National Pediatric Practice Community on ACEs Pilot Site Program · 2019-10-02 · The National...

National Pediatric Practice Community on ACEs Pilot Site Program

Cohort 1 Final Evaluation Report

Center for Community Health and Evaluation

September 2019

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Pilot Site Program

1 Program Overview

2 NPPC Pilot Site Progress

3 Screening for ACEs in Pediatric Clinics: Lessons Learned

4 Next steps for ACEs screening

5 Summary

6 Appendices

Table of Contents

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San Francisco, CA 94124

Administrative Office:

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Table of Contents

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1 Program Overview

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The National Pediatric Practice Community (NPPC) on ACEs was started by the Center for Youth Wellness (CYW) to support professionals interested in applying ACEs and toxic stress science to pediatric practice and shaping the field of trauma-informed medical practice. To date, more than 1,000 individuals have joined the virtual practice community. The NPPC pilot program was created in 2017 to better understand the experience and process of integrating ACEs screening into pediatric clinical settings by working closely with a small group of practices in varied settings.

Program Overview

Pilot Sites

NPPC supported six pilot sites of various sizes, five in California and one in New York City. Sites included a variety of types of service delivery settings—four federally qualified health centers (FQHC), one integrated health system, and one community hospital/academic medical center.

Sites were introduced to the NPPC in a variety of ways, with about an even split between sites where senior leadership were the driving force, and sites where an individual provider championed the opportunity. All sites noted a perception that trauma was high among their populations and saw ACEs screening as a way to improve patient care with a more systematic way to assess and address patients’ needs. For two sites ACEs screening was part of a larger effort: in one case to address the impact of trauma and implement trauma-informed-care on a system level, and in another case the health center was involved in a research study to assess the acceptability of screening and effectiveness of parenting interventions.

Acknowledging that screening for ACEs is not yet standard practice in pediatric clinics in the United States, the NPPC pilot program was framed as a quality improvement endeavor using a plan-do-check-adjust (PDCA) framework with coaching and systems in place to monitor, reflect on, and formally document their experience and learning.

To accommodate sites’ context, be responsive to current practice, and capture learning about how ACEs screening can be successfully implemented in different types of pediatric practices, sites were able to tailor the details of their implementation. With support from NPPC, they chose:

• Which ACEs screening tool and supplemental questions to use

• Which patients to screen and at what frequency

• How they distributed the work among the care team (e.g., who administered thescreen, who interpreted the results, who interacted with patients and their families,who connected them to follow-up resources, who did data entry)

• What the workflow entailed (when and how the screen was administered)

• What constitutes a “positive” score and resulting follow-up approach, includingwhether the sites included symptoms as part of their scoring algorithm

• Which internal and external follow-up services and resources they provided, alongwith the process around referral and linkage

Program Overview nppcaces.org | cche.org

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The table below summarizes the NPPC pilot sites, along with key screening details.

OrganizationPilot Site Description

ToolTracked Symptoms

Ages Screened, Frequency

Institute for Family

Health (IFH)

FQHC with 27 clinic

sites, including

several school-based

health centers

School Based Health Center at Harlem Children’s Zone’s Promise Academy 2New York, Harlem

Teen self-report version of ACE-Q core 10 questions + 7 suggested supple-mental questions

No 13- to 18-year-olds annually

Kaiser Permanente

Southern California,

Downey (KP)

Integrated health

system with 12 clinic

sites

Bellflower ClinicCalifornia, Bellflower

ACE-Q core 10 questions + 7 suggested supple-mental questions

Yes 3- and 5-year-olds at annual well child visits

La Clinica de la Raza (LC)FQHC with 28 clinic sites

Fruitvale Village PediatricsCalifornia, Oakland

ACE-Q core 10 questions + 7 suggested supple-mental questions and 5 additional questions about behavioral health and physical symptoms

Yes 7-to 11-year-olds annually

Marin Community

Clinics (MCC)

FQHC with 3 clinic

sites

Novato, San Rafael clinics California, Novato and San Rafael

Reworded and condensed version of ACE-Q

No New patients under 12, 9-month and 30-month-old well child visits

Santa Barbara Neighborhood Clinics (SNBC)FQHC with 4 medical and 2 dental clinic sites

Goleta Neigh-borhood Clinic California, Santa Barbara

ACE-Q core 10 questions + 7 suggested supple-mental questions + 1 question about experience with natural disasters

No At 4-, 6- and 9-month visits, then annuallyAlso screened parents at one point in time

Zuckerberg San Francisco General Hospital and Trauma Center (SFGH)Community hospital and academic medical center

Children’s Health Center, Pediatric Integrated Behavioral Health TeamCalifornia, San Francisco

Modified version of the ACE-Q, integrated with The Childhood Resilience Screener and The Edinburgh-3

Yes 1- to 12-month- olds, annually

Program Overview nppcaces.org | cche.org

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NPPC Pilot Program Components

Phase 1:

Intensive six-month period where practices tested and refined screening implementation. CYW provided:

• Staff training on ACEs

• Educational reference and promotional materials for professionals and patients

• QI coaching to support implementation, data tracking and reporting

• $15,000 stipend

Phase 2:

An additional six months where NPPC helped sites embed and spread their screening practice as appropriate, including supporting systems for ongoing data tracking and monitoring

Program Overview

2 NPPC Pilot Site Progress

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NPPC Pilot Site Progress


NPPC sites had between one and 18 providers implementing screening. There was not a consistent relationship between how many providers were participating, the number of patients eligible for screening and the number of patients screened. For example, one site with six providers screening reported results for fewer patients than sites with only one or two providers screening. This suggests that the eligible patient population was influenced more by the sites’ patient population and the target population selected for screening.

Figure 1: NPPC General Screening Workflow

Follow-up provided per protocol

Provider interprets the results & discusses with patient

Clinical support staff or providers score the screen

Patients complete the paper screen

Clinical support or frontline staff give & explain the screen to patients

All six sites successfully implemented ACEs screening.

All six sites implemented ACEs screening during their six-month pilot period. Across the cohort, 1,900 children under the age of 18 were screened for ACEs. As stated above, there were variations across the sites in how screening was implemented, including: scope of the pilot (i.e., target population determining the number of eligible patients, number of providers screening), screen scores that triggered follow-up, the extent to which symptoms were formally assessed as part of the screening process, and types of follow-up and referrals provided.

The number and role of the individuals involved in the screening process varied by clinic. However, there were a few elements of the screening workflow that were consistent across all sites (Figure 1). All pilot sites had clinical support or front-line staff hand out and explain the screening tool to patients. Either clinical support staff or providers scored the screen. Once the screen was scored, providers would discuss it with patients during their visit. There was general agreement across the sites that the interpretation of the score, symptoms (when included), and determination of level of risk and appropriate follow-up should be a clinical decision. Some sites had a clinical support staff member (e.g., care navigator, health educator) who would then discuss referral options with patients as appropriate.

nppcaces.org | cche.org

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Figure 2: The number of eligible patients ranged from 112 to 1,314.

LC(18 providers) 934

1314

217

180

123

112

KP(15 providers)

MCC(7 providers)

IFH(2 providers)

SBNC(6 providers)

SFGH(1 provider)

Eligible Patients

The percentage of eligible patients screened ranged from 50% to 94%, with most sites screening at least two-thirds of their eligible patients.

Clinics’ “positive” scores cannot be compared because they screened different age ranges, used different screening instruments, and defined a “positive” ACE score in a variety of ways (e.g., score of 2+, score of 1-3 with symptoms, score of 4+ with or without symptoms).

Most of the cohort (4 sites) had fewer than 20% of patients screen positive, while the other two sites had positive scores in about half of their screened patients.

There was a split among the sites in terms of referral to services—three referred about one-third of the patients with positive scores while two referred around three-quarters.

Figure 3: All sites screened at least one-half of their eligible patients.

(n=# of eligible patients)

LC(n=934) 68%

63%

53%

94%

86%

50%

KP(n=1314)

MCC(n=217)

IFH(n=180

SFGH(n=123)

SBNC(n=112)

Patients screened Patients not screened

0% 80% 100%60%40%20%


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Figure 4 : Between 7% and 58% of screened patients had a “positive score.”

(n=# of patients screened)

Figure 5: Around either one-third or three-quarters of patients screening positive

were referred to services. (n=# of “positive” screens)

LC(n=635)

LC(n=44) 34%

33%

74%

36%

77%

7%

13%

15%

19%

58%

46%

KP(n=544)

KP(n=71)

MCC(n=115)

MCC(n=20)

IFH(n=169)

IFH(n=32)

SFGH(n=61)

SBNC(n=44)

SBNC(n=96)

Positive score

Positive score

Negative score

Negative score

0% 80% 100%60%40%20%

0% 80% 100%60%40%20%

Sites reported various additional benefits resulting from NPPC pilot participation.

Sites and their staff were starting in different places in terms of how much exposure they had to ACEs prior to participating in NPPC. Some clinics had done a lot of education about ACEs with their staff prior to the pilot, and some were starting with low levels of familiarity with the topic. Being part of the pilot meant that the ACEs concept was more visible, providing exposure to a lot of other people (providers, other clinic staff).

All sites reported several other important outcomes including: increases in provider knowledge and comfort regarding screening, gathering results that helped them interpret patients’ symptoms and broadened their conversations with patients. In addition, all sites made some improvements to their data tracking systems in their electronic health record (EHR). Half of the pilot sites strengthened their referral networks to support patients’ newly identified needs. Finally, half of the clinics rolled out screening to other sites in their organization within the first six months of the pilot program, even though this was not an explicit goal during that timeframe.

NPPC Pilot Site Progress nppcaces.org | cche.org

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Outcome# of clinics

Description of progress Site example

Increased

provider

knowledge

& comfort

regarding ACEs

screening

NPPC staff trained over 170 staff and providers on ACEs2 across the cohort. The number trained at each site ranged from 4 to 52 individuals, depending on the size of the organization and/or pilot site as well as the organi-zations’ interest in training staff beyond those directly involved with screening. In post-training surveys, 85-95% of training participants reported some level of knowledge or confidence improvement from the trainings, especially related to concept of ACEs and toxic stress and understanding the need to address ACEs.

Some participants said the following was the most valuable:

• Explanation on how we

can make our patients understand that we care about their problems.

• Description to staff about science behind stress and its effects on health.

• To be exposed to the larger network of NPPC.

• The scripts that were provided for providers.

• Understanding intervention planning and the difference between diagnostic vs screening tool.

Enhanced

understanding

of patients,

which aided in

symptom inter-

pretation and

treatment

Most providers found screening useful to identify needs, aid in the interpretation of symptoms, learn more about the individual experience of patients and their families (especially new patients), meet patients and families where they were in the moment, build the therapeutic relationship and shared goals, and improve the quality of the whole person care provided.

At one site, a doctor connected the family history uncovered through screening with the four-year old’s severely delayed speech development, and the parent was very open to exploring the connection. When the doctor sent the patient to a specialist, she included infor-mation about the relevant ACE and the specialist was very receptive as well.

Broadened scope of conver-sation with patients, setting the tone around whole person care

Sites found screening provided a neutral way to start an important discussion about patients’ histories in a non-crisis situation, which made it smoother. Providers were able to introduce a conversation that wouldn’t have normally happened, set a tone that the clinic cares about patients as whole people, and offer ways to understand and respond to related symptoms that might emerge in the future.

At one site the process of discussing ACEs with parents led providers to realize that postpartum mood disorders were more common than they had previously known. As a result, they began screening relevant patients more systematically and connecting them to appro-priate services.

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1. These data are based on information from five of the pilot sites (excluding San Francisco General Hospital)

2. Post-training evaluations were administered in four of the pilot sites (excluding Institute for Family Health and San Francisco

General Hospital)


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Outcome# of clinics

Description of progress Site example

Strengthened

data systems &

capacity

All sites reported strengthened data systems and capacity primarily through adopting changes in their EHR, although the specifics of these changes varied. Some sites built a best practice alert or shortcut to make it easy for providers to remember to document screening, including the ability to reset the reminder for the next appointment if the patient was too sick and screening was skipped. Other sites added functionality to track whether patients were referred to a service, were already in treatment, and/or were exhibiting ACEs-related symptoms.

At one site, integrating data tracking into the EHR was essential for organizational spread. By the end of Phase 1 of the pilot, the team had partnered with IT to develop a comprehensive template for tracking screening, results, and follow-up provided into the site’s electronic health record, NextGen. They planned to pilot test implementation of the form during Phase 2.

Improved referral networks & coordination

The majority of sites strengthened their internal and external referral systems during the pilot program. This took a variety of forms: creating a new list of local external referral sources unique to each clinic site, embedding behavioral health providers in the pilot clinic, tightening coordination with their main internal and external referral sources, and adding a way to document referrals in their EHR.

At one site, clinical support staff made tailored lists of community resources to use for referrals for each of their locations.

Spread screening beyond initial pilot clinics/providers

Even though the NPPC pilot

program was designed to

start small during the initial

six months and spread during

the next six months, two sites

spread their screening practice

to new providers or clinic sites

earlier.

One site leveraged their internal network of child abuse prevention specialists to champion the introduction of the ACEs screener at additional clinic sites. Their regional structure and culture of innovation facilitated the spread. For another site, participating in the NPPC pilot helped launch them into doing trauma-informed-care work more broadly across their health center.

Broader visibility of the health center in the community

Participation in the pilot brought

expertise, credibility and

leadership around an important

emerging topic.

One site reported getting positive media attention, new funders, and feedback that the public now sees the health center as innovative and effectively meeting patients where they are.


3 Screening for ACEs in Pediatric Clinics: Lessons Learned

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Screening for ACEs in Pediatric Clinics: Lessons Learned


Acknowledging that screening for ACEs is not yet standard practice in pediatric settings in the United States, the NPPC pilot program was framed as a quality improvement (QI) endeavor with systems in place to reflect on and capture lessons and insights along the way. In general, this approach worked for sites and partners throughout NPPC, which found that staying open to changing initial plans resulted in more innovative ideas and an ability to check and adjust to maximize effectiveness or mitigate problems. This allowed NPPC to meet pilot sites where they were starting and support them based on their organizational context and current practice. There is no one-size-fits-all approach for screening implementation; practices will need to make a variety of key decisions at various stages in the process, including training approach, screening and follow-up practices (e.g., tool, target populations, scoring algorithm, internal and external resources available), systems for tracking and reporting on data, and what stakeholder engagement and communication should entail. While contexts and practices varied across the cohort, six key lessons emerged that we believe have broader applicability as more and more practices take on this work.

Clear organizational alignment: sites benefitted when the NPPC pilot was well aligned with broader organizational goals and priorities.

Sites were interested in providing the best possible care and support to their patients, and all initially reported that they perceived their patients to be frequently touched by trauma and anticipated high ACE scores. Beyond that, the reasons pilot sites gave for their interest in ACEs screening varied. For two pilot sites, leaders were very supportive because they saw screening as fitting in with a larger effort to make the organization trauma-informed. For two other sites, this pilot fit within a larger community focus on ACEs and was supported by partners outside of their organizations. Other motivations included:

• A hope that the pilot would establish new referral paths for patients to better address their needs.

• A funded continuation of a provider champion’s interest in toxic stress.

• A path to clearly identify best practices related to screening and related interventions that will help the organization drive towards changing payment reimbursement structures.

• Aligning with goals around behavioral health integration and a strengthened network of partner organizations.

Generating buy-in: Clinics found it was important to involve all stakeholders early in planning and to build support among organizational leaders, providers, and clinical support and front-line staff.

Organizational leadership support

All clinics reflected on the necessity of having leadership support, especially from individuals with the power to clear calendars and grant administrative time to providers in order to focus on this work. One clinical champion worked hard to get the leaders in her large health system on board, attributing her eventual success to persistence and willingness to compromise on the details of the pilot, such as the age groups to be screened.

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I worked hard to get leadership on board with screening, not

taking no for an answer. I found talking about the long-term

effects of ACEs for children and health care generally was very

compelling. It also helped to emphasize that the screening

helped providers diagnose people. I reminded them that you

need to do the right thing even if it takes more time.

Kaiser Permanente staff member

We were reassured to learn that screening wasn’t going to

uncover a lot of hard things and bog down the system, but that

it’s another tool to help you understand your patients.

La Clinica de la Raza staff member

When leaders realized at the end of the pilot that the quality improvement summary drafted by the NPPC coach from the screening pilot could be used for other organizational priorities (e.g., patient-centered medical home designation, joint commission accreditation), they were excited and interested. One organization leader was so convinced of the organizational value that they allowed their clinical champion to maintain her administrative time for this project even after the stipend from NPPC was exhausted.

Provider support

Even when organizational leadership support is in place, generating the buy-in of provider champions or early adopters is essential. Integrating ACEs screening, like other new screening practices, tends to be more effective if supported by a dedicated clinician with some funded time to devote to the work. Each participating clinic designated a provider to “champion” the process for integrating screening into existing clinic systems. This model reportedly worked well and was a key success factor, especially when that provider was seen in the organization as an authority on ACEs or related issues.

Several factors were reported to support provider buy-in for ACEs screening, including: previous training on the topic, a current focus on social determinants of health, familiarity with similar workflows for other screening processes, having a project manager or clinical staff support, and working with a patient population that already believes stress can make you sick. Additionally, knowing that their diagnostic practice is typically supported by the additional information that ACEs screening provides helped with creating buy-in.

Screening for ACEs in Pediatric Clinics: Lessons Learned nppcaces.org | cche.org

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The only way to demonstrate that everyone is behind and

supports an initiative like this is to have everyone trained so

they understand their role and what is happening.

La Clinica de la Raza staff member

Providing training: Training at all levels helps builds buy-in for and confidence critical for effectively implementing ACEs screening.

The amount of exposure to ACEs that providers and clinic staff had prior to the NPPC pilot varied widely across the sites. Even among those with some level of training and expertise in ACEs, providers reported experiencing some level of discomfort and trepidation about having conversations about ACEs with patients, which sometimes interfered with screening implementation. Peer support and training helped build comfort and confidence among providers, as well as clinical and frontline support staff responsible for administering the screening tool.

The NPPC pilot launched with training providers and staff involved with the pilot (at a minimum), and all the sites identified that as one of the most useful elements of the program. They also reported it was important that this training was provided by someone external to their organization and that it was professional and brought credibility to the effort. Sites also found that more training was needed as the screening practice was rolled out to additional providers and clinic sites. Leaders found that each site had different concerns, workflow challenges, and unique patient population issues to work through so benefitted from individualized attention.

Providing adequate follow-up: With appropriate scoring definitions and some attention to strengthening referral systems, NPPC sites were able to adequately respond to screening results.

While the experience of this cohort suggests that health centers will likely find their patient population’s ACE scores are not as high as they expect, before implementing screening practices, clinicians should assess whether they have the internal and external resources needed for referrals and work to strengthen those networks if necessary.

When first considering implementing screening, many organizations and providers have concerns about not being able to appropriately follow up with all the patients who need it with appropriate internal or external resources. Across the wider NPPC membership group, this is consistently the highest rated concern. Similarly, respondents to the ACEs training evaluations at the beginning of the pilot period indicated lower levels of confidence related to discussing screening results with patients, providing appropriate follow up, and creating care plans based on results.

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Clinical support and front-line staff support

How sites established buy-in among their staff varied, including making sure the team in charge of the pilot represented the staff that would be implementing the screening. A few clinics found the buy-in of their front-line staff was very high, which they attributed to many staff coming from the community that the clinic serves and so wanting to support efforts to take care of the community. Receiving training and feeling involved and aware of the reasons behind the new screening practice also helped garner support.


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While all sites found creating a clear algorithm to guide providers in the scoring and referral process helpful, three sites spent some of their time and energy to improve their referral networks and coordination. One site found that it needed to research and create a list of locally relevant resources for each of their clinic locations. A few of the clinics worked, or plan to work, to create closer relationships between providers and the clinic staff with more knowledge of available referral sources (e.g., care navigators, health educators). Providers reported being comforted that patients were getting connected to needed services, even though some sites continued to face an internal and external behavioral services network that has limited capacity.

We learned you have to get providers and staff comfortable

enough to do the screening a few times and then get them to

realize that their big fears don’t come to fruition.

Marin Community Clinics staff member

Electronic Health Record (EHR) integration: Building data tracking capabilities into the EHR early can help support implementation, embedding and spread of screening.

It is important to build data tracking capabilities into a clinic’s EHR to catch implementation issues (e.g., eligible patients not being screened, patients refusing) and fully integrate the new screening process into existing practice and workflows. Building the right systems requires time and expertise, so bringing an information technology (IT) professional onto the implementation team early in the planning and design process was beneficial to pilot sites.

All sites built (or were working on building) custom fields and workflows within their EHR to facilitate the tracking of screening uptake. Sites varied in what they decided to track in their EHRs beyond the ACE score, including elements like: symptoms, referrals, screening refusals, and indicating when a patient was already in services or was too sick to be screened.

By the end of the pilot, four sites were able to successfully pull screening-related reports out of their EHR, while others encountered barriers that prevented them from pulling the relevant data from the system. IT professionals were engaged later in the project by four sites, at which point they found competing priorities and timelines delayed their ability to build what was needed for data collection and reporting. Sites reported that leaders look to data to better understand or demonstrate the value and effectiveness of screening. In the case where an efficient and effective data collection and reporting system was not yet built, there were concerns about the feasibility of sustaining and rolling screening out more broadly.

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6Patient experience: Overall, sites perceived that patients responded neutrally or positively to the screening and follow-up process.

Sites reported that patient responses to the new screening practice were generally positive, although not everyone wanted to talk about the experiences mentioned in the screen. A few sites believed that some clients under-reported their scores, perhaps because they were not ready to disclose or felt that the experiences were far in the past and no longer relevant. One site found that existing patients tended to share more than new patients who may not have yet developed a sense of trust with providers and their care team. Another site reported that screening was especially helpful for new patients or new providers, offering them the opportunity to get better acquainted and for the patients’ experiences to be more deeply understood.

Patients have become better advocates for their children,

seeming to feel more empowered and comfortable to ask

for referrals.

Santa Barbara Goleta Clinic staff member


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4 Next steps for ACEs screening

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Next steps for ACEs screening

Next steps for ACEs screening

At the end of the initial pilot period, all sites reported planning to expand their ACEs screening practice either to other providers in the original clinic and/or to new clinic sites. Additionally, one site is developing a way to expand its screening to a population with high incidences of trauma and major language barriers that would best be served by a video or audio file to walk them through the screening tool. Multiple sites were also planning to add functionality to their EHRs to enhance their screening practice (e.g., documenting patients’ symptoms or number/type of referrals made).

Sites that rolled out screening to additional clinic sites during the pilot period found that each site had unique workflows and cultures to consider when designing screening implementation. All affected staff and providers were supported by NPPC, which provided a training about ACE science and mapped out the details of their clinic’s new workflow. Best practice may be to provide space for participants to discuss concerns and practice messaging with their peers as screening becomes integrated into practice.

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5 Summary

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Summary

Summary

NPPC successfully supported six diverse sites in implementing ACEs screening and 1,362 children under the age of 18 were screened during the initial pilot phase. Most sites also reported sustainably integrating ACEs into their practice, including making concrete changes in data systems. All sites reported that NPPC increased provider and staff knowledge about ACEs and built comfort with initiating related conversations with patients. Providers found that screening enhanced their understanding of patients and aided in symptom interpretation and treatment. They found that the scope of their conversations with patients was broadened, helping to set the tone around whole person care. For two sites, NPPC support during the pilot period helped them roll out their screening practice to other clinic sites in their organization, and all of the other sites had plans to expand screening to either other providers in the original clinic or to new clinic sites in phase 2.

Due to competing priorities for the team within SF General, their participation in NPPC was somewhat inconsistent and they were not fully integrated into evaluation processes. As a result, while the evaluation gathered information about the technical pieces of their screening process from the NPPC and other program documents, it did not have an opportunity to gather the team’s reflections and lessons learned so data were not robust enough to compile a case study.

Since the practice of ACEs screening in pediatric settings is emerging, much can be learned from the work of this first NPPC cohort. Many of the lessons align with what it takes to do clinical quality improvement and practice transformation more broadly, including ensuring alignment with organizational priorities, building buy-in among leaders, providers and staff, providing appropriate training and support, and establishing electronic systems for data collection and early reporting. With some attention to strengthening internal and/or external referral networks and processes, NPPC sites were able to effectively respond to patients’ needs uncovered through ACEs screening. Finally, sites found patients to be neutral to receptive to the conversations initiated through the screening process. These learnings will immediately influence the second cohort of NPPC’s pilot program and may inform other clinical practices interested in implementing ACEs screening.

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6 Appendix A: Evaluation approach and methods

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Appendices

Appendix A: Evaluation approach and methods

CCYW engaged the Center for Community Health and Evaluation (CCHE) to conduct the evaluation of the National Pediatric Practice Community on ACEs Screening (NPPC), including both the pilot program and activities related to the broader practice community. The evaluation has two goals: 1) to assess progress and impact on screening practices; and 2) capture lessons learned to inform program improvement and contribute to the field more broadly. The evaluation is focused on answering five questions:

1. To what extent has the NPPC increased participants’ awareness and knowledge related to ACEs screening and appropriate follow up?

2. To what extent has the NPPC changed participants’ practice related to ACEs screening and appropriate follow up?

3. What has been the broader impact of NPPC:

a. On patient care

b. On broader pediatric practice

4. What are the lessons learned about ACEs screening from providers/sites participating in NPPC, including reported barriers/ facilitators to ACEs screening?

5. To what extent has the NPPC program been successfully implemented? What has been the relative contribution of different components of the NPPC program?

CCHE used a mixed methods approach, including both quantitative and qualitative data to evaluate the first cohort of the pilot program. Data collection methods are detailed in the table below.

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Data collection method

Purpose Sample

Pilot site visits Meet with the pilot site core team. Document site context, current screening processes, and observe programmatic activities (e.g., in-person coaching, training)

n=101-3 visits per site (1-2 days each) (SFGH excluded)

ACEs training post-event survey

Trainings conducted one time per site at the beginning of the pilot period. Document participant changes in awareness, knowledge & confidence related to screening. Gather satisfaction data on training content, structure, and presentation.

Paper evaluation from completed on paper by participants at 4 sites. (IFH and SFGH excluded)KP: n=11LC: n=25MCC: n=38SBNC: n=93Total: n=167

Pilot site interviews Collect structured qualitative data on site context, process, outcomes, and experience with the NPPC at the end of Phase 1.

1-hour interviews with 1-5 representatives (individually or collectively). (SFGH excluded) n=7

Initial site visit

planning calls

Observe site visit planning calls to

document site context, rationale for

participating in NPPC, and baseline

screening practice.

n=6

Document review Review site applications, coaching

notes, and sites’ monthly quantitative

data reporting to document site

context, screening process, and results.

N/A

Reflective discussions

with NPPC program

staff and coach

Gather program staff and coach

impressions of sites’ progress and

themes related to key outcomes and

lessons learned

Bi-annually (formally)Ad hoc (informally)

Analysis

CCHE used a case study methodology to understand and track progress at each pilot site. For qualitative data from interviews and observations, we conducted thematic analysis to identify commonalities across the cohort. Quantitative data (e.g., post-event surveys, monthly data reporting) was analyzed with support from Excel for basic descriptive statistics when appropriate.

Appendices nppcaces.org | cche.org

Institute for Family Health’s School-Based Health Center at Promise Academy 2

NPPC Pilot Site Clinic Profile:

September 2019

The National Pediatric Practice Community (NPPC) on Adverse Childhood Experiences (ACEs) is a program of the Center for Youth Wellness (CYW) to support health care professionals in applying ACEs and toxic stress science to pediatric practice and shaping the field of trauma-informed medicine. The NPPC pilot program launched in 2017 to support integrating ACEs screening in pediatric clinical settings by providing training, technical assistance, and practice coaching to a small group of medical practices. The pilot included an intensive six-month period where organizations tested and refined screening implementation. For an additional six months, NPPC helped sites embed and spread their screening practices as appropriate, including supporting clinical systems for ongoing data tracking and monitoring.

Acknowledging that screening for ACEs is not yet standard practice in pediatric clinics in the United States, the NPPC pilot program was framed as a quality improvement endeavor using a plan-do-check-adjust (PDCA) framework with systems in place to monitor, reflect on, and formally document their experience and learning.

NPPC Overview

Pilot Site: Institute for Family Health in Harlem, New York

The Institute for Family Health (Institute) was introduced to the NPPC pilot program through its partnership with the Harlem Children’s Zone (HCZ). HCZ is a nonprofit, community-based organization focused on child welfare in a 97-block area in Harlem, New York. It operates two K-12 charter schools that house the Institute health centers to provide primary care services. HCZ leaders believed that ACEs screening at the Institute would complement existing efforts to make their schools more trauma informed. The Institute was interested in the pilot because its staff members perceived a high prevalence of trauma among their patients and potential alignment between ACEs screening and the mission of their school-based health centers. Finally, HCZ and the Institute’s partnership was relatively new, and they hoped that the pilot would strengthen their collaboration overall.

Federally qualified health center with 27 clinics

School-based health center at Harlem Children’s Zone’s Promise Academy 2 (PA 2) with 1 full-time provider and an integrated clinical social worker. See ~15 patients per day.

Organization:

Description:

Institute for Family HealthProduced by: Center for Community Health and Evaluation | cche.org

2

Screening activities & outcomes

12-15 staff were trained in the science of ACEs

all 13-18-year-olds

annually

Teen self-report ACE-Q core 10 questions + 7 suggested supplemental questions

4 or more ACEs, did not formally track symptoms

Leveraged the workflow from an existing survey. In the vitals room prior to the visit, the MA explained the screen and gave it to patients to complete on paper. The MA tallied and communicated the score to the provider prior to the appointment.

Providers referred patients with a positive score to the clinic’s social worker. Patients with negative scores were intended to be connected to the clinic’s health educator for information about toxic stress. However, the health educator position remained vacant throughout the pilot, so this element of the workflow was not implemented.

• 94% of eligible patients were screened

• 19% screened received a positive score

• 36% of patients with a positive score were referred to services

• Saw higher scores in the supplemental adversities than the

core ACEs

Training

Ages screened:

Frequency:

Tool:

“Positive” score:

Workflow:

Follow up:

Screening results:

180

170

12

33

Eligible for screening

Screened

Received positive score

Referred to services


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The Institute reported several important outcomes from the pilot project. While pilot leads were bought into the concept of ACEs, the training increased provider and clinical staff knowledge and comfort regarding ACEs screening. Providers said that screening results enhanced understanding of patients and aided in symptom interpretation and treatment and reported opportunities for more systematically assessing symptoms in a more pro-active way.

Additionally, the Institute strengthened data capture in its electronic health record (EPIC) by building a best practice advisory that alerts them that the screening is due every 365 days from the last time it was done; although, at the time of this report it was unknown if this build and corresponding reporting function had been fully implemented.

The Institute anticipates continuing to screen patients at Promise Academy 2 and, after making some additional changes to its data system, plans to implement screening at its other school-based health center at HCZ (Promise Academy 1). This will require training a new group of staff and working through any differences in workflow at the new site.

A personal accomplishment [is] becoming familiar with the ACEs theory and comfortable with the screening.... I think we’ve all become more familiar with childhood trauma and sensitive to that.

Institute staff member


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There is no one-size-fits-all approach for screening implementation, and practices will need to make a variety of key decisions at various stages in the process. Four key lessons learned for the Institute are detailed below.

Putting forward this philosophy that we care about these issues is important. Some patients...commented, ‘no one asks me about this anywhere else.’”

Institute staff member

Lessons learned

Organizational buy-in was supported by ACEs screening aligning with organizational priorities and providing clinical value to providers.

ACEs screening aligned well with the Institute’s organizational priorities around integrated behavioral health and trauma-informed care. Additionally, when leaders realized that the quality improvement summary by the NPPC coach at the end of the screening pilot could be used for other organizational priorities (e.g., patient-centered medical home designation, joint commission accreditation), they were excited and interested. Providers found patients receptive to the screening tool and it helped them identify patient needs. Importantly, the capacity of their social worker could absorb the additional patients into her workload.

For their teen population, administering the screen in a private setting was necessary to preserve data quality.

Initially the health educator explained the screen and gave it to patients to complete on paper in the waiting room before their appointment. They observed patients consulting each other while filling out their screens, so decided to change their workflow to have patients fill it out in the vitals room before their appointment. Overall, the new screening process was easily integrated into existing workflows, so the small staff was able to adapt quickly.

It is necessary to have early and consistent involvement from technical professionals to integrate data tracking and reporting capabilities into electronic health records.

The Institute was able to build a best practice alert in EPIC for recording screening scores but found that without the consistent involvement of an EPIC “super user,” the project team hit barriers and delays in building reports that provided data on screening roll-out. By the end of the pilot period, the team decided they would like to make four changes to their data recording capabilities in EPIC: add a way to postpone the screening until the next visit if the patient was too sick, and to document whether the patient refused the screening, was exhibiting related symptoms, and whether referrals were made.

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1

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5

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Serving teens in a school-based health center setting influenced the Institute’s choice of screening workflow, educational materials, screening tool, how staff members communicated with parents, and how they coordinated around referrals.

As mentioned previously, the Institute learned it was preferable to administer the screen in private. Additionally, the Institute decided to use a self-report version of the ACE-Q since parents do not generally attend appointments at a school-based health center. Parents provide general consent for their child to receive services from the Institute, so did not need specific consent for ACEs screening. However, they coordinated with the school to send home a letter explaining the purpose of the new screening process. HCZ staff were initially concerned that the screening activity might jeopardize their relationship with students’ families. However, they reported hearing no feedback or complaints about the screening from students. This project provided the impetus for the Institute and HCZ to explore new ways to strengthen their partnership. For example, HCZ offers a variety of programs for their students that were identified as possible referral resources for the Institute.

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Kaiser Permanente Southern California Bellflower Clinic


September 2019



NPPC Overview

Pilot Site: Bellflower Clinic in Downey, CA

Kaiser Permanente Southern California region’s Bellflower pediatric clinic was the only NPPC pilot site that was part of a private, integrated health system. The regional chair for child abuse prevention was personally inspired to bring ACEs screening to the Bellflower clinic, where she practices as a pediatrician, to illustrate the extent to which their patient population has experienced trauma and make the case for screening across the region. She obtained permission from regional leadership to participate in NPPC, paving the way for ACEs screening throughout the whole Southern California region (Los Angeles to San Diego).

Kaiser Permanente is a large national, integrated health system serving around 12 million members across 8 regions.

Bellflower Clinic is part of Kaiser Permanente Southern California region’s Downey system, which serves medically underserved communities at 12 sites in Downey, CA.

Organization:

Site Description:

Kaiser PermanenteProduced by: Center for Community Health and Evaluation | cche.org

2


14 staff were trained in the science of ACEs

all 3- and 5-year old children at well child visits

ACE-Q core 10 questions

1-3 ACEs with symptoms or 4+ with or without symptoms

Front desk staff explains and gives patients the paper screen to complete. The medical assistant (MA) or licensed vocational nurse (LVN) enters the score into EPIC prior to the provider entering the exam room, flagging scores of 1 or more for provider review.

Providers assess for safety and symptoms and assign patients to intermediate or high-risk groups for follow up. All patients with a positive score receive education, and high-risk patients are referred to behavioral health services as appropriate.




Training

Ages screened:

Tool:


Workflow:

Follow up:

Screening results:

1314

825

37

132


Screened




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Bellflower reported several other important outcomes from the pilot project. It increased provider and staff knowledge and comfort regarding ACEs screening, which the provider champion plans build on by facilitating peer sharing. It also enhanced providers’ understanding of their patients, which aided in symptom interpretation and treatment. For example, because of screening a provider better understood a significant speech delay in a 4-year-old who had experienced family trauma several years prior. Clinic staff also strengthened their referral practices—every site compiled a list of potential local resources (e.g., parenting classes through ECHO and Exchange Club)—and improved the ability to track relevant data in their electronic health record (EPIC), including exploring adding drop-down boxes for recording symptoms and referrals.

The Bellflower champion for ACEs screening was able to leverage the Kaiser Permanente child abuse prevention network and spread to five additional sites during the first six months of the pilot. The clinic plans to continue the screening currently underway and has plans to spread across the region to nine additional sites in 2019. In 2020, the organization plans to extend the age range and add screening for 10- and 13-year-olds.

A couple [providers] have said parents are very happy to

be asked, and the screener helps them understand patients’

symptoms.

Kaiser Permanente Bellflower provider


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There is no one-size-fits-all approach for screening implementation, and practices will need to make a variety of key decisions at various stages in the process. Three key lessons learned for Kaiser Permanente Bellflower are detailed below.

You need to do the right thing, even if it takes more time.”

Kaiser Permanente Bellflower provider

Lessons learned

2

1

Spreading to five additional clinic sites benefitted from a focus on implementation and illustrating the value of screening to providers.

The champion developed a training presentation for all staff at additional sites that included equal parts of an ACEs foundational overview, samples of workflows and the screening process, and options for follow-up resources. Providers who requested additional information received one-on-one coaching from her. Since the pediatricians are juggling a lot of competing demands, the champion worked to integrate the screening process into their typical practice. She helped them see how this screening helps to answer some of their questions and improves their ability to issue diagnoses and provide quality care. She tells providers, “It will make your life easier.”

Active engagement and strategic thinking ensure that the screening data collected are useful for monitoring and communicating about progress along the way.

Bellflower reflected that it is helpful to involve an information technology (IT) professional early on who is thinking critically about how to obtain and report on the best data to answer key questions related to implementation. Screening roll-out at the additional five sites was supported by monthly calls with the Bellflower champion who reviewed the data and made recommendations if necessary.

Leadership support was a critical element that was gained by communicating the value of ACEs screening and illustrating how it positions Kaiser Permanente to be on the

“cutting edge.”

The provider champion at Bellflower reflected that Bellflower started implementing ACEs screening when the national conversation around ACEs was gaining traction. Since Kaiser Permanente likes to be at the forefront of medical practice, that was a helpful frame for increasing buy-in and support for screening, which combined well with an organizational culture that promotes innovation and peer pressure to adopt new practices.

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La Clínica de la RazaFruitvale Village Pediatrics Clinic


September 2019



NPPC Overview

Pilot Site: Fruitvale Village Pediatrics Clinic in Oakland, California

Fruitvale Village Pediatrics providers became interested in ACEs screening because of the frequency with which trauma touches their patient population and a desire to have a more systematic way to assess their patients. Providers often see patients with symptoms that stem from trauma and wanted to address the trauma before puberty, when old experiences often emerge in a painful way. The clinic had an existing annual screening practice for 3- to 11-year-olds focused on behavioral health issues and saw ACEs screening process as a complementary opportunity to see if they could identify other patients who had experienced trauma.

Federally qualified health center with 28 clinics serving medically underserved patients, about 95% of whom speak Spanish.

Clinic staff consists of 7 medical doctors, 3 nurse practitioners, 12 medical assistants (MAs), and 5 front desk staff seeing around 100 patients daily.

Organization:

Site Description:

La Clinica de la RazaProduced by: Center for Community Health and Evaluation | cche.org

2


20 staff and providers were trained in the science of ACEs

7-11-year-olds

annually

Spanish and English versions of ACE-Q core 10 questions + 7 supplemental questions + 3 questions from the clinic’s existing behavioral health screen + 5 questions about trauma-related physical symptoms

1-3 with symptoms or 4+ with or without symptoms

The front desk staff distributed and explained the screen and gave it to patients to complete on paper. The medical assistant (MA) answered patients’ questions and recorded the score and any symptoms in the electronic health record prior to the visit for the provider to review. The MA reported positive scores in the pre-visit huddle with the provider.

For positive scores, the provider asked safety questions, offered anticipatory guidance, and referred to internal behavioral health providers or an outside behavioral health agency if indicated and the patient was willing. Staff also considered earlier follow-up with the provider at the clinic.




934

633

16

47


Screened



Training

Ages screened:

Frequency:

Tool:


Workflow:

Follow up:

Screening results:


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Fruitvale Village Pediatrics reported several other important outcomes from the pilot project. These included increased provider knowledge and comfort regarding ACEs screening. They found the screening process gave new patients and providers the opportunity to get to know each other better and build trust. Fruitvale Village Pediatrics also strengthened data tracking in the electronic health record (NextGen) after building a template for the medical assistant and provider to record scores, referrals, and trauma-related symptoms captured by the ACEs screen and the discussion during the visit.

Going forward, the clinic brainstormed ideas of how to expand to a second patient population— Guatemalan immigrants who speak Mam, a Mayan language. This population is often illiterate in Mam and Spanish, and so were not included in the initial pilot because of logistical barriers. Given the high incidence of trauma in this population, the clinic was exploring the idea of administering the screen with the aid of an audio or visual recording of the screen questions.

We found that the screener wasn’t going to uncover a lot of

hard things and bog the system down. Instead it was helpful to

think of it as another tool to help you understand the patients.”

Fruitvale Village Clinician


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There is no one-size-fits-all approach for screening implementation, and practices will need to make a variety of key decisions at various stages in the process. Three key lessons learned for Fruitvale Village Pediatrics are detailed below.

Lessons learned

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1 Staff buy-in to the new screening process was greatly increased by the NPPC training on ACEs, particularly among the medical assistants.

The team attributed the high level of buy-in among its front-line and clinical support staff to the fact that many of them come from the community that the clinic serves and thus support efforts to take care of their community. Additionally, feeling involved in the process and aware of the reasons behind the new screening practice helped garner support among staff. Through NPPC, team members were introduced to the concept that even having the discussion can be therapeutic for patients, which was particularly helpful in creating buy-in with providers.

The ACEs screening process did not overextend the clinic’s referral systems and gave providers ideas for how to better use their health educator.

The pilot core team administered a survey to understand providers’ experiences with the pilot. At the start, they worried about overwhelming their internal behavioral health services. This did not occur—they indicated that they still had some capacity, and providers reported that 90% of the time they were able to provide needed resources. In addition to behavioral health, patients were often linked to the organization’s positive parenting program.

Prior to the pilot, Fruitvale Village Pediatrics Clinic had a robust behavioral health screening practice in place but found the ACEs screen expanded the information gathered in useful ways.

At the outset of the pilot, the providers were interested in learning if combining the ACEs screen with their existing behavioral health screen would give them more useful information about clients. They added the following behavioral health questions to the back of the ACE screen.

1. Does your child demonstrate more worry or sadness than other children of similar ages?

2. Has your child ever experienced or witnessed anything traumatic at home, school or anywhere else?

3. Does your child consistently demonstrate more oppositional behavior or more problems paying attention than other children of similar ages?

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5

The medical assistants seemed very engaged, never forgetting

to give out the screener. They tend to like things that take

extra care of the community. The initial training successfully

increased their knowledge and created a lot of buy-in since

they felt involved in the reason behind the practice change.

Fruitvale Village Clinician

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Providers found the combination of the ACE and behavioral health screen provided a neutral way to delve into less common topics, giving new patients and providers the opportunity to get to know and trust each other. The specificity of the questions on the ACE screen expanded the information gathered about patients’ experiences with trauma in ways providers found valuable. Additionally, the way the two screens ask about symptoms complemented each other to give a more complete picture for providers.

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Marin Community Clinics Novato & San Rafael Clinics


September 2019



NPPC Overview

Pilot Site: Marin Community Clinics in Marin County, CA

Marin Community Clinics is a multi-clinic network with a wide array of primary care, specialty, and referral services in Northern California. Leadership wanted to address the impact of trauma on a system level and joined the NPPC pilot to identify patients at risk for trauma and intervene as early as possible. ACEs screening fit within broader efforts related to prevention, including ACEs screening and coordination with their high-risk obstetric program and implementing universal social and psychosocial screening. During the pilot, Marin Community Clinics was also accepted into a complementary initiative focused on increasing health centers’ efforts to become more trauma- and resilience-informed organizations.

Federally qualified health center with 3 main primary care sites and integrated behavioral health services. Serves over 32,000 insured and uninsured patients annually.

Implemented ACEs screening with select providers across 3 sites (7 providers total).

Organization:

Site Description:

Marin Community ClinicsProduced by: Center for Community Health and Evaluation | cche.org

2


27 staff were trained in the science of ACEs

9 months and 30 months at well-child visits and new patients up to 12-years-old. Pregnant women in the high-risk obstetrics program also screened, but not reflected in their data.

combined and simplified an existing tool they were using with the ACE-Q (7 questions, deidentified ACEs)

2+ ACEs, did not formally collect symptoms

Medical assistants (MA) administer to caregivers in the exam room. Primary care provider reviews and discusses with patient.

Patients screening positive are connected to a care navigator who provides information on ACEs and links to appropriate services (e.g., behavioral health, positive parenting program, legal).




• Note: manual data collection made it difficult to determine the exact number eligible for screening

Training

Ages screened:

Tool:


Workflow:

Follow up:

Screening results:

217

114

14

19


Screened




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Marin Community Clinics reported several other important outcomes from the pilot project. It introduced the concept of ACEs to several providers, medical assistants, and care navigators; while some had heard about it previously, they had not put it into practice until the pilot. The project also helped increase providers’ understanding of patients, which helped in symptom interpretation and treatment. Both pediatric and behavioral health providers indicated that screening has given them a language for talking to patients when not in crisis and shifted the care and conversation to be more preventive. They believed it “plants the seeds” and that patients exhibit more motivation and follow-through on behavioral health or programmatic referrals. Furthermore, providers reported that the process of screening enhanced the relationship between the [medical doctor] and behavioral health provider.

Additionally, towards the end of the pilot program the pilot team was working to integrate data tracking related to screening and follow-up into their electronic health record (NextGen) by developing a screening form that they planned to test out at one clinic. The pilot provided the foundation for the organization to be competitive for other programs supporting this work. Marin Community Clinics planned to leverage participation in a trauma-informed care initiative to conduct organization-wide training on trauma- and resilience-informed care, continue refining their data tracking and reporting systems, roll out screening to additional providers throughout the organization, and further strengthen families’ transition from obstetrics to pediatrics.

As a provider you are always looking for more information and

to build the therapeutic relationship [with patients] and shared

goals. I found [screening] was a neutral way to start the

conversation…. Parents either nod or they start to put things

together. It sets the tone that I’m here for you and your family

as whole people.

Marin Community Clinics provider


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There is no one-size-fits-all approach for screening implementation, and practices will need to make a variety of key decisions at various stages in the process. Three key lessons for Marin Community Clinics are detailed below.

The [medical assistant] care navigator staff buy-in was important. We made them feel like they had a part in developing the protocol.


Lessons learned

2

1

Marin Community Clinics pilot providers found screening to be useful and easy—when they did identify needs, they were able to connect patients with appropriate resources.

The pilot core team administered a survey to understand providers’ experiences with the pilot. At the start, they worried about overwhelming their internal behavioral health services. This did not occur—they indicated that they still had some capacity, and providers reported that 90% of the time they were able to provide needed resources. In addition to behavioral health, patients were often linked to the organization’s positive parenting program.

Provider champions and effective care navigators were key ingredients to implementing across sites.

Having a committed provider champion at each site with some dedicated administrative time to support the change process helped implementation occur across sites. And since care navigators are the first line of response to a positive screen, staff requested and received additional training from NPPC to support them in identifying patient needs. Additionally, navigators’ work is context-specific for each site—they must know the local resources available and how to access them, while also effectively connecting effectively and compassionately with patients.

Early stakeholder engagement, especially with leadership and information technology (IT) staff, helps to build buy-in and ensure that the project has the support it needs.

It may require different approaches to secure the support you need. Pilot staff reflected that it can be difficult to get providers to change their practice, and a provider champion as the project lead helped make the case for others. In addition, the NPPC quality improvement framework and approach helped achieve small wins that assisted in building additional leadership support.

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5

Something we did right is having the planning team represent

who’s going to be implementing it. Having the lead pediatrician

on the grant helped create buy-in among other providers..


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4 Integrating data tracking related to screening and follow-up into the electronic health record (EHR) is crucial for sustainability and broader implementation.

For the NPPC pilot program, Marin Community Clinics tracked its screening and follow-up data manually and had an intern clean and analyze the data for monitoring and reporting, which was time-consuming and burdensome. To support rollout of ACEs screening to other providers, the pilot team engaged an internal data analytics representative to build out a form for their EHR (NextGen) that medical assistants would complete that mimics other screening processes. The form would collect myriad items, including the screen score and action checklist (e.g., ACEs information, housing resources, and a referral to behavioral health). Marin Community Clinics is still developing systems to more easily report on the data captured to monitor progress and use for decision making.

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Santa Barbara Neighborhood Clinics Goleta Neighborhood Clinic


September 2019



NPPC Overview

Pilot Site: Goleta Neighborhood Clinic in Santa Barbara, California

Santa Barbara Neighborhood Clinics (SBNC) believed trauma was prevalent in their population and became interested in screening to improve patient care, support behavioral health integration, and strengthen local referral partnerships. SBNC is part of the Santa Barbara Resiliency Project, a multi-sector collaboration supported by a local funder that includes a community-based research study with the University of California Santa Barbara and a mental health agency called Child Abuse Listening and Mediation (CALM). The study is evaluating the acceptability and feasibility of screening infants and parents for ACEs within pediatric settings and assessing the effectiveness of clinic and home-based parenting interventions at improving parental attunement, decreasing parenting stress, and promoting child development. One clinician commented, “The climate was ripe for ACEs screening because of the Santa Barbara resilience group’s goals around universal screening in medical practices and how the recent local natural disasters raised people’s awareness of mental health.”

Federally qualified health center serving 21,000 medically underserved patients annually at 4 medical and two dental clinics

Staff consists of 3 medical doctors, 3 nurse practitioners, 3 medical assistants, 1 wellness navigator, 2 clinical social workers.

Organization:

Description:

Santa Barbara Neighborhood Clinics Produced by: Center for Community Health and Evaluation | cche.org

2


93 staff were trained by NPPC on the science of ACEs

Infants: at 4, 6, or 9 months then annually at well-child visits. Caregivers: at child’s 4-month visit.

Infants: ACE-Q core 10 questions + 7 suggested supplemental questions + 1 question about experience with natural disasters. Caregivers: tailored teen self-report version of the same ACE-Q as above. Used Spanish and English versions of both tool.

Infants 1+ ACEs. Caregivers: 2+ ACEs. Did not formally track symptoms.

Medical assistants (MA) explained the screener and gave it to patients to complete on paper in the exam room. The MA tallied and communicated the score to the provider prior to the visit.

Providers connected patients with a positive score to the wellness navigator to assess referral needs, explain the research study, and enroll those who were interested.




Training

Ages screened:

Tool:


Workflow:

Follow up:

Screening results:

112

96

34

44


Screened




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SBNC reported several other important outcomes from NPPC pilot participation. These outcomes included increased provider knowledge and comfort regarding ACEs screening. They enhanced understanding of patients, which aided in symptom interpretation and treatment and expanded the scope of the conversation with patients, setting the tone around whole person care. For example, the process of discussing ACEs with parents led providers to realize that post-partum mood disorders were more common than they had previously known. As a result, they began screening relevant patients more systematically and connecting them to appropriate services. Additionally, Santa Barbara Neighborhood Clinics strengthened data capture in its electronic health record (NextGen), by creating a shortcut in their well-child visit intake documentation process to a custom-built section about ACEs. Participating in the pilot also had a positive impact on public relations and funding for the site. New donors have become engaged, the organization has received media attention, and staff members believe the community has an expanded view of what the clinic does and how innovative they are. Providers reported that families appreciated being asked about their experiences and in some cases have become better advocates for their children, requesting more referrals for all family members.

During the 6-month pilot, Santa Barbara Neighborhood Clinics expanded the scope of their project from one provider at the Goleta clinic to eight providers at four of their clinics. Clinic leaders were also considering expanding screening to include older ages and are planning on training all staff on self-care, acknowledging that talking about trauma with patients can be triggering. The organization is also positioned to disseminate promising practices to other pediatric providers in Santa Barbara once the team concludes the research study and identifies the most successful interventions.

Screening enables me to learn more about the individual experience of the child and their family and meet them where they are and improve the quality of the whole person care that we can provide

Santa Barbara Neighborhood Clinic Provider


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There is no one-size-fits-all approach for screening implementation, and practices will need to make a variety of key decisions at various stages in the process. Four key lessons learned for Santa Barbara Neighborhood Clinics are detailed below.

Having senior leaders engaged is important. Our Chief Operations Officer is unique in that she’s the person writing our grants and clearing people’s calendars when necessary to focus on this project.”


Lessons learned

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1 Santa Barbara Neighborhood Clinics was involved in a research study, which strengthened their pilot by bringing additional resources and increased visibility to the work.

The study gave the multi-sector collaborative team a year to plan and build a strong partnership, which helped things run smoothly once the pilot began. Clinic staff found patients were often interested in being part of the study (which involved random assignment to various types of intervention), motivated by the feeling that they were helping others. The pilot team also reported that clinic staff were concerned about

“messing up” the study if they implemented the protocol incorrectly. This meant there was an increased need for training and reassurance at the beginning of the process. A number of other local health care providers approached Santa Barbara Neighborhood Clinics about following their model, aided by the legitimacy that the study lent to their efforts.

Senior leaders’ commitment to ACEs screening was a key contributor to the success and spread of the pilot project.

Prior to the pilot, Santa Barbara Neighborhood Clinics sent some of its leaders to the CYW conference on ACEs, where they learned more about ACEs and started to plan for screening. Clinic leaders drove the implementation of screening at the Goleta site and set the project up for success by encouraging the engagement of key staff, including the technical support needed to build out data capturing and reporting capabilities in the electronic health record (NextGen) from the beginning. Leaders also led the process of rolling out ACEs screening to three other clinic sites. This involved identifying provider champions at each site and adapting the process to be relevant to sites’ contexts (e.g., unique work flows, differing patient populations, varying levels of staff and provider knowledge, skills, and comfort).


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Face-to-face meetings work the best, time during an all-staff meeting gives an issue special importance. People have been very open about sharing their own life experiences, but this is not the kind of work that you can do fast.”


3Trainings helped generate buy-in for the pilot by increasing staff members’ knowledge of ACEs and related topics across the organization.

Before the pilot began, the organization held trainings for 150 of their staff and providers about protective factors, implicit bias, and resilience. At the beginning of the pilot, all staff and providers from the four clinics that implemented screening were invited to NPPC’s training on the science of ACEs and the new screening process. Leaders took an inclusive approach to the training saying, “From billing to clinic staff, everyone was invited because they all have to understand what we are doing and be trauma informed…. Everyone in our organization is an ambassador for this initiative.” Staff from CALM, the intervention partner on the research study, were available to support providers and medical assistants who were initially uncomfortable with talking about trauma with patients, coaching them through the process the first few times to build confidence.

4Employing a quality improvement approach and conducting plan-do-check-adjust (PDCA) cycles helped resolve workflow challenges.

SBNC conducted quality improvement cycles each week in the beginning of the pilot, which helped them integrate or strengthen new or innovative ideas, such as pre-visit planning, a PCMH huddle and a pocket-sized script for MAs to help them explain the screening process to patients. The staff found this increased their screening implementation rates. They also discovered that the screen added time to some visits, so they worked to complete screenings during the “down time” that families already had in the clinic while waiting for their appointments. Senior leadership reported the written PDSA to be a benefit that they could take away from the pilot because it was useful in Quality Improvement Activities The staff closest to the work needed to practice and provide feedback, and the site reported that being part of the pilot provided the necessary time and technical assistance to guide them through the process.

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