5 Questions for Dr. Erica Didier, Skyline Clinic
Bringing Integration and Trauma-Informed Care to a Growing Southwest Washington Community
Dr. Erica Didier is a family medicine provider at Skyline Medical Clinic in White Salmon, which overlooks the scenic Columbia Gorge in Skamania County, Washington. She’s at the forefront of an effort to develop a fully-integrated medical clinic that serves residents of her primarily rural county. She’s also championing a trauma-informed approach at the clinic and neighboring Skyline Hospital. This month, Skyline is offering trauma-informed trainings to all staff members — from physicians to front line staff. We sat down with her to learn more about the benefits of integration and trauma-informed training for staff and the community.
What led you to pursue an integrated approach to physical and behavioral healthcare at Skyline Medical Clinic?
When I started my career, I was very focused on the medical facts of my cases. Over time, I developed a greater understanding of how what happens in people’s homes and communities — the social determinants — impacts health. As providers, if we’re not attuned to those social needs we’re not helping people as much as we can.
That’s why team-based care and the idea of the patient-centered medical home is so important, where we’re the hub and the spokes go out to social services, specialists, behavioral medicine, vision, etc. It allows us to connect patients to experts on social determinants that can help address those social needs.
Both SWACH and Comprehensive Mental Health have been instrumental in preparing us to hire a behavioral health specialist. It’s exciting. Having that resource will significantly enhance my ability to provide medical care because they can help with things like anxiety, depression, parenting, relaxing or substance abuse issues.
What will that integration look like and what are the benefits for your patients and team?
It makes a big difference. We might look at the schedule and see things like uncontrolled high blood pressure, depression and a child with abdominal pain. And we know the high blood pressure is related to alcohol abuse. Or perhaps childhood sexual abuse leading to depression. Or that kid with abdominal pain is being bullied at school. There’s nearly always a social and behavioral component. If we address those underlying issues we can help people get better faster.
So, we’ll huddle in the morning, go through the list and plan out the day. If a patient is resistant to seeing the behavioral health specialist, I’ll see them first. However, the person experiencing depression could see the behavioral specialist while waiting to see me. Then we talk. It gives us a much fuller picture of people’s lives and allows us look at things from different points of view.
It also breaks down barriers. For some people, thinking about the link between physical and emotional health is new. They may not want to go find a counselor. But when that resource is a here on my team I can say, for example, “oh, you’re interested in quitting smoking? I have an expert here that helps with that.” In the next room I might say “I have someone here that works with people when they are feeling down. Is it ok if they come and visit with you?” It’s what we call warm handoffs.
In western society we’ve made such a distinction between physical and behavioral health. Now we’re sort of reintroducing the idea of whole-person care.
What led you to champion trauma-informed care training at Skyline?
A trauma-informed approach makes us more effective healers. We need to learn the language and practices to avoid re-traumatizing people. You know, primum non nocere, “first, do no harm.”
I also want to spread that knowledge to front line staff. Sometimes I hear “this person yelled at me” or “this person keeps missing appointments.” The idea is that instead of asking what’s wrong with that person, we ask what has happened to that person. We want to bring that shift in thinking to our front desk, to our billing dept, to the people taking x-rays, etc.
For example, a person perpetually late to appointments might have ADHD because of neglect as a child. As a provider I often know the backstory. However, one of the principles of trauma-informed practice is you don’t need the backstory. The goal is to use trauma-informed practices with all our patients; it’s a universal precautions approach. We know to wear gloves because someone might have an infectious disease. Similarly, as an organization we choose to treat everyone in a way that avoids re-traumatization, empowers patients and leads to a better cooperation. That’s why we’re so excited to offer trauma-informed training to all the staff at Skyline.
Tell us a little more about the training. What’s happening? Who’s it for?
We’re hosting two trainings in October for everyone in the hospital and clinic, whether they are physicians, front-line staff, housekeepers or people who work in the kitchen. The trainer is Tim Shields, an expert from Comprehensive Mental Health out of Yakima.
We’re very grateful for the support we’ve received from Skyline CEO Rob Kimmes. The trainings aren’t mandatory, which aligns with principles of trauma informed practice. However, people are paid for their time and we’re offering it twice and working with all the department heads to make it easy for everyone to attend.
Plus, on Thursday, October 18th we’re hosting a free community event with a great speaker, Claire Ranit from the Gorge Resilience Network, on the effects of toxic stress and how to build resilience. That event is open to the community and we’re inviting teachers, parents, law enforcement, NEMT and others. We’re also excited about doing this during October’s Gorge Happiness Month, which is organized by One Community Health and focused on the three habits proven to improve health and happiness: gratitude, acts of kindness and moments of silence
How do you get leadership buy-in around integration and trauma-informed practice when there isn’t always a model that supports it?
We’re constantly asking ourselves what’s right for the patient; as an organization, if you think about what’s best for the patient you’ll often reach the right decision. It’s also helpful to have organizations like SWACH, which is tied to bigger movements nationally, reinforcing messages locally around trauma-informed care and integration.
Plus, there’s the relationship between social determinants and healthcare costs. Existing reimbursement models often lead us to look for and treat physical diagnoses before we look at social determinants. There’s a lot of money spent on healthcare that might be better spent on housing, food, sidewalks, etc. And the research backs that up. That’s where the community partners are so important. For example, Washington Gorge Action Programs (WGAP), a regional partner that helps people with things like housing. Because, ultimately, healthcare is just one part of a healthy community.
Learn more about Skyline Hospital and their upcoming events on their Facebook page