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From Wildfires to Childhood Trauma, a Resilience Cooperative Transformed the Way Clinics Face the Unthinkable

 

Over the last two years, Sonoma County has been at the epicenter of California’s raging wildfires, which burned hundreds of thousands of acres in the region and millions across the state. In the small town of Guerneville, residents had to flee both fires and floods. “2019 was a really heavy year for us,” recalled psychologist Emilio Licea of the West County Health Centers. “We had a major flood—a historic flood, and our clinic was almost underwater. Water came right up to the parking lot and we were lucky enough to avoid that, but a lot of our patients and community were not.”

“We also had the fires that same year, and that deeply impacted not only our patients, but our staff. We had a heavy year for personal loss among our staff, too; people who passed away, people who lost their homes, people whose partners committed suicide," said Licea. "It was just a difficult year to be at West County.” And if 2019 was nightmarish, 2020 was equally harrowing. It ushered in the deadly COVID-19 pandemic, along with another terrifying wildfire that forced tens of thousands of Western Sonoma residents to evacuate.

What helped Licea and other Sonoma health center staffers successfully navigate one unthinkable crisis after another was what they had learned about trauma in the Resilient Beginnings Collaborative (RBC), according to an October 2020 report by the Center for Community Health and Evaluation.

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“Teams reported that the foundational work of RBC strengthened their organizations’ ability to respond to the traumas of 2020—COVID-19, wildfires, police violence towards Black people—and has reinforced the importance of this work,” the CCHE evaluators noted, discussing RBC’s two-year program to help seven Bay Area safety net clinics screen, treat and heal childhood adversity, a program led by the Center for Care Innovations in partnership with Genentech Charitable Giving.

Transforming trauma

Launched in June 2018, Resilient Beginnings Collaborative was one of the first collaboratives in the state to explore identifying and addressing adverse childhood experiences (ACEs), which, left unaddressed, are associated with learning, physical and behavioral problems in childhood and a higher risk of depression, heart disease, cancer and other life-threatening illnesses in later life.

“At the beginning of the initiative, most teams reported being relatively early in their journeys to being healing organizations,” noted the CCHE evaluators, adding that RBC focused on helping teams to change their structure to embrace the principles of resilience and trauma-informed care. Those principles, according to the CDC, include creating a feeling of safety, trustworthiness and transparency, peer support, collaboration, empowerment and choice, and paying close attention to culture, historical and gender issues.

It turned out to be an ideal time for such work. In 2018, the field of trauma-informed care and resilience was nascent but had gotten increased attention with the appointment of Dr. Nadine Burke Harris, a longtime advocate for addressing childhood trauma, as California’s first Surgeon General, the report explained. The public initiative she led to financially reimburse clinics for ACEs screening in primary care – known as ACEs Aware — also generated interest across the state.

What the Resilient Beginnings Collaborative couldn’t have foreseen is how quickly its training would be put into action.

“Halfway through the program is when we started to have the floods and the fires, and [our work in RBC] allowed us to engage with our especially staff trauma in a way that we hadn’t before,” Licea said. “Most of Sonoma County was evacuated, including all our staff members and patients. And very early on, we created the task force to help identify what staff members were in danger that needed help” and reach out to them. Thanks in part to RBC, he said, executive leaders in West County all backed this idea and supported a partnership with Petaluma Health Center to support traumatized health workers and community members.

“Trauma thrives in darkness,” added Licea. “Silence is what perpetuates trauma, and us asking the questions is an endeavor to stop that silence.”

A staff member at Marin Community Clinics interviewed for the report echoed this theme.

“It’s been a very difficult time for everyone, with COVID and now with police brutality,” she said. “The sentiment when I reach out and check with people across all staff levels is exhaustion. Originally there was the adrenaline rush with COVID, going from practically zero telemedicine to almost 100 percent telemedicine. Now people are just exhausted. On top of that many staff have school-aged children. The RBC work has been critical in that we were able to use trauma language to name what was going on. We had several meetings where it was nice to see our CEO and CMO talk about how this is traumatic, this is grief, and call for kindness, grace, and patience with one another.”

The RBC training, she said, helped staffers recognize why some colleagues were uncharacteristically testy or irritable and on edge, so they could support each other while moving forward.

Other key findings

The CCHE evaluation report also outlined several other key themes from work in the 24-month collaborative:

LEADERSHIP SUPPORT IS CRITICAL.

According to the report, RBC coaching “played an important role in engaging organizational leaders, advancing dialogue, [and] building understanding. This leadership commitment contributed to teams’ ability to sustain other aspects of their RBC work, as well as foster a more positive and productive response to the traumas of 2020.” Added one clinic employee at Lifelong: “Since COVID leadership has been having town hall meetings so staff can give their thoughts and feedback, and they’re being responsive and getting back to staff about the questions they ask. That’s been a huge difference.”

Dr. Dayna Long and team

Dr. Dayna Long and team

DECIDE HOW TO DEFINE SUCCESS AND HOW TO MEASURE PROGRESS.

As one provider from UCSF Benioff, which co-developed the PEARLS tool used for ACEs screening tool and reimbursement in California, told CCI, “For me, this has been a fascinating journey. Dayna [Long] was out front shouting out the science and engaging the policy work; her colleague was managing the research. We were so focused on the research – what we weren’t doing was changing our practice. That’s not unusual, since can take years to translate new science into practice change. RBC actually came in and supported the practice transformation to pair with the science and the policy work.  It was so important to get that work done – I don’t think we realized how much we changed pediatric practice across the country.”

DEVELOP A SHARED LANGUAGE AND UNDERSTANDING OF THE RELATIONSHIP BETWEEN TRAUMA AND RESILIENCE AND LONGER-TERM HEALTH.

“Moms just brought their babies in, and as we started talking, they said stop: I want to call dad so he can hear this,” said researcher and pediatrician Dayna Long. “That allowed me to show up and be present and comfortable in the awkwardness. Those have been some of our most meaningful conversations and connections. The framing was ‘we are asking because we care about you and want what’s best for you.”

SUPPORT FOR STAFF AND PROVIDERS IS PART OF BEING A HEALING ORGANIZATION.

As one team lead told evaluators, “We developed a real recognition that we can’t serve patients and community without serving ourselves. We are part of our patient population and community. In serving ourselves, we do our work better.”

SCREENING FOR TRAUMA AND RESILIENCE WAS A CONCRETE PLACE TO START.

Since a new state policy reimbursed providers for screening state-insured patients, the report noted, over 2,300 children ages 0-5 were screened for trauma and/or resilience in the RBC project. Providers reported it was critical to do trauma screening with kindness, empathy, and respect, and all offered “universal education” – that is, information on ACEs and their long-term impact on health. Several teams found screening helped them improved their ability to respond to patient needs; they integrated Care Navigators into their clinic pods to help with food and housing issues. Others offered parenting classes, including those for Spanish speakers, which were well-received.

Inspiring community partnerships

ACEs screenings also inspired clinics to create more partnerships. “One of the big lessons from this collaborative was there are a lot of community resources out there, and we just need to look for them because they could actually help us do some of the work we’re trying to do,” said Dr. Omoniyi Omotos, a pediatrician at the Lifelong Willian Jenkins Health Center in Richmond. “The work we do sometimes is very challenging. So it’s nice to be able to hear from other people doing similar things and how they are dealing with those challenges. It’s very helpful because sometimes it gets very challenging, you know, and it’s nice to see that you’re not doing this alone.”

Although RBC finished its work this year, many of its participants will continue their learning in a new venture: The Resilient Beginnings Network. Also led by CCI and Genentech Charitable Giving, the network involves 15 safety net clinics in the Bay Area.

“We are both incredibly humbled and inspired to be on this journey with Bay Area clinics as well as our partners at Genentech and from across the state and the country,” said Megan O’Brien, senior program manager. “As we move forward, we are dedicated to deepening and spreading this important work in safety net settings and bringing clinics together to innovate and test solutions to identify adversity and promote resilience and protective factors, support staff and organizational wellbeing, center equity and racial justice, and strengthen community partnerships — all while doing this work in a post-COVID, more virtual world.”

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