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The Louisiana Mental and Behavioral Health Capacity Project Trauma-Informed Integrated Care Model and Improved Posttraumatic Stress Outcomes

Osofsky, Howard J. MD, PhD; Osofsky, Joy D. PhD; Hansel, Tonya Cross PhD, LMSW; Flynn, Trevor BS

Journal of Public Health Management and Practice: November/December 2017 - Volume 23 - Issue - p S25–S31
doi: 10.1097/PHH.0000000000000652
Research Reports: Research Full Report
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Objective: The Mental and Behavioral Health Capacity Project in Louisiana has been addressing health disparities by increasing accessibility and availability through integrating services into primary care clinics. Integrated health is becoming the standard of care, providing an opportunity to address the trauma-specific needs of communities, and allowing for informed and less stigmatized services. The purpose of this study is to test the efficacy of the Mental and Behavioral Health Capacity Project in Louisiana model in the primary care settings to reduce posttraumatic stress symptoms and physical health complaints.

Design: A pre-experimental time series design was used on the basis of participants self-reporting at least 1 trauma at intake and follow-up collected at 1-, 3-, and 6-month intervals. The hypotheses were that posttraumatic stress and physical health complaints would significantly decrease over the course of treatment.

Setting: This study was part of a larger study to evaluate the effectiveness of the Mental and Behavioral Health Capacity Project in Louisiana–integrated health efforts. Sample parameters included (1) intake date from January 2013 through December 2015; (2) at least 18 years of age; and (3) presented at 1 of 5 primary health care clinics in Southeast Louisiana.

Participants: A total of 235 patients were selected; the mean age was 44.7 years (SD = 13.6) and the majority were white (68%) and female (76%).

Intervention: Brief behavioral-based trauma treatment was delivered using both on-site and telemedicine therapies provided by a psychologist, psychiatrist, or through a combined treatment model.

Main Outcome Measure: The main outcome measures were the Posttraumatic Stress Civilian Checklist (PCL-C) and the Patient Health Questionnaire (PHQ-15).

Results: The hypothesis was supported. Statistically significant decreases in posttraumatic stress symptoms and physical health complaints were shown over the course of treatment, with 63% of the group demonstrating clinically significant change.

Conclusions: This study supports brief trauma treatment in primary care clinics as an effective method of reducing trauma and physical health symptoms in postdisaster environments.

Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana.

Correspondence: Tonya Cross Hansel, PhD, LMSW, Louisiana State University Health Sciences Center School of Medicine, 1542 Tulane Ave, New Orleans, LA 70112 (tcros1@lsuhsc.edu).

The Gulf Region Health Outreach Program was developed jointly by BP and the Plaintiffs' Steering Committee as part of the Deepwater Horizon Medical Benefits Class Action Settlement, which was approved by the U.S. District Court in New Orleans on January 11, 2013, and became effective on February 12, 2014. The Outreach Program is supervised by the court and is funded with $105 million from the Medical Settlement.

The authors declare no conflicts of interest.

The Gulf Coast region, specifically southeastern Louisiana, has experienced multiple natural and technological disasters over the past decade; the most significant of the events was Hurricane Katrina and the Deepwater Horizon oil spill. In addition to the environmental devastation affecting the region, the population has suffered from psychological damage that may not have appeared as immediately evident.1 Two years post-Hurricane Katrina, approximately 16% of residents in Louisiana, Alabama, and Mississippi showed signs of post-traumatic stress disorder (PTSD) while 30% of residents from the New Orleans metropolitan area met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria for PTSD.2 Comparatively, the lifetime prevalence of PTSD in the general population is estimated between 5% and 10%3 and approximately 4% for current reported PTSD.4 These multiple disasters have contributed to the high levels of trauma reported in the region and result in troubling mental health trajectories.2,5,6 Osofsky and colleagues7,8 conducted a study designed to assess the immediate mental health impact on residents in Southeastern Louisiana heavily impacted by the Gulf oil spill using telephone and face-to-face interviews. Results showed that factors having the greatest effect on mental health were the extent of disruption on participants' lives, work, family, and social engagement, resulting in increased symptoms of anxiety, depression, and posttraumatic stress. Given that the location of the oil spill affected individuals and communities with prior devastation from Hurricane Katrina, results also revealed that losses from Hurricane Katrina were highly associated with negative mental health outcomes.7 Additional studies conducted across the Gulf States have concurred with these findings and support the need for continued mental health treatment of children and adults due to increased mental health concerns and symptoms.9–12

Trauma-informed services to meet the increased mental health needs following disasters are evident; however, behavioral health needs tend to outweigh disaster recovery services available.13,14 For all types of trauma, the literature documents both the acute and long-term treatment needs and the lack of treatment options.15–18 Often mental health needs will go unmet for various reasons including individuals not recognizing mental health as a problem and health disparities such as access to care, especially in rural clinics unequipped to deal with mental health needs.8,19–21 In response to these shortages, health care funding and delivery is undergoing a historical and unprecedented paradigm shift on multiple levels, with emphasis on integrated health care homes.22,23 The Substance Abuse and Mental Health Services Administration has emphasized the importance of health care homes, where primary and behavioral health services are colocated as a means for delivering quality care and improving overall health outcomes.24,25 The Agency for Healthcare Research and Quality considers behavioral health integration to be “care resulting from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.”26

Van Dyke and colleagues27 note that one way to address the shortage of behavioral health services is to link postdisaster behavioral health response within integrated care settings as a practical, scalable, and sustainable approach to recovery efforts. Studies following Hurricane Katrina found that if survivors sought mental health treatment, they were more likely to do so at general medical facilities, emphasizing the need for training of primary care staff and colocation of physical and mental health services.28,29 In addition, when clients do present with trauma symptoms and PTSD in a primary care setting, they are often related to underlying physical health complaints.30 Trauma-informed postdisaster behavioral health services located within primary care clinics or collaborative care clinics hold great potential for areas such as the Gulf Coast, where vulnerability to both natural and human cause disasters occurs on a continuing basis. However, relatively few studies are available on the efficacy of trauma treatment in primary care setting as a disaster response initiative, suggesting that it is an underutilized service location.

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Trauma Treatment and Telemedicine

Innovative methods, such as telemedicine systems, are needed to meet the trauma-based needs of communities. In these situations, technology and telemedicine can be used in similar collaborative care models targeting PTSD. One trial identified participants from an electronic medical record screen to find those who were injured trauma survivors and reported high baseline PTSD symptoms. They split patients into a usual care group and an intervention group that received additional stepped measurement-based care for more than 6 months postinjury from a trauma mental health team. They found that both groups demonstrated modest reductions in PTSD symptoms; there was not a significant difference between the groups.31 Another trial followed a telemedicine-based collaborative care model in veteran populations across 3 large urban Veterans Affairs medical centers. This study involved 265 patients at intake and, of those, 225 patients who completed follows-ups at 6 and 12 months after the initial intake. The sample was split into 2 groups, 1 that received telemedicine-based outreach in addition to the services received at the clinic, and a control group that received only clinic-based services. Results indicated that the group receiving telemedicine follow-ups experienced a significant decrease in PTSD symptom severity when compared with the control group.32

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Purpose

Operating as a result of the Deepwater Horizon Medical Benefits Class Action Settlement, the Mental and Behavioral Health Capacity Project in Louisiana (MBHCP-LA) has provided services to the 5 affected parishes in Louisiana; many of these communities were affected by the oil spill and previously had been impacted by Hurricanes Katrina and Rita. The parishes are largely made up of rural communities that may have only 1 primary care clinic with little or no access to mental health professionals. The MBHCP-LA, directed through the Louisiana State University Health Sciences Center Department of Psychiatry, has developed an interprofessional collaboration model (psychology and psychiatry) of care to provide on-site and telemedicine services in parishes affected by the disaster.33,34 The program model that the MBHCP-LA team developed allows mental health clinicians to provide high-quality care for the greatest number of patients in an efficient, time-sensitive manner without sacrificing the level of care. The purpose of this study is to test the efficacy of the MBCHP-LA model in the primary care setting through both on-site and telemedicine therapies in addressing posttraumatic stress symptoms and physical health complaints. The hypotheses were that posttraumatic stress and physical health complaints would significantly decrease over the course of treatment.

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Methods

This study was part of a larger study to evaluate the effectiveness of the MBHCP-LA-integrated health efforts. Sample parameters included intake date from January 2013 through December 2015, at least 18 years of age, reporting of at least 1 traumatic experience at intake, and presented at 1 of 5 primary health care clinics in southeast Louisiana. Two of the clinics located in remote rural areas received a combined in-person and telemedicine-based treatment. Written consent was obtained at intake; however, patients who opted out of the research received the same treatments as the research participants. Follow-up data were collected via telephone at 1, 3, and 6 months after initial intake. The study sample was selected on the basis of participants self-reporting at least 1 trauma at intake and completion of evaluation measures at 6 months and either 1 or 3 months. All procedures were approved by the Louisiana State University Health Sciences Center Institutional Review Board.

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Trauma-informed behavioral health services

Clinic patients are referred into MBHCP services on the basis of clinic screening protocol using the Patient Health Questionnaire, primary care physician recommendation, or self-referral. At MBHCP intake patients received psychiatric or psychological consultations on the basis of availability. Consultations at intake are used to determine their behavioral health needs and whether treatment by a psychiatrist, psychologist, or both is warranted and/or desired. During intake, patients were asked whether they had experienced a traumatic event and, if patient responded yes, further trauma questions were asked. If current or ongoing trauma was suspected, a report was made to the appropriate governing agency (in Louisiana Department of Children and Families or Office of Aging and Adult Services); when mandatory reporting was not required, resources and safety plans were encouraged. If trauma was endorsed, referrals were made to an appropriate trauma-informed clinician who tailored individualized treatments to meet the needs of each presenting client. Psychiatric treatment included evaluations and medication management, and brief trauma-informed supportive therapies that utilized coping skills, cognitive restructuring, and trauma narratives.

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Participants

The mean age of participants was 44.7 years (SD = 13.6). The majority of participants were white (n = 159, 68%) and female (n = 179, 76%). Patients presented with multiple behavioral health concerns including anxiety (69%), depression (61%), relationship problems (17%), adjustment problems (22%), substance abuse (9%), and harm to self (8%). Only 6% presented with traumatic stress symptoms. Table 1 presents the frequency and percentages of trauma types in which participants reported a minimum of 1 and a maximum of 8 (M = 3.3, SD = 1.9). Fifty-two received a hybrid of telemedicine and in-person treatment (22%). The mean number of sessions was 4.6 (SD = 3.7) and 54% (n = 126) had a combined psychiatry and psychology treatment.

TABLE 1

TABLE 1

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Measures

As part of the evaluation measures, participants completed the 15-item Patient Health Questionnaire (PHQ-15) and the 17-item PTSD Checklist–-Civilian Version (PCL-C). Physical health complaints were assessed using the PHQ-15.35 Items included stomach pain; back pain; pain in your arms, legs, or joints; headaches; chest pain; dizziness; fainting spells; feeling heart pound or race; shortness of breath; pain or problems during sexual intercourse; constipation, loose bowels, or diarrhea; nausea, gas, or indigestion; feeling tired out or low in energy; and trouble sleeping. The 15 items are rated 0 (not at all), 1 (bothered a little), and 2 (bothered a lot). Posttraumatic stress symptoms were assessed using the PCL-C.36 The 17-item scores range from 1 (not at all) to 5 (extremely) and total scores can range from 17 to 85. A cutoff score of 36 was used to determine significant clinical symptoms of posttraumatic stress; 185 (79%) met the cutoff at intake. Over the course of treatment, 48 (20%) demonstrated clinically significant (5- to 9-point difference from intake to follow-up) change and 99 (42%) demonstrated reliably clinically significant change (≥10 point improvement). Satisfaction was assessed on a 5-point Likert Scale by asking patients whether they were satisfied with their access to mental health services (very dissatisfied to very satisfied) and the mental health services received (poor to excellent). A total satisfaction score was created by adding response of access and satisfaction (M = 7.62, SD = 2.19). Over the course of treatment, 93% reported that they were satisfied with access and 99% reported that they were satisfied with services.

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Data analysis

Data were analyzed using SPSS version 24.0. This investigation examined PTSD symptoms and physical health complaints over the course of 6 months following intake into mental and behavioral health services. Missing data were less than 5% and linear interpolation was used. Bivariate analyses (Pearson and point-biserial correlations) were conducted to assess association among treatment, demographic, and trauma variables with the intake and 6-month posttraumatic stress symptoms and physical health complaints. Given the number of preliminary bivariate analyses, α was set at P value of less than .01 significance. To address the study hypothesis, a 2-way repeated-measures analysis of variance was conducted to assess change in symptom scores over time.

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Results

Bivariate analyses (see Table 1) suggest that as number of clinic visits increase, physical health complaints (intake) and posttraumatic stress (intake and 6 months) increase. Those with a combined treatment type had increased posttraumatic stress scores (intake and 6 months) and those who utilized telemedicine had lower posttraumatic stress scores at intake. Those reporting sexual abuse reported increased physical health complaints (intake and 6 months) and posttraumatic stress scores at 6-month follow-up. Those reporting physical abuse, emotional abuse, or domestic violence reported increased physical health complaints and posttraumatic stress scores at intake and 6-month follow-up. Those reporting serious injury/accident had higher physical health complaints at intake. Those reporting unresolved loss and bereavement had higher physical health complaints (intake) and posttraumatic stress scores (intake and 6 months). As total number of traumas increased, physical health complaints and posttraumatic stress scores also increased. An independent sample t test was conducted on satisfaction by whether the patient received telemedicine; results were not significant, t236 = −1.75; P = .08.

To address the hypothesis—posttraumatic stress and physical health complaints would significantly decrease over the course of treatment—a 2-way repeated-measures analysis of variance was conducted on posttraumatic stress scores and physical health complaints over time (intake vs mid–follow-up vs 6-month follow-up). Results are presented in Table 2, in which significant within subjects' effects were revealed on posttraumatic stress symptoms and physical health complaints over time. Pairwise comparisons showed significant differences between intake and mid–follow-up and intake and 6-month scores—no significant differences were revealed between 3 months and 6 months. A significant posttraumatic stress by physical health complaints within factors interaction effect was also shown, suggesting that improvements in trauma symptoms result in improvement in physical health complaints and vice versa.

TABLE 2

TABLE 2

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Discussion

Collaborative care, in which behavioral health services are integrated and colocated with primary care, holds promise for addressing the lack of available trauma treatment options.15–18,27 Trauma treatment provided at a traditional outpatient mental health clinic requires the patient to not only recognize his or her behavioral health needs but also locate a clinic, schedule an appointment, and often be waitlisted because of limited services postdisaster.13,14 As found in this study, only 6% of participants self-identified relating their behavioral health concerns to trauma; however, 79% met the clinical cutoff, suggesting significant trauma symptoms. It is highly probable that if trauma treatment was not integrated into primary care, these individuals would still be left without informed treatment options. In addition, patients may identify physical health problems more readily than the underlying mental health issues. These somatic complaints or physical symptoms, for which no organic cause can be found, occur in approximately one-third of patients seen in primary care clinics.37 Trauma-informed treatment integrated into primary care provides an option to increase appropriate diagnosis, and access to behavioral health services is needed.

The purpose of this study is to test the efficacy of the MBCHP-LA behavioral health trauma treatment in primary care settings. The hypothesis was supported; statistically significant decreases in posttraumatic stress symptoms and physical health complaints were shown over the course of treatment; further 63% (n = 147) demonstrated clinically significant change. Decreases in posttraumatic stress symptom results were associated with decreases in physical health symptoms and vice versa. Mental and physical health gains were stabilized as no additional decreases were revealed from mid to 6-month follow-up; findings suggest that brief treatment models within integrated care systems are beneficial for decreased trauma symptoms and somatic complaints. Furthermore, more than 90% of patients reported satisfaction with access and services received.

Findings also suggest that additional clinic visits and a combined psychiatric and psychological treatment are necessary for individuals presenting with increased trauma symptoms. Supporting a trend in using technology to enhance access to quality behavioral health care,37,38 findings also suggest that telemedicine can be a useful method of treating trauma symptoms, especially for individuals with lower posttraumatic stress scores at intake. Furthermore, there was no significant difference on satisfaction for patients who utilized telemedicine versus those who did not. Use of technology within trauma treatment can provide flexible support to patients as active partners in their management and delivery of mutually determined intervention strategies. Trauma treatment in primary care facilities is effective with a variety of trauma types including sexual, physical, and emotional abuse or domestic violence, serious injury/accident, unresolved loss and bereavement, and multiple traumas—although certain types of trauma including interpersonal and multiple traumas may require additional or booster session over the course of treatment.

While this study supports brief effective trauma treatment in primary care clinics, it is not without limitations. Lack of a control group was unavoidable due to the availability of services; without a waitlist, it would be unethical to withhold services to those in need. Physical health symptoms served as a proxy for somatic complaints, and additional research is needed to understand improved physical health beyond symptoms. While initial gains were maintained and held stable for more than 6 months, studies are needed to determine whether these gains are maintained over time. The study lacks generalizability and results are valid only for adults living in Southeastern Louisiana presenting with trauma symptoms at primary care clinics in rural areas. Despite these limitations, a collaborative trauma treatment holds much promise for improved population health outcomes.

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Implications for Policy & Practice

  • This study supports brief trauma treatment in primary care clinics as an effective method of reducing trauma and physical health symptoms in postdisaster environments.
  • When clients do present with trauma symptoms and PTSD in a primary care setting, they are often related to underlying physical health complaints.
  • Improved posttraumatic stress symptoms were associated with decreases in physical health symptoms and vice versa.
  • Telemedicine can be a useful method of treating trauma symptoms, especially for individuals with lower posttraumatic stress scores at intake.
  • Primary care clinics are likely to be where individuals present with their trauma-related symptoms.
  • Collaborative care holds promise for addressing the lack of available trauma treatment options and increasing access to trauma-informed care for underserved populations.

Treatment models that can provide trauma-informed services are important considerations for primary care clinics.39 This is especially necessary for clinics in disaster prone areas; however, given that more than 50% of the population will experience at least 1 trauma in their lifetime, general trauma treatment is also warranted.20,40 In a postdisaster environment, understanding behavioral health factors that directly and indirectly influence recovery is central to disaster response.41 In fact, the importance of behavioral health in disaster recovery has been named 1 of the 9 core principles in the National Disaster Recovery Framework.42,43 Given that many individuals experiencing disaster have past traumas,44 this can be an efficient public health response process. Primary care clinics, due to their location and familiarity with residents, are likely to be where individuals present with their trauma-related symptoms.45 Locating trauma-informed disaster services in collaborative care centers also centralizes efforts to provide support to health care and disaster recovery workers in efforts to address and minimize secondary traumatic stress and other disaster effects of workers who also live in the region.46 For technological disasters, where recovery can be slow,17,47–49 primary care clinics are an obvious choice for postdisaster response, given their availability in communities.

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Keywords:

disaster; primary care; telemedicine; trauma treatment

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