Bridging the Chasm: The Current State of the Art

  • Alexander Blount


For many multiply-disadvantaged patients, the likelihood of their adhering to a medical regimen is correlated with their experience of the caring and support coming from their healthcare providers. The best of team-based patient-centered care is required to develop a successful interaction pattern in the care of these patients. A robust approach combines what is known about caring for these patients in multiple literatures, joining the care management and team approach of the “complex” patient literature with the respect and cultural competence of the low-income patient literature and the support and refusal to be directive and re-traumatizing of the trauma-informed care (TIC) literature. The delivery of integrated primary care, including behavioral health clinicians and care enhancers, is particularly crucial in the success of patient-centered care for these patients. In addition, using skills learned from primary care behavioral health practice can help promote a culture in the team that generates the new mental models of care and the corresponding routines of practice needed for developing true partnership with these challenging patients. Two successful programs are presented. Finally, a brief discussion of what is still missing sets the stage for the next section of the book.


Trauma-informed care Patient-centered care Healthcare reform Primary care Behavioral health 


  1. 1.
    Pollack KI, Alexander SC, Grambow SC, Sulsky JA. Oncologist patient-centered communication with patient with advanced cancer: exploring whether race and socioeconomic status matter. Palliat Med. 2010;24:96–8.CrossRefGoogle Scholar
  2. 2.
    Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns. 2005;56:139–46.CrossRefGoogle Scholar
  3. 3.
    Boissy A, Gilligan T, editors. Communication the Cleveland Clinic way. New York: McGraw-Hill; 2016.Google Scholar
  4. 4.
    Lee TH. An epidemic of empathy in healthcare. New York: McGraw-Hill; 2016.Google Scholar
  5. 5.
    Steiner R, Morse J, Myers IJ. Re-framing primary care and patient-centered medical homes in the lens of complexity, culture and relationship-centered care. Virginia Beach: Convergent Publishing; 2015.Google Scholar
  6. 6.
    Windover AK, Isaacson JH, Pien LC, Merrell J, Moore AS. Relationship-centered healthcare communication: an advanced topic guide. North Charleston: Create Space Independent Publishing Platform; 2014.Google Scholar
  7. 7.
    Mautner DB, Pang H, Brenner JC, Shea JA, Gross KS, Frasso R, Cannuscio CC. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Popul Health Manag. 2013;16:S26–33.CrossRefGoogle Scholar
  8. 8.
    Bateson G. A social scientist views the emotions. In: Knapp P, editor. Expression of the emotions in man. New York: International University Press; 1963. p. 230–5.Google Scholar
  9. 9.
    Rosland A-M, Piette J, Choi HJ, Heisler M. Family and friend participation in primary care visits of patients with diabetes or heart failure: patient and physician determinants and experiences. Med Care. 2011;49:37–45.CrossRefGoogle Scholar
  10. 10.
    Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277:678–81.CrossRefGoogle Scholar
  11. 11.
    Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155:1877–84.CrossRefGoogle Scholar
  12. 12.
    Dzau VJ, McClellan MB, McGinnis JM, et al. Vital directions for health and healthcare: priorities from a national academy of medicine initiative. JAMA. 2017;317:1461–70.CrossRefGoogle Scholar
  13. 13.
    Furman D. Alignment healthcare: changing healthcare one patient at a time. Presentation at the July 7th National Academy of Medicine Models of Care for high need patients meeting, Washington, DC. 2015.Google Scholar
  14. 14.
    Long P, Abrams M, Milstein A, Anderson G, Lewis Apton K, Lund Dahlberg M, Whicher D, editors. Effective care for high-need patients: opportunities for improving outcomes, value, and health. Washington, DC: National Academy of Medicine; 2017.Google Scholar
  15. 15.
    Bodenheimer T, Berry-Millett R. Care management of patient with complex health care needs. Robert Wood Johnson Foundation. 2009.
  16. 16.
    Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Aff. 2011;30(12). Scholar
  17. 17.
    Piteikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care and healthcare expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. 2009;301:603–18.CrossRefGoogle Scholar
  18. 18.
    Dorr DA, Wilcox A, Jones S, Burns L, Donnelly SM, Brunker C. Care management dosage. J Gen Intern Med. 2007;22:736–41.CrossRefGoogle Scholar
  19. 19.
    Counsell SR, Callahan EM, Clark DO, Tu W, Buttar AB, Stump TE, Ricketts GD. Geriatric care management for low-income seniors. JAMA. 2007;298:2623–33.CrossRefGoogle Scholar
  20. 20.
    Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ. 2012;345:1–10.Google Scholar
  21. 21.
    Bogner H, de Vries HF. Integration of depression and hypertension treatment: a pilot, randomized controlled trial. Ann Fam Med. 2008;6:295–301.CrossRefGoogle Scholar
  22. 22.
    Katon W, Lin E, von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611–20.CrossRefGoogle Scholar
  23. 23.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775–9.CrossRefGoogle Scholar
  24. 24.
    Ratzliff A, Unutzer J, Katon W, Stephens A. Integrated care: creating effective mental and primary health care teams. Hoboken: John Wiley & Sons; 2016.Google Scholar
  25. 25.
    Ramsey R. Health resilience specialists: the key to providing quality care to high-risk patients. 2014.
  26. 26.
    Harris M, Fallot R, editors. Using trauma theory to design service systems. San Francisco: Jossey-Bass; 2001.Google Scholar
  27. 27.
    Davis R, Maul A. Trauma-informed care: opportunities for high need, high cost Medicaid populations. Center for Health Care Strategies. 2015. Downloaded 28 May 2018.
  28. 28.
    Earls MF. Trauma-informed primary care: prevention, recognition, and promoting resilience. N C Med J. 2018;79:108–12.PubMedGoogle Scholar
  29. 29.
    Green BL, Saunders PA, Power E, et al. Trauma-informed medical care: a CME communication training for primary care providers. Fam Med. 2015;47:7–14.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg LS. From treatment to healing: the promise of trauma-informed primary care. Womens Health Issues. 2015;25:193–7.CrossRefGoogle Scholar
  31. 31.
    Candib L, Savageau J, Weinreb L, Reed G. Inquiring into our past: when the doctor is a survivor of abuse. Fam Med. 2012;44:416–24.PubMedGoogle Scholar
  32. 32.
    Crane S, Collins L, Hall J, Rochester D, Patch S. Reducing utilization by uninsured frequent users of the emergency department: combining case management and drop-in group medical visits. J Am Board Fam Med. 2012;25:184–91.CrossRefGoogle Scholar
  33. 33.
    Frampton S, Guastello S, Hoy L, Naylor M, Sheridan S, Johnston-Fleece M. Harnessing evidence and experience to change culture: a guiding framework for patient and family engaged care. Washington, DC: National Institute of Medicine; 2017.Google Scholar
  34. 34.
    Bloom S, Farragher B. Restoring sanctuary: a new operating system for trauma-informed systems of care. Oxford: Oxford University Press; 2013.CrossRefGoogle Scholar
  35. 35.
    Esaki N, et al. The sanctuary model: theoretical framework in chapter 6: strategy, sanctuary and turnaround. In: Mortell M, Hansen-Turon T, editors. Making strategy count in the health and human service sector: lessons learned from 20 organizations and chief strategy officers. New York: Springer Publishing; 2014.Google Scholar


    Doctor-Patient Communication

    1. Mauksch L. Patient centered observation form. University of Washington, Department of Family Medicine. 2011.

    Trauma Informed Care

    1. Trauma Informed Care Project –
    2. National Center for Trauma Informed Care & Alternatives to Seclusion and Restraints –
    3. Wisconsin Department of Health Services site on TIC –
    4. Access to materials by Sandra Bloom, creator of the Sanctuary Model –

    TIC in Primary Care

    1. Center for Health Care Strategies, Inc.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Alexander Blount
    • 1
  1. 1.Department of Clinical PsychologyAntioch University New EnglandKeeneUSA

Personalised recommendations