ACES IN PRIMARY CARE –BEYOND SCREENING AND TOWARD PREVENTION

Cayenne Bierman, MSW, LCSW; Caren Schmidt, PsyD and Tracey Hessel, MD

The California Surgeon General’s office has made screening for Adverse Childhood Experiences (ACEs) in California’s primary care settings one of its core priorities. Launched in 2019, the ACEs Aware Initiative was created to train primary care providers in health care settings to systematically screen for ACEs in pediatric patients. As one of the early adopters of screening for ACEs, Marin Community Clinics has been at the forefront of these efforts and benefited from the support of multiple funding and research collaboratives.1

In conjunction with the State’s ACEs Aware Initiative, Marin Community Clinics helped create a model case study of implementing screening practices for interested healthcare sites across the state of California. As a result of these efforts and collaborations, we now have a robust screening program across our clinics. We screen all pediatric, obstetrics, and adult patients for exposure to ACEs. California as a whole has made great gains in this area, and we are moving towards a point in which screening is the rule, rather than the exception. As is now true for many health organizations in California, our medical assistants and primary care providers are trained in how to introduce the screeners and the topic of ACEs in a strengths-based, traumainformed manner. We have made great strides to reduce the stigma of discussing traumatic experiences—building resilience amongst patients and staff alike.

Beyond Screening

As healthcare professionals, we view screening as an integral first step in addressing ACES, with response to positive screening representing a critical next step. We recognize the need for a multifaceted approach to interventions and supports to truly promote healing and resilience. Marin Community Clinics has increased our response to positive screenings with a variety of evidenced-based interventions and supports for families. We are fortunate that Marin Community Clinics has developed robust integrated behavioral health, complex case management, nutrition, and alternative healing programs, and we are able to provide many services to patients on-site. However, the manifestations and treatment of trauma are often complex—requiring support that goes beyond the traditional scope of primary care settings. And, the need for these supports is everincreasing.

As ACEs screening and response is becoming the standard of care in health care settings, it is time to set our sights on a larger goal: prevention. Many groups are looking towards this goal and Marin Community Clinics is fortunate to be supported by two large efforts including RBN (funding partnership with Genentech Charitable Giving and the Center for Care Innovations (CCI)) and PRACTICE (funding supported by UCLA-UCSF ACEs Aware Family Resilience Network (UCAAN) in collaboration with the Office of the California Surgeon General (OSG), the California Department of Health Care Services (DHCS), and the Population Health Innovation Lab (PHIL), a program of Public Health Institute (PHI)).

Policy Change and Prevention

The California Department of Health Care Services (DHCS) has spent considerable time and effort creating new funding and reimbursement streams to support preventative work for the first time. The crown jewel of these initiatives is CalAIM, California’s ambitious plan to transform how Medi-Cal delivers care to the state’s most complex and vulnerable residents. This initiative inherently recognizes the interplay between trauma, Social Determinants of Health (SDOHs), and health, and provides opportunities to integrate new supports into healthcare practice.

For the first time, there is a sustainable pathway to integrating social workers and community health workers into primary care where they belong—working with individuals, families, and communities to build on existing strengths while addressing barriers to care (including marginalization by healthcare systems). This enlightened understanding has allowed clinics like ours to add preventative pediatric programs including Healthy Steps and Triple P to existing supports such as Comprehensive Perinatal Services Program (CPSP). These efforts mitigate risk factors and provide skills and support to families before they are in a crisis. At Marin Community Clinics, we believe the care trifecta of primary care, behavioral health, and complex case management addresses ACEs in a meaningful way. We are grateful to work in a state that increasingly recognizes and values the tenets of whole person care. The changes being made at the state level allow clinics like ours to address the cycle of trauma and unmet psychosocial needs in a way that expands preventative opportunities and promotes resilience. Both RBN and PRACTICE are particularly committed to finding ways to prevent the effects of ACEs and support our most vulnerable patients: children.

Innovating Amidst Challenge

These are unprecedented times in healthcare. While DHCS and Managed Care Plans are creating new and exciting funding opportunities to implement supports to respond to ACES such as the Dyadic Services Benefit, Community Health Worker reimbursement, and CalAIM case management and housing supports, it has not been an easy lift for frontline providers. As these new benefits roll out, healthcare as a whole is experiencing critical staff shortages, provider burnout, and increasingly traumatized patients. To understand and implement these new services involves a significant administrative burden at the local level. For safety net clinics already operating beyond their bandwidth, it can feel overwhelming, if not impossible, to successfully add these services. We are here to tell you it can be done. Groups like Aliados Health (formerly Redwood Community Health Coalition) are bringing together “peer networks” of Federally Qualified Health Center (FQHC) providers implementing these services to share experiences and best practices with agencies newly contemplating them.

Similarly, RBN and PRACTICE have brought together missiondriven providers and provided expert coaching and education— providing a roadmap to accessing new reimbursement streams and services. Beyond implementation and reimbursement, peer networks like these provide opportunities for mutual support and shared advocacy opportunities to report back up to the managed care plans and state agencies like the Department of Health Care Services (DHCS). The greatest resource we share is our commitment to serving the most vulnerable patients. If we continue to support each other in these efforts, our clinics, staff, and patients can succeed. It is our hope that other healthcare providers will join us in these efforts to move beyond screening, and work towards preventing the effects of trauma for the next generation.

For more information: CCI- https://www.careinnovations.org/ UCAAN/ACEs Aware https://www.acesaware.org/

Cayenne Bierman, MSW, LCSW, is the Director of Complex Care services at Marin Community Clinics. She is a project co-Lead on MCC’s RBN and PRACTICE grants. Caren Schmidt, PsyD is a child psychologist and the Associate Director of Behavioral Health at Marin Community Clinics. She is a project co-Lead on the PRACTICE grant and a Team Member on the RBN grant.

Tracey Hessel, MD, is the Associate Medical Director of Pediatrics at Marin Community Clinics. She is the Provider Champion on the PRACTICE grant and a Team Member on the RBN grant.

1 The National Pediatric Practice Community on Adverse Childhood Experiences (2017); Resilient Beginnings Collaborative (2018-20); California ACEs Learning and Quality Improvement Collaborative (2020-2021); ACEs Aware (2020-2021); Resilient Beginnings Network (RBN) (2021-2023); and Preventing and Responding to ACEs-Associated Health Conditions and Toxic Stress in Clinics Through Community Engagement (PRACTICE) (2022-2023).