The state of California, led by California’s Surgeon General Nadine Burke-Harris, in partnership with Governor Newsom, the California Department of Health Care Services (DHCS), and health and community leaders, is leading system reform that recognizes, and responds to, the effects that adverse childhood experiences (ACEs) and toxic stress have on our biological systems and addresses the lifelong impacts of ACEs.
Key to that roll out is the ACEs Aware initiative. Starting on January 1, 2020, DHCS will provide a payment to Medi-Cal providers for screening their patients for ACEs. The Office of the California Surgeon General and DHCS are committed to providing organizations and providers across California’s health care system and communities the training, tools, and resources needed to effectively and equitably incorporate ACEs screening into patient care.
ACEs are stressful or traumatic events experienced by age 18 that relate to adversities across three domains:
- Physical, emotional, or sexual abuse;
- Physical or emotional neglect; and
- Household dysfunction (e.g., a parent with a mental health condition or substance use disorder, absence due to separation or divorce, or intimate partner violence).
In recent years, ACEs research has expanded, and the current screening tools approved by the state include assessing for other traumatic experiences, like discrimination, food and housing insecurity, separation from a caregiver due to foster care or immigration, and community violence.
According to the most recent California Department of Public Health data reporting from the Behavioral Risk Factor Surveillance System, 63.5 percent of Californians have experienced at least one ACE, and 17.6 percent of Californians have experienced four or more. Nationally, the prevalence rate is similar. Research also shows that individuals who experienced ACEs are at greater risk of numerous ACE-associated health conditions, including nine of the 10 leading causes of death in the United States.
At the same time, research also shows that early detection, early intervention, and trauma-informed care can improve outcomes. Trauma-informed care refers to care in which all parties involved recognize and respond to the impact of traumatic stress and resiliency factors on patients and service providers. Recently, the U.S. Centers for Disease Control and Prevention issued a special report on ACEs and suggested that the prevention of ACEs may lead to a reduction in a large number of health conditions, including heart disease, stroke, cancer, and diabetes, as well as depression, unemployment, and substance dependence.
Despite all of the mounting research, ACEs screening and response is still an early-phase health care innovation. CALQIC has been designed to support clinics and providers in adopting successful ACEs screening and response and aligning efforts with the larger ACEs Aware initiative. CALQIC’s ultimate goal is to integrate ACEs screening and response in health care settings in a way that enhances relationships between patients and providers, helps connect patients to supportive services, and leads to better outcomes such as reduced disparities and positive experiences with care.
Learning Collaborative Structure & Core Content
The goal of CALQIC is to support organizations over a 15-18 month period with experience and commitment to ACEs screening for and responding. The learning collaborative will build on existing organization-led initiatives and interventions so that clinics can further test, develop, and strengthen their role as a place to screen for ACEs, treat trauma, and promote resilience.
CALQIC will offer training, tools, expertise, and support to address clinical and organizational issues associated with ACEs screening and response, including, but not limited to:
- Trauma-informed care principles and how to achieve them in patient care and for your organization;
- Information on ACEs and toxic stress physiology related to implications for patients’ short- and long-term health;
- Clinical algorithms and workflows to address ACE-associated health conditions by supplementing usual care with education on toxic stress and strategies to regulate the stress response;
- Tools and interventions to promote resilience;
- Knowledge and tools for preventing, recognizing, understanding, and responding to vicarious trauma and burnout among staff; and
- Knowledge and approaches for involving patients and families in designing and implementing trauma informed approaches to care.
A cohort of up to 15 California health care safety net organizations that have demonstrated experience in addressing trauma and adversity, as well as a commitment to build on their work and learn with others, will be selected to participate in CALQIC.
This program will include three in-person sessions and two regional workshops over the course of the 15-18 month period, webinars to hear from experts and your peers, monthly coaching calls, and site visits to exemplar organizations. Key partners and faculty from across the country will be available for participating clinics to connect with and learn from throughout the learning collaborative. An external evaluator will help in developing and collecting metrics at the site and organization level and in assessing the overall impact of the program.
Selected organizations will participate in the following phases of the program. The length of time for each phase may vary depending on an organization’s capabilities as teams begin this program.
Phase 1: Building a Foundation for ACEs Screening & Response
Organizations will build on their internal program infrastructure to communicate and implement ACEs screening at their initial clinic site and participate in the following activities:
- Identify a project team to participate in the learning community and champion the organization-wide efforts.
- Ensure clinical and administrative leaders are knowledgeable and regularly involved in the initiative.
- As a team, complete a baseline assessment in order to identify strengths and opportunities related to ACEs screening and response.
- Work with the selected evaluator to finalize metrics and collect baseline data.
- Understand current state of ACEs screening and response, including what’s working and what could be better.
- Develop a plan to identify goals, the activities and approaches for ACEs screening implementation, and what technical assistance resources would support your success.
Phase 2: Test and Implement ACEs Screening and Response
After selected organizations have set up the internal program infrastructure, identified goals, needs, and started collecting baseline data, they will:
- Begin testing and implementing the core changes (i.e., workflows and protocols to strengthen internal clinic infrastructure) identified to drive ACEs screening and response.
- Build or strengthen a cadre of internal and external referral resources and design a process for referrals.
- Co-design strategies with patients and community partners to ensure screening, referral resources, and coordination efforts to meet the needs of patients and families.
- Report data and insights regularly to CCI coaches and the evaluation team.
Phase 3: Spread and Sustain
Teams will build upon plans for broader organization-wide implementation. This phase is critical to set organizations sustain efforts over time. They will:
- Standardize and embed workflows and protocols for screening and response into organizational policies, procedures, and systems.
- Spread ACEs screening and response to additional sites (if applicable) as identified in the initial application.
- Document, communicate, and spread lessons and stories of success within the clinic and across the learning collaborative.
- Report data and insights regularly to CCI coaches and the evaluation team.
The learning collaborative will include up to 15 organizations representing at least 50 sites that provide comprehensive primary care services to Medi-Cal adult and pediatric patients. Organizations will be selected across the state with the goal of achieving geographic diversity.
While the participation and funding for CALQIC will be at the organizational level, ACEs screening and response is expected to be carried out at an initial pilot site (or sites) with the goal of spreading ACEs screening to additional sites (for organizations with multiple sites). We will be offering two tiers of grant support depending on the organization’s size and ability to spread to other sites:
- Tier 1 (1-2 sites): $50,000 per organization
- Tier 2 (3-5 sites): $70,000 per organization
In the application, organizations will be asked to identify at least one pilot site as well as up to four additional spread sites, depending on which tier you are applying for.
Qualifying organizations include:
- Federally qualified health centers (FQHC) and FQHC look-alikes
- Community clinics, rural health clinics, and free clinics
- Ambulatory care clinics owned and operated by public hospitals
- Indian Health Service clinics
- Other primary care (or pediatric) practices serving mostly Medi-Cal patients
Regional clinic consortia and statewide clinic associations are not eligible to apply.
What Makes a Strong Applicant?
- Foundational Trauma-Informed Care Efforts in Place: Successful applicants will have started their journey to become healing organizations and should have some elements of trauma-informed care in place. For example, clinics should already have provided some level of education or training about trauma-informed care at the site or organizational level, made strides at promoting emotional wellness and addressing secondary trauma in staff, or worked to transform their office environment to be more welcoming of patients from different backgrounds and cultures.
- Prior Experience and Strong Commitment to Screening for ACEs: Successful applicants will have piloted or started screening for ACEs in at least one clinical site or population OR the ability to begin screening at one or more clinical sites by mid-2020. Organizations should have some level of experience in integrating practices to address trauma (vs. not starting from scratch) and an early implementation of practices to promote resilience and address trauma (at the clinical and/or organizational level).
- Desire to Align with Statewide Goals: Successful applicants will have a desire to align their efforts with the statewide initiative, ACEs Aware, including ensuring that providers complete the two-hour credentialing training, understand systems for billing for screening, and plan to use the approved screening tools (including the PEARLS tool for pediatrics and the ACES-Q for adults).
- Evidence of Behavioral Health or Other Internal Supportive Resources, or Partnerships with External Agencies or Community-Based Organizations: Successful applicants will be able to demonstrate evidence of behavioral health resources available and the ability to make effective warm-offs to internal clinical staff and other supportive resources. For applicants without robust internal behavioral health resources, organizations should be able to demonstrate existing (even if early) partnerships with external agencies or community-based organizations focused on addressing adversity or other related topics (i.e., early childhood development or social determinants of health).
- Data, IT, and QI Systems in Place: Successful applicants will have data, IT, and QI systems in place with the ability to track patient level data and make improvements to ACEs screening and response processes.
This program is intended to be flexible and responsive to the needs of participants, so we ask each organization to act as a partner in shaping the program by committing to the following:
- Leadership Buy-In: Successful organizations will require leadership that is committed to ACEs screening and response. It will also require leaders to understand the importance of how a trauma-informed approach relates to both organizations and clinical interventions and willingness to change internal systems to best support staff and patients. We expect strong leadership support from the CMO and COO at a minimum, as demonstrated through the letter of leadership support.
- Patient and Community Involvement: Successful organizations will involve patients and community members perspectives and experiences in plans to implement ACEs screening and response.
- Continuity and a Dedicated Team: At least four individuals are required to be committed to the core program team to promote continuity, with a maximum of eight members per organization participating in core activities (i.e., in-person convenings and evaluation interviews). The team should include:
- At least one senior leader who can ensure protected time for team members to participate in learning collaborative activities as well as lead change within their organizations. This individual should also have decision-making authority to move ACEs screening and response work forward.
- A provider champion that has a significant role in your organization’s ACEs screening efforts;
- At least one frontline staff or provider who can inform and lead the operational and clinical implementation within the organization; and
- A data or IT staff that can help to manage data and metrics collection and reporting.
- Representatives from additional sites beyond the pilot site (as appropriate).
- Participation in Program Activities: Team members are expected to fully participate in program activities including all three in-person sessions, virtual sessions, and monthly coaching calls. Teams will be asked to complete defined pre-work assignments for virtual and in-person sessions as well as share lessons learned by presenting examples of their project successes and challenges.
- Metrics Collection & Evaluation Activities: Teams are expected to work closely with an external evaluator to collect and submit quarterly data on a standardized set of measures as well as quarterly progress reports to share stories about the impact of the work. Teams will submit data on five required measures and up to one additional optional measures during each quarter of the program. (See the Sample Metrics tab for a current draft description of the measures.) The finalized definitions of program measures, including detailed specifications, will be shared during the program’s kickoff webinar. The evaluation team will work with individual organizations about how best to pull and report data, with the goal of all clinics providing CPT-code based reporting by December 1, 2020.
Finally, there will be an option to collect and report data monthly for those organizations which would prefer to track data more frequently than quarterly in order to use more rapid data cycles for improvement.