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Best practice №7

Implement Trauma-Informed Care to optimize patient engagement

by Holly Smith, Margaret Yonekura

Last updated September 3rd, 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 (OUD) have experienced significant traumatic events, adversity, and toxic stress 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. In many cases, prescription and/or illicit opioid use begins as a coping mechanism 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?” Just as with “universal precautions” for infection control, Trauma-Informed Care necessarily assumes that every patient, and indeed every provider or staff person, has a history of traumatic stress. 

In order to be successful, Trauma-Informed Care must be adopted at both the organizational and clinical levels and cannot be implemented as a singular, disconnected intervention that occurs between providers and a few patients who are seemingly appropriate for this kind of care based on their diagnosis and social history. Successful implementation requires a commitment from the agency, service line, or department for significant culture change at the organizational and clinical levels. Trauma-Informed Care is not a “one and done” training for staff and management. Rather, it is a comprehensive journey to implement systematic changes in how care is delivered for every person who enters care. 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.

SAMHSA recognizes six principles that are fundamental to a Trauma-Informed Approach: 
  • Safety. Do we help promote a sense of safety for every person? 
  • Trustworthiness and Transparency. Do we conduct all patient care with complete transparency and with the goal of building and maintaining trust? 
  • Peer Support. Do we provide any peer support services or mutual help services that build upon the trauma-informed framework of safety, trust, and collaboration in care? 
  • Collaboration and Mutuality. Do we share power in decision making in a meaningful way and maximize the ability of patients to engage in care decisions? 
  • Empowerment, Voice, and Choice. How are we providing the resources necessary to both staff and patients in order to ensure skill building, goal-setting, and non-coercive treatment for every patient
  • Recognition of cultural, historical, and gender issues. Are we actively working to move beyond cultural stereotypes based on gender-identity, race, sexual orientation, socio-economic status, and more? Do we recognize historical trauma and impact on race-based disparities? 

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 the following: 
    • foundational content 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
    • 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. Identify how this model of care can be integrated into your current care model.

  • 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 examples can be found in the Resources section of this Best Practice. 

  • Start to 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 and shared decision making about treatments
    • Train both clinical and non-clinical staff in trauma-specific approaches and build a trauma-informed workforce
    • Create a safe physical and emotional environment
    • Prevent secondary traumatic stress in staff
    • Hold each other accountable
    • Screen all patients for trauma
    • Engage referral sources and partner organizations that are also trauma-informed



  • Harris M, Fallot RD. New Directions for Mental Health Services: Using Trauma Theory to Design Service Systems. San Francisco, CA: Jossey-Bass/Wiley; 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. Published January 2018.
  • Finding Your ACE Score. National Council of Juvenile and Family Court Judges. Your ACE Score.pdf. Published October 24, 2006. Accessed December 18, 2019.
  • SAMHSA’s Trauma-Informed Approach: Key Assumptions and Principles. National Association of State Mental Health Program Directors. Published August 18, 2015. Accessed December 18, 2019.
  • SAMHSA-HRSA Center for Integrated Health Solutions. SAMHSA.
  • Greater Richmond Trauma-Informed Community Network. SCAN. informed-community-network/. 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. J Midwifery Womens Health. 2017; 62(6): 661-72. doi:10.1111/jmwh.12674.
  • Substance Use Disorder Services Treatment on Demand. San Francisco Department of Public Health. 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. 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, NY: 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 Reduct J. 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. Curr Obstet and Gynecol Rep. 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. Fam Soc. 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.

Holly Smith


Holly Smith is a certified nurse-midwife with 20 years' experience in diverse practice settings. She is the project manager for the CMQCC/CPQCC Mother and Baby Substance Exposure Initiative. Previous to this role, she was a the lead editor for the CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, and a clinical lead for the CMQCC Collaborative to Support Vaginal Birth and Reduce Primary Cesareans, a large-scale quality improvement project with over 90 California hospitals. Her primary role as clinical lead focused on assisting southern California hospitals with the implementation of evidence-based practices to reduce cesarean. She is a hospital coach and steering committee member for the American College of Nurse-Midwives' Reducing Primary Cesareans Project, and expert consultant on various national and state quality improvement and health policy initiatives. Additionally, she chairs the Health Policy Committee of the California affiliate of the American College of Nurse-Midwives and is a health policy consultant to the California Nurse-Midwives Foundation. 

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.