About two years ago, a team from LifeLong Medical Clinics jumped at the opportunity to integrate practices based on adverse childhood experiences when it joined a two-year learning collaborative known as the Resilient Beginnings Collaborative (RBC). RBC began in 2018 and includes seven safety-net organizations in the San Francisco Bay Area. (Here’s a link to a report about the RBC.)
To join the RBC, LifeLong Clinics — which has 14 primary care clinics in Alameda, Contra Costa and Marin Counties — and the other collaborative teams had to agree to introduce all staff members to the science of childhood adversity and trauma-informed practices. LifeLong went full steam ahead with a 2.5-hour introductory training for more than 100 employees who work at its clinics that serve pediatric patients. Trauma Transformed, a program of the East Bay Agency for Children in Oakland, CA, did the training in October and November 2018.
LifeLong Clinics’ decision to move forward on integrating ACEs science and trauma-informed practices into its clinics is important particularly in California where a state policy has made childhood adversity a front and center issue. On Jan. 1, 2020, as an incentive to doctors who serve Californians in the state’s Medicaid program, the state began offering supplemental payments of $29 to doctors for screening the estimated 12 million pediatric and adult patients for adverse childhood experiences (ACEs).
ACEs comes from the groundbreaking Adverse Childhood Experience Study (ACE Study), first published in 1998 and comprising more than 70 research papers published over the following 15 years. The research is based on a survey of more than 17,000 adults and was led by Drs. Robert Anda and Vincent Felitti. The study linked 10 types of childhood adversity — such as living with a parent who is mentally ill, has abused alcohol or is emotionally abusive — to the adult onset of chronic disease, mental illness, violence and being a victim of violence. Many other types of ACEs — including racism, bullying, a father being abused, and community violence — have been added to subsequent ACE surveys. (ACEs Science 101; Got Your ACE/Resilience Score?)
The ACE surveys — the epidemiology of childhood adversity — is one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, the epigenetics of toxic stress (how it’s passed on from generation to generation), and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.
After it trained employees in 2018, brainstorming around workflow was provided for staff at the LifeLong Howard Daniel Health Center in Oakland, CA, in February 2019, where LifeLong plans to pilot ACEs screening in newborns to five-year-olds, said Dr. Omoniyi Omotoso, the pediatric lead at LifeLong Clinics, who led the brainstorming about workflow and additional training.
Four months into that training, in June, Omotoso showed staff the ACEs questionnaire and asked them how they thought patients would feel about it.
And that’s when Omotoso realized that they had to put on the brakes. “A lot of the staff were uncomfortable because they themselves had similar instances that they personally were triggered by as they read the [ACE] questions themselves,” said Omotoso, who splits his clinical time between LifeLong Howard Daniel Health Center and LifeLong William Jenkins Health Center. He said that LifeLong will be using the de-identified PEARLS ACE screener for its pediatric population, which asks those surveyed to write on the form the number of ACEs that apply to them. (Here’s a link to ACEs Aware, where you’ll find out more information about PEARLS, the only pediatric ACEs screener for which California providers can be reimbursed.)
Omotoso credits the realization that LifeLong had to take a step back before jumping full throttle into ACEs screening with what he observed and learned from a June 2019 visit to the Montefiore Medical Center, in the Bronx, NY. Montefiore is one of the first medical systems in the country to transform its entire workforce into embracing trauma-informed practices based on ACEs science, and introduce universal ACEs screening.
Omotoso said the visit, which was organized as part of the Resilient Beginnings Collaborative, was “mindblowing.”
“When patients come in, there are security [guards] at the front. They greet the families. They say, ‘How are you doing?’ When they’re leaving they say, ‘I hope everything was ok, you got what you needed,’” said Omotoso. “And when they notice someone is having a difficult time, they can call ahead to the front desk and say, ‘The patient walked in; they seem to be struggling with this.’ Or, when some of the security staff members have some personal issues, they’ll say to each other ‘Take a day off and we’ll cover for you.’ Just the way they became so mindful, it was very astounding to see. It made me see we had to fine-tune things. It was the impetus for saying before we do the ACEs screen, we have to be attuned to staff readiness and meet them where they are.”
So, in July 2019, 13 months after the launch of the Resilient Beginning Collaborative, Omotoso and his colleagues’ response was to pivot and provide the clinic’s staff with a deeper dive into training and support. Since July, they’ve talked every month about the transition. The topics, which were facilitated by Dr. Madeleine Lansky, a consultant with Alameda County Child Psychiatry, included discussions about ACEs science research, screenings of the Ted Talk by pediatrician and California Surgeon General Dr. Nadine Burke Harris, and the documentary Resilience. Each activity was followed by discussions about topics, such as intergenerational trauma. Staff also developed emergency self-care cards with five items they can quickly deploy to help them decompress when they’re feeling triggered or overly stressed.
“For example, for some people it could be looking at a picture of their kids or pets. Some people could take a five-minute walk. It goes in the back of your ID badge, so you could always see it when you flip it around,” said Omotoso.
Besides the deeper dive to ensure that the staff feel prepared and ready to move forward on screening patients for ACEs, LifeLong has some other pressing tasks at hand. These include setting up a new electronic health record system to record ACEs screening results and developing materials for parents about ACEs science, including resilience. An example is a “prescription card” for parents that suggests daily activities such as: “Say ‘I love you’ to your child every day. Hug your child for 20 seconds every day. Think about what you hope to see your child doing in the future,” said Omotoso.
While LifeLong continues to prepare for implementing its ACEs screening, Omotoso says that the training and work in the RBC collaborative has already shifted some aspects of LifeLong’s workplace. In every staff meeting, he says, they now incorporate a team-building activity. “We have tried to make it a lot more interactive, where staff feel like they can be heard, they can talk and speak up, and we can actually come up with solutions together,” says Omotoso. “It’s really transformed how we interact on a day-to-day basis.”