The collaborative’s data and findings form the basis for the next phase of the state’s ACEs Aware initiative
Nearly 18 months ago, just as the pandemic lockdown began, CCI announced a learning collaborative called CALQIC to screen, treat and heal for adverse childhood experiences, or ACEs, in partnership with the UCSF Center to Advance Trauma-and-Resilience-Informed Health Care – part of a statewide screening initiative that was complicated by the COVID-19 pandemic.
At CALQIC's final session this September, Dr. Nadine Burke Harris, Surgeon General of California, praised its accomplishments during a time of unprecedented hardship. “I want to thank you all for this incredible hard work and partnership with the state,” she told participants via Zoom. The state would continue to build on CALQIC’s “extraordinary” work, she said, in the next phase of this work.

Why CALQIC centers respect and dignity in ACEs screening
The movement for childhood trauma screening has emerged because a landmark CDC-Kaiser Permanente study and dozens more have linked ACEs with an increased risk for a host of serious diseases and conditions across the lifespan, including cancer, depression, suicide, diabetes, substance use and heart disease. The fallout from ACEs is also costly. Researchers have found the annual health-related costs of ACEs and toxic stress to California to be $112.5 billion a year, which includes both health care spending and “disease burden,” which includes premature death and years of productive life cut short by disability. ACEs screening and treatment has the potential to lower the risk of chronic disease and keep ACEs from being passed from one generation to the next, according to the CDC. In addition, researchers like Dr. Robert Sege of Tufts University School of Medicine and others have found that positive childhood experiences, support, and strengths-based counseling from provider can reduce and even reverse the impact of ACEs and toxic stress. But ACEs screening done with little explanation -- or interventions that seem patronizing or threatening -- could backfire, experts say. To create a bridge to patients, the CALQIC team developed a healing approach based on trust, empathy, dignity, and mutual respect for ACEs screening and response in primary healthcare settings known as the TRIADS framework. The TRIADS framework urges providers to explore their patients’ experiences with racism, discrimination, and maltreatment as well as their sources of resilience. “Patients with histories of adversity often experience healthcare and other systems as personal, judgmental, and harmful. For this reason, we believe that it is essential to conduct ACEs screening and response within a safe and caring healthcare team-patient relationship” and to focus on the patient’s strengths and healing, according to UCSF researchers. [caption id="attachment_28109" align="alignleft" width="560"]
CALQIC coaches and clinics share their stories
After a meditation led by Jackie Nuila of CCI, the discussion turned to program data and a powerful conversation that Dr. Ken Epstein, PhD, LCSW, facilitated with the CALQIC coaches and providers in a Wireside Chat. The discussion mirrored the same principles used by CALQIC providers talking with patients: an open, reflective discussion in which speakers were supported and affirmed. The group explored how trauma screening and response changed their relationships with patients, providers, and families, talking about their initial anxiety and stress over trauma screening as well as their joyful successes. [caption id="attachment_28110" align="alignleft" width="790"]
A clinic roundup on healing challenges, victories
In subsequent Zoom breakout rooms, clinics around the state reported how they rolled out screening during the pandemic. Some obstacles were physical -- besides contending with the pandemic, one Southern California clinic was plagued by flooding on its top floor and had a car crash into its bottom floor reception room (after hours, fortunately). Others faced social challenges, including opposition to screening from exhausted nurses. But despite barriers, nearly all had made strong progress. Here are a handful of highlights from their stories:LA County Department of Healthcare Services: More than 8,000 screens and 2500 referrals
Los Angeles County is one of the largest and most diverse counties in the US. “I’m most proud of our team, which as of this week has done more than 8,000 screens among the nine DHS clinics in the program and made about 2500 referrals to social and mental services,” said CALQIC lead Nina Thompson. “We’ve also trained 280 clinical staff in ACEs Aware and trauma-informed practices, including providers, nurses, nutritionists, clerks, community health workers and case managers.” She added that ACEs screenings have opened up important conversations with patients and trauma-informed care practices further strengthened that bond. To meet social needs such as food insecurity identified by the screens, LACDHS obtained a Network of Care grant to reach out to 700 community-based organizations in the county and are currently linking up patients to them through provider referrals and platforms like One Degree.Santa Barbara Neighborhood Clinics: “Screening opened the door to seeking further treatment”
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Marin Community Clinics: “Including all the voices”
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Borrego Health: Overcoming A Maze of Obstacles
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Family Health Centers of San Diego: “Walking the walk” in Arabic, Vietnamese, Cambodian, and more
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Sonoma County Indian Health Project: “We want to get our community involved in treatment”
During the pandemic the Sonoma County Indian Health Project lost three licensed therapists, along with a psychologist and a psychiatrist who were working for the clinic part-time. It is now down to one licensed full-time therapist. To be able to work on ACEs screening and response, the team lead turned to their primary care provider and medical assistant. “Our population faces intergenerational trauma dating back to the settlement of California and the Gold Rush, and the displacement of tribes and traumas faced in that history,” said Kurt Schweigman .“So we want to educate all our staff about that, and to get the community involved” in treatment.Santa Rosa Community Health: Everyone from front desk staff to clinical is trained in ACEs screening and response

La Clinica: “People whose voices don’t usually get raised are speaking up and blossoming”
Dr. Sara Johnson remembers Dr. Alicia Lieberman, in her first webinar for CALQIC, “saying that healing occurs in relationships. And that has been a deepening epiphany throughout the project. We’ve seen that we need to prioritize our resilience work at the clinic before we heal anyone else. We’ve integrated the domain of wellness into all our work – for example, when talking about intergenerational ACEs, we talk to our patients about how that impacts parents and children.” She also noted the clinic, which started as a close-knit storefront organization, now has thousands of employees across many counties. “We’ve seen people whose voices don’t usually get raised speaking up and blossoming as a result of this work, and that is really cool,” she said.Northeast Valley Health Corporation: Treating trauma we would not have known about were it not for screening
Northeast Valley Health Corporation is a large federally qualified health center with 17 clinics. Their screening focuses on patients zero to five years old at the two-week visit, the 15-month visit and at the well-child exam visits yearly from two to five years old, as well as a small subset of adult patients at the Sun Valley Health Center. As a follow-up to one screen, providers talked with a mom who had recently migrated to the US with her children, who were now anxious, bedwetting, and showing other signs of trauma. It turned out, as the mother tearfully said, that she had been separated from her children at a shelter and sexually assaulted, and her children did not know where she was for several days. “If we had not done ACEs screening, we would not have known about that,” Carolina Aguilar said, explaining that they were much better able to help the family as a result.Petaluma Health Center: All-staff ACEs trainings and virtual parenting groups
Petaluma was most proud of its trainings, which, occurring amid the pandemic and natural disasters, “was no small feat,” according to Director of Innovation Jessicca Moore, FNP. Besides hosting virtual parenting support groups, all their providers took ACEs Aware training and new hires trained in ACEs and toxic stress as part of onboarding. “Engaging with patients about ACEs isn’t as scary as it seemed,” she said. “For some patients, understanding the impact of ACEs can be the missing piece that helps them understand their lives and challenges.”Eisner Health: “It takes a village”
Sometimes the most humble people in an organization can create the most transformational care, UCSF trauma researcher and professor Alicia Lieberman has said. Eisner Health leaders stressed this point when they talked about their pride in training all their employees about ACEs and toxic stress. “From people taking calls to the front desk staff, each person’s role really matters and makes an impact,” said trauma informed care coordinator Andy Fetzer of Eisner Health. “Our CALQIC coach was amazing, too, and her materials helped us tailor our offerings to our patients’ needs.”The next phase: “Cutting ACEs and toxic stress in half in our generation”
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UPDATE: Providers may also want to check out the evaluation of our CALQIC program. This report by the Center for Community Health and Evaluation (CCHE) presents findings from the initiative-wide evaluation that spanned across all 15 organizations and 48 clinic sites participating. It used a mixed methods approach to understanding progress, facilitators, and barriers, including quarterly clinical data reporting, a clinic capacity self-assessment, interviews with clinic representatives, and document review.