Nearly 20 years after the landmark Adverse Childhood Experiences study linked traumatic childhood experiences to the leading causes of morbidity and mortality in the U.S., some primary care practices have begun screening for exposure to trauma and are adopting the principles of “trauma-informed care” to engage patients whose childhood and adult experiences may be affecting their health and willingness to seek care.

As health systems adopt hot-spotter programs and other initiatives to identify and direct resources to high-need, high-cost patients, some are discovering that the patients who may benefit the most—including those whose physical problems are exacerbated by mental illness, substance abuse, poverty, homelessness, and other social ills—can be the hardest to engage. In clinics, these patients are often labeled as “difficult” or “non-compliant” because they don’t show up for appointments or disregard medical advice. But experts who’ve spent years working with high-need patients say that for many, experiences of trauma—including emotional and physical abuse, rape, combat, and other violence—make it difficult for them to seek medical care or trust their providers.¹

This is a problem given growing evidence of the link between traumatic experiences and poor health. Much of that evidence comes from the landmark Adverse Childhood Experiences (ACE) study, which nearly 20 years ago established the association between traumatic childhood experiences and the leading causes of morbidity and mortality in the U.S. In that study, researchers from Kaiser Permanente and the Centers for Disease Control and Prevention found a direct relationship between instances of trauma (defined in the study as sexual, emotional, or physical abuse as well as being raised in neglectful or dangerous households) and rates of chronic obstructive lung disease, lung cancer, heart disease, and liver disease as well as depression, substance abuse, suicide, and risky behaviors.²

Since the ACE study, scientists have begun to identify the mechanisms by which traumatic experiences—among both children and adults—can have long-term impacts on brain development, physiology, and behavior.³ These include changes that affect the way brains perceive pleasure and rewards (implicated in substance abuse), changes to the brain and hormonal systems that react to perceived threats (the “fight-or-flight” response), and even changes to genes that can affect the immune system (making people more vulnerable to some diseases).⁴

The effects appear to be worse if traumatic experiences occur repeatedly over time. In extreme cases—say prolonged abuse at the hands of a parent or repeated battlefield deployments—some people develop symptoms of post-traumatic stress disorder, which may include difficulty regulating emotion, impulsivity, and/or persistent anxiety. To cope, they may drink or take drugs, overeat, or adopt other risky and unhealthy behaviors.

The ACE study made it clear that traumatic experiences are widespread, including among the largely middle-class, educated, and insured population surveyed. But certain groups of vulnerable patients including the poor may be more likely to experience severe and persistent trauma. The Medicaid health plan CareOregon, for example, has found that more than half of its high utilizers have experienced trauma and a third suffer from post-traumatic stress disorder (PTSD). Similarly, more than half of women living with HIV have experienced domestic violence and nearly one-third have PTSD (see Q&A with Edward Machtinger, M.D., director of UCSF’s Women’s HIV Program.)

This issue of Transforming Care focuses on early and evolving efforts to change the way primary care providers screen for and respond to the effects of trauma and describes particular steps practices can take to become what’s been described as “trauma-informed.” Many include elements commonly associated with patient-centered models of care, including encouraging shared decision making, but go a step further by:⁵

• creating clinical environments that are less likely to trigger traumatized patients—for instance by offering quiet waiting areas and attending to potential triggers during medical exams;
• introducing screening approaches that help patients understand the link between traumatic experiences, unhealthy behavior, and health outcomes; and
• increasing access to treatment in part by streamlining referral pathways to specialty care and/or embedding behavioral health providers in primary care settings.

A New Framework

Many of the early adopters of trauma-informed approaches are health care providers who work with high-risk patients (e.g., veterans, women with HIV, or the homeless) and have struggled to get them to change risky behaviors or manage their conditions. Trauma-informed care offers these providers a new lens through which to view their “difficult” patients. For example, they might come to see certain behaviors—say taking drugs—as traumatized patients’ way of self-medicating, and understand it may take more than just offers of advice or referrals to promote change.

Some of these efforts are supported by The Robert Wood Johnson Foundation and led by the Center for Health Care Strategies, which launched a multi-site demonstration to test whether use of trauma-informed practice improves patient engagement, enhances outcomes, and reduces costs. One of its grantees, Bronx, N.Y.–based Montefiore Medical Group, is training all staff at its 22 ambulatory care clinics in approaches to trauma-informed care. The clinics already have behavioral health specialists working side by side with primary care clinicians, helping to serve residents of the nation’s poorest congressional district. Rahil Briggs, Psy.D., director of Montefiore’s pediatric behavioral health services, who is co-leading the effort, notes that while trauma “doesn’t discriminate based on age or sex or socioeconomic status,” many residents of poor neighborhoods are traumatized by community-level violence and the stresses of poverty as well as from direct traumatic experiences.

In addition to offering learning collaboratives on the nature and effects of trauma for clinic leaders, Montefiore will train all staff—from receptionists and schedulers to patient service representatives and providers—in ways to be attuned to how trauma may affect people’s behavior. It then plans to study whether this training influences the diagnosis of trauma and use of behavioral health services, as well as patient satisfaction rates and the incidence of staff burnout (see sidebar on secondary traumatic stress among the health care workforce).

Building Safe Environments

Once primary care staff understand trauma’s pernicious effects, they can work to reduce instances in which a health care visit itself may prove traumatizing. Many practices seek to create more welcoming and soothing physical environments—introducing private waiting areas or in the case of UCSF a therapy dog—since those who’ve experienced trauma may be acutely sensitive to things like chaotic waiting rooms.

Edward Machtinger, M.D., director of UCSF’s Women’s HIV Program says having Pepper, a therapy dog, in the waiting area has had a calming effect on patients who’ve experienced trauma and on staff. From left to right: Cassandra Steptoe, patient; Beth Chiarelli, L.C.S.W., lead clinic social worker; and Vicki Blake, patient. 

Practices may also try to anticipate how certain parts of medical exams—undressing and being touched by strangers, for example—may trigger anxiety or fear. Traumatic events are often crimes of power and control,” says Alissa Mallow, D.S.W., director of social work services and interim director of adult behavioral health at Montefiore Medical Group. One way of addressing this it to have providers inform patients of what’s going to happen during each step of a procedure to give them a sense of control and even opt out if something makes them uncomfortable.

While such efforts may sound like the treatment every patient would expect to get, providers may have to “bend over backwards” to build trusting relationships with traumatized patients, says Jennifer Perlman, Psy.D., a psychologist and coordinator of trauma-informed care for the Colorado Coalition for the Homeless. Nearly all of the clinic’s homeless patients have experienced the “trifecta” of trauma, poverty, and addiction, she notes, and they are highly attuned to perceptions of mistreatment. “They often feel like they would rather die before they’ll be further humiliated,” she says.

To make patients feel more comfortable, the Colorado Coalition for the Homeless has used soothing paint colors and offers private spaces to wait. They also make ample use wood and plants. “I often think that’s why some homeless patients who’ve experienced trauma stay outside. Nature is oftentimes more comfortable,” says Jennifer Perlman, Psy.D., the coalition's coordinator of trauma-informed care.

Identifying Trauma

Given the prevalence of traumatic exposure in the U.S. population, advocates advise health care providers to assume that any one of their patients may have experienced trauma, an approach known as universal precaution. And most (but not all) advocates also encourage primary care providers to screen for trauma, using formal tools that ask patients whether they’ve experienced traumatic events without requiring them to elaborate. Others avoid the direct approach by instead seeking to identify trauma through its common consequences—depression, suicidal thoughts, substance abuse, or chronic pain, or even less tangible behaviors such as being quick to anger or zoning out. Noticing such signs is “a good time for a primary care provider to take a step back and wonder what’s happened to this person,” says Glenda Wrenn, M.D., M.S.H.P., a psychiatrist at the Morehouse School of Medicine who works with primary care providers to help patients see the link between unresolved trauma and poor health.  

When asking directly about trauma, providers should explain their reasons for doing so, Wrenn says. A physician might tell her obese and potentially diabetic patient with a history of childhood sexual abuse that “the goal is to give you all the resources you need to achieve your optimal health, you have a traumatic background, and we know these experiences can have lasting impacts on your health,” she says. “To do this, you have to feel comfortable talking about the neurobiology of PTSD and how avoidance makes it worse,” she says.

Just broaching the topic can be a challenge for providers. “I think providers are nervous about asking and concerned about their ability to do it well. Fear often gets in the way,” says C. Vaile Wright, Ph.D., director of research and special projects for the American Psychological Association.

Responding Appropriately

Their fear is not misplaced. If patients do reveal a traumatic event, how providers respond makes a difference, Wrenn says: “In those first conversations, you are either going to build on that person’s underlying fear or instill hope.” Providers should acknowledge patients’ courage in being willing to discuss their trauma history and model calm and compassionate responses. “We need to help them start managing and adapting rather than avoiding—teaching them how to calm down their body and pay attention to what’s really happening rather than being caught in a flight-or-fight response,” says Laurie Lockert, L.P.C., an independent consultant who helped set up and run CareOregon’s health resilience program for high-needs patients, described below (see a profile of one health resilience specialist).

Providers should also be ready to help patients find counseling, a support group, or other services, though getting treatment may not be an easy sell. In talking to patients who’ve reported trauma in primary care settings, Wrenn frequently hears things like “I am just messed up because I was raped” or, in many cases, “I brought this on myself.” To engage them, she underscores that the goal of treatment is to improve on their strengths and promote resilience. The initial conversations might focus on areas where patients are functioning well—they’re raising a child, for example, or they’ve gotten themselves to a medical appointment. Emphasizing choice is also important, Perlman says, because lack of control is often one of the defining features of past trauma. “It has to be in your mind at all times that you are trying to empower the person. I always say here are some options.”

Recruiting Allies

Some practices also rely on peer counselors to work with patients who’ve been through traumatic events. In other cases on-site behavioral health staff can join primary care visits to introduce themselves and offer help. CareOregon has a team of 32 social workers, known as health resilience specialists, who are embedded in 24 primary care clinics and serve as intermediaries between primary care providers and patients who are high utilizers of health care services, many of whom suffer from trauma. The health resilience specialists work to improve communication between patients and providers. In one case, a specialist worked with a patient with a history of drug abuse whose doctor assumed was drug seeking when he complained about an injured back. In getting to know the patient, the specialist learned about his trauma history, recognized he felt disrespected by the physician, and helped persuade a new provider that the patient’s solution—a daily dispense program—was worth pursuing. “The specialists are not taking sides,” Lockert says. “They help both patients and providers move forward in a collaborative way.”

The Veterans Health Administration, which screens all patients for PTSD, embeds behavioral health clinicians in primary care practices because many patients are reluctant to seek mental health services. It has also established a free consultation service that allows any clinician treating a U.S. veteran for PTSD to get advice from experienced clinicians about medications, diagnoses, and treatment, and provides educational materials for patients and providers via its website.

Implications

Efforts by primary care providers to become “trauma-informed” will require more than just training, experts say. For the approach to spread, the field likely needs to establish evidence of the impact of such interventions on patient outcomes and utilization rates and to more specifically define trauma-informed care. “I worry about how you determine whether you are a trauma-informed system. Is it what patients think? Is it a self-assessment and if so, what are you using? Without more parameters I think we run the risk of diluting the importance of this,” Briggs says.

The process of changing clinical culture can also take years and it’s a big ask of primary care clinicians, who already have too little time and too many responsibilities. Still, understanding trauma can go a long way toward helping patients whose behaviors may have seemed intractable, advocates say. “I think it’s gaining traction because more people are practicing it and seeing the benefit,” Lockert says. “One of my dreams is to see this being taught in all health care training programs. It is so valuable and can be leveraged to build a trusting relationship so much more quickly.”

¹ See CDC site, http://www.cdc.gov/violenceprevention/acestudy/about.html.

2 E. L. Machtinger, Y. P. Cuca, N. Khanna et al., “From Treatment to Healing: The Promise of Trauma-Informed Primary Care,” Women’s Health Issues, May/June 2015 25(3):193–7.

3 Ibid. and R. Oliver, “Traumatic Experiences Weaken Immune-System Gene,” PsychCentral.

4 We do not report on efforts to address trauma among children. For more on this subject, see the TED talk by Nadine Burke Harris, M.D., on the effects of childhood trauma.

⁵ National Traumatic Stress Network, Secondary Traumatic Stress: A Fact Sheet for Child-Serving Professionals. 

⁶ C. S. Melvin, “Historical Review in Understanding Burnout, Professional Compassion Fatigue, and Secondary Traumatic Stress Disorder from a Hospice and Palliative Care Perspective,” Journal of Hospice and Palliative Nursing, Feb. 2015 17(1):66–72.

As one of 32 health resilience specialists employed by CareOregon, the state’s largest Medicaid managed care plan, Emily Adler works with high utilizers who’ve frequently been hospitalized or visited the emergency department for what appear to be avoidable problems. More than half of these patients have experienced trauma, which often manifests in the difficulties they have managing their health. Because Adler, a social worker, finds such trauma affects her patients’ willingness to seek care, she keeps this in mind as she offers them help navigating the care system, connecting to social support services, and achieving their health goals. An evaluation of the program found that on average, behavioral health visits among members working with health resilience specialists increased by 16 percent, while E.D. visits and hospitalizations dropped by roughly 20 percent.¹  

When I describe our work, I talk about how we’re identifying people who are not getting their needs met for whatever reason—what we do at a basic level is to try and meet them where they’re at and figure out what’s happening.

Emily Adler, M.S.W., a health resilience specialist with CareOregon, helps patients navigate the health care system. More than half of the patients she serves have experienced trauma.

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Because we are assigned to primary care practices but are employed by the health plan, we know what their diagnoses are and how they use services; what we’re trying to do is take a step back and look at the bigger picture.

We don’t screen for trauma. When you find out someone has been homeless for 10 years, has been in a corrections facility, has battled addiction their entire adulthood as many of our clients have, you don’t need to get into details about what’s happened to them. You understand those life experiences suggest they have experienced trauma. You see it playing out in symptoms—anxiety, depression, addiction—and even more specific things like having a hard time building relationships with people in power, having a hard time making appointments, or taking meds on a specific regimen. These things might not seem that complicated to their providers, but for those who’ve experienced trauma these details can become really difficult.

Each of us works with about 20 to 25 patients. We initially meet clients in the clinic. Then what I like to do is meet clients wherever they’re staying—in their homes, friends’ houses, homeless shelters, camping on the streets. We might go out for a walk, do something to break down that power dynamic that might happen in an office with someone sitting across the desk from me.

Then if patients want, I attend their specialist appointments. We are there as an advocate for the client and help guide the discussion. I do a lot of prep beforehand with the client: We go over what’s going to be discussed and ask them about their needs and what they want to get out of it. Afterwards we debrief: I’ll ask what did you hear? What’s your understanding of what just happened? Then I bring information back to the primary care providers in the clinic, looping them in on the visits and other details, like what the clients’ home life is like, what other stressors they might be experiencing.

One of the clients I worked with was homeless and living on the streets. This person had battled alcoholism for decades, and had Crohn’s disease and had to take care of a colostomy bag, Because of the circumstances, the patient couldn’t really control diet, and didn’t have any place to have supplies delivered or take care of basic needs. This person was in the ED a couple times a week for colostomy care.

When we first met I focused on basic needs: can we get your supplies delivered? How can we troubleshoot your bathroom situation? As our relationship developed, I learned why this person wasn’t coming to the primary care provider’s office. This member had experienced a significant trauma—their partner had recently died tragically and they’d thus lost their only housing in years and many of the social supports that were connected to the partner. Making matters worse, while living on the streets they had been attacked numerous times and lost all their possessions including colostomy supplies. 

Understanding what had happened helped me brainstorm solutions. We ended up having supplies delivered to a local homeless shelter, got food vouchers to get healthier foods at a farmer’s market, and then got the member into drug and alcohol treatment—and that was a big step. But we couldn’t really start talking about that until their basic needs were met.

The other part of my job is working with primary care doctors to help them understand patients with such complex needs. We often do a lot of prep work with physicians in terms of managing expectations about where our clients are at. For example they may be really concerned about someone’s A1c level. But when they come into an appointment not knowing this person only gets their food from a food pantry, or runs out of their food stamps the first week of month, talking about counting carbs isn’t going to get us anywhere.

Our work is different from a clinic-based social worker because we’re not stuck in the clinic; we are out in the community with people. We can take a broader look of what’s going on with a person. That’s part of the trauma-informed approach: instead of looking at the problem list—how to fix that person—it’s taking a deep breath and wondering what’s happening in this person’s life and how can we help.

¹ K. Vartanian, S. Tran, B. Wright et al., “The Health Resilience Program: A Program Assessment,” The Center for Outcomes Research & Education, January 2016.

The effort to convert the University of California San Francisco’s (UCSF) clinic for women with HIV into a trauma-informed practice began six years ago with the murder of a patient. Like many women who sought help there, she had been addicted to drugs, socially isolated, and caught up in an abusive relationship that resulted in savage beatings and several hospitalizations. Clinic staff and social service workers had tried to protect her by moving her to a hospice, but her husband, perhaps sensing that she was serious about leaving this time, tracked her down and murdered her.

Up until that point, clinic staff thought they were doing the best they could and that the challenges patients’ faced outside of the clinic were beyond their ability to influence. “Like so many other programs, we just didn’t think that was in our domain,” says Edward Machtinger, M.D., director of UCSF’s Women’s HIV Program. “We figured we couldn’t relive people’s lives in childhood, couldn’t reduce racism and community violence, and couldn’t control who they picked as partners. I think we thought of all those issues as just the human condition.”

The patient’s gruesome murder prompted them to reconsider. As Machtinger and some 30 people from across the city who’d tried to help her began to dissect what had gone wrong, one of the conclusions was that the clinic needed to do more to address intimate partner violence and the early childhood and lifelong traumas that seemed to draw its patients toward abusive relationships and hold other adaptive but ultimately self-destructive behaviors—including alcoholism and drug use—so firmly in place.

Machtinger and his colleagues began by closely studying every death in the clinic and discovered the majority of women died not of HIV, but of overdoses and suicides, as well as lung and liver disease linked to years of substance abuse. The common denominator seemed to be a long history of trauma, and the program’s research team’s analysis of the national literature on trauma seemed to suggest the same (see box).

Machtinger and his colleagues found more than half of women with HIV in the U.S. had experienced intimate partner violence, approximately twice the national rate, and 60 percent had experienced sexual abuse at some point in their lives—approximately five times the national rate. Nearly a third suffered from post-traumatic stress disorder (PTSD), six times the national rate.

“It was a huge epiphany for us. It helped explain why our patients were so reactive when we would engage them in simple ways, why so many patients were having a very difficult time with substance abuse despite the availability of what appeared to be high-quality treatment, why so many patients were depressed, and why ultimately so many patients committed suicide or overdosed and died,” Machtinger says. “I’ve [now] come to see HIV—like obesity, diabetes, depression, substance abuse, and the lung and liver disease—as a marker of a high burden of childhood and adult trauma.”

Machtinger and his colleagues used grant funding to convene a group of experts in trauma and HIV from government, academia, and community-based organizations, as well as patients themselves. The group has developed a trauma-informed approach to primary care for women with HIV that includes training for staff and changes to the design of health care settings, as well as new approaches to screening and treatment interventions. It will be piloted at UCSF as part of a demonstration testing whether the model can disrupt the link between recent or life trauma and disease progression, hospitalization, and death.¹ Transforming Care asked Machtinger about the approach.

Transforming Care: We understand one of your first goals is to make the clinic more inviting to patients who’ve experienced trauma. How are you going about it?

Machtinger: We want it to feel safe, calm, and empowering. Before we got started, our waiting room was incredibly chaotic and loud. Patients frequently showed up high or late for appointments. They would be inpatient at the front desk or, the opposite, stand there quietly, as if trying to be invisible and our frontline staff—the medical assistants and receptionists—were pretty reactive. They might tell someone who had a history of being incarcerated or being controlled by a partner to “sit down and wait their turn” and they really didn’t understand why patients would react poorly or were behaving the way they did. So a large component of creating a trauma-informed environment has been educating the staff and providers about the impact of trauma on health and behavior. We now have a receptionist walk around the counter and greet the patient and we’re just about to hire a woman living with HIV—a peer—to welcome patients and help them navigate the clinic. We also have a service dog in the waiting room, who has as calming an impact on providers and staff as patients. We’re trying to break down barriers between patients and providers, so we’ve set up a dining area in the conference room where staff and patients can sit together to have a hot breakfast. With just these recently implemented changes, the vibe in clinic now feels more communal, loving, and mutually supportive.

Transforming Care: How do you handle screening?

Machtinger: We have multiple providers ask about intimate partner violence and do it regularly because it can lead to immediate injuries and murders. If someone screens positive, they’re referred to our social worker, who assesses the lethality risk and develops a safety plan. They’re also referred to a therapist who recognizes that patients facing intimate partner violence are likely suffering from PTSD and may have experienced lifelong abuse, which requires more than just supportive therapy. In terms of screening for trauma related to other forms of abuse, our conclusion was that that a discussion of it needs to occur in the context of a long-term relationship. So what we do is screen for the consequences—substance abuse, depression, and PTSD. That’s part of our intake program and at least annually we will repeat it.

Transforming Care: And if you suspect trauma from that, what’s the response?

Machtinger: The interventions we’re developing are based on our observation that trauma ruptures three types of connections. First, connections with others. People who’ve experienced trauma frequently have a very hard time relating to other people and feeling safe around them. Oftentimes this is because the person who was charged with loving them and keeping them safe was the exact person who violated them the most deeply. Second, trauma—especially childhood trauma—also ruptures physiological connections. There is more and more evidence it changes our brains and bodies, changes the way our genes are expressed, and predisposes us to anxiety and different types of adaptive and ultimately unhealthy behaviors like substance abuse. Lastly, trauma profoundly ruptures our connection with our own bodies. Many patients end up very ashamed of them and have really tricky sexual relationships.

Transforming Care: What treatments or interventions will you use?

Machtinger: There’s a variety, some of which we’ll offer in the clinic and others through partnerships with agencies that have specific trauma recovery expertise such as the Trauma Recovery Center at San Francisco General Hospital. There are many evidence-based strategies for ruptured psychological and physiological connections: trauma-specific cognitive behavioral therapy, re-exposure therapy, mindfulness-based stress reduction, and therapies that couple substance abuse treatment with treatment for trauma. There are also medications that can help patients handle intolerable feelings and triggers, and there are treatments like eye movement desensitization and reprocessing, which helps patients identify and re-process traumatic memories. To overcome problems connecting with others, we think the most promising treatments will be peer-based expressive therapy. Ours include the Medea Project, a theater program that was designed to help incarcerated women build a supportive community with women who shared their difficult experiences. Until I saw how effective this program was, I wouldn’t have believed it.

I’ll give you one example. I was talking to a patient the other day about getting into substance abuse treatment. I’d been talking about it with her for a decade and she had been highly resistant. But this time she said yes and when I asked why, she said it was because she had seen Debra driving a car. Debra was a homeless, crack-addicted, middle-aged woman who lots of people in the community knew and thought was a lost cause. Joining the Medea Project helped her come out about her HIV status and begin a process of healing that led to her getting housed, getting off drugs, getting her teeth fixed, gaining weight and dressing beautifully, becoming articulate and proud. This patient saw Debra, the most impossibly traumatized down-and-out-individual you can imagine, looking beautiful and composed and driving around the streets of San Francisco. And she realized if Debra could do this, she could too.

Transforming Care: Other than evidence of impact, what do you think will facilitate the spread of trauma-informed care?

Machtinger:  Part of it is acknowledging the reality that hospitals and clinic administrators and primary care doctors, staff, nurse practitioners, and social workers are facing day-to-day. The idea that they can go from chaotic, every-20-minute visits to trauma-informed care practices is often just overwhelming because they don’t feel like they have support and resources to make that change. Partnerships can help a lot. For this new effort, we’ve pursued foundation and federal funding as a collaborative with other agencies, and we decide as a group who is best able to provide the services for our patients.

In the meantime, providers can begin by educating themselves about trauma’s impact. With that, so many mysteries are solved: why a patient has not been able to overcome their obesity for a decade, why a patient is still addicted to alcohol despite what would seem to be good treatment programs, and why a patient is still depressed despite supposedly effective antidepressants. It can change an experience of almost hopelessness, powerlessness, and mystery into one of compassion. And that small change can have an enormous impact on the well-being of that provider and the quality of that relationship and the healing and openness that you can achieve with a patient.

¹ E. L. Machtinger, Y. P. Cuca, N. Khanna et al., “From Treatment to Healing: The Promise of Trauma-Informed Primary Care,” Women’s Health Issues, May/June 2015 25(3):193–7.

Functional Limitations and Geriatric Syndromes Key to Identifying Health Risks in Older Adults 
A study of U.S. adults age 50 and older that sought to identify the combinations of chronic conditions, functional limitations, and geriatric syndromes that predict poor health outcomes found that functional limitations such as difficulty walking several blocks and geriatric syndromes such as visual impairment were more important than chronic conditions in predicting outcomes, self-ratings of health, and mortality. To identify these subgroups of patients, the authors recommend providers use such instruments as the Comprehensive Geriatric Assessment. S. M. Koroukian, N. Schiltz, D. F. Warner et al., “Combinations of Chronic Conditions, Functional Limitations, and Geriatric Syndromes that Predict Health Outcomes,"Journal of General Internal Medicine, June 2016 31(6):630–7. 

CMS May Need to Move Slowly When Changing ACO Benchmarks
To address concerns that the Medicare Shared Savings Program rewards accountable care organizations (ACOs) that are more inefficient and offers little incentive for high-performing ACOs to continue to reduce costs, the Centers for Medicare and Medicaid Services (CMS) is considering revising its benchmarking formula. Rather than assessing an ACO’s performance largely on its past spending, ACOs would be judged by how their spending compares with that of  other providers in their region. To understand the impact of this change, researchers looked at how spending varies among ACOs in a given region and between ACO and non–ACO providers. They found wide differences and concluded that in areas where there is great variation, CMS may need to move slowly to avoid discouraging participation by higher-cost providers and to ensure ACOs are not penalized for serving sicker patients. S. Rose, A. M. Zaslavsky, and J. M. McWilliams, “Variation in Accountable Care Organization Spending and Sensitivity to Risk Adjustment: Implications for Benchmarking,” Health Affairs, March 2016 35(3):440–8.

Lower Patient Activation Scores Linked to Higher Spending
Using data from a large health system in Minnesota, researchers found that high-risk patients who had the lowest scores on a patient activation measure made the greatest use of hospital and emergency department care. The measure, which assesses patients’ knowledge, skills, and confidence in managing their health, also accurately predicted the use of these costly services three years later. The authors say adding a behavioral assessment to risk-scoring models will help identify high-need patients who would benefit from additional support. J. H. Hibbard, J. Greene, R. Sacks et al., “Adding a Measure of Patient Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs,” Health Affairs, March 2016 35(3):489–94.

Improved Depression Care May Lower Mortality Risk Among Patients with Comorbid Conditions
A study designed to determine whether evidence-based depression care management would reduce long-term mortality risk among adults with increasing levels of medical comorbidity found that it mitigated the combined effect of comorbidity and depression. In the usual care group, patients with the highest level of medical comorbidity were at increased risk of mortality compared with depressed patients with minimal comorbidity. In contrast, patients in the intervention group with the highest level of medical comorbidity and depression were not at significantly increased risk compared with depressed patients with minimal comorbidity. As part of the intervention, a depression care manager worked with primary care physicians to provide care—including offering psychotherapy, increasing antidepressant use if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence. J. J. Gallo, S. Hwang, J. H. Joo et al., “Multimorbidity, Depression, and Mortality in Primary Care: Randomized Clinical Trial of an Evidence-Based Depression Care Management Program on Mortality Risk,” Journal of General Internal Medicine, April 2016 31(4):380–6.

Depression Care Lacking in Primary Care Practices
Researchers found large primary care practices in the U.S. used significantly fewer care management processes for depression than for other chronic illnesses, including asthma, congestive heart failure, and diabetes. On average, they used less than one of five depression care management processes, while small and medium-sized practices appeared to be using few care management processes overall. They also found no significant increase in the use of depression care management processes between 2006 and 2013. The authors say the findings indicate that U.S. primary care practices may not be well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide, and incentive programs may be necessary to spur their use. T. F. Bishop, P. P. Ramsay, L. P. Casalino et al., “Care Management Processes Used Less Often for Depression Than for Other Chronic Conditions in U.S. Primary Care Practices,” Health Affairs, March 2016 35(3):394–400. 

Greater Attention to Measure the Quality of Behavioral Health Care Needed to Spur Improvement
In this article the authors provide an overview of current measures of behavioral health, identify priorities for measure development, and outline the most significant challenges. They note that although there are more than 500 measures related to behavioral health, only 5 percent are used in quality-reporting programs and only 10 percent have been endorsed by the National Quality Forum. Quality reporting so far also appears to have had limited effect on behavioral health: based on Healthcare Effectiveness Data and Information Set (HEDIS) reports from commercial health plans, patients receive recommended behavioral health care less than half the time, with slow improvement in recent years. In terms of measure development, the authors identify five priorities: expanded outcomes measurement; structural measures, such as accreditation programs for health homes; recognition of efforts to integrate physical and behavioral health care; attention to psychosocial interventions; and attention to substance use disorders. H. A. Pincus, S. H. Scholle, B. Spaeth-Rublee et al., “Mental Health and Substance Abuse: Gaps, Opportunities, and Challenges,” Health Affairs, June 2016 35(6):1000–8.

FQHCs with Strong PCMH Capability Share Certain Characteristics
In this study of federally qualified health centers (FQHCs), patient-centered medical home (PCMH) capability appeared to be enhanced by having an electronic medical record system (EMR), being located in a state with state-supported PCMH initiatives, having access to more types of financial incentive programs, and having more hospital-health center affiliations. Researchers also found that the percentage of minority patients was negatively associated with PCMH capability, suggesting that health centers serving a larger proportion of minority patients need additional support. Because EMRs are widely in place in FQHCs, the authors suggest improvement efforts focus on providing more types of financial incentives, supporting hospital-health center affiliations, and implementing state-level PCMH initiatives. Y. Gao, R. S. Nocon, K. E. Gunter et al., “Characteristics Associated with Patient-Centered Medical Home Capability in Health Centers: A Cross-Sectional Analysis,” Journal of General Internal Medicine, Published online May 23, 2016.

Payment Reform and More Public Reporting May Advance ACA’s Mission

This commentary outlines some of the key accomplishments of the Affordable Care Act (ACA), including reducing the number of uninsured Americans, and suggests ways of promoting further reform such as increasing the use of bundled payments (particularly for spine surgery and cardiac procedures, and for treatment of common medical conditions such as congestive heart failure or asthma); reining in escalating drug costs, perhaps by predicating payment upon value; and making public comparisons of physician practices on such measures as total hospital days for ambulatory care–sensitive conditions and number of hospital days in the last six months of life. E. J. Emanuel, “How Well Is the Affordable Care Act Doing? Reasons for Optimism,” Journal of the American Medical Association, April 2016 315(13):1331–2. 

Commentary: Reform Efforts Need Alignment
The authors of this commentary say two competing reform efforts—encouraging physicians, hospitals, and others to improve the way they deliver care and making consumers more price-sensitive by increasing cost sharing—must be aligned to ensure they do not undermine one another. If not, the success of the provider-focused reform strategies, which depend on engaging patients with care teams and increasing preventive and chronic disease care, may be undercut by substantial or poorly targeted cost sharing that may discourage patients from such care. California, as a purchaser of health care services and through its exchange, offers an example of how to minimize the conflict, they say. The state has standardized the design of deductibles, copayments, and other cost sharing for health plans, helping to ensure patients can obtain primary care without being subject to a deductible. At the same time the state is encouraging plans to support medical home and accountable care organization models. E. S. Fisher and P. V. Lee. “Toward Lower Costs and Better Care—Averting a Collision Between Consumer- and Provider-Focused Reforms," New England Journal of Medicine, March 2016 374(10):903–6.

Renewed Focus on Community Benefit Spending Practices Could Lead to Greater Investment in Public Health
The author of this commentary describes the reasons for renewed attention to tax-exempt hospitals’ community benefit spending practices, which include an intensifying focus on the social determinants of health, payment reforms that encourage collaboration among public health and hospitals, and recent clarification from the IRS about what constitutes acceptable practices. The author notes that amendments to the Affordable Care Act specify that tax-exempt hospitals undertake triennial community health assessments with public health and community input. Even a modest increase in hospital spending on community health improvement could lead to significant investment in public health initiatives, she says. S. Rosenbaum, “Hospital Community Benefit Spending: Leaning In on the Social Determinants of Health,” Milbank Quarterly, June 2016 94(2): 251–54.

The Benefits and Possible Pitfalls of Global Payment for Oncology Care 
This commentary describes the Centers for Medicare and Medicaid Services’ new Oncology Care Model, which combines key features of global payment, medical homes, and pay-for-performance programs in an effort to encourage providers to improve the quality and lower the cost of cancer care. The authors describe how provider payment is structured in the program and note some of its potential pitfalls including the fact that opportunities to achieve savings will vary widely by cancer type and across patients. Its success may also hinge on convincing physicians and private payers to participate in the initiative. Z. Song and C. H. Colla, “Specialty-Based Global Payment: A New Phase in Payment Reform,” Journal of the American Medical Association, June 2016 315(21):2271–2.

Transitional Care Intervention Significantly Reduced Readmission Rates
A study of the Bridge Model, a social work–based transitional care intervention, found it produced a 20 percent relative reduction in all-cause 30-day admission rates for Medicare fee-for-service beneficiaries discharged from an urban medical center. The authors note the model, which links patients to existing community resources, may be of interest to organizations that are accountable for the care of patients with complex social needs, such as individuals who are dually eligible for Medicare and Medicaid or newly eligible for Medicaid coverage. M. E. Boutwell, M. B. Johnson, and R. Watkins, “Analysis of a Social Work–Based Model of Transitional Care to Reduce Hospital Readmissions: Preliminary Data,” Journal of the American Geriatrics Society, May 2016 64(5):1104–7.