Integrating ACE Screening and Intervention into Primary Care

There needs to be involvement with child protective services. 

If a child is at risk, it would be unethical to allow that child back into an environment like that. The longer a child is exposed, the more likely they will develop DESNOS. 

Hi Marcus, Check out the Centre for Youth Wellness and Nadine Burke Harris’s book The Deepest Well.  She includes an example of the screen they developed for primary care.   I’m in Canada but have been watching California make great strides in this area with Burke Harris as Surgeon General.  Allocated 500 million to train doctors and others on screening.  Wow!  

Hi Marcus,

You might want to check out this website: https://nppcaces.org/ - you can join for free and they have lots of resources regarding best practices for implementing ACEs screening/ intervention in pediatric practices. 

This change package was just released and gives detailed guidance. https://www.thenationalcouncil...ry-a-change-package/

Fostering Resilience and Recovery: A Change Package 

Hi Marcus! I've done work implementing ACEs screening and other screening into pediatric primary care. We use a model that consists of a quality improvement framework with intensive technical assistance. I would be happy to discuss further with you if you'd like. maggie@docsfortots.org 

you could also refer patients' families to www.griefrecoverymethod.com, where they could find community-based GRM groups or one/ones for adults (with some specialists able to provide the program to youth under 18), AND to refer adults who care for, or are responsible for working with children and youth, to the Helping Children with Loss Program.  These programs are available throughout the US - and local providers can be found by using the online directory - by zip code or city/town.  The HCWL program is less frequently provided, but all Certified Grief Recovery Method Specialists are also certified to provide the program.  So if none appear initially when doing your search, you could contact the specialists you do find, and ask them to assist you in providing the HCWL program.  I'd also be glad to help you find someone in your area - or find other options - for providing this program in your area.  I can be reached at lhall@griefrecoverymethod.com or at 541-389-7906.  It would be wonderful if physicians, clinics, counselors, school personnel, youth leaders and others knew more about the GRM and HCWL programs and would intentionally make referrals to these programs.  They are generally very inexpensive, and as "educational programs" do not carry the stigma of "counseling,"  thereby being more likely accepted by parents, families and other youth-serving professionals.    

I really appreciate this forum - and the opportunity to tell you about the GRM and HCWL programs.  Thank you, Lois Hall

Marcus,

A colleague and I have been screening for ACEs in our internal medicine practice for a year. There's more written on addressing ACEs in a pediatric setting, such as the Center for Youth Wellness mentioned above, with very little in the literature for adult patient settings. We use the traditional ACE Questionnaire, though look at it more as a conversation starter as to how one's childhood was. We feel it has been very successful doing such screening, and the patient response has been overwhelmingly positive, with essentially no negatives. A few caveats are that I've yet to find a way to do the screening and follow up discussion without taking a longer than scheduled visit (I typically go 45-50 min, while the slots are 30 min); it's hard for me not to stop talking, as it's typically such a powerful educational opportunity, and the patients are almost always into it (if they aren't I keep the discussion short). Another very important point is that screening needs be done in a trauma informed way, with the patient feeling it's a safe environment. If I sense someone is in a anxious state, I won't screen. That being said, there are several studies looking at medical assistants, or other non-clinical staff, giving out questionnaires to parents of pediatric patients, and the results show the high majority of parents appreciate the screening. I'm not sure how well this translates to adult patients.

Hi Marcus, please consider reading this story: https://www.pacesconnection.com...med-from-head-to-toe  Over the five years, there were so many lessons learned, input from focus groups, staff responses to the efforts, etc.  While not specifically a primary care site - they do function in a community that is primarily Family Medicine doctors (in an FQHC setting) as there is a local Fam Med residency program.  http://www.srfmr.org/  

The SRFMR also offers community fellowships that integrate ACEs:  
Integrative-medicine-fellowship-santa-rosa
"Provide direct support to local FQHCs and other community partners to meet the shared goals of eliminating health disparities, reducing the impact of Adverse Childhood Events (ACEs), and supporting culturally mindful, integrated approaches to community health."

I hope this is useful!
Karen   

Hi, Marcus!

In addition to the Center for Youth Wellness and the National Council on Behavioral Health, I would recommend that you check out the Trauma-Informed Implementation Resource Center from the Center for Healthcare Strategies: https://www.traumainformedcare.chcs.org/

Additionally, we have been working with a local Family Medicine Residency Program to implement screening into their work. Our partners have presented a couple of webinars on their process to the Collaborative Family Healthcare Association, the recording of the most recent one can be viewed here: https://www.youtube.com/watch?v=cDZCx6-OY0g

Finally, the NPPC also produced a podcast series called Voices from the Field that might be of interest. You can find those anywhere you listen to podcasts.

Congratulations on considering this work - and good luck!

Vanessa Lohf | Wichita State University

Is the goal to simply screen or is it preventing the negative emotional, physical and social outcomes that come from exposure to toxic stress?   That should be a question, I think. 

Jack Schonkoff, one of the authors on the original policy statement about Toxic Stress published in 2012 in Pediatrics, states that we have to be careful about developing biological markers that can be used to identify toxic stress in individuals because of the potential for misuse but a score in an electronic medical chart that is being used as a proxy for a biological marker (the ACE Score), which will not be able to be removed from the medical record once it is there has the potential to be misused too. That’s something that should be considered. 

On average, it will be the poor and disadvantaged in society who will have the highest ACE score and that leaves the poor and disadvantaged the most vulnerable to misuse of this data. 

Mike Flaningam posted:

Marcus,

A colleague and I have been screening for ACEs in our internal medicine practice for a year. There's more written on addressing ACEs in a pediatric setting, such as the Center for Youth Wellness mentioned above, with very little in the literature for adult patient settings. We use the traditional ACE Questionnaire, though look at it more as a conversation starter as to how one's childhood was. We feel it has been very successful doing such screening, and the patient response has been overwhelmingly positive, with essentially no negatives. A few caveats are that I've yet to find a way to do the screening and follow up discussion without taking a longer than scheduled visit (I typically go 45-50 min, while the slots are 30 min); it's hard for me not to stop talking, as it's typically such a powerful educational opportunity, and the patients are almost always into it (if they aren't I keep the discussion short). Another very important point is that screening needs be done in a trauma informed way, with the patient feeling it's a safe environment. If I sense someone is in a anxious state, I won't screen. That being said, there are several studies looking at medical assistants, or other non-clinical staff, giving out questionnaires to parents of pediatric patients, and the results show the high majority of parents appreciate the screening. I'm not sure how well this translates to adult patients.

This is the way that I feel this is done best. One on one with a patient and the physician who is comfortable with this where there is trust.  And there is no need to be mandated to have a score in the EHR. That just breaks trust for me and how I could feel comfortable introducing this to the patient. I don’t want to be used as a data collector for any purpose besides caring for my patients in a caring and sensitive manner. 

Tina Cain posted:

Is the goal to simply screen or is it preventing the negative emotional, physical and social outcomes that come from exposure to toxic stress?   That should be a question, I think. 

Jack Schonkoff, one of the authors on the original policy statement about Toxic Stress published in 2012 in Pediatrics, states that we have to be careful about developing biological markers that can be used to identify toxic stress in individuals because of the potential for misuse but a score in an electronic medical chart that is being used as a proxy for a biological marker (the ACE Score), which will not be able to be removed from the medical record once it is there has the potential to be misused too. That’s something that should be considered. 

On average, it will be the poor and disadvantaged in society who will have the highest ACE score and that leaves the poor and disadvantaged the most vulnerable to misuse of this data. 

Hi Tina, excellent point. I have seen some information about "allostatic load" - a (developing) battery of biological measures related to the stress response system - providing a potential more personalized/direct measure of the impact toxic stress. If this biological measure can be shown to be a valid measure of the accumulative impact of toxic stress then this could be used to complement an ACE screening (perhaps screening out those for whom ACE has not translated into relative increase in poor health outcomes).

Sample article:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4163075/

Laurie Robinson posted:

Hi Marcus, Check out the Centre for Youth Wellness and Nadine Burke Harris’s book The Deepest Well.  She includes an example of the screen they developed for primary care.   I’m in Canada but have been watching California make great strides in this area with Burke Harris as Surgeon General.  Allocated 500 million to train doctors and others on screening.  Wow!  

Thank you! I've added her book to my priority list.

Hannah Lang posted:

Hi Marcus,

You might want to check out this website: https://nppcaces.org/ - you can join for free and they have lots of resources regarding best practices for implementing ACEs screening/ intervention in pediatric practices. 

Thank you! I have requested membership. Looks like a great resource. This thread have given me/us some wonderful resources!

Margaret Wayne posted:

Hi Marcus! I've done work implementing ACEs screening and other screening into pediatric primary care. We use a model that consists of a quality improvement framework with intensive technical assistance. I would be happy to discuss further with you if you'd like. maggie@docsfortots.org 

Thank you so much Margaret!!

Kristin Meola posted:

This change package was just released and gives detailed guidance. https://www.thenationalcouncil...ry-a-change-package/

Fostering Resilience and Recovery: A Change Package 

 

 

This looks amazing!

Mike Flaningam posted:

Marcus,

A colleague and I have been screening for ACEs in our internal medicine practice for a year. There's more written on addressing ACEs in a pediatric setting, such as the Center for Youth Wellness mentioned above, with very little in the literature for adult patient settings. We use the traditional ACE Questionnaire, though look at it more as a conversation starter as to how one's childhood was. We feel it has been very successful doing such screening, and the patient response has been overwhelmingly positive, with essentially no negatives. A few caveats are that I've yet to find a way to do the screening and follow up discussion without taking a longer than scheduled visit (I typically go 45-50 min, while the slots are 30 min); it's hard for me not to stop talking, as it's typically such a powerful educational opportunity, and the patients are almost always into it (if they aren't I keep the discussion short). Another very important point is that screening needs be done in a trauma informed way, with the patient feeling it's a safe environment. If I sense someone is in a anxious state, I won't screen. That being said, there are several studies looking at medical assistants, or other non-clinical staff, giving out questionnaires to parents of pediatric patients, and the results show the high majority of parents appreciate the screening. I'm not sure how well this translates to adult patients.

Hi Mike! Thanks so much for sharing your experience with me/us. This gives an insightful window into implementation in primary care and highlights one of the biggest challenges. I am familiar with a program that integrates health coaches with the potential for them taking on more of the individual dialogue and coaching related to positive ACEs, however the vast majority of providers do not have these additional staff. It sounds like any academic detailing or practice facilitation with providers/clinics should include exploring ways to streamline and include other staff in the screening and intervention process.

Karen Clemmer (ACEs Connection Staff) posted:

Hi Marcus, please consider reading this story: https://www.pacesconnection.com...med-from-head-to-toe  Over the five years, there were so many lessons learned, input from focus groups, staff responses to the efforts, etc.  While not specifically a primary care site - they do function in a community that is primarily Family Medicine doctors (in an FQHC setting) as there is a local Fam Med residency program.  http://www.srfmr.org/  

The SRFMR also offers community fellowships that integrate ACEs:  
Integrative-medicine-fellowship-santa-rosa
"Provide direct support to local FQHCs and other community partners to meet the shared goals of eliminating health disparities, reducing the impact of Adverse Childhood Events (ACEs), and supporting culturally mindful, integrated approaches to community health."

I hope this is useful!
Karen   

Thank you so much Karen!