Kaiser family medicine clinic launches 4-question ACE survey pilot for adults

 

In July, medical residents in family medicine at Kaiser Permanente in San Jose, CA, began screening adult patients for adverse childhood experiences (ACEs). But it’s an ACE survey with a twist: it’s shorter, not the  10-question survey of the original CDC-Kaiser Permanente ACE Study, according to Dr. Kathryn Ridout who is leading the pilot along with Dr. Francis Chu and Dr. Alec Uy.

Why a shorter ACE survey?

KRidout headshot2
Dr. Kathryn Ridout

“When we were doing our initial discussions with stakeholders in the clinical setting, one of the barriers was the perception of the amount of time it takes to do a screening,” says Ridout. So, she and her colleagues developed a shorter ACE survey of four questions. The questions were adapted from the original ACEs screen of 10 questions as well as expanded ACE surveys that include statements about experiencing bullying or racism, living in a war zone, or in a violent neighborhood. (Since the four-question survey is currently being piloted, it’s not yet available for public release, according to Ridout.)

Ridout, who came to Kaiser in August 2017, says her own interest in ACEs science stems from her medical residency in psychiatry. “Despite the diagnosis, there was this common theme of stressful exposures in childhood,” recalls Ridout. That realization led her to begin researching the biological underpinnings of early life stress, she said. And then, she pursued a four-year post-doctoral fellowship at Brown University investigating the neuroscience of ACEs exposure in adults and children, and health outcomes. She focused on epigenetics and markers of aging.

For the pilot, if patients answer yes to two of the questions, doctors consider offering them other support, says Ridout. Ridout says about 100 patients have been screened since July, and they expect to screen about 1,000 patients by the end of the pilot in December 2019.  

But Ridout and her colleagues are clear that to get a true sense of what further support their patients might need, they have to understand how resilient they are.

“We can ask people did you have these exposures [to ACEs]. But it’s really how did they experience these exposures that’s important,” says Ridout. To measure and understand how patients weathered ACEs exposures, says Ridout, they'll be adding screening for resilience in January. While they haven’t yet selected a resilience screening tool, one they’re considering is the Connor Davidson. 

And for patients who do need support in building resilience, Kaiser offers a range of services, she says, including online programs and in-person classes, and referrals for therapy or psychiatry.

The goal, says Ridout, is that by the end of this year, all of the approximately 65 family medicine health care providers, nurses and medical assistants at Kaiser San Jose will begin screening patients who are 18 and older for ACEs.

Similar to the training provided to residents and other staff who began screening patients for ACEs in July, the entire family medicine staff will be trained in ACEs science, including the nuances of interacting sensitively with patients who have experienced trauma. The training, Ridout says, follows established guidelines of the Substance Abuse and Mental Health Services Administration (SAMHSA), which also influenced decisions about the workflow.

For example, instead of patients receiving the ACE survey in the waiting room, medical assistants give it to patients privately in the exam room, explains Ridout. The medical residents collect the filled-out ACEs survey, and give their patients handouts with options for seeking further support.

What are the conversations that residents have with their patients after they’ve filled out the screen?

“That really varies,” says Ridout. “We have scripts that say: ‘Thank you so much for sharing. Would you be interested in tools to show you how these experiences could potentially impact your health, and also to build skills that might help modify the health risks associated with these experiences of ACES?

But Ridout says, several residents have reported conversations beyond the scripted statements. “Some residents have shared that they had really impactful discussions with their patients that helped deepen the doctor-patient relationship, and helped bring a joint meaning into the practice where they feel a connection with patients on another level.”

“I think we all didn’t go into medicine to prescribe another betablocker, or regulate blood sugar.  While those things are important -- and that is our role -- I think it’s the connection with the patient that really draws most of us to medicine,” she says. “And I think this  ACEs screening tool helps facilitate that.”

Ridout says that they expect to analyze the data they will be collecting at the end of 2019, when they finish the pilot.  Among the questions they’ll be examining are how the abbreviated ACE screen compares with traditional ACE screens in capturing ACE exposure.

“The plan is this will be ongoing,” she says. “Certainly, as we validate the [screener], the hope is it will actually expand within other clinical realms in Kaiser, and more broadly.” 

 

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Congratulations!  This is a major change in clinical practice and I urge you to document and publish its effects.  In San Diego, integrating the ACE questions into the lengthy and comprehensive adult medical history questionnaire that everyone had to fill out at home as Step 1 of Health Appraisal led to profound changes.  Specifically, in a 130,000 person sample (2.5 years throughput) this led to a 35% reduction in doctor office visits the next year compared to their prior year, and an 11% reduction in ER visits.  Although the economic implications are huge, this has not yet been pursued, other than what you are now doing.  As a now-retired SCPMG internist, I am delighted to see your efforts.   

Dr. Felitti wrote an article for ACEs Connection in 2012 about how he integrated the ACE survey into the Health Appraisal Center at Kaiser Permanente in San Diego. He started doing this in 1998 after the initial results came in from the ACE Study, because he could see what a difference it made in patient care. Here's the link:

https://www.acesconnection.com...manente-in-san-diego

Over the next few years, 440,000 adults took the ACE screener.

Looking forward to seeing more details as this program grows!

In our internal medicine and family medicine residency program here at OU Tulsa, we have been training residents on how to screen and discuss ACEs with adult patients.  We have not implemented across the board screening but have used more of a "case-finding" approach, using screening on those patients who are having difficulty managing chronic disease.  There is some controversy about screening all comers in adult primary care (see Finkelhor in Child Abuse and Neglect, http://dx.doi.org/10.1016/j.chiabu.2017.07.016).  There is so much more we need to learn about how to do this right and what interventions work best!

Art Wagner posted:

Could we see what the four questions are?

Hi Art, 

Thanks for writing! Dr. Ridout and her colleagues are just beginning to pilot the 4-question ACE survey, so the specific questions are not yet publicly available.

Alfred White posted:

Awesome...Thank you...This is needed in our Behavioral Healthcare Community!

I would like an Adult Assessment and a Connor Davidson Resilience Tool...is this possible?

Thank you,

Alfred 

Hi Alfred, Thank you! Here's a link for more information about the Connor Davidson Resilience tool, which is proprietary and copyrighted according the their website: http://www.connordavidson-resi...scale.com/about.php#

I know that Dr. Ridout and her colleagues are in the beginning stages of testing their new tool. For additional ACE survey tools that are available, you'll find examples in the ACEs Connection Resource Center here

Here's the url: https://www.acesconnection.com...xtended-aces-surveys

Great reporting Laurie. I'm always curious about the nuts and bolts of implementation. I know many survivors and parents are dubious about sharing much related to trauma and childhood abuse, because the most marginalized have not historically been treated the best in medical settings and sometimes been re-traumatized. It's great to learn who is doing what, and how, and what that process looks like. Thank you. 

Cissy

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