TIA/CHANGE: E2i

Trauma-Informed Approach & Coordinated HIV Assistance and Navigation for Growth and Empowerment (TIA/CHANGE) is an evidence-informed intervention developed by HIV experts in collaboration with community members to improve health outcomes among people with HIV. Using a strength-based approach to HIV service provision, TIA/CHANGE offers guidance and structure for an organization to become trauma-informed. Additionally, TIA/CHANGE includes enrollment of clients in trauma-informed intensive case management services. The Alaska Native Tribal Health Consortium implemented TIA/CHANGE as part of Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i), an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017–2021. Among clients participating in TIA/CHANGE there were improvements in prescription of ART and viral suppression.

Anchorage, AK

Evidence-Informed Intervention
Support service delivery model; Systems/structural interventions
Prescription of antiretroviral therapy; Viral suppression
Treat
People with diagnosed mental illness; American Indian/Alaska Native people
RWHAP SPNS
Tribal health organization
Need Addressed

People with HIV disproportionately experience trauma and posttraumatic stress disorder (PTSD), which are associated with lower adherence to HIV medications and higher mortality.1 Trauma-informed approaches aim to improve health outcomes by better addressing this need. Using a strength-based approach to HIV service provision, TIA/CHANGE offers guidance and structure for an organization to become trauma-informed. A trauma-informed organization is one that understands, recognizes, and responds to the effects of trauma.

“These clients are finally being heard as human, as a whole human. They know they have value.”

Core Elements
Organization-level implementation and commitment to trauma-informed approaches

TIA/CHANGE involves a modification to culture and approach that affects all aspects of the organization. All key stakeholders are involved, including community members, partner organizations, and staff and leadership of the organization. All staff, not just clinical providers, need to develop competencies in trauma-informed care. People with HIV who have experienced trauma, as well as their family members, are meaningfully involved in all aspects of the process of change and implementation of TIA/CHANGE.

Trauma-informed approach

A trauma-informed organization realizes the widespread impact of trauma and understands potential paths for recovery. Organizations must understand the impacts, signs, and symptoms of trauma as well as opportunities for healing and recovery. Organizational policies, procedures, and practices must fully integrate guiding principles of trauma-informed care.

Guiding principles

To become trauma-informed, organizations should adopt guiding principles that establish a solid foundation for all planning, implementation, and evaluation activities. Guiding principles should align with the organization’s mission, while supporting a trauma-informed approach.

Outcomes

HIV care continuum outcomes were measured at the time of TIA/CHANGE enrollment and at 12 months. The Alaska Native Tribal Health Consortium enrolled 32 people in TIA/CHANGE. Clients were middle aged (40-59 years); 56% were women, 44% were men; and nearly all (94%) identified as American Indian/Alaska Native. Among the clients enrolled in TIA/CHANGE, there were no statistically significant changes in outcomes, possibly because there were relatively few clients enrolled. However, all clients were prescribed ART and 85% were virally suppressed at 12 months after the intervention, an increase of 11%.

Category Information
Evaluation data Clients’ demographic, service utilization, and medical data
Measures

Included percentage of clients who were:

  • On ART— prescribed ART in the last 12 months
  • Virally suppressed—HIV viral load test in the past 12 months AND having a result of less than 200 copies/mL at the last viral load test
Results
  • ART prescription increased from 97% to 100% 
  • Viral suppression increased from 73% to 85%

Source: Trauma-Informed Approach & Coordinated HIV Assistance and Navigation for Growth and Empowerment (TIA/CHANGE): E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.

Planning & Implementation

TIA/CHANGE has three implementation phases: early, mid, and late implementation. However, there is no “one-size-fits-all” approach. An organization may work on any phase, at any point in time, if it makes sense for their local community needs.  

To support the planning and implementation of the intervention across all phases, the Alaska Native Tribal Health Consortium hired a full-time intensive case coordinator (ICC) to complete an assessment with intervention participants, develop a care plan in coordination with the medical and support services team, and to develop partnerships and facilitate referrals to partner organizations. The ICC also participated in clinical huddles twice a week to discuss client needs and ensure the care team continued to practice a trauma-informed approach to care. The ICC was responsible for developing community partnerships with programs to refer clients for additional services. Clients were referred out for additional medical, behavioral, and support services as needed.

Early Implementation Phase

  • Community needs assessment. A needs assessment allows an organization to better understand the effects of trauma on the local community and staff, ultimately leading to programs that are more effective and meaningful to the community. The Alaska Native Tribal Health Consortium conducted a needs assessment that included interviews with key informants, focus groups, and a review of existing relevant data—for example, crime rates, substance use and mental health patterns. This needs assessment allowed them to identify current resources and where additional resources were needed. 
  • Onsite resource identification. The purpose of onsite resource identification is to evaluate the organization’s current policies, practices, and preparedness and determine additional resources needed to provide trauma-informed care.
  • Guiding principles of trauma-informed care. To help plan and implement TIA/CHANGE, organizations should adopt clear and meaningful guiding principles—such as the trauma-informed principles developed by the Substance Abuse and Mental Health Services Administration (SAMHSA)—that align with their organization’s mission and help guide planning, practice, and evaluation activities. (See Resources & Tools).
  • Champions of trauma-informed care. Organizations should establish a group of “champions” that includes leadership, staff, and clients to spearhead the implementation.

Mid-Implementation Phase

  • TIA/CHANGE committee. TIA/CHANGE champions and other staff members should establish a committee that works to create and sustain and monitor trauma-informed care at the organization.
  • Organizational assessments and SMART goals. It is important to conduct a baseline organizational assessment to identify areas of strength and areas of needed development and growth within two competency areas: 1) the service environment and 2) staff competencies. 
  • Staff training. All staff should participate in ongoing training to build and strengthen their competencies. Staff at the Alaska Native Tribal Health Consortium completed trainings on trauma-informed care, and received ongoing support such as supervision and wellness training.
  • Community partnerships. It is essential to develop referral partnerships with a network of trusted providers in the community to fill in service gaps for clients.
  • Client-level interventions to identify and address trauma. When considering a client-level intervention, organizations should ensure it addresses gaps in trauma-informed service provision according to the identified guiding principles, SMART goals, and organizational assessment results.
  • Support for staff. All staff require ongoing support to prevent vicarious trauma and burnout.

Late Implementation Phase

  • Evaluation. A formal and structured evaluation process can identify the strengths, areas for growth, and challenges and barriers to implementation. In the late implementation phase, the Alaska Native Tribal Health Consortium evaluated the intervention and updated their guiding principles. 
  • Adjustment to address barriers. Due to challenges in implementation, the scope of the intervention changed several times during the implementation period. For example, during the COVID-19 pandemic, staff adapted their care procedures, and switched to conducting phone assessments monthly with each client, and providing phone/video visits with providers, mail delivery of medications and safe transportation options.

Alaska Native Tribal Health Consortium participated in the TIA/CHANGE E2i initiative. Learn more about their implementation below.

Sustainability
  • Ongoing support for this intervention typically comes through grant funding and reimbursement for services—for example, psychotherapy. Mental health and peer services are allowable under RWHAP and some state Medicaid programs.  
  • To maintain an organization-wide trauma-informed approach over time, designate an administrative leader to oversee the continuance of TIA/CHANGE, periodically review policies and procedures, provide ongoing training to staff, and continue to build relationships with community partners.  
  • Costs incurred by the sites were related to planning and implementation, including hiring new personnel, training, supplies, incentives, and outreach activities. For more information on costs, see the implementation guide.
Lessons Learned
  • Staff turnover was a challenge during implementation of the intervention; staff reported that implementing both an organization-level change and intensive case management intervention in the same period was difficult. 
  • Staff reported difficulty in how to apply the guiding principles to everyday work, and how this work differed from other case management services. Clearly defining roles and how they interact is helpful in the early implementation phase of this intervention.  
  • Gaining organizational buy-in was challenging, because the implementing site was a small RWHAP Early Intervention Services (EIS) provider within a larger organization. The TIA/CHANGE committee eventually transitioned from implementing the intervention across the organization to focusing on the EIS clinic. Buy-in was improved by facilitating a well-received “Principles of Trauma-Informed Care” training.
  • Having the ICC staff person embedded in the medical clinic was helpful to facilitate communication. It is beneficial for this staff person to have strong familiarity with the population of focus and the service landscape in the area.
Contact
Alaska Native Tribal Health Consortium

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