Dr. Elizabeth Grady is a pediatrician at the South San Francisco Clinic, a community clinic of San Mateo Medical Center. She and Susana Flores, a senior public health nurse with San Mateo County Health, spoke with me about how the clinic and other health agencies in San Mateo have been able to craft ways to work together to prevent and heal toxic stress in children. Grady also talked about how she and Flores have been working with the Resilient Beginnings Collaborative (RBC), a group of seven SF Bay Area clinics who’ve been integrating practices based on ACEs science. Flores supervises public health nurses and community workers in some of the County’s home visiting programs. This is the second in a series about RBC participants in the Resilient Beginnings Collaborative. Here is a link to the first story.
Laurie Udesky: What was your interest in being a part of RBC?
Dr. Elizabeth Grady: Interestingly, when we heard about the RBC grant, we were already basically doing what the RBC was trying to encourage, which was working together across sectors to address ACEs (adverse childhood experiences) in the pediatric clinic. A few years ago, two things converged. I have always been interested in learning more about how to address trauma, having been a pediatrician for almost 25 years. Based on my training, I didn’t feel like I knew what to do about it. I had actually heard Dr. [Vincent] Felitti present the ACE Study [CDC-Kaiser Permanente Adverse Childhood Experiences Study] at a meeting of the American Academy of Pediatrics shortly after it was published [in 1998,] and I thought it would be big news. I was kind of surprised I didn’t hear much about it back then. But it validated my suspicion that these types of traumatic experiences did really have an impact on people throughout their life course.
So around four or five years ago, there started to be more in the literature about ACEs science. And at the same time, the leader of the Center for Youth Wellness (CYW), Dr. [Nadine] Burke Harris, was spreading the word about ACEs, as was (and obviously, also) Jane [Stevens, founder of ACEs Connection].
At that time, I’d been talking with my boss about wanting to do a better job for patients who are victims of sexual abuse or other trauma. We ended up adding questions about childhood trauma to our version of the Staying Healthy Assessment (SHA), the health and safety questionnaire that the State of California requires be given to all patients enrolled in the state’s Medicaid program. The questions were adapted from the AAP Trauma Toolbox for Primary Care. We also implemented the SEEK model. After we piloted the expanded SHA for several months, all of the other pediatric clinics in the San Mateo Medical Center system adopted it in 2016.
The work on addressing ACEs in the pediatric clinic fit in with wider efforts in San Mateo County Health. Our Behavioral Health and Recovery Services (BHRS) was the first to introduce trauma-informed care principles. A couple of years ago, leadership in San Mateo County Health recognized that 53% of youth clients in probation and 43% in BHRS came from four zip codes, one of which was South San Francisco. A series of cross-sector meetings led to the Community Collaboration for Children’s Success. (Please see the attached document about CCCS).
One goal of the CCCS was to improve outcomes by improving communication and service coordination between the pediatric clinic, Family Health Services and BHRS. While we are fortunate that in our county these sectors are all under the same umbrella, all are separately located and none use the same computer systems, so communication was not seamless. Because of these barriers, we were not making optimal use of the available resources, including Prenatal-to-Three, a home visiting program that includes home visiting nurses and therapists specializing in addressing postpartum depression.
South San Francisco Clinic does not offer prenatal care and San Mateo Medical Center does not have labor and delivery, so my patients are born at hospitals outside our county system, usually at Stanford/Lucille Packard Children’s Hospital. If I saw a family with a newborn, and the family was struggling, I put in a referral for Prenatal-to-Three. But because of a paper referral process, it would take about two weeks [for the family to get help]. When you have a newborn, the hardest part is the first two weeks. It could be the difference between breastfeeding or not. That’s a long time for a stressed-out parent without support to be alone with that baby. As we know, that impairs the development of the baby’s social-emotional system.
Our Prenatal to Three program created a rapid-response team specifically for referrals from South San Francisco Clinic so families could get connected to supportive services as soon as possible. As I mentioned, the Prenatal to Three program includes a dedicated mental health team focused on addressing maternal depression. A team of therapists come to the parents’ home to do therapy. A psychiatrist is available for mothers who need medication. The idea was that if they had a rapid-response team, they could contact people within days and have higher involvement among new parents in supportive services. And, in fact, our data has shown that.
Susana Flores: In terms of involvement in home visiting services, since we started responding to referrals within 24 to 48 hours, we have increased families’ engagement in home visiting services from a baseline of 31% to 41%. We used to take 12 days or so to respond to a referral; now we respond within one day and clients are engaging better. Case managers are able open a case within 11 days. Before they would take about 18 days. The earlier we respond, the more likely it is that patients are open to receiving the support we offer.
Grady: What I didn’t expect was the impact that this collaboration would have on me — it reduced my secondary trauma. Pediatricians see a lot of childhood trauma. At South San Francisco Clinic, we see a lot of new patients. We don’t know who is going to walk through the door and what their experience will be. So, it’s fairly common that you go in to see a patient and they have some horrific story of trauma that's obviously affecting everybody, and this is a 15-minute visit and you have all this other stuff you’re supposed to be doing.
The advantage of having this closer collaboration [in San Mateo County] is that I have felt much more confident that I wasn't the only person tasked with helping this family with their trauma. At the end of the day I felt a little less stressed. Also, since referrals were now done in our electronic medical record, when a family I was concerned about showed up later on for an urgent care visit, I could go in and check to make sure that the family was referred and also communicate back and forth with other people (in behavioral health and home visiting).
The value of strengthening cross-sector relationships between providers should not have been surprising, given the central role of relationships in helping with trauma cited by many leaders in the study of ACEs science and resilience, including Drs. Bruce Perry, [Bessel] Van der Kolk, and [STEPHEN] Porges.
Udesky: What was the opportunity for joining and participating in the RBC?
Grady: It was just the recognition of the importance of doing this work in safety net clinics. I’d followed this work for a long time and read about amazing trail-blazers — Dr. R.J. Gillespie at The Children’s Clinic in Oregon, [Dr. Nadine Burke Harris at] CYW, [Dr. Ariane Marie-Mitchell at] Loma Linda University. It always seemed to me what really needed to happen was to make it work in an imperfect community clinic like ours, because that’s where most kids go to the doctor.
CYW is amazing, but their model — and I’ve talked with people there and they freely acknowledge this — is not really sustainable for most community clinics. They have a lot of well-deserved outside funding. To make this scalable you have to come up with something that’s going to work everywhere. That’s why I appreciated that the RBC was specifically looking at “safety net” clinics — public or nonprofit Federally Qualified Health Clinics with challenges in funding and other areas. The support provided by the collaborative was in the form of coaching and reimbursement for staff time to attend meetings, trainings and to go on site visits. There was no funding for new positions. The idea was to work with what we have.
As a requirement of participation in the RBC, in November 2018 all South San Francisco Clinic staff participated in a half-day training about trauma-informed care presented by Dr. Jill Sulka of Trauma Transformed.
Udesky: Can you give me specific examples of how collaborating with others has worked for your team?
Grady: The main way that’s happened has been at RBC convenings and site visits. Those were opportunities to hear from other groups about what they were doing, what kind of obstacles they were running into and how they were addressing them.
One example: One of the major decision points that became clear to me even before we joined the RBC was: Would we be doing screening in an identified or de-identified way? (De-identified ACEs screeners instruct those filling it out to read the questions, count up the number that apply to them or their child’s experience, and to put that total number at the top of the form. An identified ACEs screener asks those filling it out to answer “yes” or “no” to each question about childhood adversity.) One reason for preferring a de-identified screener would be to address parents’ fears about being reported [to Child Protective Services.]
When we first started in 2015, we decided to go with an identified screener. We were already screening for two ACEs in an identified manner — we were asking about exposure to maternal depression and domestic violence. And it felt right for us as a small clinic where we know many of our patients well. It seemed weird to use a de-identified [screener].
I knew that CYW was using PEARLS [Pediatric ACEs and Related Life-events Screener], in a de-identified way and thought that was because they found their patient population was more comfortable with that. But I wasn't sure that using PEARLS in the same way that CYW was using it would be a good fit for our clinic.
At the most recent convening in June, however, Dr. Dayna Long at UCSF Benioff Children’s Hospital Oakland reported that members of recent focus groups had preferred that the questions be asked in an identified manner over a de-identified manner. That was really interesting to me. I wasn’t aware that people were using PEARLS in an identified manner. [The hospital created the PEARLs tool with CYW as part of a Bay Area Research Consortium.]
The PEARLS contains all of the ACEs questions, and they worked with their focus groups to help them phrase the questions in a way that’s empathetic to make it easier for families to answer questions. For example, one of the questions is: “Do you think your child at any point has ever felt uncared for?” It’s less in-your-face phrasing [than the original 10 ACE questions, which asks about emotional neglect this way: Did you often feel that no one in your family love you or thought you were important or special or Your family didn’t look out for each other, feel close to each other or support each other? (Because the CA Department of Health Care Services is in the midst of working on a legal agreement with the owners of the PEARL tool, the final version of it is not yet available online, according to DHCS spokesperson Katharine Weir.)
I was already thinking about the fact that we weren’t addressing all of the ACEs, emotional neglect in particular, in our screening. When I heard that BCHO patients preferred to have the PEARLS questions asked in an identified manner, that gave me the courage to consider doing that in our clinic. The other thing that helped was the work of Dr. Burke Harris [California’s Surgeon General] through AB340 to get the recommendation for universal screening using the PEARLs tool.
Udesky: You began screening patients with the PEARLs screening tool in September. How did you fit it into your workflow?
Grady: We considered adding the PEARLS to our existing workflow, in which families receive all questionnaires at registration, complete them alone and give them to the medical assistant for provider review. At the same time, we wanted to make sure that we were able to offer families information about resilience and resources for social determinants of health. We felt that a community worker would be best suited to provide that information.
Unlike larger clinics of San Mateo County, we did not have an on-site community worker, so we were grateful that one of the community workers from Susana’s team was able to come to our clinic half-time to do the PEARLS work.
Initially, we thought that the community worker would hand the questionnaire to the family at registration. We quickly shifted to having her ask the questions in the exam room, after the medical assistant had taken vitals and done other routines. We also considered the experience of our colleagues at WIC who had noted more positive responses to the Brief Child Abuse Prevention Screen when they asked questions verbally instead of having clients check boxes: (Please see the attached document for preliminary data.)
Udesky: What would you say is your biggest takeaway from participating in this journey thus far?
Grady: If I had to pick one takeaway from the year and a half with the RBC — and to a greater extent the four years or so that I have been looking at this through ACEsConnection.com and other work we’ve done — it’s that social connection through non-judgmental empathy and acceptance is just incredibly important and not that complicated. It applies to both the provider-patient relationship, but also to the inter-system provider relationships.
Udesky: Inter-system provider relationships?
Grady: As I said earlier, initially when I thought about implementing the rapid-response referral process, I thought about it from the perspective of efficiency and improving the quality of care we provided to patients. What I didn’t anticipate was the impact it would have on me. When I feel like I am part of a team working to help children and families with ACEs, it is a lot easier to keep trying to do work that is inherently painful.