Members of the multidisciplinary TRAIL Clinic team huddle in the Brigham Medical Specialties Clinic earlier this month.

Traditionally, trauma care means saving lives in real time. Whether the trauma has occurred from a car accident, fall, stabbing or gunshot wound, the trauma team does everything possible to keep patients alive. But what happens after the acute care, when patients need to put back together the pieces of their lives and move on? What if patients don’t have the resources or support to return to work or school, or to move forward from their injuries?

These are the questions that prompted a group of clinicians from Brigham and Women’s and Spaulding Rehabilitation to create the pilot Transforming Recovery After Injury for the Long- Term (TRAIL) Clinic. Spearheaded by trauma surgeon Geoffrey Anderson, MD, MPH, and physician-scientist Juan Herrera-Escobar, MD, MPH, both of the Brigham’s Center for Surgery and Public Health, and Spaulding occupational therapist Shonali Gaudino, OT, BCG, the TRAIL Clinic identifies trauma patients at higher risk for poor outcomes due to social determinants of health and provides them with holistic follow-up care.

Patients are referred from the Brigham’s Trauma, Burn and Surgical Critical Care Unit and identified based on their eligibility for being at increased risk for poor long-term outcomes. These risks include having an injury that has resulted from interpersonal violence, limited English proficiency, a weak social support network or low perceived socioeconomic status.

“These patients are often left to their own devices because they’ve been labeled as non-compliant. This clinic changes that mentality and gives them the resources to be successful and have better health outcomes,” said Brigham physician assistant Jessica “Morgan” Jones, PA-C. “I think that starts to create a positive, self-fulfilling cycle, instead of the negative one that they’re often stuck in.”

The one-year pilot program — supported by a 2023 Innovator Award from The Gillian Reny Stepping Strong Center for Trauma Innovation and the Mass General Brigham Springboard Studio’s SheSolves Award — launched in April 2024. At twice-monthly clinic sessions, patients meet with a multidisciplinary team of providers including a surgeon, physician assistant, patient navigator, community health worker, occupational therapist (OT), physiatrist, social worker and other providers as needed. During each clinic, the providers come together to listen to patients’ needs and create the best plan of care for the patient from a team-based perspective.

“Transportation is a big issue for a lot of our patients,” said Katie Foley, MSc, the patient navigator in the TRAIL Clinic who works in the Division of Trauma, Burns, and Surgical Critical Care at the Brigham. “So, the fact that our clinic allows patients to get holistic medical and social support in one appointment is huge. They don’t have to rearrange their whole life to get care from 10 different providers. And we do whatever it takes to get them a ride here.”

Blazing the TRAIL

Gaudino, who is an OT at Spaulding, says the clinic hopes to better understand and fulfill patients’ medical, social and mental health needs after traumatic injury.

“Historically, the medical system is set up to treat traumatic injuries in the traditional medical model,” said Gaudino, who also serves as administrative director of the Rehabilitation Outcomes Center at Spaulding. “Our patients come in with significant traumas, like spinal cord injuries, brain injuries and burn injuries. Some have injuries from domestic violence. We treat their wounds, and then maybe they go to rehab or get some outpatient care, and that’s it. But these are conditions patients are going to live with for the rest of their lives, and we’re looking for ways to be better equipped to treat them in the long term.”

Foley says the idea for the program started a few years ago, after she and her colleagues noticed some of their trauma patients were doing worse when they came in for follow-up care.

“Our research team noticed it was specific groups who tended to do worse, including those with lower socioeconomic status, non-English speakers and people with weak social supports,” Foley said. “After seeing this data, we started looking at ways we could make a difference. Dr. Anderson and Dr. Herrera Escobar got a grant, and that was the birth of the TRAIL Clinic.”

Creating a safe space

Foley reviews all BWH trauma patients to identify those who meet the criteria for the clinic. Then, she and two other clinic coordinators are assigned to specific patients. Jones is the main clinical contact for all patients at the clinic.

“I meet with each patient and their clinical coordinator, and then work with OT or social work to determine what else they need and create a plan from there,” Jones said. “We do everything we can to get them the care and support they need, from specialist referrals and finding a primary care provider to nutrition and transportation needs.”

Ana Hoffman, a community health worker, is the clinic coordinator. In this role, she focuses on removing any obstacles that might prevent patients from engaging in care. A former member of the Brigham’s Interpreter Services team, Hoffman works especially closely with patients whose first language is not English. She says these patients are among the most vulnerable.

“They don’t know the language, and they are afraid,” Hoffman said. “Many of my patients have problems with food insecurity or transportation, or they’re in pain because they have trouble getting their prescriptions filled. We can help them with whatever they need — insurance, medications or just calling the doctor — things that can make a big difference. We also connect them with violence recovery programs or other resources they may not know about.”

Gaudino says that many of their patients have substance use issues, which they also try to address. “The Substance Use Disorder Bridge Clinic takes walk-ins on Friday mornings, which is the same day as our clinic. So, we can just take them right down to the Bridge Clinic if they need help.”

It will be some time before the TRAIL Clinic has enough data to measure outcomes, but clinic staff say they already see a positive effect on patients.

“Our patients have a lot of complex needs that affect their lives pretty significantly, and they are so grateful to have a place where they can share everything,” Foley said. “We’ve had patients tell us, ‘There’s never been someone who would listen to all my issues and be so receptive to how much I’m dealing with.’ And that’s exactly the vision we had for the clinic — to create a safe place where people can come after a traumatic injury and be heard on all levels, and then be confident in their care moving forward.”