Implementation of a Stepped Care Program to Address Emotional Recovery among Traumatic Injury Patients

Abstract

BACKGROUND:

Annually, over 600,000 adults served in US trauma centers (≥20%) develop posttraumatic stress disorder (PTSD) and/or depression in the first year after injury. American College of Surgeons guidelines include screening and addressing mental health recovery in trauma centers. Yet, many trauma centers do not monitor and address mental health recovery, and it is a priority to learn how to implement evidence-informed mental health programs in trauma centers.

STUDY DESIGN:

This report describes our application of the Exploration, Preparation, Implementation, Sustainment model to implement the Trauma Resilience and Recovery Program (TRRP) in 3 Level I and II trauma centers to address patients’ mental health needs. TRRP is a scalable and sustainable stepped model of care—one of the few in the US—that provides early intervention and direct services after traumatic injury.

RESULTS:

Trauma centers are well positioned to accelerate patients’ mental health recovery via early identification, education, screening, and referrals to mental health agencies that provide best-practice care. We found that TRRP was acceptable to the 3 partnering trauma centers we studied. Early engagement of patient, provider, and hospital administration stakeholders enhanced buy-in during the early stages of the implementation process and promoted sustainability. Active processes to support monitoring, evaluation, and adaptation were critical.

CONCLUSIONS:

Our work demonstrates the feasibility of implementing and adapting TRRP, a cost-efficient and sustainable stepped care intervention, in Level I and II trauma centers. Several factors should be carefully considered by trauma centers seeking to integrate behavioral health interventions into their trauma program.

Each year, 3 million Americans experience injuries so severe that they require hospitalization.¹ Traumatic injury contributes to individual and societal costs of more than $210 billion annually.² At least 1 in 5 individuals hospitalized after traumatic injury develop posttraumatic stress disorder (PTSD), depression, and/or other health risk outcomes that may lead to poor physical recovery, functional impairment, and lost productivity.³ Trauma centers are well positioned to address patients’ behavioral health needs. American College of Surgeons (ACS) guidelines include an expectation for routine screening and mental health treatment referrals⁴ and recently published best practice guidelines that outline recommendations for integrating screening, intervention, and referral services to improve outcomes for traumatic injury patients.⁵ Recent data indicate that many US trauma centers do not provide education, screening, and/or direct treatment services for traumatically injured patients.^6–9 Programs adhering to the ACS best practice guidelines may consider various models of care. Examples may include in-person and/or technology-based bedside and ongoing mental health screening, psychoeducation, brief inpatient intervention, family support, symptom self-monitoring, care management, pharmacotherapy, and outpatient psychological and/or psychiatric services.⁶ Whereas some models of mental health follow-up in trauma centers have been evaluated,^10–12 few studies have examined implementation of established models.¹³ A recent large-scale implementation study¹⁴ sought to assess the effectiveness and implementation of a brief, front-line provider delivered stepped collaborative care intervention in 25 US Level I trauma centers, aiming to target symptoms of PTSD among adult traumatic injury survivors. Trauma center clinicians (eg social workers, nurses, physicians) completed a one-day workshop and the site interventionist received supervision over the course of the intervention implementation. Results demonstrated that the brief collaborative intervention was feasibly delivered by trauma center providers and that when properly implemented, resulted in reduction of PTSD symptoms 6 months post-injury, and for firearm survivors, 6 and 12 months post-injury.

Implementation initiatives to integrate behavioral health programs into trauma centers often encounter numerous challenges and needs for adaptation due to the level of variability with respect to hospital resources, community partnerships, predominant mechanisms of injury, organizational culture, and other factors. Application and examination of implementation strategies is needed to inform adoption of mental health programs. This report describes a quality improvement effort to implement the Trauma Resilience and Recovery Program (TRRP) in 3 Level I and II trauma centers in the Southeastern US, guided by the Exploration, Preparation, Implementation, Sustainment (EPIS)¹⁵ framework. TRRP is an evidence-based program launched in 2015 at our Level I trauma center to address patients’ mental health recovery after traumatic injury. TRRP was informed by needs assessments with diverse samples of traumatic injury patients,¹⁶ and we have tested feasibility of our model with adults and youth.^11,17 Each step of the TRRP model is supported by a significant body of research indicating the utility and effectiveness of mental health screening,^10,18,19 symptom self-monitoring,^20–23 and referral to best-practice mental health treatment.^24,25 TRRP is an interdisciplinary model with 4 steps: (1) in-hospital patient education about mental health recovery after traumatic injury and mental health risk screening (~10 to 15 minutes); (2) a 30-day, automated SMS-based service to promote mental health symptom self-monitoring (~5 minutes); (3) a brief, telephone-based mental health screening 30 days following hospital discharge to assess PTSD and depressive symptoms (~15 to 20 minutes); and (4) referral to best-practice mental health treatment for patients who exceed clinical thresholds for PTSD and/or depression (~10 to 15 minutes).

TRRP is directly in line with ACS best practice guideline recommendations⁵ in that it uses a robust bedside and 30-day screening protocol that includes education, use of standardized and well-validated screening instruments, and referral to relevant hospital and community-based mental health treatment resources. TRRP staff are equipped with a comprehensive referral database of resources and trained to educate patients about when and how to access these resources, if needed. Use of post-discharge screening allows us to more carefully screen out patients identified as high-risk at bedside who have trajectories consistent with resilience or rapid natural recovery.⁵ Finally, patients may enroll in the automated symptom self-monitoring program to increase emotional awareness and engagement in services downstream and to mitigate mental health symptoms. We have found this model to be feasible with moderate to high and equitable levels of patient engagement at each step.^11,17,26 The success of this model in our hospital system, coupled with the national movement toward embedding evidence-based mental health programs in trauma centers, set the stage for the current quality improvement initiative to implement TRRP in 3 Level I and II partnering trauma centers.

METHODS

Conceptual framework and implementation strategy

The EPIS framework directed the process of implementation¹⁵ via its 4 phases: exploration, preparation, implementation, and sustainment (Figs. 1 and 2). The EPIS model has guided implementation of numerous mental health programs.^27–29 EPIS recognizes the unique role of outer system (ie environment external to the organization) and inner organizational context (ie characteristics within an organization) and how the implementation process is affected by the interplay between these contexts (bridging factors) and factors relating to the characteristics of the practice (innovation factors). Implementation efforts using EPIS can uncover new or existing needs of a population, help to identify what treatments address those needs, guide integration of treatment into routine practice, and inform efforts to sustain it.¹⁵ The EPIS framework was chosen for several reasons. First, the EPIS framework facilitates balancing and contextualization of input from many sources (eg trauma center staff, administrators, community stakeholders) across all phases of implementation. Active involvement of these sources in decision-making enhances quality of the evolving implementation strategy and allows tailoring to the unique context of each trauma center.³⁰ Second, EPIS takes into consideration the specific needs and available resources of the trauma centers. Trauma centers have varying capacities and infrastructure, and this framework guided efforts to examine alignment of TRRP with each center’s capabilities and priorities. This increases potential for successful implementation and promotes long-term sustainability.³⁰ Additionally, the EPIS framework emphasizes continuous monitoring of progress and outcomes. This enabled the identification of challenges or areas requiring improvement and facilitated timely adaptations and refinements.³⁰ TRRP is a stepped care model that adheres to ACS best practice screening and intervention guidelines.⁵ It is readily adaptable based on patient needs and those resources available in a trauma center. We set forth to evaluate our implementation efforts, characterize needed adaptations, and evaluate how adaptations impacted program effectiveness, acceptability, and sustainability in 3 trauma centers with diverse needs and resources (Table 1). We adhered to the SQUIRE 2.0³¹ reporting guidelines.

Figure 1.

Exploration, Preparation, Implementation, Sustainment (EPIS) framework and Trauma Resilience and Recovery Program (TRRP).

Figure 2.

Exploration, Preparation, Implementation, Sustainment (EPIS) phases and key implementation strategies. TRRP, Trauma Resilience and Recovery Program.

Table 1.

Exploration, Preparation, Implementation, Sustainment Phases across Each of the 3 Trauma Resilience and Recovery Program Implementation Sites

Site	Exploration	Preparation	Implementation	Sustainment
A	Psychiatrist adopted the role of “champion” and ensured key stakeholders were informed and involved. Preliminary action plan driven from stakeholder input identified structural barriers to implementation.	Outside hiring of TRRP clinic coordinator was needed and roles and responsibilities were delineated. Barriers identified through the Exploration phase were addressed.	Training in mental health assessment and service was provided to personnel without previous background or training in this area. Adaptions were made as needed based upon the hospital’s ongoing procedures and needs	We encountered difficulties with reimbursement due to not having a licensed provider. Our solution was to embed the clinic coordinator into trauma program via monthly trauma meetings. Longterm adjustments were included as needed.
B	Weekly conference calls allowed the implementation team to work with the broader trauma program team. Meetings with the site’s personnel (eg information security) as needed to overcome site-specific barriers.	Trauma program manager facilitated the hiring of the TRRP clinic coordinator and oversaw all clinic operations. Other hospital personnel (eg hospital case manager) provided support as needed. Implementation plan accounted for barriers.	Monthly conference calls for discussion of ongoing clinical operations and problem-solving barriers to implementation. Adaptations to the recruitment and referral process were made as needed.	Ongoing assessment allowed for comprehensive plans to enhance engagement and reduce provider burden. There were billing/ reimbursement challenges due to not having a licensed healthcare professional or established behavioral health services. We remedied this by incorporating the clinic coordinator into the trauma team and having them also administer substance use screening and referral to treatment.
C	Hospital leadership determined implementation barriers and facilitators. Barriers were centered on the hospital’s patient demographic.	TRRP clinic coordinator was hired externally. Biweekly calls facilitated development of an implementation plan based upon previously determined barriers and facilitators. TRRP protocols were adjusted as a result.	The TRRP clinic coordinator was trained in mental health service provision and assessment. Monthly calls allowed for discussion of clinical operations and barriers/facilitators to service delivery. Protocol adjustments were made based upon site-specific patient needs.	A referral process was created to achieve billing practice. Bimonthly communication was enacted to assess enrollment and adjust the model as needed. Personnel adjusted work schedules as needed to balance dual responsibilities.

TRRP, Trauma Resilience and Recovery Program.

Phase 1: Exploration

Our goal was to promote adoption of TRRP, learn how to feasibly implement TRRP within the trauma center’s workflow, and identify strategies to promote sustainability. We identified and addressed several outer and inner context factors (eg leadership buy-in, available funding). First, initial communications with partnering centers were led by our trauma surgery chief. This reinforced the multidisciplinary nature of the effort and the critical role of a champion at the highest levels of leadership in trauma surgery. Second, we conducted a full-day site visit with each center to provide the larger trauma program and hospital team with education about mental health recovery following traumatic injury, ACS requirements for trauma center verification,⁵ and best practice approaches for education and intervention⁵ to formally present our model and clinical operations data; convey recognition that one size does not fit all and our intention to approach implementation guided by the needs of the center; answer questions about program implementation and potential areas of adaptation; and identify personnel responsible for delivering TRRP services. We explored factors to promote sustainability, such as billing and reimbursement practices. We offered sites the use of our web-based, HIPAA-compliant patient management database software system that provides a simple, cost-efficient patient navigator tool to support providers as they deliver TRRP and track patients’ symptoms and program engagement. Third, we assessed trauma center’s needs, resources, and organizational workflow. This included learning the responsibilities of trauma program staff (eg managers, coordinators), patient volume/characteristics (eg injury mechanism, insurance status), existing screening practices and referral resources (eg psychiatric consultations), other services or departments that may serve as potential partners (eg outpatient behavioral health services), and perceived barriers (eg limited time/personnel) and facilitators (eg program recognized as a priority by hospital leadership) to TRRP implementation.

Phase 2: Preparation

A site-specific implementation plan was outlined. Because this initiative required partnering sites to be early implementers and evaluators of the TRRP implementation process, and because resource limitations were a known major barrier among trauma centers, each site received approximately $50,000 per year over a 3-year period (funded by the Duke Endowment) to support the initial roll-out of TRRP. However, because it was known at the time the partnerships were formed that the program could not be sustained with grant support beyond the award period, we addressed this at the onset. First, we problem-solved challenges to implementation based on centers’ available resources and workflow. We identified members of the implementation team, usually consisting of a provider to deliver TRRP services to patients, a supervisor to oversee operations, and additional personnel to assist with implementation (eg psychiatrist consultation for highly distressed patients). We identified possible model adaptations to anticipate implementation barriers (eg integration with current screening practices). Consistent with ACS best practice guidelines,⁵ we worked with each center’s implementation team and billing department to explore billing practices to promote sustainability (eg learning which healthcare providers could be reimbursed for services; which billing codes would be appropriate for reimbursement for each level of TRRP), strategies to integrate TRRP within providers’ daily workflow (eg scheduling time for bedside screening), and mental health service settings for referrals. We developed training materials and outlined strategies to manage potential crisis situations (eg patients with suicidal ideation) at bedside and during the 30-day mental health screen.

Phase 3: Implementation

Our goal was to train providers to deliver TRRP, monitor clinical operations, assess need for program adaptations, and identify opportunities for improved integration. We addressed several outer and inner context factors throughout the implementation process using several implementation strategies.^32,33 First, we trained the implementation team on trauma-informed care and delivery of TRRP services, adhering to local adaptations made during the preparation phase. Second, we worked with the implementation team to monitor clinic operations to assess the degree to which TRRP was delivered according to the adapted model (ie audit/feedback; fidelity measurement), as well as patient engagement in each step of TRRP. This allowed identification of barriers to service delivery (eg certain components being more challenging to implement than anticipated). We managed resources needed to administer the program, including an iPad that uses our data management system to identify patients who are eligible for screening and referral. Third, we tracked billing and reimbursement and assessed potential cost-savings related to centers’ use of automated TRRP components. Finally, we assessed reactions to TRRP implementation as it related to the center’s ability to meet patients’ needs without disrupting organizational workflow. This allowed for an iterative adaptation process to help promote patient and provider satisfaction and sustainability.

Phase 4: Sustainment

We worked with each center to support development and execution of billing and reimbursement practices matched to the local care delivery model. Trauma centers that had the capacity to offer outpatient mental health treatment via an institutional department or embedded mental health provider were well positioned to sustain the full model due to revenue generated at Step 4. We actively worked with leadership to ensure that services were streamlined within their workflow, accounting for variable roles and responsibilities of key personnel.

RESULTS

Program implementation in Level I and II trauma centers

We partnered with 2 Level I and 1 Level II centers in the Southeastern US to implement TRRP within their respective trauma programs. These 3 centers were strategically chosen with guidance from our trauma surgery chief as they were diverse regarding geographic location (eg rural vs urban), patient volume, infrastructure and workflow (eg number of trauma team providers), and populations served to provide valuable data on best strategies for maximizing adoption and sustained use of TRRP. Given varying needs and resources, local adaptations and variations in the implementation process were necessary to promote adoption and sustainability (Table 2).

Table 2.

Trauma Center Characteristics and Trauma Resilience and Recovery Program Model Adaptations Across the Level I and II Trauma Centers

Characteristic	Original TRRP model	Site A	Site B	Site C
Trauma center level	Level I	Level I	Level I	Level II
ACS-verified	Yes	Yes	Yes	Yes
Annual trauma registry	2,000	3,300	3,500	1,500
Implementation team	Trauma surgery chief/ trauma program director; psychiatry faculty; full-time staff members	Trauma program director; inpatient psychiatrist; trauma program manager	Trauma program director; trauma program manager; hospital case manager	Trauma program manager; trauma program director
Site champion	Trauma surgery chief	Inpatient psychiatrist	Trauma program manager	Trauma program manager
TRRP coordinator	Full-time staff member	Externally hired, full time	Externally hired, full time	Externally hired, part time
Most common mechanism of injury	Motor vehicle collision; motorcycle collision; fall	Motor vehicle collision; gunshot wound; fall	Motor vehicle collision; motorcycle collision; fall	Motor vehicle collision; fall; gunshot wound
Model adaptations
Step 1: Bedside screening and education	Staff approach TRRP-eligible patients at the bedside to introduce the program and screen all patients using Injured Trauma Survivors Scale, a 9-item measure of peritraumatic distress and provide education about mental health recovery post-injury. Patients are enrolled in the automated mood monitoring system and in 30-day screening and are provided with additional information regarding emotional recovery (eg TRRP flyer, Trauma Survivors Network).	Integration of TRRP screening with already established SBIRT services for patient’s admitted with reported alcohol use time on injury. Screened and educated 1076 patients.	Program personnel expressed concern regarding use of an external patient management system in addition to the hospital’s electronic medical record. Thus, inclusion of a consent process regarding data storage in patient management system was enacted. The majority of patients consented. Those who did not consent were provided with a TRRP handout that contained basic psychoeducation and TRRP contact information. SBIRT services were coupled with TRRP services at bedside to reduce patient and provider burden. Screened and educated 1066 patients.	Protocols were developed to maximize patient privacy due to shared patient space (ie some patients had shared hospital rooms). Almost half of TRRP-eligible patients were older adults and/or experienced falls, both of which evidenced lower levels of enrollment. Protocols to increase patient engagement at the bedside were created. Falls from standing as the mechanism of injury were not approached given the low likelihood of peritraumatic distress and development of PTSD or depression. Screened and educated 288 patients.
Step 2: SMS system self-monitoring	TRRP staff provide rationale for purpose of the texting program. Patients provide consent to receive texts, which are sent once per day for 30 days. Each text contains a question about a specific symptom. If the patient endorses the symptom, they are provided with a coping strategy related to that symptom.	No adaptations. Enrolled 1,070 (64%) patients.	Due to low rates of engagement in the text-messaging program, the bedside script was amended to include a clear rationale for Step 2 including examples of questions and tailored feedback if patients were to endorse the respective symptom. Enrolled 194 (18%) patients.	No adaptations. Enrolled 84 (29%) patients.
Step 3: 30-day mental health screen	Patients are screened for PTSD via the PTSD Checklist- Short Form and depression Patient Health Questionnaire – 8* via email/text (preferred) or phone call (if patient refuses email/text). Patients who receive the surveys via email/text will receive 3 invites and 1 phone call if they have not completed. Patients who opted for phone completion will be called 3 times. After these attempts with no response, patients are considered lost to follow-up. Patients who screen positive on are provided with treatment referrals.	No adaptations. 310 (35%) of patients screened significant for PTSD and/or depression.	No adaptations. 86 (18%) of patients screened significant for PTSD and/or depression.	No adaptations. 53 (23%) of patients screened significant for PTSD and/or depression.
Step 4: Referrals to best practices	Patients screening positive at Step 3 are contacted via phone to provide referral information. If patient declines referral, they are asked if TRRP can follow-up in 2 months; if they decline, staff provides contact information. If patient accepts referral, they are oriented to evidence-based psychotherapy and asked if they would prefer services with TRRP (and informed of the waitlist, if applicable) or another provider. If preferring TRRP services, the patient is informed that a TRRP clinician will contact them in a week, and telehealth-related issues are troubleshooted (eg ensuring WiFi availability, private space). If preferring community-based services, ensure referrals are to providers that specialize in trauma-informed care, provide evidence-based treatments, and offer telehealth or are nearby to patient.	The hospital lacked built-in behavioral health services that could provide formal mental health treatment for those who were symptomatic at 30-day screen. As such, we developed a comprehensive referral database of community-based services and resources in the hospital’s catchment area to guide appropriate referrals for symptomatic patients. 216 patients (70%) accepted treatment referrals.	Several patients were observed to request needs outside the scope of TRRP (eg housing, transportation, assistance navigating the legal system) at the 30-day screen (ie Step 3). Community-based agencies that address these needs were identified and included in the comprehensive referral database. 73 patients (85%) accepted treatment referrals.	Leveraged the adjunct outpatient behavioral health center for referrals. A collaborative effort ensued to outline a referral mechanism for symptomatic patients, including a communication plan between clinics to ensure all patients were contacted. 34 patients (74%) accepted treatment referrals.

^*The Patient Health Questionnaire - 8 removes the suicidal ideation item (item 9) and instead has one question assessing functional impairment.

PTSD, posttraumatic stress disorder; SBIRT, Screening, Brief Intervention, and Referral to Treatment; TRRP, Trauma Resilience and Recovery Program.

Site A: ACS-verified adult Level I trauma center

This site is an ACS nationally verified adult Level I trauma center providing care for traumatic injury spanning from prevention through rehabilitation. Most common injuries include motor vehicles collisions, gunshot wounds, and falls.

Phase 1: Exploration

Center leadership expressed a commitment to addressing the mental health needs of their patients from the beginning. The lead psychiatrist on the trauma unit readily adopted the role of TRRP “champion” and led initial internal conversations and coordinated efforts to ensure that all major trauma center stakeholders were present during our site visit, including hospital administration (eg chief operating officer), program leadership (eg trauma surgery chief), and other key personnel (eg nursing staff). Having all stakeholders together during our visit allowed facilitators and barriers to be assessed more readily. This resulted in a strong preliminary action plan that considered the roles and responsibilities of different providers, patient volume and characteristics, and structural barriers (eg limited space to conduct telephone-based 30-day screens).

Phase 2: Preparation

The implementation team consisted of the trauma program director, inpatient psychiatrist, and program manager. Given the limited time available among these providers to deliver direct TRRP services to patients, this site hired outside of the trauma program and our team assisted with the hiring process. The TRRP clinic coordinator was a retired trauma nurse who had previously worked in the trauma program, and as such, was familiar with the center infrastructure. Next, we outlined the responsibilities of each member. For example, the inpatient psychiatrist volunteered to assist with crisis management, as needed, for highly distressed patients at bedside and during the 30-day screen. The trauma program manager agreed to oversee the responsibilities of the TRRP coordinator and support clinical operations (~1 to 2 hours per week). Finally, we created a plan to address program implementation barriers identified during the Exploration phase. One key barrier was the lack of outpatient behavioral health services to provide treatment to patients who are symptomatic at the 30-day screen. In response, we worked with the implementation team to develop a comprehensive referral database of community-based services in the respective catchment area.

Phase 3: Implementation

This phase began with training the TRRP coordinator on delivery of the model. Because the TRRP coordinator did not have previous experience providing mental health screening and education, we began with guided readings on best practices for screening and mental health services following injury. The coordinator then completed a 4-day training at our facility that included structured presentations, role-plays on delivery of the TRRP model, and live observation of our experienced TRRP coordinator delivering bedside and follow-up services. This was followed by a 4-day training at the implementation site where our team provided guidance as the TRRP coordinator implemented clinical services. The implementation team observed service delivery and at the end of the training, we assessed the need for model adaptations. For example, we integrated bedside TRRP mental health screening services with the center’s already established protocol for alcohol use problems—screening, brief intervention, and referral to treatment (SBIRT), a required element of trauma care for all ACS-verified trauma centers. The adapted process therefore included the following: bedside education on common mental health symptoms following injury, enrollment of patients in TRRP follow-up, completion of TRRP and SBIRT bedside screenings, handoff patients with positive SBIRT screens to the psychiatrist for brief intervention, and referral and arranging for continued PTSD and depression symptom monitoring and follow-up. Our success in executing and sustaining this model of care over the first year led to the expansion of services to this site’s ACS-verified Level II pediatric trauma center at their request.

Phase 4: Sustainment

We encountered several challenges to establishing billing and reimbursement practices. First, the limited funds available to hire a TRRP coordinator were not sufficient to hire a licensed healthcare professional and therefore the coordinator who was hired was not able to bill for services. The coordinator did have significant return on investment in other ways that supported the trauma program, however, including delivery of SBIRT services, delivery of grand rounds presentations and other reports to update the site on progress, and regular coordination with the medical team. Second, the trauma center did not have an adjacent outpatient behavioral health center, limiting the site’s capacity to support sustainability through revenue generated via delivery of mental health treatment. However, because the trauma program had an inpatient psychiatrist, billable referrals for psychiatric consults for medication management or for patients in acute distress were possible. Additionally, we worked to develop procedures to systematically track program goals (eg enrollment, provision of service referrals). This included conducting in-person quarterly on-site booster sessions, consisting of live observation of service delivery, and holding monthly videoconferencing calls to assist the site to monitor clinical operations, problem-solve challenges, and adjust the delivery model as needed to improve potential for sustainability. At the end of the 3-year grant period, the TRRP coordinator was fully integrated into the trauma program, was seen as a valuable member, and was granted full-time employment under the trauma program budget beyond the grant period.

Site B: ACS-verified adult Level I trauma center

Site B is an ACS-verified adult Level I trauma center and has a comprehensive multidisciplinary trauma team serving 3,500 trauma patients annually. The most common injuries result from motor vehicles collisions, motorcycle collisions, and falls.

Phase 1: Exploration

After an introductory session to initiate the partnership, our team held weekly conference calls with the trauma program director and trauma program manager to describe the TRRP program, learn more about the center, and answer questions related to program implementation. We guided the site team as they outlined an implementation plan with the support of their larger trauma program team. This was followed by a site visit with the trauma program director, trauma program manager, and hospital case manager to brainstorm how to overcome potential challenges to implementation (eg ability to screen all patients given large patient volume, use of technologies to support patient data management). For example, whereas the trauma program team recognized value in the use of a patient management system to assist in delivery of the TRRP model, there was concern about whether use of an external patient management system may be burdensome on providers who must also record encounters in the electronic medical record. This prompted a formal security review, before making decisions about the use of the patient management system.

Phase 2: Preparation

The implementation team consisted of the trauma program director, the trauma program manager, and the hospital case manager. Like Site A, existing personnel did not have sufficient bandwidth to manage full TRRP operations, so we assisted with the hiring process. The TRRP clinic coordinator held a bachelor’s degree in psychology and formerly worked as a substance abuse counselor providing counseling and crisis intervention. It was decided that the trauma program manager would oversee and support clinical operations. The hospital case manager, a licensed social worker, agreed to assist with crisis management and development of a comprehensive referral database to connect symptomatic patients to community-based services. Finally, we developed an implementation plan that considered noted barriers. For example, it was decided that patients would need to consent to having their data stored in the patient management system. A consent form was developed to explain how data would be stored in the system if a patient enrolled in TRRP.

Phase 3: Implementation

Training procedures were comparable to the other sites in that the TRRP coordinator completed 4 days of training at our center followed by a 4-day training at their site. Guided readings were not needed due to the coordinator’s experience providing behavioral health services. Moreover, the TRRP coordinator required fewer shadowing experiences before moving into service delivery with observation. TRRP bedside service delivery procedures were adapted to include the consent process. The TRRP coordinator approached patients at bedside to describe the program. If interested in enrollment, patients consented to use the patient management system. Approximately, 97% of patients signed the consent and were enrolled in services. Those who did not consent were provided a standard flyer that provided basic psychoeducation and referral resources. Finally, we established monthly conference calls to consult on issues related to clinical operations and problem solve unforeseen barriers to implementation. During the first 3 months of TRRP delivery, we found much lower rates of engagement in our text messaging program (Step 2) than we have observed in our hospital system.²⁰ We anticipated that the bedside script explaining the purpose and potential benefits of the text messaging program required further development, and we added rationale and examples to the existing script. We also found that during the 30-day screen, a higher than anticipated percentage of patients were requesting services for needs outside of mental health, including housing, transportation, and financial assistance. The implementation team identified and added community-based agencies to address these needs to the referral database.

Phase 4: Sustainment

We sought feedback on whether TRRP satisfactorily addressed the needs of the trauma program, which allowed us to develop comprehensive plans to promote patient engagement and reduce provider burden. We encountered challenges to billing and reimbursement because the TRRP coordinator was not a licensed healthcare professional who could bill for services. To this end, we sought to identify opportunities for the coordinator to be fully integrated within the trauma program, including attending key trauma program meetings, assisting with site review and accreditation visits, and assisting with research. Like the approach used at Site A, the TRRP coordinator also began administering SBIRT services at bedside. The ability for the TRRP coordinator to become integrally involved in the trauma program and be seen as a key member of the patient’s care team was essential to successful implementation. After the end of the grant period, the TRRP coordinator continued to effectively screen and connect patients to follow-up mental health services. The coordinator was granted full-time employment by the hospital under the trauma program budget.

Site C: State-verified adult Level II HCA-affiliated site

This site is a ACS-verified Level II adult HCA Healthcare-affiliated trauma center providing care to ~1,500 traumatic injury patients admitted annually from initial assessment and continuing through outpatient clinic follow-up to promote physical recovery. The most common injuries result from motor vehicles collisions, falls, motorcycle collisions, and gunshot wounds.

Phase 1: Exploration

We met with the leadership team, 2 trauma surgeons, and the chief operating officer, all of whom expressed enthusiasm about implementing TRRP and developing an avenue to refer symptomatic patients to the hospital’s outpatient behavioral health center. Moreover, as the site was a Level II center working to achieve Level I designation, leadership was particularly interested in collaborating in research to enhance their portfolio. Discussion of barriers focused on the site’s admitted trauma population—this Level II center treats a relatively high proportion, compared to most Level I centers, of older adults and patients who had experienced falls (vs injury due to penetrating mechanism). Patients with ground-level fall injuries tend to be less distressed at bedside and have fewer mental health needs in the weeks following injury that would require intervention.³⁴

Phase 2: Preparation

It was decided that a TRRP coordinator would be hired externally given the limited availability of existing personnel to add extra duties. Our team assisted with the hiring process but encountered significant delays around onboarding due to HCA protocols (eg onboarding process, access to electronic medical record). The TRRP coordinator hired for this role held a bachelor’s degree in psychology and had experience as a research assistant on a clinical research program to improve quality of child mental healthcare. The implementation team consisted of (1) the TRRP coordinator, responsible for delivery of TRRP services; (2) director of trauma services, who oversaw daily operations; and (3) trauma program director, who assisted in problem-solving implementation barriers. Over the next few months, we worked to outline a preliminary implementation plan through biweekly calls that focused on barriers and facilitators identified during the Exploration phase. One noted barrier was that some of the patient units did not have private rooms. We developed protocols to maximize privacy in the shared space. One noted facilitator was the existence of an adjunct outpatient behavioral health center. We worked with the implementation team and the behavioral health team to outline a referral mechanism for symptomatic patients identified at the 30-day screen.

Phase 3: Implementation

We implemented the training process that was developed for Site A because the TRRP coordinator did not have previous clinical experience. We worked with the site to establish key performance indicators to capture rates of enrollment and engagement in services. Clinical operations data initially indicated lower levels of enrollment at bedside among older patients and among patients admitted after experiencing a fall, which comprised almost half of TRRP-eligible patients. Protocols for increasing patient engagement at bedside (eg providing more education about possible symptom trajectories) were applied, evaluated, and modified. Approximately one year into implementation, the TRRP coordinator resigned from the institution, which resulted in a pause in patient care as the position was filled. Due to lower patient volume and lower levels of patient engagement among patients with falls, it was observed that the previous TRRP coordinator needed approximately 20 hours per week to deliver TRRP services. Program leadership therefore decided to provide effort to the trauma administrative coordinator to take on TRRP coordinator duties. We repeated the training process and, because the new TRRP coordinator was already integrated into the trauma program, the transition was seamless with strong continuity of communication and reporting to the broader trauma care team around TRRP services, progress, and patient engagement.

Phase 4: Sustainment

First, we worked to achieve a consistent billing practice by referring patients with clinically elevated symptoms to the hospital’s outpatient behavioral health clinic. This included implementing a referral process and communication plan between the clinics to ensure that all referred patients were contacted. We maintained regular bimonthly communication to assess enrollment and engagement milestones and adjust the delivery model to ensure sustainability. For example, over time, it was decided that patients with injuries caused by ground-level falls generally had low risk for development of mental health problems and were not good candidates to approach for enrollment unless other risk factors were observed that warranted engagement. The TRRP coordinator balanced the dual roles by scheduling specific blocks of time during day to accomplish daily administrative tasks and TRRP service delivery.

DISCUSSION

Challenges and lessons learned in implementing TRRP in Level I and II trauma centers

The implementation strategies at each phase of the EPIS model were guided by the outer organizational context (eg ACS policy, external funding), inner organizational context (eg leadership support, organizational workflow), and the interplay of these variables (ie bridging factors) as they served to identify local adaptations to facilitate the implementation and sustainment of TRRP (innovation factors). Common barriers and facilitators to implementation and program successes are summarized in Table 3. Below we provide recommendations for trauma centers seeking to integrate mental health programs into their existing services but that may have limited funds to do so.

Table 3.

Common Implementation Barriers and Facilitators and Program Successes

Variable
Innovation factor
Facilitator
HIPAA-compliant technology elements created efficiencies and were viewed favorably
TRRP model adaptable based upon site needs and available resources
Outer setting
Facilitator
American College of Surgeons guidelines mandate screening and referral practices
Best practice guidelines provide roadmap for screening and follow-up practices
Barrier
External policies limited billing and reimbursement practices based on provider credentials
Inner setting
Facilitator
High enthusiasm and support for mental health services and screening
TRRP coordinators with clinical background had greater readiness for implementing TRRP
Site champions facilitated program implementation process
Embedding TRRP coordinator with the medical team
Barrier
Only licensed mental healthcare professionals can bill and receive reimbursement for delivery of TRRP services
Most centers do not have adjunct outpatient behavioral health programs for follow-up services and to generate downstream revenue
Bridging factor
Facilitator
Our center’s trauma surgery chief established initial communications with partnering centers
Barrier
Centers had limited knowledge relating to mental health treatment and community mental health referral sources
Success of implementation
TRRP was successfully implemented and sustained at each center
Integration of TRRP with existing SBIRT services minimized provider burden and supported trauma program goals
TRRP coordinators were granted full-time employment by the hospital under the trauma program budget
Implementation of TRRP in pediatrics following success at adult center

SBIRT, screening, brief intervention, and referral to treatment; TRRP, Trauma Resilience and Recovery Program.

Outer context

Trauma centers are well positioned to address the emotional recovery of traumatic injury patients by implementing programs that provide education, identify patients at risk for developing PTSD and/or depression, and provide referrals to mental health services. Stepped care models, like TRRP, are well-suited to provide these services within trauma centers because they are designed to match patients’ needs to the appropriate level of intervention. Whereas most patients will experience distress following an injury, 60–80% of these patients will recover naturally over a 1 to 2-month period post-injury without additional intervention. However, many patients require additional services ranging from education to formal outpatient mental health treatment. Therefore, as recommended by the ACS Best Practice Guidelines,⁵ screening at multiple time points allows for the provision of targeted interventions to meet the specific needs of the patient both in-hospital and following discharge. Stepped care models offer a cost-efficient and sustainable solution for trauma centers to satisfy ACS guidelines. These models have also been found to be feasibly implemented in acute care settings and effective at addressing mental health symptoms post-injury.^{11,12,14,17,35} The funding our team secured for this initiative allowed us to integrate a clinic coordinator at the time of initial launch of TRRP, thus mitigating concerns expressed during initial conversations regarding the limited availability of existing trauma center personnel to assist with program delivery. Because this was a pilot initiative, this funding was critical to assuring trauma center leaders that the financial risk of this partnership in the early years post-launch was low. Notably, once the model was implemented and managed successfully over time with grant support, all 3 partnering centers continued to implement the program without additional grant support. Moreover, the results of this pilot initiative will be valuable to future partners who may wish to implement TRRP or a similar program with fewer resources.

Inner context system-level factors: Organizational characteristics and leadership

Only 3 trauma centers were approached for this initiative and all 3 were enthusiastic partners, largely due to the recognized need to launch a mental health program for trauma patients coupled with the ability to do so with an established program, expert support, and adequate resources. This was critical to building momentum in the early stages of the Exploration phase as well as active participation among key stakeholders in the Preparation phase; and it continued to motivate the implementation teams as they systematically monitored ongoing clinical operations and billing and reimbursement practices in the Implementation and Sustainment phases. Site champions facilitated the implementation process and held leadership roles within the trauma program which ensured effective decision making around model adaptations, direct clinical operations, and support for the TRRP coordinator in problem-solving barriers to service delivery. Finally, embedding the TRRP coordinators within the medical team was essential to the success of the program and ensured high and consistent levels of patient engagement. This also allowed assistance with delivery of other existing practices and protocols (eg SBIRT), which helped to promote sustainability of the position in the long-term.

Inner context individual-level factors: Individual characteristics and quality monitoring.

Mental health screening and referral does not require specialized mental health expertise and can be administered following appropriate training and oversight.⁵ As such, trauma centers have several staffing options to address the ACS requirements. TRRP coordinators hired to provide services had varied educational and employment backgrounds. Whereas all coordinators delivered TRRP services effectively and were fully integrated into the trauma program, we found that congruence between TRRP responsibilities and prior training and experience had significant implications for efficiency and quality of start-up activities. For example, coordinators who did not have a background in mental healthcare required additional training and oversight. This resulted in a prolonged training process and required increased monitoring (ie weekly check-ins, followed by monthly, then quarterly), as well as problem-solving barriers to implementation during the first several months. To support training and quality of care, we ensured that the implementation teams were integrally involved in the training planning and implementation process and were provided with easily accessible and user-friendly training protocols (eg manuals, recorded demonstration trainings) to be used to train new future personnel. We also worked to establish procedures that allowed each center to systematically track program goals and generate reports highlighting key performance indicators (eg number of patients screened and referrals offered). Finally, we learned that only licensed mental healthcare professionals can bill and receive reimbursement for services. Hiring trauma-informed psychologists and licensed clinical counselors or social workers should be carefully considered by trauma centers when implementing behavioral health programs.⁵ They can provide best-practice mental healthcare in the hospital and following discharge with minimal additional training and supervision, and their services are reimbursable. Centers that do not have licensed providers for screening and services should seek additional opportunities to generate revenue, such as referring to in-house outpatient behavioral health programs. Hiring a licensed provider who can generate revenue, in the context of future partnerships, may support the capacity to launch and sustain mental health programs without grant funding.

Bridging factors: Community–academic partnerships

Building partnerships with community mental health agencies was a top priority identified during the exploration phase. Centers without adjunct behavioral health clinics expressed concern about not knowing what resources were available in the community and how to refer patients to those resources, if needed. Consistent with ACS guidelines,⁵ 2 key priorities for discussion included the availability of best-practice mental health treatments and the local and national shortage of mental health providers that may produce long wait lists for referred patients. We worked with the implementation teams to conduct an online search of available community-based organizations and created a comprehensive database of available resources, including information found in the organization’s website about services provided (eg individual therapy, family therapy), types of treatment provided (eg trauma-focused, substance use), types of providers delivering care (eg psychologists, psychiatrists), accepted insurance plans, and preferred referral process (eg online referrals). This enabled the TRRP coordinator to provide referrals to patients who screened positive on the 30-day screen, as well as education about available treatments and personalized recommendations for the most appropriate type of care. Implementing referral processes for centers with adjunct outpatient behavioral health clinics was also necessary. This involved meeting with outpatient clinic personnel to provide information on TRRP clinical operations, identifying and adopting existing referral processes for other hospital-based programs, and evaluating and adapting this process to ensure efficient referral of patients to needed care. Relatedly, because centers serve patients who live in geographically isolated areas or even out-of-state, we identified strategies to connect patients with local referrals. To this end, we worked to educate the implementation teams on the availability and use of credible behavioral health treatment locators for identifying facilities across the US (eg Substance Use and Mental Health Services Administration). Finally, because trauma center leadership voiced concerns around limited resources, and in particular the limited personnel available to deliver TRRP services, during the Exploration phase, trauma centers should consider additional partnerships within the trauma program to divide tasks associated with service delivery. For example, trauma centers can leverage nursing personnel to administer the bedside screening and rely on social work support to administer the 30-day screening and connecting symptomatic patients to appropriate mental health resources.

Innovation factors: Innovation fit

Adaptations to the TRRP model were necessary across all our sites and our research team conducted regular quality improvement evaluations to assess TRRP fit within the trauma program. One initial major area of focus was working toward integrating TRRP with existing embedded services, such as SBIRT, to help to support trauma program goals. During the implementation phase, we found this model to be successful in addressing another critical area of focus, reducing both patient and provider burden (ie completing different screens with different providers at different time-points during their stay), and in helping the TRRP coordinator to become an integral member of the trauma program. Trauma centers should consider integration with additional hospital-based programs, such as peer navigation programs (eg Trauma Survivors Network), to consolidate similar practices, reduce burden and increase overall satisfaction.⁵ Finally, we leveraged our HIPAA-compliant patient management database software system to track clinical operations to quantify service delivery efforts through creation of formal reports to share with trauma program leadership to promote program sustainability.

CONCLUSIONS

Trauma centers in the US are uniquely positioned to address the mental health needs of traumatic injury patients through early identification, screening, and provision of follow-up services. In the current quality improvement initiative, our work demonstrates the feasibility of implementing and adapting TRRP, a cost-efficient and sustainable, technology-enhanced, stepped care intervention, in Level I and II trauma centers. Our prior work determined that TRRP is feasible and acceptable to both adult and pediatric traumatic injury patients and provided preliminary evidence that patients have high and equitable levels of engagement in the model. Although effectiveness of the full model in trauma centers has not yet been established, each step of the model is supported by a wide range of evidence, and our team is conducting 2 multi-site hybrid I effectiveness-implementation trials to rigorously assess the impact of the model with adults and adolescents.

Several factors should be considered by trauma centers seeking to integrate behavioral health interventions into their trauma program. Careful consideration of implementation frameworks is needed to adequately meet the needs of all traumatic injury patients and successfully integrate behavioral health services, such as TRRP, into existing trauma centers. We chose to use the EPIS framework to guide our implementation process as it incorporates several factors deemed as essential to program implementation and sustainment,³⁰ including incorporation of partner input, consideration of available resources and needs, and enabling ongoing progress monitoring and adaptations to improve program delivery. Although we selected the EPIS model to guide our initiatives, there are many other implementation models³⁶ that could be considered, and the conceptual framework that best fits the proposed intervention, patient needs, and existing organizational structure should be chosen. Consistent with ACS guidelines,⁵ engaging patient, provider, and hospital administration stakeholders early in the implementation process is critical for informing the most suitable intervention. As well, hospital systems need active processes for monitoring and evaluating implementation of behavioral health services, and informing adaptation as needed for patients, providers, and the larger hospital system. Notably, it is imperative that programs consider the unique needs of vulnerable patients, including children and victims of violent injury, and make adaptations beyond the standard implementation infrastructure (eg integrating violence prevention programs) to best meet needs of all traumatic injury patients.

Abbreviations and Acronyms

ACS

American College of Surgeons

EPIS

Exploration, Preparation, Implementation, Sustainment

HCA

Hospital Corporation of America

PTSD

Posttraumatic stress disorder

SBIRT

Screening, Brief Intervention, and Referral to Treatment

TRRP

Trauma Resilience and Recovery Program