

wellness

Q&A session