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Upstream thinking at Klinic
Community Health
CACHC Webinar
January 14, 2016
Linda Dawson Kiri Shafto
Overview
• Klinic (Then & Now)
• Upstream Thinking
• The Project
– Social Justice Roots– Social Justice Roots
– Decision support
– Trauma-informed?
• Next steps & Challenges
2
Klinic (Then & Now)
Klinic – 1970s
• Takin’ it to the streets
• Student docs start seeing people on the
street and in the park – sex, drugs and
rock n’ rollrock n’ roll
• Move into the crypt (church basement)
4
Klinic
Crisis
Response
Acute Medical
Care
Klinic – 2015
5
Klinic Service Delivery
• Medical services – Community*
• Counseling services – City
• Crisis lines & education – Province
• Manitoba Trauma Information and• Manitoba Trauma Information and
Education Centre – North America
(www.trauma-informed.ca)
• Calm in the storm app – World
6
Klinic Innovation
• Calm in the Storm - http://calminthestormapp.com/
7
Upstream Thinking @ Klinic
“…community health centres face the
challenge of transferring knowledge of
trauma and the social determinants of health
into policy and practice”into policy and practice”
– Excerpt from Klinic’s application to PHAC
9
Hide logo
Public Health Agency of Canada
and Community Health
What is the Canadian Public
Health Service (CPHS)?
• Created as part of the 2006 Avian and
Pandemic Influenza Preparedness
Treasury Board Submission, intended to:
– Focus on surveillance (infectious/chronic),– Focus on surveillance (infectious/chronic),
EPR and health promotion
– Work on specific projects in jurisdictions
across Canada, for short-term (1-4year)
placements
11
Who are the PHOs?
• Qualified public health employees, trained in
epidemiology, policy analysis and nursing
• PHOs offer a variety of expertise:
– Infectious disease
– Chronic disease– Chronic disease
– Vaccine preventable disease
– Injury prevention
– Health promotion
– Public health policy
– Environmental health
• Not involved with delivery of front-line patient
care
12
CPHS Accomplishments
14 –Active federal Public Health Officers
(PHOs) across Canada
5 – Currently placed with northern and/or
First Nations organizationsFirst Nations organizations
63 –Different projects across Canada since
2006 (F/P/T/local and NGOs)
60 –Co-op students
13
Hide logo
Innovative Partnership
Klinic & the Public Health Officer
• PHAC annual call for placements
• Klinic proposal
– Develop a strategy/framework to become a
trauma-informed organizationtrauma-informed organization
– Integrate knowledge of trauma and SDH into
policy, procedures, practices, and settings
– Share learnings
15
Benefits of the partnership
• PHAC strengthens its public health capacity
by building:
– Workforce
– Infrastructure
– knowledge & networks– knowledge & networks
• Klinic
– Time
– Naivety and Curiosity (new eyes)
– Deadline
16
The Project
The Project…
1. Decision support – Develop and
implement a decision support tool to
inform program and policy development
2. Trauma-informed – Develop and2. Trauma-informed – Develop and
implement a strategy to guide Klinic as
we become a trauma-informed
organization
18
Hide logo
Rooted in Social Justice
Position Papers
• Mark a commitment to Klinic’s social
justice roots
• Encourages staff to speak with one voice
• Allows staff to speak on behalf of Klinic• Allows staff to speak on behalf of Klinic
• Protects staff who are speaking on behalf
of Klinic
20
Process
• Representatives from different program
areas and the board
• Priorities Identified by:
– Individual staff members– Individual staff members
– Program area
– Current events
– Community
– Board
• Feedback sessions with staff and board
21
Progress
• Refugee Health – Complete
• Access – Feedback
• Poverty – Feedback
• Trauma – Feedback• Trauma – Feedback
• Violence – Feedback
• Indigenous Health – First draft
• Sexual Exploitation – In progress
22
Hide logo
Part One: Decision Support
Decision support tool
• Develop and implement a decision
support tool to inform program and policy
development that addresses:
o the social determinants of healtho the social determinants of health
o the root causes of disease
o community development
o concepts of trauma-informed practice
24
Goals
• Develop a tool to use to evaluate how a
proposed program or service fits with
Klinic’s priorities
• Form the basis for future ongoing program• Form the basis for future ongoing program
evaluation
• Build capacity among Klinic staff
• Expand to help evaluate existing programs
25
Process
• Invited representatives from across
program areas to act as advisory group
• Regular meetings to brainstorm, share
knowledge, provide feedback to createknowledge, provide feedback to create
decision support tool
• Participate in piloting tool
26
Logic Model
Resources/Inputs Activities Outputs/Products Outcomes/Results
Decision-making support
tool that accurately
reflects the current
priorities of Klinic, staff
and clients, and the
community
Staff from each program
area and management
Materials and equipment
Information technology
Increased ability to quickly
and systematically assess
project
Collaborate with
Increased staff
understanding of planning
Learn, brainstorm, and
provide feedback on the
components of the
decision-making support
tool
Information technology
and social media
Research/Best practices
Partnership with Public
Health Agency of Canada
Participate in a pilot test
of the tool
Provide a link to other
staff at Klinic for
additional input and
feedback
Collaborate with
representatives from
program areas across
Klinic
understanding of planning
process
Increased capacity for
evaluation
Presentation for
management team, the
board, staff describing the
tool and the process
Write-up of process to
share with other
organizations
As collaboration is an essential part of Trauma-Informed Practice, this collaborative process will strive to embrace principles of Trauma-
Informed Practice and will be guided in this effort by the Trauma experts on the advisory group.
27
Schematic
Physical Mental
Social
Justice
Trauma-
Informed
Gender-
Based Community
28
Physical Mental
Emotional
Community
Development
Klinic
History
Klinic
Individual
Health
Equity
Spiritual
Culture
Tool
29
Hide logo
Part Two: Trauma-Informed
Trauma-Informed Strategy
• Develop and implement a strategy to
guide Klinic as we become a trauma-
informed organization
31
Goals
• Develop a tool based on emerging
literature and local experts in the field to
guide Klinic in becoming a trauma-
informed organizationinformed organization
• Share tool and learnings across the
organization and externally
32
WHAT IS TRAUMA?
Background
Trauma defined
• Defining trauma
– severe emotional shock and pain caused by
an extremely upsetting experience
(Cambridge dictionary)
– a deeply distressing or disturbing experience
(Oxford dictionary)
34
What is Trauma?
“…out of control, frightening experience that
has disconnected us from all sense of
resourcefulness or safety or coping orresourcefulness or safety or coping or
love”.
- Tara Brach
35
Types of trauma
1. Single incident trauma
2. Developmental trauma
3. Complex trauma
4. Intergenerational trauma4. Intergenerational trauma
5. Historical trauma
36
Adverse Childhood
Experiences Study
• Kaiser Permanente and Centers for
Disease Control
• Over 17,000 participants (1995-1997)
– Mostly middle-class, employed, educated,– Mostly middle-class, employed, educated,
insured
• Link between childhood trauma and long-
term health and social outcomes
http://www.cdc.gov/violenceprevention/acestudy/
http://www.research4children.com/data/documents/ACF1114.pdf
37
WHAT IS TRAUMA-INFORMED?
Context
Trauma-informed defined
• Concept of service delivery influenced by
understanding the impact that trauma may
have on an individual’s life and
development
39
Trauma-Informed Services are…
40
Trauma-Informed Organization
• Commitment to providing services in a
manner that is welcoming and appropriate
to the special needs of those affected by
trauma
• Integrating an understanding of the impact
of trauma and violence into the
organization’s policies, procedures, and
interactions.
41
Trauma-Informed Staff
Communication
• Curiosity
• Vulnerability
• Listen compassionately
• Connect meaningfully
Self-care
• Burnout
• Emotional fatigue
• Mindfulness
• Self-compassion• Connect meaningfully
• Appreciate silence
• Tolerate uncertainty
• Develop mindful
presence
• See the patient as a
person
• Self-compassion
• Social supports
• Exercise
• Trauma exposure
response
• Eating and sleeping well
• Communities of practice
42
Trauma-Informed Space?
• Calming and welcoming
– Waiting and treatment rooms have space
for people to move
– Confidential space available for intake– Confidential space available for intake
• The space inside the building is safe
– Common areas are well lit
– Bathrooms offer privacy
• The space around the building is safe
– Parking lot and sidewalks well lit
43
Klinic’s space needs work!
• Cluttered
• Public washroom
visible
• Harsh lighting• Harsh lighting
• Dying plant
• Utilitarian
• TMI!
Assessment tool
• Trauma-Informed Organizations
– policies and procedures
Plus:
• Trauma-Informed Staff• Trauma-Informed Staff
– individual practice
• Trauma-Informed Space
– environment
45
3. TRAUMA-INFORMED ORGANIZATION
For an organization to be trauma-informed, the commitment must be imbedded in the service delivery model, and must incorporate aspects of
trauma-informed practices related to staff and space.
3.1 Overall Policy and Program Mandate
A commitment to trauma-informed practice may represent a shift in culture and values. This wide spread commitment to trauma-informed practice
increases the liklihood that all people who come into this service setting, regardless of where/how they enter the system, will encounter services
that are sensitive to the impact of trauma.
Philosophy
Fully
achieved
In progress
Not
achieved
Not
applicable
Comments
The organization recognizes the value of trauma-informed practice
as part of its mandate.
The organization has a policy or position statement that includes a
commitment to trauma-informed principles and practices.
The policy/position statement identifies the relationship between
trauma and recovery.
The policy/position statement identifies the implications for service
access and design.access and design.
The policy/position statement is endorsed by leadership.
3.2 Policies and Procedures
The policies and procedures of the organization should reflect their commitment to trauma-informed practices and be based on available
evidence.
Overall
Fully
achieved
In progress
Not
achieved
Not
applicable
Comments
The organization ensures that all current policies and protocols
are respectful, promote safety and flexibility, and are not hurtful or
harmful to the individual who has experienced trauma.
Privacy and confidentiality
Fully
achieved
In progress
Not
achieved
Not
applicable
Comments
There are established processes that support client awareness
and understanding of informed consent.
All staff and clients understand the informed consent process (e.g.
the extent and limits of confidentiality, what records are kept, and
where records are kept).
Next steps & Challenges
Piloting
• Decision support tool
– Started this week
• Trauma-informed checklist
– Starting next week– Starting next week
48
Project Challenges
• Kiri’s time with Klinic is limited
• Information sharing
• Integrating Trauma Informed with SDOH?
• Defining physical and psychological• Defining physical and psychological
trauma differently
49
Project Summary
• What is Klinic left with when Kiri leaves?
– Staff understand the tool and the process
behind the tools
– Klinic Quality Lead is left with a structured– Klinic Quality Lead is left with a structured
evaluation plan
– Share information broadly
– Integrate Trauma Informed with SDOH into
one tool
50
Linda Dawson
Director of Health Services
Klinic Community Health Centre
(204) 784-4063
ldawson@klinic.mb.ca
Kiri Shafto
Public Health Officer
Klinic Community Health Centre
Public Health Agency of Canada
204-784-4207
kshafto@klinic.mb.ca
51

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Klinic CHC: Upstream Thinking and Trauma-Informed Care

  • 1. Upstream thinking at Klinic Community Health CACHC Webinar January 14, 2016 Linda Dawson Kiri Shafto
  • 2. Overview • Klinic (Then & Now) • Upstream Thinking • The Project – Social Justice Roots– Social Justice Roots – Decision support – Trauma-informed? • Next steps & Challenges 2
  • 4. Klinic – 1970s • Takin’ it to the streets • Student docs start seeing people on the street and in the park – sex, drugs and rock n’ rollrock n’ roll • Move into the crypt (church basement) 4 Klinic Crisis Response Acute Medical Care
  • 6. Klinic Service Delivery • Medical services – Community* • Counseling services – City • Crisis lines & education – Province • Manitoba Trauma Information and• Manitoba Trauma Information and Education Centre – North America (www.trauma-informed.ca) • Calm in the storm app – World 6
  • 7. Klinic Innovation • Calm in the Storm - http://calminthestormapp.com/ 7
  • 9. “…community health centres face the challenge of transferring knowledge of trauma and the social determinants of health into policy and practice”into policy and practice” – Excerpt from Klinic’s application to PHAC 9
  • 10. Hide logo Public Health Agency of Canada and Community Health
  • 11. What is the Canadian Public Health Service (CPHS)? • Created as part of the 2006 Avian and Pandemic Influenza Preparedness Treasury Board Submission, intended to: – Focus on surveillance (infectious/chronic),– Focus on surveillance (infectious/chronic), EPR and health promotion – Work on specific projects in jurisdictions across Canada, for short-term (1-4year) placements 11
  • 12. Who are the PHOs? • Qualified public health employees, trained in epidemiology, policy analysis and nursing • PHOs offer a variety of expertise: – Infectious disease – Chronic disease– Chronic disease – Vaccine preventable disease – Injury prevention – Health promotion – Public health policy – Environmental health • Not involved with delivery of front-line patient care 12
  • 13. CPHS Accomplishments 14 –Active federal Public Health Officers (PHOs) across Canada 5 – Currently placed with northern and/or First Nations organizationsFirst Nations organizations 63 –Different projects across Canada since 2006 (F/P/T/local and NGOs) 60 –Co-op students 13
  • 15. Klinic & the Public Health Officer • PHAC annual call for placements • Klinic proposal – Develop a strategy/framework to become a trauma-informed organizationtrauma-informed organization – Integrate knowledge of trauma and SDH into policy, procedures, practices, and settings – Share learnings 15
  • 16. Benefits of the partnership • PHAC strengthens its public health capacity by building: – Workforce – Infrastructure – knowledge & networks– knowledge & networks • Klinic – Time – Naivety and Curiosity (new eyes) – Deadline 16
  • 18. The Project… 1. Decision support – Develop and implement a decision support tool to inform program and policy development 2. Trauma-informed – Develop and2. Trauma-informed – Develop and implement a strategy to guide Klinic as we become a trauma-informed organization 18
  • 19. Hide logo Rooted in Social Justice
  • 20. Position Papers • Mark a commitment to Klinic’s social justice roots • Encourages staff to speak with one voice • Allows staff to speak on behalf of Klinic• Allows staff to speak on behalf of Klinic • Protects staff who are speaking on behalf of Klinic 20
  • 21. Process • Representatives from different program areas and the board • Priorities Identified by: – Individual staff members– Individual staff members – Program area – Current events – Community – Board • Feedback sessions with staff and board 21
  • 22. Progress • Refugee Health – Complete • Access – Feedback • Poverty – Feedback • Trauma – Feedback• Trauma – Feedback • Violence – Feedback • Indigenous Health – First draft • Sexual Exploitation – In progress 22
  • 23. Hide logo Part One: Decision Support
  • 24. Decision support tool • Develop and implement a decision support tool to inform program and policy development that addresses: o the social determinants of healtho the social determinants of health o the root causes of disease o community development o concepts of trauma-informed practice 24
  • 25. Goals • Develop a tool to use to evaluate how a proposed program or service fits with Klinic’s priorities • Form the basis for future ongoing program• Form the basis for future ongoing program evaluation • Build capacity among Klinic staff • Expand to help evaluate existing programs 25
  • 26. Process • Invited representatives from across program areas to act as advisory group • Regular meetings to brainstorm, share knowledge, provide feedback to createknowledge, provide feedback to create decision support tool • Participate in piloting tool 26
  • 27. Logic Model Resources/Inputs Activities Outputs/Products Outcomes/Results Decision-making support tool that accurately reflects the current priorities of Klinic, staff and clients, and the community Staff from each program area and management Materials and equipment Information technology Increased ability to quickly and systematically assess project Collaborate with Increased staff understanding of planning Learn, brainstorm, and provide feedback on the components of the decision-making support tool Information technology and social media Research/Best practices Partnership with Public Health Agency of Canada Participate in a pilot test of the tool Provide a link to other staff at Klinic for additional input and feedback Collaborate with representatives from program areas across Klinic understanding of planning process Increased capacity for evaluation Presentation for management team, the board, staff describing the tool and the process Write-up of process to share with other organizations As collaboration is an essential part of Trauma-Informed Practice, this collaborative process will strive to embrace principles of Trauma- Informed Practice and will be guided in this effort by the Trauma experts on the advisory group. 27
  • 28. Schematic Physical Mental Social Justice Trauma- Informed Gender- Based Community 28 Physical Mental Emotional Community Development Klinic History Klinic Individual Health Equity Spiritual Culture
  • 30. Hide logo Part Two: Trauma-Informed
  • 31. Trauma-Informed Strategy • Develop and implement a strategy to guide Klinic as we become a trauma- informed organization 31
  • 32. Goals • Develop a tool based on emerging literature and local experts in the field to guide Klinic in becoming a trauma- informed organizationinformed organization • Share tool and learnings across the organization and externally 32
  • 34. Trauma defined • Defining trauma – severe emotional shock and pain caused by an extremely upsetting experience (Cambridge dictionary) – a deeply distressing or disturbing experience (Oxford dictionary) 34
  • 35. What is Trauma? “…out of control, frightening experience that has disconnected us from all sense of resourcefulness or safety or coping orresourcefulness or safety or coping or love”. - Tara Brach 35
  • 36. Types of trauma 1. Single incident trauma 2. Developmental trauma 3. Complex trauma 4. Intergenerational trauma4. Intergenerational trauma 5. Historical trauma 36
  • 37. Adverse Childhood Experiences Study • Kaiser Permanente and Centers for Disease Control • Over 17,000 participants (1995-1997) – Mostly middle-class, employed, educated,– Mostly middle-class, employed, educated, insured • Link between childhood trauma and long- term health and social outcomes http://www.cdc.gov/violenceprevention/acestudy/ http://www.research4children.com/data/documents/ACF1114.pdf 37
  • 39. Trauma-informed defined • Concept of service delivery influenced by understanding the impact that trauma may have on an individual’s life and development 39
  • 41. Trauma-Informed Organization • Commitment to providing services in a manner that is welcoming and appropriate to the special needs of those affected by trauma • Integrating an understanding of the impact of trauma and violence into the organization’s policies, procedures, and interactions. 41
  • 42. Trauma-Informed Staff Communication • Curiosity • Vulnerability • Listen compassionately • Connect meaningfully Self-care • Burnout • Emotional fatigue • Mindfulness • Self-compassion• Connect meaningfully • Appreciate silence • Tolerate uncertainty • Develop mindful presence • See the patient as a person • Self-compassion • Social supports • Exercise • Trauma exposure response • Eating and sleeping well • Communities of practice 42
  • 43. Trauma-Informed Space? • Calming and welcoming – Waiting and treatment rooms have space for people to move – Confidential space available for intake– Confidential space available for intake • The space inside the building is safe – Common areas are well lit – Bathrooms offer privacy • The space around the building is safe – Parking lot and sidewalks well lit 43
  • 44. Klinic’s space needs work! • Cluttered • Public washroom visible • Harsh lighting• Harsh lighting • Dying plant • Utilitarian • TMI!
  • 45. Assessment tool • Trauma-Informed Organizations – policies and procedures Plus: • Trauma-Informed Staff• Trauma-Informed Staff – individual practice • Trauma-Informed Space – environment 45
  • 46. 3. TRAUMA-INFORMED ORGANIZATION For an organization to be trauma-informed, the commitment must be imbedded in the service delivery model, and must incorporate aspects of trauma-informed practices related to staff and space. 3.1 Overall Policy and Program Mandate A commitment to trauma-informed practice may represent a shift in culture and values. This wide spread commitment to trauma-informed practice increases the liklihood that all people who come into this service setting, regardless of where/how they enter the system, will encounter services that are sensitive to the impact of trauma. Philosophy Fully achieved In progress Not achieved Not applicable Comments The organization recognizes the value of trauma-informed practice as part of its mandate. The organization has a policy or position statement that includes a commitment to trauma-informed principles and practices. The policy/position statement identifies the relationship between trauma and recovery. The policy/position statement identifies the implications for service access and design.access and design. The policy/position statement is endorsed by leadership. 3.2 Policies and Procedures The policies and procedures of the organization should reflect their commitment to trauma-informed practices and be based on available evidence. Overall Fully achieved In progress Not achieved Not applicable Comments The organization ensures that all current policies and protocols are respectful, promote safety and flexibility, and are not hurtful or harmful to the individual who has experienced trauma. Privacy and confidentiality Fully achieved In progress Not achieved Not applicable Comments There are established processes that support client awareness and understanding of informed consent. All staff and clients understand the informed consent process (e.g. the extent and limits of confidentiality, what records are kept, and where records are kept).
  • 47. Next steps & Challenges
  • 48. Piloting • Decision support tool – Started this week • Trauma-informed checklist – Starting next week– Starting next week 48
  • 49. Project Challenges • Kiri’s time with Klinic is limited • Information sharing • Integrating Trauma Informed with SDOH? • Defining physical and psychological• Defining physical and psychological trauma differently 49
  • 50. Project Summary • What is Klinic left with when Kiri leaves? – Staff understand the tool and the process behind the tools – Klinic Quality Lead is left with a structured– Klinic Quality Lead is left with a structured evaluation plan – Share information broadly – Integrate Trauma Informed with SDOH into one tool 50
  • 51. Linda Dawson Director of Health Services Klinic Community Health Centre (204) 784-4063 ldawson@klinic.mb.ca Kiri Shafto Public Health Officer Klinic Community Health Centre Public Health Agency of Canada 204-784-4207 kshafto@klinic.mb.ca 51