2022 MIPS Improvement Activity IA_BMH_11: Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice

Activity Description

Create and implement a plan for trauma-informed care (TIC) that recognizes the potential impact of trauma experiences on patients and takes steps to mitigate the effects of adverse events in order to avoid re-traumatizing or triggering past trauma. Actions in this plan may include, but are not limited to, the following:

  • Incorporate trauma-informed training into new employee orientation
  • Offer annual refreshers and/or trainings for all staff
  • Recommend and supply TIC materials to third party partners, including care management companies and billing services
  • Identify patients using a screening methodology
  • Flag charts for patients with one or more adverse events that might have caused trauma
  • Use ICD-10 diagnosis codes for adverse events when appropriate

TIC is a strengths-based healthcare delivery approach that emphasizes physical, psychological, and emotional safety for both trauma survivors and their providers. Core components of a TIC approach are: awareness of the prevalence of trauma; understanding of the impact of past trauma on services utilization and engagement; and a commitment and plan to incorporate that understanding into training, policy, procedure, and practice.

Activity ID Activity Weighting Sub-Category Name
IA_BMH_11 Medium Behavioral and Mental Health


Ensure delivery of responsive care for patients and clinicians who have experienced physical or mental trauma.


Documentation of an implemented plan for delivering care to patients who have experienced trauma, and for addressing needs of clinicians and staff who have experienced trauma. Include the first element and one of the following elements:

  1. Implementation of a Trauma-Informed Care (TIC) plan – Documentation of the creation and implementation of a TIC plan; AND
  2. Training materials – Documentation of materials on TIC integrated into new employee orientation or annual employee training; OR
  3. TIC education materials – Documentation that materials on TIC are supplied to third-party partners, such as care management companies and billing services, to ensure a system-wide approach to TIC; OR
  4. Adverse events screener – Copy of implemented survey tool or prompt in electronic health record is used to assess and identify if a patient has experienced one or more adverse events that may have caused trauma.


  • Centers for Disease Control and Prevention’s Guiding Principles to Trauma-Informed Approach: www.cdc.gov
  • Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). TIP 57: Trauma-informed care in behavioral health services: store.samhsa.gov.



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