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Best practice №7

Implement Trauma-Informed Care to optimize patient engagement

by Margaret Yonekura

Last updated May 6th, 2020

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Implement Trauma-Informed Care to optimize patient engagement in prenatal care.

Why we are recommending this best practice

Many pregnant women with opioid use disorder have experienced significant trauma in their lives, including sexual abuse and other Adverse Childhood Experiences (ACEs). Trauma refers to intense and overwhelming experiences that involve serious loss, threat, or harm to a person’s physical and/or emotional well-being. These experiences may occur at any time in a person’s life; they may involve a single traumatic event or may be repeated over many years.  These traumatic experiences often overwhelm a person’s coping capacity. Prescription and/or illicit opioid use often begins as a survival mechanism in order to manage the symptoms of post-traumatic stress disorder (PTSD). 

Trauma-Informed Care is a strengths-based service delivery approach “that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper E, et al, 2009).   

Trauma-Informed Care acknowledges a patient’s life experiences as key to improving engagement and outcomes while lowering unnecessary utilization.  It changes the paradigm from one that asks, “What’s wrong with you?” to one that asks, “What has happened to you?” In order to be successful, Trauma-Informed Care must be adopted at both the organizational and clinical levels.   It involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals, and it upholds the importance of consumer participation in the development, delivery, and evaluation of services. Furthermore, a trauma-informed organizational structure addresses the impact of trauma across the lifespan and the critical role of health care service delivery systems to interrupt the cycle of trauma by employing trauma-aware services, policies, and mindsets.

Strategies for implementation

  • The Trauma-Informed Care Implementation Resource Center, developed by the Center for Health Care Strategies with support from the Robert Wood Johnson Foundation, offers a one-stop information hub for health care providers interested in implementing Trauma-Informed Care. It houses foundational knowledge regarding the impact of trauma on health, testimonials from providers who have adopted trauma-informed principles, in-the-field examples illustrating how to integrate Trauma-Informed Care into health care settings, practical strategies and tools for implementing trauma-informed approaches, and information for state and federal policymakers interested in supporting Trauma-Informed Care.

  • Review SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach (refer the Resources section of this Best Practice), which offers first steps to organizational assessment and development around the Trauma-Informed Care model of care.

  • Create a comprehensive organizational structure, whereby the entire workforce operates under a Trauma-Informed Care model.  The San Francisco Department of Public Health Workforce Training Model and The Sanctuary Model can be found in the Resources section of this Best Practice. 

  • Adopt new organizational and clinical practices that address the impact of trauma on patients and staff, including but not limited to:
    • Lead and communicate about being trauma-informed
    • Engage patients in organizational planning
    • Train both clinical and non-clinical staff
    • Create a safe physical and emotional environment
    • Prevent secondary traumatic stress in staff
    • Build a trauma-informed workforce
    • Hold each other accountable
    • Involve patients in the treatment process
    • Screen all patients for trauma
    • Train staff in trauma-specific treatments
    • Engage referral sources and partner organizations that are also trauma-informed



  • Harris M, Fallot RD. Using Trauma Theory to Design Service Systems: New Directions for Mental Health Systems. San Francisco: Jossey-Bass; 2001.
  • Menschner C, Maul A. Key Ingredients for Trauma-Informed Care Implementation. Center for Health Care Strategies. Published January 8, 2019. Accessed December 18, 2019.
  • Resources for Implementing Trauma Informed Care. Trauma Informed Oregon. Accessed December 18, 2019.
  • Tkach MJ. Trauma-Informed Care for Substance Abuse Counseling: A Brief Summary. Butler Center for Research-Research Update 40 (1/18) 6378-1-Issue #67. Hazelden Betty Ford Foundation, 2018.
  • Adverse Childhood Experience (ACE) Questionnaire . National Council of Juvenile and Family Court Judges. Your ACE Score.pdf. Accessed December 18, 2019.
  • SAMHSA’s Trauma-Informed Approach: Key Assumptions and Principles. National Association of State Mental Health Program Directors. Accessed December 18, 2019.
  • Organizational Self-Assessment Domains and Standards for Primary Care. SAMHSA-HRSA Center for Integrated Health Solutions.
  • Trauma-Informed Community Network. SCAN. Accessed December 18, 2019.
  • The Sanctuary Model . Accessed December 18, 2019.
  • Sperlich M, Seng JS, Li Y, Taylor J, Bradbury-Jones C. Integrating Trauma-Informed Care Into Maternity Care Practice: Conceptual and Practical Issues. Journal of Midwifery & Womens Health. 2017;62(6):661-672. doi:10.1111/jmwh.12674.
  • Substance Use Disorder Services Treatment on Demand. Department of Public Health: Training Resources for Substance Use Treatment Providers. Accessed December 19, 2019.
  • San Francisco Department of Public Health. Accessed December 18, 2019.
  • Schulman M, Menschner C. Laying the Groundwork for Trauma Informed Care. Issue Brief. Center for Health Care Strategies. Published November 6, 2019. Accessed December 19, 2019.
  • TIC IC Implementation Planning Guide. SAMHSA-HRSA Center for Integrated Health Solutions. Accessed December 19, 2019.
  • SAMHSA's Concept of Trauma and Guidance for Trauma-Informed Approach. SAMHSA . Accessed December 19, 2019.
  • Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg LS. From Treatment to Healing: The Promise of Trauma-Informed Primary Care. Womens Health Issues. 2015;25(3):193-197. doi:10.1016/j.whi.2015.03.008.
  • The Trauma Informed Care Project . Accessed December 19, 2019.
  • Beyond ACES: Building Hope and Resiliency in Iowa. Trauma Informed Care Project. Accessed December 19, 2019.
  • Publications. Sanctuary Institute. Accessed December 19, 2019.
  • Bloom SL, Farragher BJ. Restoring Sanctuary a New Operating System for Trauma-Informed Systems of Care. New York: Oxford University Press; 2013.
  • Torchalla I, Linden IA, Strehlau V, Neilson E, Krausz M. "Like a lot’s happened with my whole childhood": violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside. Harm Reduction Journal. 2014;11(1):34. doi:10.1186/1477-7517-11-34.
  • Implementing trauma-informed practices throughout the San Francisco Department of Public Health. Center for Health Care Strategies. Accessed December 15, 2019.
  • S.E.L.F.: A Trauma-Informed Psychoeducational Group Curriculum. The Sanctuary Model.
  • Saia KA, Schiff D, Wachman EM, et al. Caring for pregnant women with opioid use disorder in the USA: expanding and improving treatment. Current Obstetrics and Gynecology Reports. 2016;5(3):257-263. doi:10.1007/s13669-016-0168-9.
  • Esaki N, Hopson LM, Middleton JS. Sanctuary model implementation from the perspective of indirect care staff. Families in Society: The Journal of Contemporary Social Services. 2014;95(4):261-268. doi:10.1606/1044-3894.2014.95.31.
  • Hopper, E., et. al. Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. The Open Health Services and Policy Journal. 2009, 2, 131-151.

Margaret Yonekura


Margaret Lynn Yonekura, M.D., F.A.C.O.G. is a board certified obstetrician-gynecologist with subspecialty certification in Maternal-Fetal Medicine. She is a recognized expert in the fields of infectious diseases in Ob-Gyn and perinatal substance abuse.  Throughout her career Dr Yonekura has established comprehensive care programs to address her patients’ complex needs. She is currently a member of the Women’s Health Policy Council of L.A. County’s Office of Women’s Health, L.A. County Perinatal & Early Childhood Home Visiting Consortium, Reproductive Health and the Environment Advisory Committee, and  L.A. County Diabetes Prevention Program Community Advisory Committee.