Exploring Collaborative Care Effects on the Mental and Physical Health of Patients With and Without Violent Victimization Histories

Abstract

Collaborative care is a multicomponent intervention delivered by frontline social work, nursing, and physician providers to address patients’ physical, emotional, and social needs. We argued that collaborative care may particularly benefit patients with a violent victimization history because it practices three principles of trauma-informed care: patient–provider collaboration, preventing repeat trauma in clinical and community settings, and delivering comprehensive mental and physical healthcare. We conducted an exploratory secondary data analysis of a collaborative care randomized clinical trial involving patients who presented with traumatic physical injury at a Level I trauma center in Washington state between 2006 and 2009. We used random-effect linear regression models to estimate how histories of multiple violent traumas moderated the effects of the collaborative care intervention on Short Form-36 Mental Component Summary (MCS) and Physical Component Summary (PCS) T-scores over time. Collaborative care significantly improved follow-up MCS scores among patients who experienced three to four types of violent victimization in their lifetime. Additionally, intervention effects on MCS scores at the 3- and 6-month follow-up were clinically stronger for patients who reported three to four types of violent victimization (3-month = 7.5, 95% confidence level [CI] = 5.1 to 18.7; 6-month = 11.9, 95% CI = 5.1 to 18.7) than those without a history of violent victimization (3-month = 0.8, 95% CI = −5.1, 6.6; 6-month = 5.6, −2.4 to 13.5). We did not find that intervention effects on PCS scores differed between these groups at any wave. Collaborative care may be a promising approach to delivering trauma-informed mental healthcare to patients with histories of multiple types of violent victimization.

Keywords

collaborative care trauma-informed care victim healthcare victim health treating violent trauma

Violent victimization has long-lasting and pernicious effects on people’s well-being (Norman et al., 2012; Rivara et al., 2019), and its impact can be particularly apparent among patients in clinical settings (Huang et al., 2014). Patients carry the weight of their violent trauma throughout their healthcare experience (O’Neill et al., 2020), which increases their risk for distress during treatment (Patton et al., 2019; Schippert et al., 2021). Routine medical procedures may invoke memories that lead to discomfort or traumatic stress (Hornor et al., 2019). Accordingly, physicians and practitioners often support trauma-informed care to address the unique needs of patients and promote positive outcomes (Grossman et al., 2021; Raja et al., 2021).

Some advocate for multidisciplinary and collaborative treatment teams as a critical element of trauma-informed care (Huang et al., 2014; Reeves, 2015). Collaborative care is a multi-component intervention delivered by frontline social work, nursing, and physician providers. In collaborative care settings, these clinicians use their collective expertise to develop a multifaceted treatment plan that addresses the unique physical, emotional, and social needs of patients. Meta-analyses have documented the effectiveness of collaborative care models for treating depression and anxiety in primary care medical settings (Coventry et al., 2014). Clinical trials of collaborative care interventions in acute medical settings after traumatic exposures have demonstrated evidence of improved patient mental health outcomes, such as reduced depression and posttraumatic stress disorder (PTSD) symptoms and reductions in behavioral risk factors, such as weapon carrying (McCarty et al., 2016, 2021; D. Zatzick et al., 2014, 2021).

Yet, it is uncertain whether collaborative care has a unique impact on patients with histories of multiple violent traumas. While collaborative care approaches may vary considerably, the multidisciplinary and multilevel approach to treatment seems well-suited to this population. Victims of violence—particularly those who experienced multiple types of violent traumas (e.g., physical, emotional, and sexual abuse; e.g., Lee et al., 2022)—report relatively poor physical health, mental health, and social functioning (Hughes et al., 2017). Multiple case studies have shown successful implementation of collaborative care for concomitantly treating the emotional and physical problems of patients with histories of child sexual abuse and sexual assault (Dunleavy & Slowik, 2012; Weisfeld & Dunleavy, 2021; Wygant et al., 2011). One clinical trial found that collaborative care improved PTSD symptoms particularly among patients for firearm injuries. However, no study—to our knowledge—has rigorously examined whether patients who report a history of violent trauma demonstrate a differential response to a collaborative care intervention.

To address this gap, the current study tests the effects of collaborative care on the mental and physical health of adult patients with and without a history of multiple types of violent trauma. We conducted a secondary data analysis of a collaborative care randomized clinical trial involving patients who presented with traumatic physical injury at a Level I trauma center in Washington between 2006 and 2009 (D. Zatzick et al., 2013). Our results have implications for clinicians caring for adult patients with a history of multiple types of violent victimization as well as investigators designing studies for treatment.

Violent Trauma and Healthcare Delivery

Violent trauma negatively impacts health throughout the life course (Semenza et al., 2021; Thompson & Kingree, 2022). Accordingly, the Substance Abuse and Mental Health Service Administration (SAMHSA) endorses trauma-informed care principals that call on care providers to realize the impact of trauma on patient recovery, recognize symptoms of past trauma, respond to these symptoms through trauma-informed practices, and resist retraumatizing patients (Huang et al., 2014). When medical treatment reflects trauma-informed principles, care providers should be better positioned to (a) develop trustworthy patient–provider relationships, (b) help patients avoid repeat trauma during recovery, and (c) implement holistic and comprehensive treatment plans (Chandramani et al., 2020; Fischer et al., 2019).

Establishing the Patient–Provider Relationship

A trustworthy and caring patient–provider relationship is central to health care delivery (Murray & McCrone, 2015). However, violent victimization can shatter people’s assumptions about interpersonal relationships, such as the expectation that healthcare providers are benevolent and trustworthy (Janoff-Bulman, 2010; Selwyn et al., 2021). This distrust worsens when providers ignore patients as “coauthors of their healthcare” and develop treatment plans without patient input (Lewis et al., 2019). Trauma-informed care prioritizes patient–provider collaborations (including patients’ families or trusted others) and transparency to build trust and rapport during patient care (Huang et al., 2014).

Preventing Repeat Trauma

When treating patients with a violent trauma history, providers must also acknowledge the risks of repeat trauma in clinical and community settings. Repeat trauma in clinical settings may occur when interactions with the healthcare team remind the patient of past trauma and trigger a stress response (Reeves, 2015). For example, people victimized by sexual violence may experience heightened sensitivity to touching and grabbing by providers. Thus, specialized training helps providers understand these sensitivities and prevent retraumatizing patients (Ades et al., 2019). Repeat trauma in community settings occurs when patients experience another violent trauma after discharge. To prevent revictimization, trauma-informed care addresses the social, behavioral, and structural risk factors that place patients at higher risk of violent reinjury (Affinati et al., 2016; McCarty et al., 2016; Nation et al., 2021).

Implementing Comprehensive Treatment Plans

Multicomponent healthcare services help meet the multifaceted needs of patients with a history of violent trauma. These needs can vary considerably by the type (Hullenaar et al., 2022), frequency (Semenza et al., 2021), and severity of the patient’s exposure to violence (Taquette & Monteiro, 2019). Thus, trauma-informed care values comprehensive and holistic treatment plans responsive to patients’ current physical, emotional, and social needs (Huang et al., 2014). This approach benefits from the seamless collaboration of multiple care providers—physicians, nurses, psychiatrists, counselors, and social workers—who bring unique skills and perspectives to the healthcare team.

Trauma-Informed Care and Collaborative Care

Collaborative care uses multifaceted interventions (e.g., combined case management, pharmacotherapy, cognitive behavioral therapy (CBT), and social services) to integrate “mental health interventions into general medical care” (for intervention model description, see D. Zatzick et al., 2004, p. 499 and D. Zatzick et al., 2011). Multidisciplinary healthcare teams composed of trauma support specialists (TSSs), psychiatrists, psychologists, trauma physicians, and patients (and their families) collectively implement collaborative care. The TSS typically coordinates care between these parties to deliver readily accessible, trauma-sensitive, and holistic treatment for mental and physical health ailments (D. Zatzick et al., 2021).

Through this model, providers develop a therapeutic alliance with patients by addressing their immediate needs and concerns (D. F. Zatzick et al., 2007). The TSS approaches recovering patients at the bedside and asks about their most significant concerns (e.g., pain, stress, contacting family members, obtaining written documentation for their employer, scheduling appointments, or transportation to and from appointments). The TSS then coordinates with the multidisciplinary healthcare team to address these needs (e.g., schedules appointments, sets appointment reminders, organizes transportation, and follows up on missed appointments). Throughout this process, patients “co-author” their healthcare plan and form a trustworthy bond with their care providers.

Collaborative care is also sensitive to patients’ risks of retraumatization in healthcare settings and repeat trauma in community settings. Knowing that they can trust their providers, patients feel more comfortable disclosing past trauma during treatment. This disclosure allows the healthcare team to organize care in ways that avoid retraumatization. Collaborative care also intervenes on the behavioral risk factors of violence through mental health interventions. For instance, providers use motivational interviewing and CBT to reduce alcohol and substance use that may place patients at risk of further violent trauma (D. Zatzick et al., 2014). Altogether, these treatment strategies aim to reduce the likelihood that patients experience further trauma.

Collaborative care prioritizes holistic and comprehensive treatment strategies supported by a multidisciplinary healthcare team. For example, in one application of collaborative care for patients who presented with injury at a trauma center:

“. . .the TSS developed a comprehensive postinjury care plan that simultaneously addressed the medical and psychosocial complications of the injury and coordinated linkages to primary care and community services. In these activities, the TSS interfaced with patients and their families, surgical and primary care providers, staff at community agencies, and outside mental health care professionals. The case management pager was covered by members of the intervention team 24 hours a day, 7 days a week, to provide care that was responsive to the spontaneous questions and needs of injured patients” (D. Zatzick et al., 2004, p. 500)

That is, collaborative care links trauma-exposed patients to healthcare, mental health services, and social services that could address their complex, severe, and everchanging healthcare needs.

In short, collaborative care is an attractive option to implement trauma-informed care to patients with a history of violent victimization. Collaborative care prioritizes patient–provider relationships, involves patients in healthcare delivery, implements trauma-sensitive care, and delivers multifaceted services that address patients’ complex needs. These practices reflect trauma-informed care principles that theoretically should improve medical and mental health care, particularly for patients with a history of violent trauma. However—aside from case studies (Dunleavy & Slowik, 2012; Weisfeld & Dunleavy, 2021; Wygant et al., 2011)—only one clinical trial has examined whether collaborative care has different effects on the mental health of patients who experienced violent victimization. That multisite evaluation study observed that patients with firearm injuries treated at “good or excellent [collaborative care] implementation sites” had among the largest 6- and 12-month reductions in PTSD Checklist scores (D. Zatzick et al., 2021).

However, that study had two limitations. First, because it focused only on firearm injuries, it did not examine how patients’ lifetime history of violent trauma impacted their recovery after receiving collaborative care. Second, the study did not measure mental and physical health recovery outside of PTSD symptoms. The current study is a secondary analysis of data collected during the Trauma Survivors and Outcomes Study (D. Zatzick et al., 2013). The current study addresses the limitations of prior work by examining whether collaborative care has heterogeneous effects on the mental and physical health of injured patients both with and without a history of violent trauma.

Methods

Study Sample and Setting

Between April 2006 and September 2009, a study team recruited survivors of traumatic injury at their bedside in University of Washington’s Harborview Medical Center level 1 trauma center to participate in a randomized clinical trial of a stepped collaborative care intervention aimed at reducing PTSD symptoms. Patients met the inclusion criteria of the study if they experienced injuries requiring surgical inpatient admission. Patients were excluded if they sustained injuries too severe to be able to participate in the study, were younger than 18 years old, did not speak English, lived more than 100 miles from the trauma center, required immediate psychiatric intervention (e.g., self-inflicted injury), were incarcerated, or were likely to face criminal charges after any perpetration of recent severe violence.

Patients who provided written informed consent to participate in the trial completed the PTSD Checklist Civilian Version for DSM-IV (PCL-C) twice—once while in the surgical inpatient setting and then again after hospital discharge. The study team randomized patients who screened positive for PTSD at both time points with scores of ≥35 (n = 207) into the stepped collaborative care intervention (n = 104) or the usual care control (n = 103) conditions. The team then collected baseline data and evaluated patients’ PTSD, depression, substance use, healthcare utilization, mental health, and physical health at 1, 3, 6, 9, and 12 months after random assignment through interviews either in person or over the telephone. The data collection team was blinded to treatment assignment. In total, data collection provided 1,242 participant-wave observations. The University of Washington Institutional Review Board approved all study procedures. Detailed descriptions of the patient selection process and flow through the trial are detailed in previous publications (see D. Zatzick et al., 2013: pp. 393–395)

Intervention

Prior studies have described the stepped collaborative care intervention in detail (see D. Zatzick et al., 2013). Therefore, we provide only a brief summary here.

A mental health team administered a stepped collaborative care intervention over 12 months in both inpatient surgical and outpatient settings. The intervention included continuous patient care organized by a care manager who coordinated care across surgical inpatient, primary care, and community service delivery settings. Treatment modalities included continuous care management, pharmacotherapy, motivational interviewing, and CBT. The intervention team included masters in social work, nurse practitioners, and a supervising psychiatrist.

Care managers monitored patient symptoms throughout the intervention and continuously reassessed mental and physical health using validated scales (e.g., Short Form 12 and 36; Ware et al., 1993). Initially, all patients received less intensive care. Patients who presented with recalcitrant symptoms received “stepped up” (higher intensity) care. The study team psychiatrist supervised patient progression through this stepped care protocol via weekly meetings with the care manager.

Control Condition

Patients in the control condition received care as usual. Post-injury care typically involved outpatient surgical visits and follow-up appointments. Additionally, patients may also have received specialty mental healthcare services.

Measures

Health Outcomes

The outcomes in the current study were participants’ mental and physical health, as measured by the Short Form 36 (SF-36) and Short Form 12 (SF-12) health surveys. Both instruments provide a reliable, efficient, and validated assessment of health status across many patient populations (Ware et al., 1993). The SF-12 survey is an abbreviated version of the SF-36. Due to the study design and to limit patient interview burden while hospitalized, we examined the SF-12 at baseline and the SF-36 at follow-up.

For the SF-12 and SF-36 instruments, we used norm-based scoring (Ware et al., 1993). In general, scores below 50 indicate worse health than the general population norm, whereas scores above 50 indicate better health than the population norm. At baseline, we used the SF-12 to measure four dimensions of emotional health—vitality, role limitations for emotional problems, social functioning, and mental health—and four dimensions of physical health—physical functioning, role limitations for physical problems, bodily pain, and general health. We used all dimensions to calculate the Mental Component Summary (MCS) and the Physical Component Summary (PCS). At follow-up, we used the SF-36 to measure the MCS and PCS.

Intervention Moderator: Violent Victimization History

We measured patients’ history of violent victimization using the baseline trauma history screen (THS) derived from the THS developed for the National Co-morbidity Survey (Kessler et al., 1995). The THS asks respondents about their lifetime exposure to traumatic events prior to sustaining their injury. In this screener, respondents report whether they were ever (a) “badly beaten up by a spouse or romantic partner, or by someone else,” (b) “mugged, held up, or threatened with a weapon,” (c) “raped,” or (d) “sexually assaulted or molested.” We coded each report of violent victimization as either 1 (experienced violent victimization type) or 0 (did not experience violent victimization type) and then took the sum of these codes to measure the violent victimization history of the respondent; scores ranged from 0 to 4.

Covariates

Our multivariable models included control measures of the patient’s injury and demographic characteristics. We calculated the Injury Severity Score (ISS) based on injuries recorded in the medical record International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Codes. We also measured whether the injury was intentional (i.e., caused by interpersonal violence) or unintentional (i.e., not directly caused by another person). Regarding patient demographics, we measured age in years, binary gender (i.e., female and male), self-reported race and ethnicity (i.e., Hispanic, non-Hispanic [NH] Asian, NH Black/African American, NH Native American, NH Other/mixed race, and NH White), education in years, and marital status (i.e., married/living with partner and not married/not living with partner).

Analytic Strategy

We conducted two sets of statistical analyses. First, we calculated descriptive statistics (i.e., means and proportions) of the baseline SF-12, patient history of violent victimization, demographic characteristics, and injury characteristics across the total sample, the control condition, and the intervention condition. At baseline, seven patients had missing data in the SF-12 scores and two patients had missing data on education. We used z tests to compare the characteristics of the control and intervention groups. We also calculated mean SF-12 scores by patients’ violent victimization history. When we compared the norm-based scores of the SF-12 (and SF-36), we treated a 5-point difference (i.e., 0.5 standard deviation units) as a clinically important difference (Ware et al., 1993).

Second, we used random-effect linear regression models to estimate how violent victimization history moderated the effects of the collaborative care intervention on patients’ MCS and PCS scores over time. We reported robust standard errors clustered by the patient identification number. To examine moderation, we estimated a three-way interaction term composed of the intervention condition (vs. control condition), the wave (1, 3, 6, 9, or 12 month follow-up), and violent victimization history (0 violent victimization types vs. 1–2 violent victimization types vs. 3–4 violent victimization types). We coded violent victimization history as a three-category variable to increase statistical power and to distinguish between patients with no violent victimization history, those with a moderate violent victimization history, and those with an extensive violent victimization history. In sensitivity analyses, we coded the violent victimization history variable as an interval measure and found similar results. All regression models controlled for patients’ demographic and injury characteristics. The SF-36 MCS model accounted for baseline SF-12 MCS scores, whereas the SF-36 PCS model accounted for baseline SF-12 PCS scores.

In the sample, 259 out of the 1,035 participant-wave observations had missing data at follow-up. We excluded these observations from the analysis. As a sensitivity check, we used multiple imputation with chained equations (MICE) to impute missing data. MICE is a set of linear and general linear models that substitute missing data values for plausible values using the observed data and an iterative stochastic approach. In the MICE procedure, we estimated 100 imputed data sets, using all variables in the regression model and auxiliary variables (e.g., PTSD checklist) that would help estimate the missing values. After multiple imputation, our results did not significantly differ (see Supplemental Appendixes A1 and A2).

Results

Descriptive Statistics

Table 1 describes the baseline characteristics of the study sample by the intervention assignment. In the total sample, the SF-12 MCS average was 43.2 (SD = 12.1), roughly 7 points lower than the population norm (i.e., 50). By contrast, the PCS average (M = 49.4, SD = 11.2) was not clinically different from the population norm. Among the SF-12 scale scores, there were clinically important differences in role limitations for emotional problems (M = 42.9, SD = 11.2), social functioning (M = 42.0, SD = 11.2), mental health (M = 44.7, SD = 11.2), and bodily pain (M = 44.5, SD = 11.2) between the study sample and the population norms. A little under one-fourth (22.7%) of injuries experienced by the patients were intentional (i.e., caused by violence). The mean ISS for all injuries was 13.6 (SD = 9.7).

Table 1.

Descriptive Statistics of Study Sample at Baseline, by Collaborative Care Intervention.

	Total(n = 207)	Control(n = 103)	Intervention(n = 104)
	M (SD)/%	M (SD)/%	M (SD)/%
SF-12 Component Summaries ^a
MCS	43.2 (12.1)	42.2 (11.6)	44.0 (12.6)
PCS	49.4 (11.2)	51.0 (10.1)	48.3 (11.9)
SF-12 Scale Scores ^a
Vitality	50.8 (11.2)	51.2 (10.8)	50.5 (11.6)
Role limitation emotional	42.7 (12.8)	42.2 (12.8)	43.2 (12.9)
Social functioning	42.0 (13.2)	41.7 (13.3)	42.3 (13.2)
Mental health	44.7 (12.2)	44.2 (12.4)	45.1 (11.9)
Physical functioning	49.8 (11.0)	51.8 (9.1)	47.9 (12.4)
Role limitation physical	48.5 (11.1)	49.6 (10.9)	47.6 (11.3)
Bodily pain	44.5 (13.8)	43.8 (14.2)	45.2 (13.3)
General health	46.9 (13.3)	47.3 (13.7)	46.5 (12.9)
Violent Victimization History
Violent victimization types
0	22.2	23.3	21.2
1	26.6	26.2	26.9
2	30.0	30.1	29.8
3	14.5	16.5	12.5
4	6.8	3.9	9.6
Injury
Intentional injury	22.7	22.3	23.1
ISS	13.6 (9.7)	14.0 (10.4)	13.2 (8.9)
Demographics
Age	38.5 (13.1)	37.7 (12.8)	39.4 (13.4)
Female	47.8	43.7	51.9
Race/ethnicity
Hispanic	5.3	5.8	4.8
NH Asian	2.4	2.9	1.9
NH Black/African American	13.5	13.6	13.5
NH Native American	3.9	3.9	3.8
NH Other/mixed race	14.0	14.6	13.5
NH White	60.9	59.2	62.5
Education (in years)^b	13.1 (2.2)	12.9 (1.9)	13.2 (2.5)
Married/living with partner	25.1	14.6	35.6

Note. PCS = physical component summary; MCS = mental component summary.

Seven patients had missing data on at least one of the SF-12 scale scores and thus were missing PCS and MCS scores.

Two patients had missing education data.

Regarding violent victimization history, the majority of the study sample reported at least one type of violent victimization in the traumatic history screen (77.8%). Among trauma patients who reported violent victimization in their lifetime, most experienced one type (26.6%) or two types (30%) of violent victimization, and 21.3% of the sample experienced three or four types of violent victimization.

The patient sample was demographically diverse. The average age at baseline was 38.5 years old (SD = 13.1). Around 47.8% of patients reported a female gender identity, whereas 52.2% reported a male gender identity. Regarding ethnicity and race, most patients were non-Hispanic (NH; 94.7%), and thus the sample underrepresented Hispanic populations. NH patients mostly reported being NH White (60.9%), followed by NH Black/African American (13.5%), NH Other/mixed race (14.0%), NH Native American (3.9%), and NH Asian (2.4%). Patients reported 13.1 years of education (SD = 2.2), and around one-fourth were married or living with a partner.

At baseline, the control and intervention groups significantly differed only in the SF-12 physical functioning scores (51.8 vs. 47.9, respectively; β = −3.9, 95% confidence level [CI] = , −6.9, −0.9) and the proportion married or living with their partner (0.15 vs. 0.36, respectively; PD = 0.21, 95% CI = 0.10, 0.32).

Baseline SF-12 Scores by Violent Victimization History

Figure 1 summarizes mean SF-12 scores at baseline by patient violent victimization history. In general, patients who reported more types of violent victimization in their THS scored lower on SF-12 scales of mental and physical health. Compared to patients with no violent victimization history, patients who reported three types or four types of violent victimizations scored 6.3 points lower (β = −6.3, 95% CI = −11.9, −0.7) and 5.1 points lower (β = −5.1, 95% CI = −12.0, 1.9)—respectively—on the SF-12 MCS. These patients also scored 8.6 points lower (β = −8.6, 95% CI = −13.9, −3.2) and 13.5 points lower (β = −13.5, 95% CI = −20.1, −6.8) on the SF-12 PCS than patients with no violent victimization history. Across all SF-12 subscales, patients who reported three or four types of violent victimization scored at least 5 points lower than patients with no victimization history.

Figure 1.

SF-12 T scores by violent victimization history (n = 200 participants).

Intervention Effects on SF-36 MCS and PCS, by Violent Victimization History

Figure 2 illustrates SF-36 MCS scores over the study period by the collaborative care intervention assignment and violent victimization history. The collaborative care intervention had inconsistent effects on patients who reported fewer than three violent victimization types. Among patients who reported no history of violent victimization (Panel A), we found no statistical or clinical difference in SF-36 MCS scores at the 1-month, 3-month, or 9-month follow-up. At the 6-month and 12-month follow-up, the intervention group scored 5.6 points higher (95% CI = −2.4, 13.6) and 8.0 points higher (95% CI = −0.3, 16.4) than the control group—respectively. While clinically significant, these differences were not statistically significant at the 95% CI. Among patients who reported one or two types of violent victimization (Panel B), we found no statistical or clinical differences in MCS scores between the intervention and control group at follow-up.

Figure 2.

SF-36 MCS T scores by collaborative care treatment and patients’ violent victimization history (n = 776 participant-waves).

The collaborative care intervention improved the SF-36 MCS scores of patients who reported three or four types of violent victimization. At the 3-month follow-up, these patients scored 7.5 points higher (95% CI = 2.4, 12.6) in the intervention group than in the control group. This difference grew at the 6-month follow-up, where these patients scored 11.9 points higher (95% CI = 5.1, 18.7) in the intervention group than the control group. At the 3- and 6-month follow-ups, the intervention had clinically stronger effects on the MCS scores of patients who reported three or four types of violent victimization than of patients who reported no victimization (β_3month = 6.7, 95% CI = −1.0, 14.5; β_6month = 6.4, 95% CI = −4.2, 17.0) or only one to two types of victimization (β_3month = 6.5, 95% CI = −0.9, 13.8; β_6month = 8.7, 95% CI = −0.3, 17.7). These effect differences were not statistically significant at the 95% CI. Interestingly, part of the clinical differences in these effects was attributed to the decline in MCS scores at the 3- and 6-month follow-up (compared to the 1-month follow-up) among the control group patients who reported three to four types of violent victimization. We found no statistical or clinical intervention effects in MCS scores at the 1-month, 9-month, or 12-month follow-up for patients who reported three or four types of violent victimization.

Figure 3 compares the SF-36 PCS scores between intervention and control groups over the study period, by patients’ violent victimization history. Regardless of violent victimization history, we found no statistically significant differences in the SF-36 PCS scores between intervention and control groups across the entire study period. Among patients who reported three or four types of violent victimization, we found one clinically meaningful difference at the 9-month follow-up, where patients in the intervention group scored 6.4 points higher (95% CI = −0.6, 13.4) than the control group.

Figure 3.

SF-36 PCS T scores by collaborative care treatment and patients’ violent victimization history (n = 776 participant-waves).

Discussion

This study examined the heterogeneous effects of a collaborative care intervention on the mental and physical health of injured patients with and without a violent traumatic history. We argued that collaborative care would particularly benefit patients with a violent traumatic history because it practices three principles of trauma-informed care: patient–provider collaboration, preventing repeat trauma in clinical and community settings, and delivering comprehensive mental and physical healthcare. We tested this argument using secondary data analysis of traumatically injured patients enrolled in a collaborative care clinical trial at a level I trauma center in Washington. Our study is one of the first to provide evidence that a collaborative care model may particularly benefit the mental health recovery of traumatically injured patients with histories of multiple violent victimizations.

We found that injured patients who reported extensive histories of violent trauma (i.e., experienced three or more types of violent trauma) scored significantly lower than patients without a history of violent trauma on baseline SF-12 mental and physical health scales. This finding echoes the voluminous evidence that interpersonal violence negatively affects future health outcomes (Rivara et al., 2019). However, this association is notable because it suggests that prior violent trauma may disadvantage patients at the outset of recovery. In our study, we found that nearly four out of five patients reported at least one type of past violent trauma. Patients burdened by extensive trauma histories have complex mental and physical health needs that may extend well beyond their primary medical complaints.

Our results also suggest that collaborative care may help providers meet the mental health needs of patients with extensive violent trauma histories. Among patients who experienced three to four types of violent trauma in their lifetime, we found that collaborative care markedly improved scores on the SF-36 MCS at the 3- and 6-month follow-up. Additionally, these intervention effects observed at the 3- and 6-month follow ups were clinically stronger than those observed among patients without a history of violent trauma. In a multisite evaluation, D. Zatzick et al. (2021) observed that collaborative care—when well implemented—improved patients’ PTSD symptoms, particularly among those who experienced firearm injury. Our results suggest that the success of collaborative care for firearm injury survivors may be partly attributed to collaborative care treating previously unaddressed trauma, as this patient population tends to report more extensive trauma histories than the general population (Schmidt et al., 2019).

However, somewhat inconsistent with our expectations, stepped-up collaborative care did not have a statistically or clinically significant effect on MCS scores at the 9- to 12-month follow-up of patients with histories of violent victimization. We believe this finding is partly attributed to changes in the intensity of the intervention over time as indicated by previous evaluations:

“Care managers spent a median of 13.2 hours (IQR = 13.3 hours) with each patient over the course of the year after injury. Care manager’s time intensity in the stepped care procedure gradually decreased over the course of the year. Over 60% of care management activity occurred during the first 6 months post injury (median hours = 9.4, IQR = 8.6 hours).” (D. Zatzick et al., 2013, p. 392)

Thus, collaborative care approaches may require more extensive follow-up with patients who report histories of violent victimization, as the impact of past trauma may continue well beyond the initial intervention period.

We observed only one clinically significant effect of collaborative care on SF-36 PCS scores at the 9-month follow-up of patients who reported extensive histories of violent trauma. In general, we found that patients with and without violent trauma histories reported clinically and statistically similar improvements in their physical health over time.

Implications

Our study has two important implications. First, violent trauma history can impede patients’ mental and physical recovery at the outset after injury. Patients burdened by violent trauma are more likely to have chronic physical and behavioral health disorders, higher rates of substance use, and heightened stress responses (Rivara et al., 2019). When entering the healthcare setting, these patients bring complex healthcare needs that can extend well beyond their primary medical complaints. To prevent impediments in patient recovery, trauma-informed care guidelines recommend that providers first recognize any signs and symptoms of trauma and then respond by collaborating with patients to develop a comprehensive treatment plan that addresses mental and physical health needs (Huang et al., 2014). By using a collaborative care approach, that combines empathic engagement through eliciting and addressing post-injury concerns with evidence-based PTSD treatments, these recommendations may be implemented through the TSS who develops a strong rapport with patients, screens for traumatic history, and coordinates multifaceted medical and mental health services through the multidisciplinary healthcare team.

Second, collaborative care may particularly benefit patients with extensive histories of violent trauma. In the current study, the collaborative care strategy implemented practices that reflect trauma-informed care principles. For example, patients who received the intervention developed close and trusting relationships with their TSS who coordinated care services, consistently evaluated patient needs, organized transportation, and followed up after patient appointments. Starting from the visit at the patient’s bedside, the TSS met the patient where they were, which allowed the TSS to screen for and better recognize symptoms of patients’ past trauma.

Finally, and perhaps most importantly, patients had readily available access to comprehensive mental health and medical services based on their perceived and evaluated needs. We could not discern the specific aspects of the intervention that were most helpful to patients with violent trauma histories. However, we suspect that the responsiveness of the multidisciplinary healthcare team partly explains the success of collaborative care for this patient population.

Limitations

Our study’s findings and implications have three critical limitations. First, we conducted a secondary analysis of randomized clinical trial data, and the trial was not designed to compare the effects of collaborative care on the health of patients with and without violent trauma histories. In the sample, only one in five patients experienced no violent trauma, which may increase statistical error. The trauma history screener had a limited specificity regarding the nature of violent trauma. For example, the history screener is not behaviorally specific, and patients may have different interpretations of choices available in the questionnaires. Further, the screener had no explicit measure of psychological abuse or physical child abuse, and we had to assume that patients who experienced child abuse responded affirmatively to being “badly beaten up” in their lifetime. Additionally, we had no measure of the severity nor frequency of violent trauma. Patients may report experiencing only one type of violent trauma, but we do not know whether there were multiple occurrences over a period of time.

Second, our data came from a clinical trial conducted over 10 years ago. Since this trial, the collaborative care intervention has been adapted. For example, in the current trial, the care manager spent on average 12 hours with each patient over the course of the year after injury, and this patient engagement reduced in the final waves of the trial. More recent investigations have worked to reduce collaborative care time allotments in an effort to increase the chances of widespread adoption (D. Zatzick et al., 2021). We found that collaborative care effects were not observed after the 9-month follow-up—limiting its clinical usefulness. Our finding suggests that reducing patient time with the care manager may risk reducing the long-term impact of collaborative care for patients who report multiple violent traumas. Further research is necessary to determine whether patient time spent with a care manager explains why collaborative care effects were reduced at the 9- and 12-month follow-up.

Third, our findings have limited generalizability due to our study sample. This single-site clinical trial recruited a relatively small sample of patients who presented with severe traumatic physical injuries at only one study site. Our sample included patients from diverse racial and ethnic backgrounds; however, the sample was majority White. Additionally, our sample excluded patients who could not speak English, which severely limited the representation of Hispanic patients and other non-English-speaking groups in the study. Thus, it is critical that future research replicates our results using a more diverse sample with a larger representation of Hispanic patients and patients who do not speak English.

Fourth, it is uncertain whether patients received specialty health services outside of those provided by the collaborative care team. For example, it is possible that the usual care group received specialty mental health care not provided to the treatment group, which would downwardly bias the estimated differences between the treatment and usual care groups.

Conclusion

Violent trauma challenges healthcare teams to implement trauma-informed practices that address the unique needs of patients who report histories of violent victimization. In this regard, providers should be purposive in developing the patient–provider relationship, involving patients in developing healthcare plans, and implementing multifaceted healthcare treatments. Collaborative care approaches offer one means to accomplish these goals by providing patients readily available access to a TSS that coordinates mental and physical care within a multidisciplinary healthcare team.

Supplemental Material

sj-docx-1-jiv-10.1177_08862605221138655 – Supplemental material for Exploring Collaborative Care Effects on the Mental and Physical Health of Patients With and Without Violent Victimization Histories

Supplemental material, sj-docx-1-jiv-10.1177_08862605221138655 for Exploring Collaborative Care Effects on the Mental and Physical Health of Patients With and Without Violent Victimization Histories by Keith L. Hullenaar, Frederick P. Rivara, Jin Wang and Douglas F. Zatzick in Journal of Interpersonal Violence

Supplemental Material

sj-docx-2-jiv-10.1177_08862605221138655 – Supplemental material for Exploring Collaborative Care Effects on the Mental and Physical Health of Patients With and Without Violent Victimization Histories

Supplemental material, sj-docx-2-jiv-10.1177_08862605221138655 for Exploring Collaborative Care Effects on the Mental and Physical Health of Patients With and Without Violent Victimization Histories by Keith L. Hullenaar, Frederick P. Rivara, Jin Wang and Douglas F. Zatzick in Journal of Interpersonal Violence

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This work was funded by the National Institute of Child Health and Human Development (5T32HD057822-11).

ORCID iD

Keith L. Hullenaar

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Keith L. Hullenaar, MS, PhD is a T32 postdoctoral fellow at Harborview Injury Prevention Research Center in the University of Washington. His research focuses on the intersection of violence and health, correlates and consequences victims’ formal help-seeking, and youth violence interventions.

Frederick P. Rivara, MPH, MD is professor of pediatrics, adjunct professor of epidemiology, and director of the Firearm Injury and Policy Program, Harborview Injury Prevention and Research Center, University of Washington School of Medicine. His research focuses on studying childhood injury and prevention.

Jin Wang, MS, PhD is a research scientist at Harborview Injury Prevention and Research Center. Her work focuses on evaluating public health approaches to trauma-focused research, such as the evaluation of collaborative care management for improving PTSD symptoms.

Douglas F. Zatzick, MD is currently a professor in the Department of Psychiatry and Behavioral Sciences at University of Washington School of Medicine. Over the past two decades, he has developed a public health approach to trauma-focused research and clinical work that has emphasized clinical epidemiologic, functional outcome, and early intervention studies of posttraumatic stress disorder (PTSD) and related co-morbid conditions.

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