The TRIADS Framework

A project of UCSF's Center to Advance Trauma-informed Health Care

TRIADS Implementation Approach

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Introduction

The TRIADS Implementation Approach promotes a model for trauma-informed health care that addresses adversity, distress and strengths to support healing. This implementation approach envisions ACEs screening as taking place in the context of healthcare values of equity, trauma and resilience-informed care; a safe and welcoming clinic environment; and the informed participation of patients. Several implementation studies found that ACE screening is associated with improved healthcare utilization and patient satisfaction and that patients find it useful as a bridge to the services they need.

The Approach includes 5 core elements that reflect this approach: 1) Foundation, 2) Environment, 3) Patient Education, 4) Screening and Assessment, and 5) Response. The Foundation and Environment elements establish the organizational culture necessary for effective ACEs screening and response. The other 3 elements, Patient Education, Screening and Assessment, and Response, focus on direct patient engagement and care.

Environment
Screening
Patient Education
Response
Foundation
  • Click on each element in the graphic for a brief overview.
  • Explore each element in depth using the Tabs above.

Each core element has its own goals, strategies, tools, and background resources:

  • Goals represent the key objectives of each element and answer the question, “What is the desired result?”
  • Strategies are the actions undertaken to meet the goals and answer the question, “What do we do to reach this goal?”
  • Tools provide mechanisms to carry out the strategies and answer the question “How do we do it?”
  • Background Resources are key essential readings that provide contextual information, but would not be considered practical self-contained tools.
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TRIADS Foundation

The TRIADS Foundation promotes trauma and resiliency-informed values; clinic champion(s); buy in from organizational leadership; interdisciplinary team-based care; community partnerships; patient/family engagement; and a commitment to health equity.

Strategies

  1. Implemention of organization-wide education about trauma and resilience-informed healthcare values.  

Strategies

  1. Review of current policies and procedures to ensure alignment with trauma and resilience-informed healthcare values.
  1. The clinic CEO, medical director, and/or clinic manager participate in the organizational trainings to signal leadership alignment. 
  2. Organization provides leadership-specific training in Trauma and Resilience-informed Systems. 
    • Leadership Competencies of a Trauma-Informed System
      Leadership competencies (including communication, inclusive, and relational leadership) of a trauma-informed system detailing descriptions and examples. Published by Trauma Transformed in 2019.
    • Hyde: Critical Self-Reflection and Privilege
      An article on critical self-reflection on power and privilege to help those focused on social justice and equity to examine their own situations, privileges, etc. through a four-step process. Published by Cheryl A Hyde in 2012.
  3. Leadership practices cultural humility, promotes workplace equity, and endeavors to reduce implicit bias.
  1. Leadership recruits and retains diverse healthcare team members who are culturally concordant with the patient population. 

Strategies

  1. Selection of champions/core team who represent different roles within the organization. 
  2. Champions/core team receive paid time and authority to implement the ACEs screening. 
  3. Champions/core team develop an implementation plan that incorporates staff feedback and communicates regularly about implementation progress.
  4. Organization adopts a continuous learning approach informed by health systems science. 

Strategies

  1. Interdisciplinary healthcare team meets regularly to coordinate patient care. 
  1. Leadership solicits regular input on policies, procedures, and workflows.
    • Building Teams in Primary Care
      A toolkit for providers/leadership with five recommendations for developing high functioning care teams to deliver high-quality evidence-based care. Published by Agency for Healthcare Research and Quality (AHRQ) Tools for Change in 2018.

Strategies

  1. Organization assesses the patient population’s needs and resources.
  2. Organization solicits input from patients, families, and relevant community groups, includes them in organizational decisions, and compensates them for their participation.
    • Working with Patients and Families as Advisors
      A handbook to help hospitals develop effective partnerships with patients and family members with the ultimate goal of improving hospital quality and safety; it outlines five steps including real-world examples from hospitals who implemented this strategy. Published by Agency for Healthcare Research and Quality in 2017.
    • Patient Advisory Councils: Giving Patients a Seat at the Table 
      A brief for providers/leadership that provides a case for patient advisory councils (PAC), how to build PACs and how to conduct PAC meetings. Published by Family Practice Management at American Academy of Family Physicians (AAFP) in 2015.
    • Diverse Voices Matter
      A toolkit for providers/leadership with steps on how to improve diversity in patient and family advisory councils. Published by Institute for Patient- and Family-Centered Care in 2018.
  1. Organization regularly examines the impact of organizational power dynamics. 
    • NCTSN Sharing Power – A Tool for Reflection
      A brief tool that guides providers through a series of reflections that will help them identify opportunities to share power with patients in trauma-responsive care. Published by National Child Traumatic Stress Network (NCTSN) in 2016.

Strategies

  1. Organization adopts a QI model to track changes and identify areas for improvement.
  1. Organization measures trauma and resilience-informed activities (e.g. types, dosage, and outcome of services).
    • CALQIC Tool: Capacity Assessment
      This capacity assessment for leadership assesses a clinic site’s capacity related to effectively integrating education, screening and response for recent and past traumatic experiences (ACEs). Published by CALQIC in 2020
  1. Organization identifies billable activities and financial and non-financial resources to support ACEs screening plan.
  • Melanie Tervalon Cultural Humility Article
    An editorial article on the difference between cultural humility and cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations. Published by Melanie Tervalon, MD, MPH and Jann Murray-Garcia, MD, MPH in 1998.
  • The Path to Continuous Learning in Healthcare Article
    An article on how the United Sates can build a smart health care system that provides best care at lower cost by advancing real-time knowledge, empowering patients, fostering high-value care and creating a new culture. Published by Robert Saunders and Mark D. Smith in 2013.
  • Greene-Moton and Minkler Cultural Competence and Cultural Humility Article
    This article for health care providers advocates for moving beyond the cultural competence or cultural humility debate by suggesting that both are necessary to eliminate health disparities. Published by Health Promotion Practice Journal in 2020.
  • Campinha-Bacote Cultural Competemility Part I Article
    This article for health care providers advocates for cultural competemility which is a synergy between cultural competence and cultural humility. Published by The Online Journal of Issues in Nursing in 2018.
  • Fitzgerald and Campinha-Bacote Cultural Competemility Part II Article
    This article for health care providers advocates for an intersectionality approach to using cultural competemility at the individual and organization level. Published by The Online Journal of Issues in Nursing in 2019.
  • Equity, Diversity and Inclusion in Recruitment, Hiring and Retention
    A guide for hiring managers to increase equity, diversity, and inclusion in their offices by addressing historical discrepancies in recruitment, hiring and retention efforts. Published by Urban Sustainability Directors Network in 2018.
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TRIADS Environment

The TRIADS Environment encourages a calm, safe and welcoming space for patients; staff receive robust training and support.

The Environment element of TRIADS refers to a calm, safe, and accessible clinic setting; staff that are welcoming and knowledgeable about the interplay of adversity, distress, and strength in patients; and the wellbeing of the healthcare team. The clinic’s physical conditions, practices, and procedures can enhance physical and psychological safety. Providers can help provide digital access for telehealth visits and establish procedures that enhance privacy and confidentiality. 

The healthcare team’s wellbeing is essential to creating a safe environment. Listening to patients’ descriptions of adversity and trauma can trigger providers’ recollections of their own adverse and traumatic experiences and/or lead to vicarious traumatization. Providing healthcare teams with trauma and resilience-informed training, supervision, self-care strategies, and ongoing support equips them with the knowledge and skills they need to respond to patients in an effective and compassionate manner while also attending to their own physical and emotional well-being.

Strategies

  1. Organization establishes safety and privacy practices for both in-person and virtual visits. 
  2. Organization conducts an assessment of physical layout that includes patient input.
    • Environmental Scan
      A brief organization checklist to scan for components of a safe and welcoming physical environment. Published by Center for Social Innovations – Grantee Data Technical Assistance, and Trauma Transformed in 2020.
    • NCBH Safe & Secure Environment Survey –  Adult Patients | Children/Adolescents
      The S&SE Patient Survey is an environmental scan designed as part of a larger environmental assessment to elicit feedback from your adult and pediatric patients on the implementation of trauma-informed care principles in the clinic environment. Published by the National Council for Behavioral Health in their Fostering Resilience and Recovery Change Package in 2019.
    • We Ask Everyone posters – English | Spanish
      Sample posters (English/Spanish) to be displayed in a pediatric clinic telling patients that the practice asks everyone about ACEs. Published by National Pediatric Practice Community.

Ideas for Creating a Welcoming Environment
For all interactions
Providers engage in trauma and resilience-informed communications with patients when they establish eye contact, use a calm and respectful tone of voice, include the patient in agenda setting, explain what will happen before doing it, ask permission, and solicit feedback.

For in-person visits
Healthcare team members can offer a smile and eye contact, a clean and organized clinic, soft music, soothing videos, minimal overall noise, friendly signs with supportive language, odor-free and well-lit public areas, screen-savers that normalize clinic procedures, warm or vibrant colors, snacks, opportunities for community and social support, and if possible, chair massage, therapy dog, or safety personnel.
 
For telehealth visits
Providers can offer friendly, supportive, and kind instruction on how to do video visits, minimal distracting noises, assessment of patient privacy, and can ask permission before discussing sensitive material.

* Ideas solicited from literature and from patient interviews

  1. Organization prioritizes accessibility for all patients and families. For in-person visits, organization ensures physical accessibility as well as mental health accommodation. For telehealth, organization assists with digital access and comfort.

Ideas for Creating a Welcoming Environment from a Disability Perspective

  • Provide enough space for wheelchairs to park in the row where other patients are seated.
  • Offer a variety of seating options (e.g. extra wide or extra tall). 
  • Ensure options for patients and families with hearing, vision, or language disabilities.
  • Place items for guests at an accessible height or have staff automatically offer to assist guests in retrieving items.
  • A clipboard may be insufficient to meet some people’s needs, and alternatives may be needed such as accessible tables in the waiting room.
  • Move chairs as needed when someone in a wheelchair is struggling or uncomfortable.
  • Do not violate HIPAA rules when someone needs an accommodation. For example, do not read medical information aloud in the waiting room if reading assistance is requested.

*Adapted from Emily Munson, 2018

Strategy: Organization implements a training plan for staff on ACEs, adversity, distress, strengths/protective factors, and cultural humility. 

  1. The science of ACEs and toxic stress, and the impact on physical and behavioral health. 
    • ACE Aware Infographic
      An infographic poster for patients explaining ACEs, toxic stress, and how to reduce the effects of ACEs and toxic stress. Published by Center for the Developing Child – Harvard University in 2020.
    • ACEs Connection Understanding ACEs
      An infographic patient handout explaining ACEs and how to build resiliency. Published by ACEs Connection in 2018.
  2. Impact of adversity and trauma on mental, physical, and behavioral health (i.e., distress). 
  3. Distress reactions to adversity and trauma across different ages.
    • NCTSN Age-Related Reactions to a Traumatic Event
      A two-page brief for providers/parents/caregivers on how children of various ages respond to traumatic events and how to help them. Published by National Child Traumatic Stress Network (NCTSN) in 2010.
  4. Role of strengths and protective factors and coping strategies in promoting health and healing.
    • Strategies to Regulate Stress Response –  Sleep Habits | Exercise | Nutrition | Mindfulness | Supportive Relationships
      Briefs for parents/caregivers on strategies to regulate stress response: Sleep Habits, Exercise, Nutrition, Mindfulness, Supportive relationships, etc. Published by Center for Youth Wellness and ZERO TO THREE in 2018.
    • What We Know About Resilience
      A guide for patients or providers with interactive images showing that resilience happens when positive supports outweigh negative experiences.
  5. Cultural humility practices to increase healthcare equity and reduce implicit bias. 

Strategy:  Organization provides healthcare team with trauma and resilience-informed training and supervision, policies, and practices that support wellbeing and prevents vicarious trauma and burnout, including:

  1. Supervision that is consistent, reflective, and relational.
  2. De-escalation and conflict resolution techniques. 
  3. Identification and addressing of vicarious trauma and burnout. 
    • Provider Resilience Staying Healthy
      A brief for providers with practical individual and team tips (ABC: Awareness, Balance, Connection) on how to promote resilience to avoid burnout, compassion fatigue and secondary stress in order to provide better care. Published by Center for Youth Wellness and ZERO TO THREE in 2018. 
  • Melanie Tervalon Cultural Humility Article
    An editorial article on the difference between cultural humility and cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations. Published by Melanie Tervalon, MD, MPH and Jann Murray-Garcia, MD, MPH in 1998.
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TRIADS Patient Education

TRIADS Patient Education provides all patients and families with an understanding of the connection between trauma and health, the role of protective factors, and available resources for safety and healing.

Patient education provides all patients and families with knowledge about the connections between ACEs, health, and distress; the role of protective factors and strengths; and available resources and opportunities for healing. Patient education can take many forms – flyers, pamphlets, posters, videos, websites, as well as formal and informal conversations with healthcare team members. Education about the impact of adversity and protective factors and available resources ensures that regardless of whether patients and families disclose traumatic events, they are given increased access to critically important information and resources.

Strategy
The healthcare team provides education about adversity, distress, and strengths to all patients/families, including:

  1. Description of ACEs 
    • What are ACEs (for patients)
      A 2-page handout for adult caregivers/parents explaining ACEs. Published by Center for Youth Wellness and ZERO TO THREE in 2018.
    • Parenting with ACEs
      A 2-page handout for adult caregivers/parents with ACEs; it explains how ACEs can affect their parenting and offers suggestions for how to reduce the effects of ACEs. Published by Center for Youth Wellness and ZERO TO THREE in 2018.
    • We Ask Everyone posters – English | Spanish
      Sample posters (English/Spanish) to be displayed in a pediatric clinic telling patients that the practice asks everyone about ACEs. Published by National Pediatric Practice Community.
    • ACEs Infographic
      An infographic poster for patients explaining ACEs, toxic stress, and how to reduce the effects of ACEs and toxic stress. Published by Center for the Developing Child – Harvard University in 2020.
    • ACEs Connection Understanding ACEs
      An infographic patient handout explaining ACEs and how to build resiliency. Published by ACEs Connection in 2018.
  1. Distress symptoms 
  1. Strengths and Protective factors

Strategy 
Healthcare team provides information to patients and families about available resources including:

  1. Physical and psychological wellness
    • Adult/Pediatric Self Care Plan – Adult | Pediatric
      A self-care tool for patients (adult/pediatric) to come up with a self-care plan. Published by ACEs Aware in 2019.
    • Zero to Three Discipline Do’s: An Empathic Approach to Addressing Challenging Behaviors in Young Children
      A brief guide for parents/caregivers with practical empathic and effective approaches to addressing challenging behaviors in young children including sample sentences to tell children. Published by ZERO TO THREE in 2016.
    • Bring out the Best in Your Children: English | Spanish
      A guide for parents/caregivers with practical tips for parenting including sample sentences to tell children. Published by America Academy of Pediatrics in 2014.
  2. Reducing parents/caregivers/children stress 
    • Parenting with ACEs
      A 2-page handout for adult caregivers/parents with ACEs; it explains how ACEs can affect their parenting and offers suggestions for how to reduce the effects of ACEs. Published by Center for Youth Wellness and ZERO TO THREE in 2018.
    • ACEs card – stress reduction, positive parenting
      A 2-page brief with national hotlines, to support parents/caregivers who had difficult childhoods that emphasizes strength and resilience. Published by Futures Without Violence in 2013.
    • SEEK Parental Stress – English | Spanish
      A 2-page brief (English/Spanish) for parents/caregivers on how to parent while stressed; it also includes the national parent helpline and a section to add local community resources. Published by Safe Environment for Every Kid (SEEK) in 2019.
    • Surgeon General’s Stress-Busting Playbook for Caregivers and Kids during COVID
      A practical guide for parents/caregivers on how to reduce stress; it has many practical tips in a checklist form including hotline numbers. Published by California for All, OSG State of California in 2020.
  3. Intimate Partner Violence 
    • Is Your Relationship Affecting Your Health? (English/Spanish/Mandarin)
      A 2-page information card (English/Spanish/Mandarin) for adult patients on recognizing healthy and unhealthy relationships, impact on health, safety planning, and national hotline/website for support. Published by Futures Without Violence in 2012.
  4. Behavioral health and mental health services

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TRIADS Screening and Assessment

TRIADS Screening provides guidance on screening for adversity (immediate safety / ACEs), current distress, and strengths.

This element of the framework encompasses the practices and policies necessary to provide safe and effective screening for ACEs, distress, and strengths. This process may occur during a visit designated for this purpose, as a part of a standard visit, or over the course of multiple interactions. 

While the TRIADS framework is focused on providing guidance on screening for ACEs, distress, and strengths, it is essential that clinics also establish screening protocols to identify and respond to urgent safety needs and social determinants of health that may be having immediate, critical  impacts on the health and wellbeing of individual patients and families.

Experiences of adversity and distress are difficult to disclose due to shame, guilt, fear of being judged, and fear of punitive consequences.  Patients from racial and ethnic groups subjected to historical trauma and ongoing racism may associate disclosure with negative consequences such as child removal, which occurs disproportionately among populations of color in spite of their not having higher rates of child maltreatment. Providers need to be aware of the systemic and structural factors that may influence patient screening response.

For this reason, ACEs screening needs to start with a supportive explanation of the rationale for the screening. Patients respond well to explanations that normalize the screening as a routine component of healthcare. Patients and families are often interested to learn that adversities are very common and have an effect on physical health and emotional wellbeing. Learning that strengths such as coping strategies and protective factors such as an available and caring adult are important aids to healing creates a hopeful tone that promotes patient engagement.  These explanations and the screening that follows can provide the patient, family, and provider with important information to improve healthcare. 

Strategies

  1. Organization identifies target population for ACEs screening.
  2. Organization selects tools and screening procedures (including whether ACEs will be identified or de-identified).
  3. Organization defines roles and responsibilities for receptionist, clinic assistant, provider, and any other staff involved.
  4. Organization creates a clear workflow for ACEs screening
    • ACEs Aware Screening Clinical Workflow (Pediatrics | Adults)
      A clinical workflow for providers with pediatric/adult patients for ACEs screening. Published by ACEs Aware in 2020.
    • ACES LA Guide to Screening Practices*.
      A detailed guide for implementation teams and the health care team including best practices for screening for ACEs, including tele-health and in-person screening. Published by ACES LA in 2020 in collaboration with a CALQIC clinic in LA County. *CALQIC clinic-created resources will be evolving throughout the CALQIC learning collaborative.
  5. Organization develops Electronic Health Record policies for documentation.
    • Medi-Cal Certification and Payment
      This fact sheet explains how Medi-Cal providers can participate in the ACEs Aware initiative by getting trained, screening patients for ACEs, responding with evidence-based interventions, and receiving payment. There is specific information on documentation in the medical record and billing codes. Published by ACEs Aware in 2020.

Strategy

  1. Healthcare team understands and describes the rationale and procedures for screening. 

Strategies

  1. Inquire about immediate safety and basic needs. 
  1. Screen for ACES using PEARLS/ACEs screen. 

Identified vs. De-identified ACEs and PEARLS Screeners

De-identified screening tracks the total number of ACEs. It asks patients to indicate only how many types of adverse events they experienced, not which specific ones. The de-identified tool is a prompt for further conversation based on what the patient is ready to disclose.

Identified screening allows providers to know the specific ACEs that patients or their caregivers endorse. This detailed knowledge is useful to offer individually tailored treatment plans and referrals, for example by providing referrals to mental health or substance use programs. 

  1. Screen for symptoms and signs of distress. 
  1. Screen for strengths, protective factors, and resiliency. 
    • Promoting Resilience
      A brief for pediatricians on their role in educating parents/caregivers on promoting resilience. Published by the Resilience Project by the American Academy of Pediatrics in 2013.
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TRIADS Response

TRIADS Response to disclosures of adversity and distress should express empathy and address immediate safety. Health care providers should collaborate with patients and family on referrals to services that promote safety, connection and healing.

The cornerstone of responding to disclosures of adversity and distress is empathic and non-judgmental validation of these experiences. The urgency of various elements of the response should be dictated by the level of risk to immediate safety, the patient’s distress level, and the patient’s use of effective coping strategies and protective factors as sources of strength and resilience.  

While disclosures of life-threatening situations require an immediate response, disclosures of past trauma do not typically require an immediate intervention beyond a statement of empathy and an offer to talk more over time about its impact and available resources to address it. 

Disclosure of immediate threat to safety calls for prompt protective action and consistent follow up. For example, when a patient or parent discloses interpersonal violence, an appropriate response is to affirm that she/he is not alone and that supportive services are available, inquire about the whereabouts of the person using violence to assess for on-site safety, assess risk of harm to all adults and children in the household, and offer an immediate referral for safety planning or a private call while on site to a local or national domestic violence agency.  In California, read about the responsibilities of health care clinical teams who conduct screenings for Adverse Childhood Experiences (ACEs) in the context of the state’s mandated reporting requirements.

For children, the impact on developmental trajectory needs to be carefully evaluated. 

For example, an immediate response and ongoing support are necessary when a child has significant behavioral issues after a recent traumatic loss or parent incarceration to ensure that the child and family receive appropriate services and to alleviate the developmental and mental health impact on the child. 

When asking parents about their child’s experience of ACEs, it helps to remember that parents often feel guilt or shame about their child’s exposure and may also fear being judged for not protecting the child.  Providers can help both the child and the parent when they support the parents on behalf of the child. This might involve, for example, speaking to the parent about the stress of raising children when the parents themselves face difficult circumstances; affirming that children can recover from adversity when they feel loved and protected by their parents; explaining that adults also can recover from the impact of traumatic experiences with family and community support; and reiterating the healthcare provider’s commitment to support the parents and the child. 

  1. Collaborate with the patient and family in deciding on a course of action.
  2. Normalize the patient’s experience by stating that adverse events are very frequent.
  3. Validate the patient’s distress as a common and understandable responses. 
  4. Affirm the patient’s strengths and protective resources as aids to recovery.
  5. Remind patient that people can recover from adversity and lead healthy and satisfying lives. 
  6. Provide education on strategies to regulate distress, including:
    • Relationships that provide protection and support.
    • Sufficient sleep.
    • Balanced, healthful food.
    • Regular physical activity.
    • Culturally congruent self-care practices that promote calmness, including spiritual pursuits such as prayer and mindfulness or meditation exercises.
    • Engagement in activities that offer pleasure and give a sense of meaning.
  1. Offer educational materials.
  2. Refer to support groups, parenting groups, patient navigation, care coordination, or social work as needed. 
  3. Refer to mental health and/or substance use treatment if indicated. 
  4. Follow up as needed, monitoring distress to ascertain the progress of treatment.

Strategies

  1. Provide immediate resources and referrals when patient or family has urgent safety concerns
    • LEAP IPV Safety Plan – English | Spanish
      A handout (English/Spanish) for patients on how to develop a safety plan if they are in an abusive relationship. Published by LEAP SF in 2009.
    • Futures Without Violence IPV information cards
      A 2-page information card (English/Spanish/Mandarin) for adult patients on Intimate partner violence with national hotlines. Published by Futures Without Violence in 2012.
    • myPlan Domestic Violence safety plan
      A free, private, and secure app to help with safety decisions for adult patients experiencing intimate partner abuse. 
  1. Respond to positive ACE score by validating patient experiences, the impact of ACEs and expressions of distress, enlisting strengths identified during screening, and engaging patients in collaborative treatment planning.
    • Self-Care Tool – Adults | Pediatrics
      A self-care tool for patients (adult/pediatric) to come up with a self-care plan. Published by ACEs Aware in 2019.
    • Addressing ACEs in Primary Care
      A roadmap for pediatricians to consider when addressing ACEs in their practices. Published by American Academy of Pediatrics in 2014.
    • Health Provider Guide to Assessing, Supporting, and Treating Trauma in Children
      An AAP guide to assess a child for trauma-related symptoms, provide treaTment, follow-up, and offer anticipatory guidance to the family. Includes a description of therapies for the traumatized child. Published by America Academy of Pediatrics in 2014.
    • ACEs Aware Clinical Response Scoring Algorithm  (Pediatrics | Adults)
      A clinical workflow for providers with pediatric/adult patients for ACEs screening. Published by ACEs Aware in 2020.
  1. Address patient and/or family distress by utilizing internal resources and external referral network to link patients and families to culturally appropriate services.
  1. Plan post-screening follow-up visits or phone/video calls to assess whether referrals were successful and adjust the plan as needed (scripting can be developed into a tool).
  2. Monitor healthcare team, patient, and family experience of screening, and response for continued improvement. 

Examples of Resources to Consider

For social needs, patient navigation and family support resources: 311, Aunt Bertha, Unite Us, Triple P Parenting (evidence-based parenting classes), home visiting programs, nurse-family partnership, HealthySteps, Help Me Grow, mentorship programs (Big Brother, Big Sister)

Foundation Tools

  • Diversity, Equity, and Inclusion
    A framework for leadership on Diversity, Equity, and Inclusion that focuses on the systemic environment; it uses Four W’s “Who, What, Where, and Why” to ensure that organization strategies are outcomes-oriented with secure tangible benefits for communities of color. Published by The Greenlining Institute in 2018.
  • Chokshi Knowledge, Attitudes, Practice
    A self-administered assessment for pediatric staff on knowledge, attitude, practice related to Trauma-Informed Care. Published by S. King, K.D. Chen and B. Chokshi. in 2018.
  • Southern Poverty Law Center Asset Mapping toolkit
    This thorough guidebook assists communities to discover the hidden assets in the community as a first step toward building positive community-based programs for children. Published by Southern Poverty Law Center (SPLC) and Alabama Youth Justice Alliance (AYJA) in 2012.
  • A Physician’s Practical Guide to Culturally Competent Care
    A self-directed training course that enables providers to better treat the increasingly diverse U.S. population.

Environment Tools

Patient Education Tools

  • NCTSN Trauma and Your Family
    A patient handout on trauma, traumatic stress, how it can impact the family, and what families can do to cope. Published by National Child Traumatic Stress Network (NCTSN) in 2011.
  • Window of Tolerance graphic
    A one-page infographic for patients on the window of tolerance. Published by National Institute for the Clinical Application of Behavioral Medicine in 2019.
  • LEAP IPV Healthy/Unhealthy Relationship checklist –  English | Spanish
    A 2-page (English/Spanish) self-assessment for adult patients to assess whether their relationship is healthy or unhealthy. Published by LEAP SF.

Screening Tools

  • Pediatric Emotional Distress Scale (PEDS) screen for traumatic stress in children 2-10 – English | Spanish
    A peer-reviewed article about the Pediatric Emotional Distress Scale (PEDS) which is used to screen for traumatic stress in children 2-10 years old; The PEDS tool (English/Spanish) is also attached. Published by Conway F. Saylor, Cynthia Cupit Swenson, Sherri Stokes Reynolds, Matthew Taylor in 1999.
  • Benevolent Childhood Experiences (BCEs)
    A one-page scale for use with adults to identify benevolent childhood experiences (BCE). Published by Narayan, A. J., Rivera, L. M., Bernstein, R. E., Harris, W. W., & Lieberman, A. F. in 2018.
  • Resilience Questionnaire
    A 2-page assessment for adult patients to measure resilience; this tool is used for parent education and not research. Published by Mark Rains and Kate McClinn and team at Southern Kennebec Healthy Start in 2013.

Post-screening Response Tools

  • Kimberg 4C‘s
    A one-page guide for providers on the Four C’s to practicing trauma-informed care (calm, contain, care, and cope) and some resources on cultural humility and healing-centered engagement. Published by Leigh Kimberg in 2019.

Additional Resources:

Race, Power, and Privilege Tools

Cultural Humility and Power Analysis Tools

  • Community Catalyst Best Practices for White-Led Organizations to Promote Health Equity and Racial Justice in Health Advocacy
    A thirteen-page toolkit to help white-led organizations ensure their health advocacy agendas, coalition work, stakeholder engagement, and communications to include, reflect, and respond to the needs of people of color. Published by Community Catalyst in 2019.
  • Cultural Humility: People, Principles, and Practices Video
    The first segment of a thirty-minute documentary describing cultural humility and its principles, in which cultural humility as a concept is introduced and features interviews with the developers of the concept. Published by Vivian Chávez in 2012.
  • Cultural Humility Video
    A thirty-minute documentary describing cultural humility and its principles. Published by Vivian Chávez in 2012.
  • Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present
    A book that traces the history of medical experimentation on Black Americans in The United States since the mid-1800’s. Published by Harriet Washington in 2007.

Recruitment and Retention of Diverse Healthcare Team Members Tools

Anti-racism Tools

Unconscious/Implicit Bias Tools

COVID-19 Tools

  • Five Cs of Leading During a Pandemic
    A one-page description for leadership on 5 C’s (Clarity, Cohesion, Connect, Communicate, Courage, and Confidence) Do’s and Don’ts of leading during a pandemic. Published by Trauma Transformed in 2019.
  • Creating a Supportive Telemedicine Visit
    A brief guide for providers with practical tips on how to create a supportive telemedicine visit including how to prepare before, during, and after the visit. Published by UCSF clinicians Brook Calton, Sarah Bellows Meister, Susannah Cornes, Jeffrey Gelfand, Marsha Blachman, Eve Cohen in 2020.
  • COVID Responder Self-Check
    A one-page self-assessment for COVID providers and responders to assess exposure to stress. Published by MN Department of Health in 2020.
  • COVID Healthcare Responder Stress information
    A two-page brief for COVID providers and responders on recognizing and managing stress including a list of organizational stress management policies. Published by MN Department of Health in 2020.
  • COVID Caregiver Toolkit for families
    A toolkit for caregivers for taking care of themselves and their families during the COVID-19 pandemic; it covers supportive relationships, eating healthy, sleeping well, using movement, practicing mindfulness, supporting mental health, and spending time in nature. Published by Center for Youth Wellness in 2020.
  • Harvard Implicit COVID19 Online test
    A self-administered test that assesses your degree of implicit bias towards coronavirus with danger and whether precautions are reasonable.

A project of

Contact: cthc@ucsf.edu