- What are adverse childhood experiences (ACEs)?
- Find out more about the Pediatric ACEs and Related Life Events Screener (PEARLS) - Example of a PEARLS tool (for screening children)
- Visit Community Medical Centers (CMC), a growing non-profit network of neighborhood health centers serving San Joaquin and Solano counties in Northern California. CMC provides primary medical, dental, and behavioral health care along with supportive services to individuals and families in need.
- More on Resilient Beginnings Network (RBN), a Center for Care Innovations learning program dedicated to advancing pediatric care delivery models that are trauma- and resilience-informed so that 100,000 young children and their caregivers have the support they need to be well and thrive.
- How One California Clinic Tapped a Bilingual Medical Assistant to Lead ACEs Work - an article featuring CMC (May 2023)
Episode Teaser // Alfonso Apu (guest): I think a word of direction is really looking at your resources, looking at how best you can screen and develop a culture. I think I always go to that because at the end of the day, we're screening folks, but I think we've developed a culture where people feel safe. [...] And I think with trauma-informed systems, a huge part of this process is wellness and self-care. We believe that through this process, we can not only impact patients, but we can impact our staff. Health Pilots podcast intro:
Welcome to the Health Pilots podcast presented by the Center for Care Innovations. This podcast is about strengthening the health and well-being of historically underinvested communities. Every episode offers new ideas and practical advice that you can apply today!Episode 51 intro // Resilient Beginnings Network (RBN):
What does it mean to be trauma- and resilience-informed and how does it impact pediatric care delivery? To answer this and to share with us deeper insights into the work, Health Pilots is featuring dedicated care teams from the Resilient Beginnings Network at the Center for Care Innovations. Facilitating this conversation with the team we have today is Dr. Dayna Long, primary care pediatrician and clinical director for the Resilient Beginnings Network, or “RBN” for short. Hear the team’s journey through this three-year program - the valuable lessons they’ve learned individually and as a care team - and the unique, transformative impact of the Resilient Beginnings model on patient care. In this episode, you’ll hear our guests speak about adverse childhood experiences, known as ACEs, as well as the screening tool to address ACEs called, Pediatric ACEs and Related Life Events Screener, otherwise known as PEARLS. For more information about these concepts and tools, please visit our episode’s show notes. With that said, I’ll pass it on to Dr. Dayna Long for our episode today!Dayna Long (host, RBN): Hello, I am Dayna Long and I'm the medical director for the Resilient Beginnings Network (RBN) at the Center for Care Innovations. Today, we have the great pleasure of talking about the work that's happening at the Community Medical Centers and what they've been doing with pediatric care delivery to be more trauma- and resilience- informed. Our hope is that by sharing the Community Medical Center's story safety net organizations can apply the lessons learned to their own context. Today I'm here with three extraordinary guests, Alfonso Apu, Maria Moreno and Victoria Franco. They are all members of our Resilient Beginnings Network, which is a 15 Bay Area Community Health Center network where we're making trauma-informed care our priority and changing systems to be more resilient and focused on children and families. The Center for Care Innovations partners within the Resilient Beginnings Network really develop models of pediatric care that help children and their families thrive. We're excited to bring today's story to you. So, let's get started, and I'm wondering if each of you can tell our listeners a little bit about who you are and your organization. Alfonso Apu (guest, CMC): Thank you, Dayna. Yes. My name is Alfonso Apu, and I'm the chief behavioral health officer at Community Medical Centers (CMC). My role is to make sure that all services under behavior health, substance use disorder, recovery and care coordination are functioning and are providing access for our patients. We are a part of a large network of clinics. In total, we have 29 clinics. Certainly, our project focuses on our Vacaville [clinics], however, we're extending to most of our clinics when it comes to trauma-informed and screening for ACEs (adverse childhood experiences). Victoria Franco (guest, CMC): Hello, my name is Victoria Franco, and I am a community health worker in trauma-informed care here at Community Medical Centers. What I can say about Community Medical Centers is that we help a lot of the low-income patients to receive the best health care that they need as far as establishing care, behavioral health, and many of the resources that we have. Maria Moreno (guest, CMC): My name is Maria Moreno. I'm a social worker case manager. I've been with Community Medical Centers for 12 years. I started off as a medical assistant and now I am a social worker case manager, taking care of all our pediatric families and patients with any resources that might need. Also, doing the PEARLS questionnaires, many transportation, any speech therapies, any clothing, any food, anything that involves with resources to help out the family and our community. Dayna Long: Thank you so much, Maria. Every time I hear that a clinic is using the PEARLS tool, it just makes my heart sing. As you all know. I'm one of the principal investigators of that tool and I just am so grateful that it has scaled and it's helping children and families across the state and across the country. It definitely makes me feel good to hear that you're using the PEARLS screen. I'm going to start with you again, Maria, if you can tell us more about what did trauma and resilience informed care mean to you before you started work and what does it mean to you now? How did it change? Maria Moreno: Before, when I was here as a medical assistant, it was more about the patient coming in for their physicals, their sick visits, any acute visits, and we would address any situations or concerns that they had, but not fully how now we have the PEARLS. We have now, I feel like the whole clinic is more of a place that families feel safe. Families feel the connection, not only with me but with the doctors. I have had families, I've been here for 12 years that they just see me walking by and they say, "Hey, Maria," and I feel like me also being bilingual, speaking their language has also helped them feel safe, be a good environment for them to be able to connect with any resources or anything that they might need or any traumas or any experiences that they might have that they need to connect with somebody that they feel safe with talking to. Dayna Long: Yeah. Thank you for that. Alfonso, what does trauma-informed and resilience-informed care mean to you and why was it a priority for Community Medical Centers? Alfonso Apu: That's a great question. Just to give you some connections. I've been here for 16 years. I was the first clinician at CMC 15 years ago, and as a clinician and certainly getting to this position of chief behavioral health from the onset through clinical work, the focus was on developing trauma-informed services. I have a lot of memories of seeing many, many patients, especially patients that are extremely impacted, have long histories of generational trauma, immigration trauma. We saw many veterans that brought the need for services in we feel a specialized way. Since the onset of my time here at CMC, I think for myself, I felt that this was a direction that we needed to take and focus. Thankfully, we've always had the support of administration, and now in my role, we certainly have way more support in terms of making sure that this concept of trauma-informed is alive and it stays consistent. Our goal is that all our staff are educated when it comes to trauma-informed. For me, it certainly has been a journey from practicing to developing systems in trauma-informed services. Dayna Long: So Victoria, hearing what Alfonso just reflected on when he was referring to trauma-informed care delivery systems specifically as it relates to intergenerational trauma and other types of ACEs, as a community health worker, what does it look like for you to be trauma informed? How are you approaching staff and patients? Victoria Franco: The way that I approach the staff, starting off with the staff, I feel that the best way was to make them feel that I am approachable, that they can come and ask me any questions because most of the times they're going to be the first ones, the patients are going to be coming up to them asking them questions about the ACEs, and if they don't know, then they need to feel comfortable. That would be maybe the best word that I should have highlighted, for the staff to feel comfortable to approach to me. Also for the patients, I feel that in the beginning I was thinking that it was more like a formal talk with the patients when I would approach them. I have learned that it has to be more informal where they feel more comfortable and not like I'm documenting every word or that I want them to feel like Maria was saying, safe and more human-like, I feel. That would be in regards to the approach with the staff and patients for them to feel comfortable with me. Dayna Long: This question is for any of you. Why did your team join the Resilient Beginnings Network? What did you see were the opportunities for your clinic in being part of the network? Alfonso Apu: If I may, and certainly Maria and Victoria, I think as we add more context. Community Medical Centers has truly been trying to implement ACEs and a trauma-informed system for maybe the last 10 years. From our initial involvement with the National Council of Behavioral Health, which was our first opportunity in a learning collaborative to start learning about what a system that is trauma-informed looks like all the way to now and our engagement with Resilient Beginnings and looking and trying many things in terms of what works in our system from initially giving the ACEs and the PEARLS out as part of our regular screenings, to now, where we feel that this project has been so important for us because it gave us the opportunity to actually hire a resource, and that resource, it's Maria and Victoria, where the resource is more personalized and someone that has, in a way grown up at CMC, with both Victoria and Maria being twelve and eight years already part of our organization, knowing our ins and outs. It also talks about this workforce development and already the sense of trust. By hiring someone that we trusted, that the patients trusted, we felt that the care teams were going to feel more comfortable and the barriers that they always present to us in terms of, and I'm going to say it - another screening, another procedure. Our providers, although they're extremely committed, basically feeling that they were overwhelmed with another task. The best thing for us was to add someone that could truly take a lot of their work off their shoulders, that knew their patients, that were trusted, and as Victoria mentioned, made them feel comfortable that the process was going to be taken care of, the screening completed, patients followed up and not fall through the cracks. That's why this opportunity was so important for us, because it allowed us to hire Maria, and then we hired Victoria. Dayna Long: Building on that, Victoria, what do you feel are the most important aspects of your job as a community health worker? Victoria Franco: The most important aspect is definitely the knowing that I'm helping others. I feel that just being part of, basically my role is to implement the ACEs in what's in the rest of the other clinics. Just knowing that I'm being part of something that is going to change people's lives because like I have mentioned to others before, I feel that if it's not being asked within a patient's... Like, right now with the kids with their pediatrician in their clinic, who else will? I feel that this is the place where they believe and they know that this is the safest. I feel like, for example, for a lot of teenagers, having it being confidential is really important, so then where else can it be more confidential than in their primary care facility? So for sure, just knowing that I'm making a difference and then knowing that someone cares and it just happens to be me, the face of the person that is helping them with that. Dayna Long: I love that. Can you share your process for screening for ACEs? Victoria Franco: Yes. The way that it starts is when the patient comes in, the receptionist provides them with the questionnaire and we have the different type of questionnaires according to their age or if the parent fills it out or is self-reported. From there, it goes into the exam room, the provider reviews it. Then once it's reviewed, it's given to me to bill and to document, and that's when I help the provider with that. Then if they're a high risk, then I follow up with the patient. Alfonso Apu: If you don't mind, I'd love for also Maria to add about the cushions in between what Victoria just mentioned. That's truly our workflow, but what both Maria and Victoria do before we give out the questionnaire and after. Maria Moreno: Usually, also, once the questionnaire comes back here and is reviewed by the doctor, we also go and talk to the patient. If we do have a positive one, I go in there. I make sure that the patient is safe, make sure that if whatever they marked on the paper is present or past, we connect them in there with resources if they would like to. But we just follow up from with the doctor. I know the doctor does have a little conversation with them, not a full conversation, but looks over to see if there's any red flags or any points that we want to bring out. We could go in there and talk to the patient or the family and make sure that they're safe and make sure that they get connected with the right resources after that. Dayna Long: Thank you, Maria, for diving in a little deeper. In the process of screening and responding, what has been the most common reaction that you have received? Maria Moreno: From our teenage [population], sometimes it's a little hard to have them fill anything out, but at the same time, sometimes I do feel like it's a really good questionnaire that they could express themselves, not just by marking it, sometimes by speaking, or sometimes by writing. I have a little quick example that I did have a teenage[r] fill out one of the questionnaires and on one of the questions, number nine that it's the sexual abuse he marked, "Yes, but nobody knows." That, to me was a red flag. I was happy that he wrote that because that we could approach, we could connect them with resources, make sure that the patient is safe, make sure that the family is safe as well. It happened a long time ago. He said he didn't need any services, but I feel that just by him mentioning that or just writing that down, it just went out of his mind and he felt like he told somebody or he at least wrote it down and he doesn't have to keep on keeping it in his mind since it was on his mind. I feel like for a teenage, these are great, for families as well because sometimes they do want to reach out and get a little more resources or more help, but sometimes our visits are so quick with physicals, and shots, and sick visits that we don't have time for them to really say what they feel or what any traumas that they've had in the past. It's been great, the PEARLS questionnaire. Dayna Long: I heard this amazing quote that "When you uncover, you can recover." By naming the unspeakable, it helped him to find a path to healing. Maria Moreno: Yes, correct. Alfonso Apu: I want to add that as part of this process, I think, that's why we went in the direction of really humanizing the screening from our previous tries because not only when the patient is filling the screener, but when the family or the patient gets the screener while they're sitting at our reception area, whether they have a question, whether there was some triggering. That's why Maria and Victoria are so important because their job is to be present, and to be present throughout the day and to at a quick call, be able to go to the front and comfort someone or just answer a question saying, "Yeah, this is a screener that we've implemented at CMC. We are interested in making sure that we address all issues that are going on in our patients' lives, and this is something that is important." I think we see that a lot and it prevents many situations where patients may feel uncomfortable or even get upset. Dayna Long: After you screen a family for ACEs, what are your typical responses? Maria Moreno: Usually, when we screen them, I do think that some families, in the beginning it was a lot of pushback just because they thought those questions were a little personal, or sometimes they just didn't want to discuss any traumas in the past. I feel that once I stepped in, once they saw my face, once I talked to them a little bit about what this was about, it's not just a questionnaire and it's going to go somewhere. I feel like they understood the process and they understood where we were coming from to be able to help them, to be able to connect them, to be able to just feel free to talk about any traumas or any experiences that they might have. Right now, it's been, I think about two years since I've been doing the PEARLS questionnaire. I feel like now it's just as it's gone so usual, the patients have just been filling them out and they don't really do any pushback. They actually like filling it out. Alfonso Apu: If I may add, this is a process for our care teams, too. Maria Moreno: Yeah. Alfonso Apu: –And our providers and then I know Maria and Victoria can tell you in terms of how even with members of our care team may feel or may have specific perceptions about the process or fears about what could happen. I know that I've spoken to many providers in terms of their fear, in terms of what do they do when a patient discloses this during a physical. What we tell them is that, "This patient has been dealing with this for a very long time way before they came into your office, and they have an opportunity in your part of that opportunity because most likely they feel trust and they're disclosing this to you. That's why we have this care team around you to be able to help you with whatever happens." So I think that by saying that, as Maria mentioned, providers now are comfortable because they know that they're going to get the support that they need. Dayna Long: Victoria, reflections from you about how the screening and referral process for ACEs has been? Victoria Franco: For myself, there is three locations that I'm working right now. I started implementing in these clinics a month and a half ago, and at the same time, those providers, it was also their first time. For me, it's been nice that at the same time that I started this, they also did. Together we're learning the process, so I always make sure that I even ask the receptionist, to the medical assistants, and the providers that any feedback that they have to share it with me. The whole point is just to make this as smooth as possible, not to have the providers think that it's another load or for them to think that it is inconvenient to do it in their physical. Basically, we're just here to help and I'm here to make their job easier. I think that that's the best thing how I try to put it for them, that I'm here to help the patient and them in the process, and we just want to help the patient's health in the long run. Dayna Long: You're a month and a half in, you said? Victoria Franco: Yes. Dayna Long: Share a little bit more about what some of the bumps in the road have been, the barriers and how you've navigated through and around them. Victoria Franco: I feel within Community Medical Centers, it's going to be 14 years that I started, so I felt really comfortable because I feel that I know the company pretty well and what it has to offer, and what it provides to the patients, and how much the patients value having Community Medical Centers within their community. Maybe the bumps within being a community health worker doing the ACEs would be, there has been times where if there is a high risk and I go in and I also offer an appointment with behavioral health and they decline it, maybe that's like the bump where you have to respect it and eventually I'll follow up. But that's maybe something that I've learned, not being judgmental, just being understanding, just knowing that I did what I could. Dayna Long: Alfonso, you mentioned that you've been on the ACEs screening and response journey for 10 years now? Alfonso Apu: Yeah, about 10 years. Dayna Long: It's nothing new. The Resilient Beginnings Network, our network, has been doing the work on being trauma and resilient informed for the last three years. We're coming to the close of those three years. What would you say that you have accomplished that you're most proud of? Alfonso Apu: Oh, wow. Well, first of all, even though Victoria exists through a bit of a different grant, certainly hiring her, but through Resilient Beginnings is our opportunity to hire Maria. In the last two years, truly looking at a workflow that we always thought was the end of the line. Not that we tried everything, but it felt like we tried everything. By having now CHWs, case managers, that are truly champions, that's our biggest accomplishment and what comes with it. We have screened, I believe, close to 3000 folks in the last couple of years and the endless interactions that both Maria and Victoria mentioned from these great interactions with patients, care staff, providers, but also making sure that we provide services to our patients in terms of really looking at how we can assist them, how can we deal with what they're dealing with, also provide them with resources in the community. Eventually, I think what I'm summarizing, it creates a culture. I think that's what we've created in Vacaville and that's where we're going at California Street, Manteca, and Dorothy Jones where Victoria is at. Dayna Long: Exciting. Your ability to scale and sustain is phenomenal. There are a lot of clinics across the state of California that are attempting to implement ACEs screening and responses standard of care. What advice would you give to them? Alfonso Apu: Well, I think that certainly looking at their system and what would work best in their system in terms of what they have tried before, for us, we felt that through the experience that we received, through the many different workflows, we felt that humanizing this was the best way. Really looking at resources, I think that in the administrative level, you're going to have to look at sustainability and how do we continue to maintain Maria and Victoria, and maybe hire other CHWs to take on this role. Certainly, I think a word of direction is really looking at your resources, looking at how best you can screen and develop a culture. I think I always go to that because at the end of the day, we're screening folks, but I think we've developed a culture where people feel safe. Now, we just have to problem solve the issues of sustainability and all that good stuff that some folks don't like to talk about, but I have to. Dayna Long: Maria, what would you say? Maria Moreno: I think just to not give up, because sometimes we have pushback not just from patients, sometimes the providers, sometimes our staff, and it sometimes just makes it difficult for one to be trying to be in every spot to help everybody out to make sure that they feel like this is a process that's going to work. I think that it's such a great questionnaire in my personal life as well. I think that this helps a lot of families and I think that they should not just not give up and to keep going. I think that I'm going into my third year and I have seen teenagers, I have seen families been really happy and overcome some of their traumas and their needs or resources. I feel that, at the end of the day, it is what we are looking forward to. Dayna Long: Everything I hear you saying is focused on celebrating the relationships and being in communities with family and their wins are our wins, too. I love that you shared that the Resilient Beginnings Network really is a learning collaborative, and as a collaborative, we believe in not reinventing the wheel, but sharing, sharing best practices and procedures. Throughout this process of being part of the Resilient Beginnings Network, what did you learn from other clinics that you ended up implementing? What worked for you? Maria Moreno: I had thought about that because every time that the RBN would do the meetings, I think those were such great experiences and tools for learning for myself. Starting here in Vacaville, since nobody else was doing it, I felt a little, "Am I doing this right? Are the patients getting what they need? Am I helping out the doctors as much as I could?" I feel that with all those meetings that we went to and everybody sharing their stories and what worked for them and what didn't work for them, I feel like it helped me a lot to not fall through the crack or just to not give up, to just keep going. There was a lot of things that would come up. I can't think of one specific one, but I do know that everything that would come up that would work for them, I would implement it here and it actually did work. Dayna Long: It's wonderful to know that those virtual meetings were helpful. I like hearing that for sure. Alfonso Apu: For me, I think it's validation. I think that sometimes there's so many feelings and emotions. We certainly always want to make sure that you do your best job, especially when patients are involved, that you're being efficient, that you're creating environments which are safe. But for me, participating in this was in terms of my role, it gave me an opportunity to almost take a step back and feel a bit of validation that maybe we were headed the right way. Maybe we've been doing it, and it hasn't been that bad. It took a lot of stress off of me to get the support from the Network and all the meetings and the webinars and just learning and just hearing other people's stories. I just wanted to share that, because personally it's allowed me to grow. Dayna Long: Speaking of growing, what's next for Community Medical Centers? What's on the horizon that you hope to achieve? Alfonso Apu: I can tell you my role, certainly. I think that we want to become this agency that's not reactionary to trauma. We truly want to be reflective, and trauma-informed, have all our staff have some training when it comes trauma-informed, but also to make sure that our staff are well. I think with trauma-informed systems, a huge part of this process is wellness and self-care. We believe that through this process, we can not only impact patients, but we can impact our staff, especially during those times where there's so much need, again, not only for patients, but that our staff are going through the same things. They most likely have suffered similar traumas, yet they're in the trenches helping our patients. My dream is to have an agency that is adaptable and truly engaged in trauma-informed services. Dayna Long: Victoria, Maria, do you want to add to what's next on the horizon? Victoria Franco: Yeah. Well, as far as me, I'm starting now with the third clinic and my role is to keep implementing the ACEs within Community Medical Centers, and I'm really looking forward to that. I really enjoy what I do and I love that I'm being part of this and that I get to educate others about this. I feel that this can be unknown to many, and then just coming in and letting them know. Sometimes I feel that I'm even like, "How is there not more providers doing this?" I feel that it just takes a little bit of being educated, and once you get to know it, it just comes so naturally, which also it comes to the giving and advice that everyone should do it. I know that in the beginning a lot of providers or staff can hesitate on this, but I feel that once you get educated... Starting this off with other providers that also are starting this off, I feel that in the beginning you just have to get into the habit. It is just something that becomes a habit as well as the front desk of, "Okay, let me remember to give this form." It’s just like anything else. It's just making the habit and then making the process and being consistent, and it just comes so natural that you feel so good afterwards. Maria Moreno: For me, I would say adding on to Victoria's, it's probably the same. I think just keeping that consistency with our patients, with our employees, with the doctors. I think that everybody's growing in their own way, and we all learn from each other, and I feel that we're going the right way, helping the community and our families and helping each other here grow, so...I think we are in a good spot. Dayna Long: I'm just smiling because everything that all three of you are mentioning, you can just feel the love and the sense of belonging that you have to the community, and I think everyone is fortunate that Community Medical Centers is there and that the three of you work there. I want to open up the floor to any of you to say any last words. Alfonso Apu: I think I'm just upset that we're coming to an end when it comes to this project. We certainly hope to still be engaged and continue to learn from everyone involved. Again, for me personally, it's been a learning experience, not only in terms of being in administration, but just seeing the process go through and just trusting Maria and Victoria to truly develop their roles and just do what they're best at. I just leave them alone. (laughs) Victoria Franco: I think that for me, I feel like how you were mentioning that you can perceive the love that we have for this. I feel that for me, having so many years at Community Medical Centers, I feel that it's something that Community [Medical] Centers is about. Even with Alfonso, I feel like since I met him, in just talking to him, you can see the passion that he has for this. It just makes it even easier for us, because we know that we have the support. We know that we have someone like Alfonso with all this knowledge that just makes it so much easier for us. Dayna Long: Thank you for the work that you do and thank you for sharing. Alfonso Apu: Thank you for the opportunity. Victoria Franco: Thank you. Health Pilots podcast outro:
Thank you for embarking on this episode of Health Pilots hosted by the Center for Care Innovations, with podcast production services by Wayfare Recording Company. Special thanks to Dr. Dayna Long, the Resilient Beginnings Team at CCI, Trauma Transformed, and the featured pediatric care team that has joined us today. Check out this episode’s show notes for relevant links, resources, and opportunities! And, if you like what you heard, please spread the word - we’re available on all major platforms and be sure to subscribe where you listen to podcasts. For more information about the Center for Care Innovations or for upcoming programming, events, and funding opportunities, please visit our website - careinnovations.org - and connect with us on our socials: LinkedIn, Facebook, and Twitter. This is Wes Gabrillo at the Center for Care Innovations, and we appreciate you tuning in. Catch you on the next episode of Health Pilots!