APPENDIX C PROLONGED STRATEGY REPORT

The mission of the City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) is to educate, strengthen, and serve individuals and communities so that all Philadelphians can thrive.

We envision a Philadelphia where every individual can achieve health, wellbeing, and self- determination. The principles on which this Prolonged Trauma Research and Best Practices Strategic Framework is built, in alignment with the core values of DBHIDS, include:

• Strength-based approaches that promote hope.

• Community inclusion, partnership, and collaboration

• Person- and family-directed approaches.

• Family inclusion and leadership.

• Peer culture, support, and leadership.

• Person-first (culturally competent) approaches.

• Trauma-informed and trauma-responsive approaches.

• Holistic approaches toward care.

• Care for the needs and safety of children and adolescents.

• Partnership and transparency.

*Read more about the Practice Guidelines for Resilience and Recovery Oriented Treatment at dbhids.org/practice-guidelines.

Overview

DBHIDS is engaged and positioned to address the behavioral health challenges experienced by Philadelphians across a variety of traumatic experiences. Our strategy includes administering existing programming, increased stakeholder engagement at the community-based organization and community level, inclusion of best practices identified across the country, and developing new programming to ensure populations most impacted by immediate and prolonged trauma are given the resources, tools, and supports to heal and ultimately thrive.

Our vision is to ensure there is an accessible continuum of services to address the various types and stages of trauma for all Philadelphians. We do this by:

• Enacting a comprehensive strategy to support people and communities across the city experiencing a variety of traumatic events or circumstances.

• Understanding existing and needed resources, using best practices, and making data-informed decisions.

• Deepening our work with stakeholders to ensure equitable access to resources.

• Bringing solutions from and sustaining solutions in communities.

From October 2021 through March 2022, DBHIDS convened the Prolonged Trauma Research and Best Practices group, a think tank of area experts from academic institutions and community-based organizations.

The goals of the work group were two-fold:

• To develop a roadmap for policies and practices to address prolonged/complex trauma in Philadelphia that will be included in DBHIDS’ comprehensive trauma plan for internal use.

• To create a repository of toolkits, effective interventions, and evidence-based practices to guide the city’s strategic response to prolonged/complex trauma.

The group met monthly for six months. Each month’s meeting was focused on one of the five P.A.C.E. priority areas to garner knowledge and expertise from the experts around Prevention and Early Intervention, Treatment and Services, Health Economics, Infrastructure and Intelligence, and Innovation related to prolonged trauma. This strategic framework is a result of this work.

Defining Trauma

“Trauma” refers to a single event, multiple events, or a set of circumstances that is experienced by an individual or community as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual well-being. Common traumatic events include domestic and intimate partner violence, physical abuse, community and school violence, medical trauma, natural disasters, terrorism, neglect, and refugee and war zone trauma.

Prolonged trauma, also known as complex trauma, describes the exposure to prolonged, repeated, multiple traumatic events and the effects of this exposure. These events are severe and pervasive, such as abuse, violence, or neglect (Adapted from National Child Traumatic Stress Network definition).

A community can experience prolonged trauma in addition to its individual members. By taking a population health approach, DBHIDS recognizes a need for initiatives that shift from event-based trauma to complex trauma experienced by a larger population, such as racism or poverty, and their effects that can last for generations.

Social Determinants of Health Related to Trauma

The Philadelphia Health of the City 2020 report found that one in five Philadelphians live in a household with an income below the federal poverty line. Although poverty rates declined in recent years, Hispanics and non-Hispanic Blacks are still twice as likely to live in poverty compared to non-Hispanic Whites. Poverty contributes to health disparities within communities. Accessibility to health care and safety from community violence are inhibited by increased poverty. Poverty rates are highest in North and West Philadelphia neighborhoods.

Likewise, these areas have the highest instance of gun violence. City-wide gun violence in 2021 was up 20 percent from 2020. Black men and children make up the majority of gun-related deaths amongst adults and adolescents. Increased prevalence of gun violence contributes to the cyclical effects of traumatic events that influence behavior and health.

Adverse Childhood Experiences in Philadelphia

Adverse childhood experiences (ACEs) are events during childhood, such as abuse, neglect, or exposure to violence, that contribute to trauma. Children of parents with behavioral disorders or who have experienced ACEs themselves or parents who are not present, experience higher instance of ACEs throughout their lives. Prolonged traumatic exposure is linked to increase risk of chronic disease and younger mortality, as well as increased engagement in risky behavioral activities into adulthood.

More than 70 percent of Philadelphia’s adults have experienced one or more ACEs, and members of higher poverty neighborhoods are more likely to experience ACEs and prolonged traumatic exposure. Half of Philadelphia’s neighborhoods have over 30 percent of resident children experiencing 4+ ACEs. NonHispanic Blacks and Hispanics possess disproportionate rates of ACEs compared to non-Hispanic Whites. Consequently, trauma-related illness and behavioral outcomes in combination with poverty and other social determinants of health increase disparities across Philadelphia’s regions. Disproportionate rates amongst race and neighborhoods suggest a need for services targeted toward stressors unique to each group. Goals of the strategic framework Include:

• To ensure that trauma services are delivered in a racially and socially conscious way

•  To reduce individuals’ unnecessary exposure to traumatic events

• To avoid re-harming or re-traumatizing people served

• To create a cohesive repository of trauma resources in Philadelphia

• To align trauma-informed care across mental health and substance use treatment modalities

• To include peers and individuals with lived experience in meaningful roles throughout the traumainformed continuum

• To strengthen connections within the behavioral health system and its partners

• To assess internal organization culture to ensure provider wellness

• To incentivize quality trauma-informed care within community partners

Addressing Special Populations in Prolonged Trauma Behavioral Health Care

The Prolonged Trauma Research and Best Practices framework aims to be accessible to all Philadelphians regardless of unique or specialized needs. Services must be adequately trained and resourced to meet the needs of specialized populations, including, but not limited to, the LGBTQ+ population; individuals with co-occurring behavioral health diagnoses and intellectual disabilities (BHID); immigrants and refugees; and transition-aged youth. When needed, language accommodations, interpreter services, or communication assistance for those using text-based communications devices will be provided. Additionally, all facilities and transports will be compliant with the Americans with Disabilities Act and emotional support and other service animals will be accommodated in facilities. A focus on equity and cultural appropriateness will be applied as trauma research and best practices are developed and expanded. DBHIDS initiatives will provide trauma training and resources that will be modified for occupation-specific needs, including law enforcement, child services and education staff, and health service workers, to ensure wellness amongst care providers in order to adequately address the unique needs of the communities they serve.

Alignment with DBHIDS P.A.C.E. Strategic Plan

In 2018, DBHIDS introduced the P.A.C.E. Strategic Plan. P.A.C.E. stands for Prioritizing to Address Our Changing Environment and is the blueprint for how DBHIDS divisions work together to align, coordinate, and integrate initiatives across the organization has been aligned with the P.A.C.E. Strategic Plan to demonstrate continuity and congruency within and across city agencies and the provider network’s delivery of services within the crisis continuum.

P.A.C.E. is comprised of five key priority areas that include:

• Prevention and Early Intervention

• Treatment and Services

• Health Economics

• Infrastructure and Intelligence

• Innovation

Each of these priority areas is accompanied by Department-wide strategic goals and key performance indicators that will help us assess our progress towards meeting our goals. Every component of the proposed strategic framework will be guided by the P.A.C.E. Strategy. Learn more about the DBHIDS PACE Strategic Framework at dbhids.org/about/PACE.

DBHIDS TEC Framework: Trauma. Equity. Community.

The City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services works to educate, strengthen, and serve individuals and communities so that all Philadelphians can thrive. In order to focus our efforts, DBHIDS works through a lens we call TEC by asking ourselves every day whether our work addresses Trauma, achieves Equity, and engages Community.

To address Goal By

Trauma Transform operations to be trauma informed Reduce traumatic experiences within systems; shift systems to be traumareducing

Equity Transform systems to reduce behavioral health disparities and promote racial equity amongst Black, Indigenous, and people of color (BIPOC)

Community Shift services to be increasingly communitybased; sustainment through integrating initiatives more fully into communities and neighborhoods

Intentionally address structural and institutional racism; shift systems to achieve equity

Shift services from institutions into community settings

Addressing Prolonged Trauma with P.A.C.E.

Prevention and Early Intervention

Prevention and early intervention services are the foundation of our population health approach, aiming to help individuals protect their health and sustain their wellness. At the community level, activities that support prevention and early intervention include those specifically focused on substance use prevention, as well as those focused on addressing trauma, social isolation, unemployment, homelessness, and other social determinants of health (SDOH) early on, which could otherwise threaten health and wellbeing and contribute to health disparities. Community-level activities also involve infusing communities with a range of advocational, educational, and other supports that increase the number of allies beyond the formal system. DBHIDS follows a three-tiered approach to prevention, developing prevention programming that is universal (for the general public), selective (for individuals or subgroups of the population at risk due to biological, psychological, and/or social factors), and targeted (high-risk individuals with detectable symptoms of mental health disorders). Key components of prevention and early intervention services should be peer-led, using community engagement teams.

Treatment and Services

Comprehensive trauma and mental health services are crucial elements of behavioral health systems. Appropriate trauma-informed services can improve outcomes for individuals, reduce cyclical trauma and violence in communities, reduce over-reliance on law enforcement interventions, and facilitate access to other necessary behavioral health services and supports.

Availability and access to behavioral health services continue to be a complex gap in Philadelphia’s behavioral health system. Evaluating the efficacy of programs is often victim to survivorship bias—efficacy based on those who “survived” or finished treatment. Special consideration toward those in which treatment and services were not successful could highlight areas in which trauma care can be improved for more diverse populations. By increasing the array of trauma-responsive services available within the communities, the goal is to ensure timely access to the most appropriate treatment resources. With improved and expanded trauma services, we can ultimately create a seamless integrated behavioral health care system, where more Philadelphians can receive appropriate, timely, and quality care.

Health Economics

Thoughtful investments within health systems for effective delivery of trauma care improve health outcomes by focusing on upstream interventions that prevent higher-cost treatments, trauma-influenced behaviors within the community, and potentially retraumatizing treatments. Effective upstream strategies include leveraging the skills and experience of peers within community and clinical settings to improve complexity and competency of care and focusing on the sustainability of participants within programs to ensure wellness before exiting. To succeed in these strategies, a value-based foundation within services can incentivize providers to shift greater focus toward the early identification of trauma and trauma-related health outcomes.

Infrastructure and Intelligence

Each division must have ready access to the specific information it needs to make evidence-based decisions, determine whether our services have the desired impact, and continually improve our system. Infrastructure and intelligence will facilitate transparency and accountability in the operation of a more prolonged traumainformed system. Up-to-date, relevant business intelligence will facilitate a transition from paying for volume to paying for value while improving health outcomes for our city’s most vulnerable residents. Organizational collaboration across all seven DBHIDS divisions and into the community ensures conscious and relevant decision-making for the health of all Philadelphians.

Innovation

As a community, we face unprecedented, complex challenges, exacerbated by the COVID-19 pandemic. The need for innovative approaches that satisfy the goals of the framework, but are adaptable to our changing world is paramount. The Prolonged Trauma Research and Best Practices Strategic Framework sets forth innovative solutions to prolonged trauma at the systemic, community, and individual levels. Innovative use of technology and the arts allows self and population expression that can serve to heal and thrive through creation and community bond while revealing hidden themes in the community that could lead to better-targeted programming. The proposed framework will utilize innovative public health approaches to prolonged trauma treatment to transform the city’s behavioral health system.

Framework Strategies

Through conversations with the Prolonged Trauma Research and Best Practices work group, recommendations were given under overarching themes reflected below. The following table visualizes how each recommendation contains targeted strategies that align with PACE and TEC.

Recommendations

Develop and Improve Asset-based Programming

Asset-based approaches to program formation accounts an individual’s well-being and strengths instead of using numbers like ACEs to determine efficacy within the program. An effective and underutilized community tool to improve trauma-based services is using the skills of the people to leverage their own abilities for sustainable future change. Innovative ways the department can move toward asset-based, skills-focused programming to prevent trauma and treat trauma-impacted individuals include:

• Mentoring and Big Brother/Big Sister programs

• Arts/athletics/other recreational activities

• Re-entry employment programs and entrepreneurial skills workshops

• Summer employment and recreational programs for adolescents at risk of juvenile justice involvement

• Co-designing spaces for place-based projects (parks, housing, art, etc.) within communities

DBHIDS’ Network of Neighbors Trauma Response Network recognizes the power of community members to address trauma within their communities. The program is designed to strengthen local efforts first, and recede into the background as neighborhood networks emerge and strengthen. The Network of Neighbors program falls under the Trauma Response and Emergency Preparedness (TREP) unit and serves as a postvention program, but the department can use these tools and existing connections to further train community members to be trauma-informed even when no immediate response is needed within a community. Educating and supporting trusted leaders within the community, like faith leaders, to understand trauma and its impact on their neighbors can provide upstream, community-based interventions that alleviate the need for clinical treatment or postvention responses along the continuum of services and supports.

There are several programs operating in Philadelphia that address trauma from an asset-based, upstream approach. Please see Appendix A for a listing of programs recommended by the work group.

Asset-based approaches must also be applied from an infrastructure and intelligence lens. Current literature rejects catastrophizing approaches to adverse childhood experiences and other prolonged trauma exposures. For example, using data to state that someone with four or more ACEs has a shorter life expectancy than someone with one or fewer ACEs removes power from individuals and communities. DBHIDS must promote the use of asset-based measurement tools as opposed to negative.

Targeted Approaches to develop and improve asset-based programming

• Implement metrics and measures that are asset-based (e.g. measuring social capital, mentorship, belonging, etc. As opposed to trauma exposures, ACEs scores, etc.)

• Develop community-based training programs (similar to Network of Neighbors) to enhance community capacity to prevent and respond to trauma.

• Invest in upstream approaches to trauma prevention and treatment, such as healing therapies through the arts, music, green spaces, etc.

Expand Upon Individual, Organizational, and Systemic Capacity Building

Philadelphia’s past approaches to moving interventions and services toward being trauma Informed have been disproportionately focused on staff-client relationships. A more sustainable approach will include more institutional approaches toward organizational culture, within the department itself, and within community organizations. Although community wellness is DBHIDS’ mission, ensuring the wellness of providers and the organization overall should be a priority to deliver the best interventions to the community. Mitigating secondary, or vicarious, traumatic stress can improve the behavioral health workforce to protect those that serve our most vulnerable populations. Organizational stress can severely impact the ability to provide for our community, from how we combat overarching collective disturbances throughout the behavioral health system, down to avoiding workplace violence and keeping providers safe. To improve the trauma-informed organizational culture, programs can start with a self-assessment:

• Professional quality of life measure proqol.org

• Trauma-informed organization assessment (includes STS) bit.ly/Trauma-informed-STS

• STACI (University of Kentucky) uky.edu/ctac/stsscale

• VTORG: Vicarious Trauma Organizational Assessment bit.ly/VTORG

DBHIDS can further assess capacity by integrating more interdisciplinary perspectives to trauma interventions throughout the whole department. By training our staff across different divisions and throughout our provider network to be more trauma-informed and how to effectively deliver EBPs, we can move siloed trauma practices toward a more multifaceted approach.

Targeted approaches to expand upon individual, organizational, and systemic capacity building

1. Address implicit biases among DBHIDS provider network staff. We will not be able to effectively build trauma-informed practices and policy without first addressing personal bias.

2. Conduct an organizational self-assessment of DBHIDS to address secondary traumatic stress internally.

a. Can repeat this process externally across the DBHIDS provider network.

3. Review existing data from CBH, EPIC, NIAC, and DBHIDS to assess DBHIDS provider network capacity (licensure, skills, trainings, etc.) and identify gaps a. Develop a summary report of readiness within the DBHIDS provider network b. Develop a needs assessment for education and training of the provider network

4. Develop an inventory of trauma-informed and healing-centered programming in Philadelphia (see Appendix A).

5. Institute modular approaches to therapy interventions for faster results. Explore Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC). EBPs, when available, can be cumbersome for families to maintain/follow through the full course of treatment. Modular approaches introduce EBPs in segments (modules) and potentially allow individuals to gain skills and make progress in fewer sessions.

6. Build network ability to serve the whole family. Examine billing policies and practices that only allow providers to bill for the primary recipient of services when the trauma is a systemic/family concern.

7. Create educational programming that teaches individuals and families how to navigate complex systems and advocate for themselves.

Institute Multifaceted and Meaningful Inclusion Practices

To address trauma within the city, acknowledging where strategies fall short is important to amend programs and avoid re-harming or re-traumatizing the people served. A pillar of this framework is a theme of inclusion—including lived experience and community voice in the program development and decisionand policy-making processes. Through this, the department can recognize what existing trauma-informed programs are not working. Inclusion of the community voice through the implementation of services shares power within the transparency of decision-making between the community and the department and ensures that programs have trauma-reducing policies targeted to the direct needs of the people served. Transferring power outside of city government into the hands and voices of community members is a proven method of ensuring needs are met through an on-the-ground perspective. Promoting policies that were designed through a participatory process ensures that programs have traumareducing policies. By sharing peer experiences through the power of storytelling, the department can learn how people navigate through the behavioral health system and find solutions where wellness and safety fall short. Community listening sessions hosted by DBHIDS can provide a new point of view for the department to work from while offering the community an outlet to discuss matters around trauma within the city. Through these sessions, different perspectives from different communities, especially those who have been underrepresented within programs, can speak to how different SDOH influence trauma and healing. Using these sessions as qualitative information gathering can be a form of departmental self-reflection on how current programs are meeting the specific needs of some communities but leave out others and can orchestrate how researchers collect quantitative data to find better evidence-based trauma interventions for community wellness.

Targeted approaches to institutes multifaceted and meaningful inclusion practices: a. Start with clear definitions of equity, power, privilege, diversity, and inclusion. b. Acknowledge the privilege and power that DBHIDS maintains, and begin to work towards providing tangible opportunities to redistribute the system’s power to the people without power and privilege. c. Ensure that shared definitions of power, equity, and inclusion are used when evaluating programs or services, who is awarded funding, and who is accessing services. a. Address survivorship bias – consider people for whom programs were not effective, and examine what it was about those programs or policies that did not work for them.

1. Focus on diversity, equity, and inclusion efforts across the DBHIDS provider network.

2. Examine programs’ inclusion/exclusion policies. Revise policies that expel individuals for noncompliance/non-adherence to programmatic restrictions.

3. Develop future DBHIDS programming and policy through a participatory process (DBHIDS advisory board, community meetings, etc.)

4. Collect qualitative data and emphasize the value of storytelling and qualitative data collection. Qualitative data must inform quantitative evaluation approaches

Strengthen Collaboration Between Systems

Collaboration with other Philadelphia public systems—the Department of Public Health, the Department of Human Services, the School District of Philadelphia, the Philadelphia Police Department—can ensure delivery of trauma-informed care at all levels while being aware of what sectors cross at the wrong paths. Integrating services where they should not be can be retraumatizing. Non-traditional approaches to treatment and services like meeting people and families within the communities they live, work, and play in to deliver behavioral health care, instead of a clinical setting, allows interventions to be delivered where people feel safest. Additionally, conducting a gap analysis within the DBHIDS network can improve collaboration between systems. Coordination of shared data between systems can connect divisions within community conversations to bring trauma programs they are needed most in the city.

DBHIDS can explore innovative funding streams to support providers in care coordination and their ability to work with families and caregivers to incentivize family models of care and address SDOH. The department can play a role in leading organizations in advocacy for increased and enhanced funding opportunities at the state and federal level.

It is critical to incentivize EBPs by offering enhanced reimbursement rates for designated providers and increase capacity of EBPS throughout the behavioral health system. Providers that receive the EBP Program Designation rates are expected to develop strategies to direct financial incentives to the clinicians delivering the EBP. Enhancing staff compensation and retention of EBP-skilled staff is a crucial strategy for EBP sustainability.

Targeted approaches to strengthen collaboration between systems

1. Conduct an assessment based in “user experience” at the intersection of multiple systems: where are the pain points? Where could someone be traumatized or re-traumatized? Focus on institutional coordination to approach an individual holistically.

2. Cross-system review of traumatic events in schools (modeled from OD-STAT)

3. Standardize metrics that are collected from DBHIDS provider network

4. Standardize screening practices across DBHIDS provider network

5. Develop the External Stakeholders Trauma Workgroup to translate research into practice

What’s Next?

The Department of Behavioral Health and Intellectual disAbility Services is seeking to expand and improve the continuum of prolonged trauma services in Philadelphia. Through discussions with stakeholders, as well as Request for Information (RFI) and Request for Proposal (RFP) processes, DBHIDS is soliciting information and ideas from behavioral health providers, law enforcement, community-based organizations, family members, people with lived experience, and other stakeholders to expand and re-imagine the adult behavioral health crisis continuum, and procure provider partners.

DBHIDS serves the city’s most vulnerable individuals, families and communities as evidenced by our longstanding commitment to recovery, resilience, and self-determination. As the leader of Philadelphia’s behavioral health system, DBHIDS has developed the Prolonged Trauma Research and Best Practices Strategic Framework to envision an expanded and improved trauma continuum in Philadelphia. The Strategic Framework responds to DBHIDS’s mission by providing an evidence-based, real-world vision to advance Philadelphia’s adult crisis system.

Acknowledgments

Jonathan Arrieta (Impact Services)

Meagan Corrado, DSW, LCSW (West Chester)

Jeanne Felter, Ph.D., LPC (Jefferson)

Racquel Fetzer, CPS, CFPS (DBHIDS)

Reginald Howard, CPS, CHW (Drexel)

Sara Jaffee, Ph.D. (Penn)

Leslie Liberman (Health Federation of Philadelphia)

Kelly Moore, Psy.D. (Rutgers)

Michael O’Bryan (Drexel, Lindy Institute)

Casey O’Donnell (Impact Services)

Joe Pyle (Scattergood Foundation)

Mary Grace Ryder (CCTC)

Antonio Valdes (CCTC)

Laura Vega, DSW, LCSW (CHOP)

Roy Wade, Jr., M.D., Ph.D., MPH, MSHP (Penn)

Roberta Waite, Ed.D. (Drexel)