دانلود رایگان مقاله ساخت سیستم بهداشت رفتاری عمومی تروما

Abstract

Exposure to traumatic experiences among youth is a serious public health concern. A trauma-informed public behavioral health system that emphasizes core principles such as understanding trauma, promoting safety, supporting consumer autonomy, sharing power, and ensuring cultural competence, is needed to support traumatized youth and the providers who work with them. This article describes a case study of the creation and evaluation of a trauma-informed publicly funded behavioral health system for children and adolescents in the City of Philadelphia (the Philadelphia Alliance for Child Trauma Services; PACTS) using the Exploration, Preparation, Implementation, and Sustainment (EPIS) as a guiding framework. We describe our evaluation of this effort with an emphasis on implementation determinants and outcomes. Implementation determinants include inner context factors, specifically therapist knowledge and attitudes (N = 114) towards evidence-based practices. Implementation outcomes include rate of PTSD diagnoses in agencies over time, number of youth receiving TF-CBT over time, and penetration (i.e., number of youth receiving TF-CBT divided by the number of youth screening positive on trauma screening). We describe lessons learned from our experiences building a trauma-informed public behavioral health system in the hopes that this case study can guide other similar efforts.

6. Moving forward with a trauma-informed behavioral health system

The public behavioral health system plays a primary role in supporting the behavioral health needs of children and youth in urban communities. Previous studies have highlighted the high percentage of children and youth experiencing traumatic events (Ford et al., 1999). Although the evidence base of robust treatment practices to address trauma has grown, “current policy and practice responses do not reflect the urgency, depth or quality required by the high level of need, low impact of many current efforts, and limited community-based service capacity,” (National Center for Children in Poverty, 2007, pp. 3). Maintaining the use of EBP after the initial implementation period ends is a critical challenge in the public health sector, and comparatively less is known in the implementation science literature about how to enhance sustainability compared to initial implementation (Stirman et al., 2012). A benefit of Philadelphia’s payer (i.e., CBH) being integrated within DBHIDS is the ability to sustain initiatives beyond grant cycles. This has begun with the city provision of an enhanced rate for the use of TF-CBT. However, while DBHIDS and CBH will continue to support the initiative, the significant funding currently available from grant funding will not exist once the grant ends. Here again, it is useful to draw on the implementation science literature, which has highlighted nine core domains that affect capacity for program sustainability: political support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, communications, public health impacts, and strategic planning (Schell et al., 2013). Rather than viewing sustainability as a static end-point, newer models of sustainability emphasize continued learning and problem-solving among stakeholders, as well as the ongoing adaptation of interventions, with a primary focus on fit between interventions and context (Chambers, Glasgow, & Stange, 2013). Taken together, this suggests that in addition to outside support from DBHIDS and CBH, agencies implementing TF-CBT will need to work together to support each other as they move into the sustainment phase of implementation. Several steps recently have been taken to move the responsibility from the grant personnel to agency leaders. First, a monthly web-based supervisors meeting to focus on the supervision of EBP and to allow for stakeholders to share challenges to successful implementation (e.g., turnover, lack of agency support, serving children and families who experience ongoing chronic stress) has been implemented to allow for collaborative problem-solving about how to best address these barriers. Second, meetings with agency leadership to discuss trauma work after the grant and to understand how to consolidate the gains made (e.g., maintaining the same number of agencies but increasing the depth of clinicians receiving training and holding new meetings with child-serving systems regarding cross-system support). It is likely that not all current agencies will continue to offer TF-CBT without ongoing support; however, many of the agencies have established strong relationships and will continue to collaborate in the future. Other future directions include expanding EBP offered to providers, including those for disruptive behavior disorders, a primary presenting concern for many traumatized youth, partnering with settings where youth spend their time, such as schools; and deliberately targeting the most vulnerable youth in the system (young children ages 2–6 years, LGBTQ youth, commercially sexually exploited children, and intentionally injured youth).