Jump to comment:

• Continuity in primary care: application and implications for trauma-informed care
  Nomi C. Levy-Carrick, Annie Lewis-O'Connor, Eve Rittenberg, Samara Grossman and Hanni M. Stoklosa
  Published on: 4 September 2019

• Published on: 4 September 2019

  Continuity in primary care: application and implications for trauma-informed care

  • Nomi C. Levy-Carrick, physician (psychiatry) Brigham and Women's Hospital, Harvard Medical School
  • Other Contributors:
    • Annie Lewis-O'Connor, nurse-scientist
    • Eve Rittenberg, physician (primary care)
    • Samara Grossman, social worker
    • Hanni M. Stoklosa, physician (emergency medicine)

  The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.

  The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.

  Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall sh...

  Show More

  The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.

  The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.

  Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall shortage of mental health providers relative to need, primary care providers have been called upon to manage an increasing range of psychopathology. There is simultaneously a growing appreciation for the relationship between early life adversity and chronic physical illnesses: our sickest patients – whether encountered in the emergency department, primary care, specialty, or psychiatric settings -- are often those who have struggled with lifelong adversity. Engagement and adherence that can promote behavioral changes hinge upon mental health, and optimization of medical outcomes thus occur when mental health is integrated into evaluation and intervention. Minimizing the number of new providers, the number of transitions, the number of times one has to provide a medical (and trauma) history, are crucial for a trauma-informed medical system: continuity is key. Application of the program elements described by Schwarz and team can inform trauma-informed interventions that strive to support health equity world-wide.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top