What the ACEs Screening Movement Can Learn from the Healthcare Hotspotting Movement


By Jim Hickman

Over the last decade Dr. Jeffrey Brenner and the Camden Coalition of Healthcare Providers took on a problem that had long plagued the healthcare system: A relatively small number of very sick patients were using the most healthcare resources.

The Coalition sparked the “hot spotting” movement focusing on social determinants of health, or SDOH — the societal and structural factors that influence health — based in part on findings that the ZIP code people live in has more impact on their health than their DNA. Data experts created maps of “hot spots” where the most diabetes or asthma emergencies occurred, which were almost always neighborhoods with high poverty rates.

The Camden Coalition coined the phrase “Better Care at Lower Cost” and devised a program that sought to take better care of low-income people before they incurred enormous emergency room and hospital bills. Their coordinated care approach included home health aides, wellness coaches, and establishing primary care relationships after hospitalization, rather than what Brenner called the existing protocol: “treating the patient like an organ with legs.”

But earlier this month, the results of a randomized controlled trial (RCT) of the Camden Coalition’s signature care management program, the Camden Core Model, were disappointing. Published in the New England Journal of Medicine, the trial showed no difference in readmissions between the intervention and control groups. Some commentators have jumped to criticize the outcome and the study’s singular focus on hospital readmission as the key goal of the intervention. However, most critiques are missing a fundamental point: these results show us that healthcare cannot do this work alone — and just how important it is to build strong communities with the resources that can effectively serve people with complex health and social needs.

Some critiques also gloss over a key point: Social determinants of health matter, but long-term disparities can’t be resolved without addressing the underlying structural problems facing many of our communities. Among other things, this includes identifying critical missing infrastructure (aka “human rights,” as alliances like Housing First might say) such as affordable housing– and demand that government create it. (And while we’re at it, what about dental insurance that actually is insurance rather than a ludicrous pittance?)

As California embarks on a campaign encouraging physicians to screen Medi-Cal enrollees for Adverse Childhood Experiences (ACEs), the Camden Core Model study is a cautionary tale.

Like the Camden Core Model, California’s ACEs screening initiative is led by a physician dedicated to changing social inequities and transforming healthcare. Having multiple ACEs is associated with seven of the major life-threatening diseases in the United States, including cancer and heart disease. Researchers estimate the annual cost of ACEs-related health and social problems to be $748 billion in North America alone, so combating the impact of child trauma is a top priority for California’s Surgeon General, Dr. Nadine Burke Harris.

The parallels between the rise of healthcare “hotspotting” and ACEs screening are striking. Both movements have a similar narrative arc:

· A lone physician in an underserved community — in these cases, Dr. Brenner and Dr. Burke Harris — sees scores of patients with a stark pattern of unmet need by the traditional health delivery system

· A big idea emerges from the physician’s clinical experience that seeks to address structural issues that prevent quality care for an underserved population

· A small group of philanthropists place a “big bet” on a physician/activist to develop a model

· Advocates and critics fail to consider the local and system-wide changes and capacity-building needed before the model can succeed

These observations are not profound, yet they have the benefit of personal experience. I’ve been fortunate enough to work with both Dr. Jeffrey Brenner and Dr. Nadine Burke-Harris, respectively. Brenner and I often discussed the need to break down the silos between health and social services when I directed Sutter Health’s Better Health East Bay initiative (Brenner’s team worked with Better Health East Bay from 2014–2017); I was also on the advisory committee for the Camden Coalition of Healthcare Providers’ National Center for Complex Health and Social Needs. In 2010 I helped design Burke-Harris’s landmark project, the Center for Youth Wellness (CYW), a leading center for ACEs and trauma research, screening, education, and care based in Bayview-Hunters Point in San Francisco. Today I’m the CEO of CYW, which has expanded its model to include capacity-building, community by community. This way we can see which gaps in healthcare and social needs exist, so we ourselves can avoid falling into those same yawning crevices in our safety net.

Recently Brenner explained that he and the Camden Coalition drastically underestimated how few resources there were for their sickest patients, known as “super utilizers.” Talking with The New York Times, he describes a safety net so tattered that patients treated for life-threatening illnesses may be released to a temporary homeless shelter or the streets; it’s not enough to make a difference, he said. In a quote I found heartbreaking, he said, “We’re coordinating to nowhere, essentially.”

The Camden Coalition study raises the stakes for organizations working on ACEs. No brief intervention or short-term infusion of services is a silver bullet that will overcome the long-term harm caused by structural racism, poverty, and multi-generational trauma.

This is the lesson for the ACEs movement. Providers cannot treat trauma properly when people are retraumatized by their living conditions or community surroundings. We need to help remove barriers to care and prevent intergenerational ACEs by addressing social inequities at the systems level — something that is essential to the success of interventions and healing.

We can all learn something from the Camden Core Model study, and in doing so, avoid writing referrals to nowhere.

 Jim Hickman, MBA, is CEO of the Center for Youth Wellness in San Francisco’s Bayview-Hunters Point district, which has developed a capacity-building model for communities who are using an equity lens to address ACEs screening and intervention.

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Mary Franklin posted:

There are so few resources, no help getting to the resources (transportation is horrible in Detroit) and very little quality measures of the resources.

Before I learned of the ACE Study, I attended a 'Grand Rounds' presentation at [then Dartmouth, now] Geisel Medical School in 2000--where an Epidemiologist reported: "52% of Detroit Metropolitan Area Schoolchildren met the DSM-IV criteria for PTSD" ; Geisel may have a record of his name and research particulars.

Tina Cain posted:

Charles Nemeroff is now saying that pediatrics patients and adults should be screened for ACEs and started off on psych drug polytherapy. What do you all think about that? Do you think that traumatized adults and kids should be put on polypsychopharmacology? There is no evidence base for it and there is evidence it can be very dangerous.

If the ACEs Screening movement becomes a way to tranquilizer more and more traumatized people with poly-psychopharmacology, we will have failed as pediatricians, as doctors and as human beings. The pediatrics field should be ashamed as far as I am concerned if they stand back and do nothing! 

Probably not "directly" applicable here, but Relatively recent research from Veterans Admin found little -to-no difference in outcomes between three treatment protocols, for adult vets with PTSD: 1) prolonged exposure therapy, 2) sertraline hydrochloride and 3)  combination of both

I wasn't expecting how this article prompted me to grieve-momentarily. I miss the "Consumer Majorities" we had under the National Health Planning and Resources Development Act of 1974 (Public Law 93-641), until the Reagan administration gutted the funding for that type of 'government-mandated Citizen Participation'...  But, ensuring the empowered and informed effective participation of 'low-income' and elderly 'Consumers' was a challenge for me at that time: "The Hippocratic Oath for Community Workers" (from TamarackCommunity.ca) wasn't published 45+years ago, but I'd had some acquaintance with Saul Alinsky and 'Community Organizing', as well as allies in the ten 'Technical Assistance' centers set up to facilitate the 1974 national health planning/resource development process.

I hadn't yet learned of the ACE study when I attended an Epidemiologist's 'Grand Rounds' presentation at [then Dartmouth, now] Geisel Medical School in 2000: "52% of Detroit Metropolitan Area Schoolchildren met the DSM-IV criteria for PTSD". Similar numbers have subsequently been reported in Philadelphia, Baltimore, Atlanta, and in June of 2018-at five charter schools in New Orleans. I'd previously [1973-4) personally witnessed some health care initiatives in the southeast Bronx [a 'neighborhood with 100,000 Heroin addicts; and 85% of the housing listed as 'sub-standard' or 'deteriorated'-at that time] where both Pediatricians and Internal Medicine Resident physicians at a nearby City Hospital made ('escorted') 'House Calls'....

Jim Hickman presents a 'compelling assertion' here, concerning 'structural racism, poverty, and multi-generational trauma', and I concur in that regard, as well as I do with the entire article.

Why peds need to be concerned and stay very alert...   


“Although the general story of ghostwriting in trials of psychiatric drugs is now pretty well known, the details of the corruption in specific trials are still emerging into the public record, often a decade or more after the original sin of fraudulent publication. The latest study to finally see the full light of day is GlaxoSmithKline’s study 352.

Perhaps the most infamous ghostwritten study is GSK’s study 329, which, in a 2001 report published in the American Journal of Psychiatry, falsely touted paroxetine (Paxil) as an effective treatment for adolescent depression. The company paid over $3 billion in penalties for fraud.

That same year, study 352 made its first appearance in the research literature. That was when Charles Nemeroff, who in the years ahead would become the public face of research misconduct, “authored” an article on the efficacy of paroxetine for bipolar disorder. It has taken 18 years for the full story of that corruption to become known, the final chapter recently emerging when a large cache of study 352 documents—emails, memos, and other internal correspondence between the key players—was made public.

The documents reveal a web of corruption that went beyond the fraud of ghostwriting into the spinning of negative results into positive conclusions, and the abetting of that corruption by an editor of the scientific journal that published the article.” 

I misheard psychotherapy and pharmacotherapy as poly-psychopharmacology...It was a Freudian slip I guess, so thanks for pointing that out...there is so much poly-psychopharmacology out there especially in traumatized kids and in the Medicaid population I cared for, almost no one gets any form of therapy anymore... however, my auditory misread  in no way changes the danger that is out there possibly waiting for traumatized kids and adults if the people who care, take their eye off the ball.  

My family was severely harmed by this conduct so I have a personal interest.  I also have a professional interest in my concern for patients. 

I have  had many, many patients who didn’t receive the care they need because they were inappropriately directed into poly-psychopharmacology to sedate their trauma symptoms. This is an all too common phenomenon in foster kids and those living in poverty.  

There is no evidence base for doing this and thus no evidence it is safe.  There is evidence that has never been reviewed as far as I know from Whitaker’s presentations (which to me are pretty convincing) that there could be long term harm.... Pediatricians need to be aware for our patient’s sake.  

Plus when we rely on psychopharmacology to “treat” (actually sedate) the behavioral symptoms of something as complex as the effects of developmental trauma on the developing child’s brain and the traumatized adult as well... we become distracted and stop looking for and studying treatments that could actually be effective.

So I misheard Dr. Nemeroff, he stated “psychotherapy and pharmacotherapy.”  I apologize.  But certainly, he has to be a doctor that all Pediatricians should be aware of.   After all, we are the ones writing many of the scripts.  If there is a negative outcome, it probably should fall on us. 

Does anyone have his article published this month in, I think, The American Journal of Psychiatry?   I’d like to take a look. Thanks 


Last edited by Tina Cain

Tina: Can you cite an article where Nemeroff says that? I found this one — https://www.medscape.com/viewarticle/923389#vp_1 — where he recommends a combination of psychotherapy and pharmacotherapy.

I agree that kids shouldn't automatically be put on drugs, and that the best approach is to remove the stressors from parents and children.

Charles Nemeroff is now saying that pediatrics patients and adults should be screened for ACEs and started off on psych drug polytherapy. What do you all think about that? Do you think that traumatized adults and kids should be put on polypsychopharmacology? There is no evidence base for it and there is evidence it can be very dangerous.

If the ACEs Screening movement becomes a way to tranquilizer more and more traumatized people with poly-psychopharmacology, we will have failed as pediatricians, as doctors and as human beings. The pediatrics field should be ashamed as far as I am concerned if they stand back and do nothing! 

Last edited by Tina Cain

One of the cruelest inequities is the variability in the quality of parenting.  Some infants go home with parents who will engage in parenting behaviors and practices generally recognized as supporting the healthy development of children.  Others will go home with parents who will neglect, hurt, and kill them.  This is not acceptable!!!  

What confounds me is that this abominable injustice has been going on for thousands of years.  Why do we let this continue???

The quality of parenting in communities can be elevated and leveled.  It requires a new kind of parenting education...one that reaches everyone, everywhere, all the time.

Visit advancingparenting.org.

Last edited by David Dooley
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