In the late 1990s, the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente conducted a landmark study on more than 17,000 adults that examined the effects of adverse childhood experiences (ACEs) on current health status. They found a powerful connection between the amount of adversity faced and the incidence of over 40 health outcomes. Since then, similar surveys conducted across several states resulted in consistent findings: exposure to adversity can put a child on a poor health and developmental trajectory, contributing to health disparities and increasing the achievement gap. However, emerging evidence shows that this trajectory can be altered. Early detection, intervention, and the promotion of resilience and protective factors can begin to reverse the detrimental effects of childhood adversity and trauma.

Early intervention, particularly in the first five years of life, presents the best opportunity to protect children from the most harmful effects of toxic stress, as the brain and other biological systems are most adaptable at this stage. Health practitioners often serve as a first point of contact for families in need: well-child visits are a common experience for families that involve at least fourteen visits from birth through age six. The early, intensive touch points that health care providers have with children and their caregivers represent a promising opportunity for intervention around childhood adversity.

Low-income children are disproportionately exposed to adversity. Safety net providers, who care for this population, are uniquely positioned to:

  • identify children at an early age (0-5 years) who have been impacted by adversity and trauma, or at risk to be impacted,
  • take steps to support these children and their families in addressing trauma, and
  • promote resilience and protective factors when care is delivered.

Bolstering the understanding of trauma-informed care among providers and clinic staff is key to identifying and appropriately supporting affected patients to mitigate the effects of trauma. Additionally, the adoption of trauma-informed approaches helps clinics reinforce the aim of the primary care medical home model by deepening the relationship between clinics and patients. By recognizing the stress and adversity that children and their families face, providers and staff can enhance patient engagement and reduce avoidable illness, chronic conditions, and health care costs.

However, given the increasing demands on safety net clinics and providers, they cannot identify and address adversity on their own. There are many community-based organizations, from county governments to early childhood care providers, working to support children and their families. Safety net providers and staff play a strategic role in identifying patients experiencing trauma, linking patients to existing resources, developing internal systems to coordinate and manage patients, and growing external partnerships to strengthen community driven efforts. By identifying partners and referral resources, safety net clinics can support the efforts of existing community-based organizations while also leveraging their expertise and experience in building resilience and strengthening families.

Program Structure & Core Content

The goal of this program is to support organizations over a 24-month period with an interest in and commitment to addressing childhood adversity in pediatric populations (with a focus on ages 0-5 and their caregivers). The program will build on existing organization-led initiatives and interventions in childhood adversity so that clinics can further test, develop, and strengthen their role as a place to address trauma and promote resilience.

The key objectives of the program are to:

  1. Deepen organization-wide commitment and internal systems to create a trauma-informed approach to care, including:
    • Training clinical and non-clinical staff.
    • Creating a safe clinic environment.
    • Preventing or addressing secondary traumatic stress in staff.
    • Dedicating organizational resources to advance the work.
    • Aligning with other care transformation efforts (e.g. value-based care, social determinants of health, behavioral health integration)
  2. Strengthen implementation strategies that could be used by safety net clinics to prevent, screen, respond, refer, and treat. This encompasses:
    • Testing and learning how to integrate important elements into clinical and operational care in safety net health care settings. These elements have shown to be effective in other health systems. Core elements to be considered include:
      • Preventing trauma and promote resilience.
      • Assessing for trauma related health issues.
      • Addressing trauma related health issues (e.g. anticipatory guidance; treatment, coordination, providing referrals).
      • Consulting, co-locating, and/or coordinating with behavioral health services.
      • Involving families in service delivery, planning, implementation, and evaluation.
    • Developing successful community-level partnerships to address trauma and strengthen child, family, and community resilience (e.g., referral partnerships, community education and empowerment, parental support).
    • For advanced organizations: supporting the development and testing of innovative solutions for prevention, treatment, and promoting resilience.
  3. Contribute to broader learning for the field which includes:
    • Participating in external evaluation by providing data and stories to better understand effective strategies and approaches.
    • Actively engaging in the learning community to share best practices and strengthen collective knowledge.
    • Sharing lessons with broader field and highlighting lessons through presentations and hosting peers (as appropriate).

A cohort of 5-7 Bay Area safety net health care organizations that have demonstrated an interest in addressing childhood trauma, as well as a commitment to experiment and learn with others, will be selected to participate in the Resilient Beginnings Collaborative.

This program will include three to four in-person sessions over the course of the 24-month period, quarterly webinars to hear from experts and share updates on your progress, bi-monthly coaching calls, and site visits to exemplar organizations. Key partners and faculty from across the Bay Area and country will be available for participating clinics to connect with and learn from throughout the program. An external evaluator will develop a learning framework, document lessons, and begin assessing impact on organizational practice change.

Selected organizations will participate in the following phases of the program. The length of time for each phase may vary slightly depending on organization’s capabilities as they begin this program.

Program Phases


Organizations will participate in an organization-wide, all staff workshop* on creating a trauma-informed system of care to ensure a foundational understanding of the following:

  • Clinical impact of trauma and adversity on children and their families.
  • Building a trauma-informed organizational culture to support enduring clinical integration of trauma-informed practices.
  • Understanding the core elements for integration of trauma-informed practices into clinical settings (i.e. patient engagement, training of non-clinical staff, leadership buy-in).

Simultaneously, organizations will participate in the following activities:

  • Identify a project team to participate in a learning community and champion the organization-wide efforts.
  • Work closely with the CCI team to clarify organizational level needs that would benefit from technical assistance.
  • Work with the selected evaluator to define metrics and start collecting baseline data.


After selected organizations have set up the internal program infrastructure, identified needs, and trained their organization on the principles of trauma-informed systems of care, they will actively develop and implement a plan for action which will include the following:

  • Develop a plan to identify the activities and approaches for implementation and how CCI technical assistance resources would support success.
  • Begin testing and implementing the core elements outlined under the Objectives section above.
  • Identify community partners with expertise in early childhood interventions and aligned with goals of addressing trauma.
  • Co-design strategies with community partners and patient advisory groups to ensure referral resources and coordination efforts meet needs of patients and families.


Teams will build upon the implementation tests to develop a plan for broader site- and organization-wide implementation. Teams will also strengthen partnerships with community-based and public agencies to ensure efforts are aligned. This phase is critical to set organizations up to sustain these efforts over time. They will:

  • Document internal workflows and protocols to strengthen internal clinic infrastructure.
  • Build a cadre of internal and external referral resources and design a process for seamless referrals.
  • Reinforce partnerships made with community and public agencies and referral resources with an emphasis on sustainability.
  • Document, communicate, and spread lessons and stories of success within clinic and across learning collaborative.

* Note: CCI is working with Trauma Transformed to offer organization-wide trauma-informed systems of care training. It is assumed that each participating organization would host the training onsite for all staff. The participating organization would be responsible for securing training space, protecting time for staff to be trained, and working with the trainers to set dates and times for the training. CCI will cover the costs of the training. The training is expected to last two hours, with an additional session geared toward organizational leadership. The expectation is that all staff will be trained within the first six months of the program but trainings can be split across different days to accommodate all staff. CCI is committed to working with organizations in the program to ensure this training model is feasible given organizational constraints (i.e. size of the organization, different sites, union contract concerns, etc).