Listen: Beyond the Screenings – Connecting Pediatric Care to Community Support

Episode Teaser // Sheshashree “Shesh” Seshadri (guest):

We do capture a lot of them in the first three years of life. As you know that we get a lot of visits, 1 month, 2, 4, 6, 9, 12, 15, 18, 24, 30 and 36. That’s a lot of visits. So this I think is the prime time when they’re establishing good relationship with the providers. This questionnaire can actually be administered at a pediatric office to get the help they need. I think most of the times parents don’t know where to ask for resources and they did not think that patient-centered medical home is the place to ask.

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 52 intro // Resilient Beginnings Network (RBN):

What happens when health care shifts its focus from “What’s wrong with you?” to “What happened to you?” 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 are teams from the Resilient Beginnings Network — a Center for Care Innovations 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. 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 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. Find out what it means to provide care in which all parties recognize and respond to the impact of traumatic stress and resiliency factors on children, caregivers, and service providers.

Today’s episode features Bay Area Community Health which was formed off the strength of Southern Alameda County’s Tri-City Health Center and Santa Clara County’s Foothill Community Health Center during the middle of the COVID-19 Pandemic in 2020. Bay Area Community Health, or BACH, brings more than 70 years of combined service to an area that stretches from Union City to Gilroy. They serve more than 100,000 people who rely on high quality healthcare services regardless of their immigration status, ethnicity, disabilities, or ability to pay.

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 conversation with Bay Area Community Health!

Dayna Long (host, RBN):

Hi, I’m Dr. Dayna Long, the medical director of the Resilient Beginnings Network, and today I’m here with two amazing members of our Resilient Beginnings Network collaborative. Can you please both introduce yourself, say your name and what your role is at Bay Area Community Health.

Melissa Pereda (guest, BACH):

Hi, my name’s Melissa. I’m the pediatric care coordinator for trauma-informed care.

Shesh Seshadri (guest, BACH):

I’m Dr. Shesh Seshadri, a pediatrician by training and clinical director at Bay Area Community Health.

Dayna Long:

Thank you so much.

So when both of you think about systems of care delivery that are trauma-informed, can you really walk us through what it looks like on a day-to-day in terms of how you approach patients at the Bay Area Community Health Center and what patients’ experience is when they come in contact with your clinic?

Shesh Seshadri:

So initially, we did not have anything in mind like trauma-, resilience- or informed care. So at that time we did not have the term, “adverse childhood experiences” or anything like that. But we were seeing the impacts of this in classroom, on the street, in our jails, and on the news, resulting in significant cognitive delays, learning difficulties as well as delinquent behavior, bullying, physical fighting, dating violence, and weapon-carrying. So, at that time our CEO, Dr. Page, would talk about three things before we actually introduced this. And those were the three missions and he said about –quality, community, and respect.

What Bay Area Community Health stands for, for the quality, is everyone deserves to enjoy quality healthcare no matter their ability to pay. And for community, by listening to our community with humility, we gain strength, purpose and partnership. And he would talk about respect, so all who enter our doors, like patients, staff, community and partners are heard with an open mind and valued for their unique strengths. So that’s how we started before we had all this trauma-informed care and so on, because our patients have suffered trauma for generations due to historical racism, structural inequities, and trauma related to immigration.

So, becoming a healing organization with a trauma- and resilience- informed pediatric care model became our vision. So, with the coaching received from your team at Resilient Beginnings Network and Center for Care Innovations, our vision strengthened and on a day-to-day basis, I think Melissa, you can talk about what exactly we do with the patients, how we screen them and so on.

Melissa Pereda:

On registration, staff reviews patient’s records to determine if PEARLS screening is indicated during visit. Staff provides PEARLS tools to the caregiver and/or to the patient that’s 12 years to 18 years of age. Medical assistant transcribes ACEs score into the EMR. Provider reviews ACEs score’s treatment plan. Provider documents ACE score, billing code, and treatment plan, follow-up and a visit note.

Shesh Seshadri:

So, initially our plan was to standardize and systematize the workflow for the screening on a day-to-day basis and to document it. So this was our very first objective in our program when this was first started by the then pediatric director, Dr. Puri. And now I think we’ve come such a long way from there, so I would like to give a shout-out to our ITIS team. So when we do log into a patient system or onto a chart, it does pop up on our electronic medical records that we have to remind our staff to screen the patients, which is our first step in becoming a healing organization, to find out our patient needs. So this pops up and it says, “Hey, let’s administer this questionnaire.” So that’s what we do as our first step and that’s what we did with you all in our first year at Resilient Beginning Beginnings Network collaborative.

Dayna Long:

Being that you’re a clinic that is relatively new, starting essentially during the Pandemic, how did you guys first start to think about, “well, we should screen for ACEs and respond.” And what was the startup like for you in terms of how did you approach staff and start to do the training that’s necessary even to initiate screening?

Shesh Seshadri:

That’s a good question. So, we were two different organizations when we first started, although we have a lot of history, well decades, of each of the organizations. So we also were on two different electronic medical records (EMR). I remember Tri-City being on NextGen and we were on ECW and then we were able to change over to Epic and eventually merge onto it.

But, we were giving out paper questionnaires and the parents would fill it out. And I think this role of Melissa was created for this. This is only in, we call ourselves Bay Area Community Health North for Alameda County and Bay Area Community Health South for Santa Clara County.

This role or title of pediatric care coordinator, that Melissa does, is only here in our Alameda County. We are still trying to carve out a role to have a separate person doing this in Santa Clara County at this time. The medical assistants are helping with that with behavioral health care coordinators, but still this particular role of her was created for this.

And again, I would like to give a shout-out to CHCN (Community Health Center Network) for having given us a grant for a pilot pediatric care coordinator project, which has become a huge success, and they’re going to continue funding it for the next four to five years.

Dayna Long:

Melissa, if you can, I do think your role as a care coordinator is so very important and I do want to give you a chance to talk about – what is a day in the life look like for you as a care coordinator at Bay Area Community Health?

Melissa Pereda:

Well, it’s helping patients, supporting the clinicians with all these referrals – BH (behavioral health) referrals, ABA (applied behavioral analysis) referrals, following up on all these positive ACEs with the patients, getting them connected with behavioral health.

In referrals, following up, making sure that they’re being connected. I mean, it’s been a little challenging, sometimes it’s hard for parents to answer the phone because they’re at work. So I always try more than three follow-ups at some times. Because I just want to make sure that they get the resources they need.

I’m just here to support. I mean it’s been good that I’ve been able to support the providers and the parents also with their children and I think the main thing is just getting all these parents connected to the services that they need.

Dayna Long:

Absolutely. What are the most common resources that you’re referring families to?

Melissa Pereda:

Still, we are referring for food insecurities. They’re still housing – I’m still getting resources for housing, also for behavioral health. If I see their scorings are high, refer them or have the providers refer the patients to behavioral health. And also a big one has been the autism evaluation and also for ABA.

Dayna Long:

When you describe your workflow, I’m wondering if you can tell us in a little more detail what that workflow looks like for you.

Melissa Pereda:

So as the workflow, like we mentioned before, the workflow starts with the front desk, the screening forms, they’re handed out to the parents. The providers also follow up with the screenings. They make sure that the patients fill out the screening forms before they leave. There’s a lot of forms that we give out, but the providers are always good with the ACEs screening forms, that they make sure the parents don’t leave before they fill out the form.

If there’s any positive ACEs and I’m available, I do warm handoffs in the exam room. I try to help them as they’re here. If I’m not available, I always collect the screening forms and I follow up with all these parents and just give them a call. I do my documentation and like I said, if I need to do any follow-ups, I continue to call the parents, making sure they get connected. And then once they get connected, I close the loop.

Shesh Seshadri:

So initially when we gave out the patient questionnaire and they fill it out like how Melissa said, we got a workflow going, they give it back and then the provider goes through this, finds out which are the adverse experiences or what needs the patient has. For example, let’s say like the food insecurity or the housing insecurity. And we call Melissa, give her a warm handoff and she takes it from there. So she looks up, which is called “Find Help” on Epic, our electronic medical records, and then she gives them the resources.

During the COVID pandemic though, we did not have all of these resources on hand or when we first started, we did not have all these resources. So we would reach out to other organizations or the community-based organizations to find out where are the food banks, what can we do at that time. And she would then call the patient and give them follow-ups. But then I think we’ve come a long way now where we can create a referral in Epic, which goes to her virtual station and then she calls the patient and closes the referral loop, which we did not have three years ago. So patients would fall through the cracks, right. We were not sure, “Did you already get to the food bank? Did you already get the legal health you needed?” Or so on. So we’ve come a long way, but this is how we started.

Dayna Long:

It sounds like that you’re screening for 12 and up. How did you guys come to the decision to start screening starting with the teenagers?

Shesh Seshadri:

We have been doing all ages, zero to 18 years, during every single physical exam. For 12 and up we do give the questionnaire for both children and adults, like the parents that they come with or guardians they come with. But for less than 12 years, it’s just for the guardian. We have behavioral health clinicians who are taking care of patients about 12 years of age. And currently, as we know, there is a national crisis of shortage of behavioral health clinicians at this time. We are still trying to recruit somebody for less than 12 years of age, but we are screening those less than 12 years of age.

Dayna Long:

Wonderful. So to clarify what you were saying, Melissa, is that you hand the screen[er] to the actual teenager if they’re 12 and up, but you are screening starting at 12 months?

Melissa Pereda:

The patient, 12 years to 18 years.

Shesh Seshadri:

12 years to 18 years, we give it to both parents and patients. We start at two months itself, like every single physical exam that we do on the patient, we do give out the PEARLS questionnaire in the language that they need.

Dayna Long:

And then so you start at two months and are you then doing it at every visit or is it annually?

Shesh Seshadri:

Every physical visit. So we do capture a lot of them in the first three years of life. As you know that we get a lot of visits, 1 month, 2, 4, 6, 9, 12, 15, 18, 24, 30 and 36. That’s a lot of visits. So this I think is the prime time when they’re establishing good relationship with the providers. And one of the patient parents actually said, “We did not know where to go for our social determinants of health or the socioeconomic needs, and that this questionnaire can actually be administered at a pediatric office for us to get the help we need.” I think most of the times parents don’t know where to ask for resources and they did not think that patient-centered medical home is the place to ask.

Dayna Long:

Let’s dive more into that response. Can you share, Dr. Shesh, more about what happens after you screen? What are the most common responses that you receive?

Shesh Seshadri:

I could give an example. So, I’ve had some families where father and mother are separated. Sometimes we would have been seeing these patients for let’s say four to six months. We ask all the questions about social history and assume that we know these patients well. But when they’re actually asked to fill out the questionnaire is when you would get to know some real answers because some families are private, some are shy, they want to keep it confidential, they just nod, they came in for a rash or some other thing. So they really don’t want to discuss all their social issues. So most of times, it was the teens who spoke out about their parent being deported or immigration issues and requested counseling to process grief. Prior to this they would just mention parents are separated, but sometimes we don’t dwell much on the reason and we just move on to the next question during a physical exam.

And the other thing that we also noticed was a lot of food insecurity and housing insecurity. Those were two big things that we noticed during the COVID Pandemic. For example, I had a parent who did not know how to read or write, a single mom with food insecurity. She sold homemade food for a living. She came in with a behavior concerns of poor school performance and defiance in the patient. And I have to appreciate the pediatric care coordinator, the wonderful teamwork where mother was able to get the food bank numbers from the coordinator and able to pick up food. And very happy that this questionnaire that we administered was able to pick up such issues and help her.

And Melissa was able to make appointments with nutritionist specialist, like behavioral health therapists for the mother and provide written communication with pictures as to how to reach that appointment place, like practical problems in life. Like mother could not read or understand Google Maps. So, if I referred them to cardiology, she would write a little heart, put the number down or the place, tell her how to go, directions, arrow marks to reach the place. And we had to find something close to her neighborhood. Or if I referred her to nephrology, put a little kidney mark on there, like the kidney bean, and tell her how to go there.

Also in the COVID lockdown and shelter-in-place, there was this kid with food insecurity had eaten junk food, which is less expensive as we know. Some of the times you can get a big bag of chips and soda, it’s less pricey than when you have to buy a salad. It’s a lot of process that takes to actually buy them all, put them together in a tasty manner. So now she was diabetic with hypercholesterolemia and she’s eight years old, A1c of 7.8, and mother was provided the food pharmacy number. So we are doing a project called, Food as Medicine, through Recipe for Health through our Alameda County. Our county network, they provide free healthy foods to those in need. And after eating these healthy foods, her A1c decreased to 7 in about two weeks. The parent was extremely happy and gave positive feedback. She said something impactful that she was never asked this question before and she was too embarrassed to ask for help, did not know, like I told you before, like where to go for this, who to ask about these things.

Dayna Long:

When you were first talking to the other staff there, was there any pushback or hesitancy about doing screening?

Shesh Seshadri:

Yeah, absolutely. So initially we went to ACESaware.org website and we had to take a long course. So we were over 40 providers. It’s a two-hour course. So just the barriers would be to actually block all of us, which is over 80 to 90 hours of work time to get this done. Actually had a few providers where they had their own adverse experiences growing up. So they said it’s going to take us extra time, we have to process these too as we have to go through this process, grieve, heal. They were able to talk to a couple of therapists and eventually finish it. And once certified, I think most of the times we, as providers and also our staff, are okay, we are going to screen. Let’s say it’s positive, then what? I think that’s where we get stuck. That’s where we are very nervous.

Us and most of the other organizations who started with Resilient Beginnings Network and Center for Care Innovations was like, “we screened, now what?” Where do we find the resources now they’re positive? So we need a person, care coordinator like Melissa, to actually do the warm handoff, follow up. Otherwise, there was no point screening is what most of the providers thought, most the staff thought. And they were all trained in this with the course, the ACEs Aware course.

And also, one other barrier that we noticed was insufficient time to discuss all of these positive [ACEs] scores. So we either have 30 minutes for a physical exam or a 15 minutes for a short visit. So, we had to schedule more visits to follow up, but this actually created a better relationship between the provider, and better trust that the provider can take care of my kids’ physical health as well as the socioeconomic issues as well.

And we’re very thankful for the role of Melissa who follows up the patient very closely now till the referral loop is closed. And that was another of our objective because initially we were all about screening and then it’s positive, “Now what?” So, we had to make a list of resources. So, we actually reached out to Alameda County and Santa Clara County to get a list of community-based organizations who can actually help us provide these resources. And now we actually, like I was telling you, we have “Find Help” on Epic itself. It’s real neat. You put in the zip code of the patient, and it takes you to a list of things that you need. “Do you want housing?” “Do you want school district?” “Do you want early intervention?” So you can ask the parent, “Where are we at? What do you need at this time?” Actually, Melissa does this, she can actually fill out forms for them and follow up and submit it.

Dayna Long:

When you are responding to ACEs, talk to us about what are the typical responses, what’s the most common response and intervention that you guys are providing?

Shesh Seshadri:

I think most of the times when we actually started out, as I said, most of our staff are worried about, “What if it’s a sexual abuse, what if it’s a physical abuse? Where do we go? How do we follow up? What is the evaluation process? What’s the workflow? What’s my role as front desk? What’s my role as a medical assistant? What’s my role as a pediatrician?” But, like I said, most of what we found was food insecurity and housing insecurity. These have been the two major things that happened. And I think although not listed as a core adverse childhood experience, since we were found during the pandemic, COVID, I think, was a big community trauma.

A lot of families got affected. And although COVID is not listed on the pediatric ACEs and life events screener questionnaire, it has exacerbated the ACEs and the vulnerable population that we see. How many of us will agree that when we ask if they’re doing well and housing is stable, parents nod? But when we ask them to fill out a questionnaire, we get the true answers. I had a single mom with four kids who lost her job due to COVID and shelter-in-place and was evicted in March with three special needs kids and was requesting family members if she can stay with them. And the teenager had actually filled out and said, “We don’t have a home right now.” So, we were able to provide resources for these patients. And the list of resources is also very limited because not everything was open due to COVID and constraints like that.

And one other thing has been developmental delays because of people coming over from other countries, war torn countries. We’ve had a lot of Afghan refugees, so our organization does a lot of work with Afghan community. We recently had some Ukrainian refugees coming in. So the whole process of them navigating the system here has been an experience for them. They’ve gone through some traumatic experiences and they ask for, “We need behavioral health, can we talk to a therapist? Can we talk to a counselor?” And as I mentioned before, we have had a huge national crisis or shortage of behavioral health clinicians at this time, especially for pediatric patients. And that’s another one that we see a lot of in the adverse child experiences is the immigration-related trauma that we notice.

And we’ve also had barriers or challenges with autism evaluation. We do not have a lot of specialists who can do this evaluation. Although I suspect autism and there is a long wait list to get them evaluated and especially in families where they started out with here just a language delay. We are bilingual family. We did come from a war torn country. We are just situating ourselves trying to find a home, trying to find food. And by the time they keep an eye on like, wait a minute, he’s not doing what he’s supposed to do at this age, like age appropriate developmental milestones are not being reached, that’s when they bring them in. And we’ve had that barrier for about autism evaluation as well.

Dayna Long:

It sounds like you scaled remarkably quickly, which is amazing. What percentage of your well-child visits do you think that you’re screening now for ACEs, if you had to guess?

Shesh Seshadri:

Almost 100%.

Dayna Long:

Wow.

Shesh Seshadri:

Maybe like 90% about. In Santa Clara County too, we’ve had new clinical directors who are all pediatricians and medical director, there is also a pediatrician. So they have made a smooth workflow now in all of our clinics. We have been screening all of the patients from zero to 18 years of age for the childhood adverse experiences in every single physical. And we are actually also screening for anxiety, depression, the PHQ-2 forms, the generalized anxiety disorder (GAD) forms. We also started SDOH or social determinants of health, forms and we have MyChart available now. So we actually send the forms over to the tablet. They come in, they fill out the forms. And I think that’s one of our objectives for this year from leadership, which we recently discussed in the senior management team meeting. Our COO, Olivia Dear, our Chief Medical Officer, Dr. Ramchandani, they were all talking about: electronically, how we can gather this data so that we can provide better resources for patients.

So we are screening for those. We are also screening for Ages and Stages Questionnaire where we check for appropriate developmental milestones. We are checking for autism with the M-CHAT questionnaire, food insecurity, which we recently started this week. We have two questionnaires for those to see hunger as a vital sign is what we are considering and doing that to provide food resources for our patients. So, they might be missing a few here and there, but I think 90-95% or all of them are provided this questionnaire. So, when you were asking before, how did we start? I think front desk was the first step where they are told this is a questionnaire, this is for this age group – What do you need to give? How do you approach a patient? How do you inform them what they’re filling out when you first give out the questionnaire? So, this was a training given to the front desk.

Dayna Long:

How comfortable do you feel the front desk is in terms of sharing that explanation with families? Have you noticed that they’re actually saying the explanation and explaining the screen[er] or has there been a situation where families are simply handed the questionnaire?

And I’m asking this because in a lot of clinics there is a struggle, there’s a bump in the road in terms of explaining why we’re doing the questionnaire and oftentimes the scores are zero because the family is handed a piece of paper about really traumatic, hurtful events without a reason why this is important.

Shesh Seshadri:

Initially we were apprehensive how the parents would take it, but the front desk has done a fantastic job. It’s as if they were waiting to be asked to jump into this because front desk, although they are the first phase or the first connection with the patients when they first come into the clinic, they’re not as clinically involved as the medical assistants and providers, right? So they were waiting for this opportunity. So when they were told how to explain this to the parents, they did a fantastic job. So when I walk around during my rounds to go see at the front desk or take a sneak peek, they’re doing really good and parents are getting an idea of why we are screening them. And initially I was also very nervous as to how the parents would take it, would they feel offended because we are asking all these really sensitive questions in their private life. But like I said, they were waiting to be asked, they were waiting to be asked. I have not had a single parent be upset about this.

They easily fill out the questionnaires. They actually point out and show me if sometimes I have missed or quickly go through. Like I said, we are screening for a lot of things. So they pointed and say, “Do you have anything for it?” Or so on. And after they come in a few times and they have filled out these questionnaires, like I said, in the first three years, we give it to them at first month, second month, fourth month, six months. By six months they’re aware they need to come early. They need to fill out all these questionnaires and ask. They not only are asking me medical questions, they also ask me the other social questions or cultural nuances like certain other questions that are not exactly there as a question on [the] PEARLS questionnaire, but very related to it. And like you said, this is a very traumatic experience for them and sometimes they have to relive it while they’re filling out these forms over and over again.

So what else we are doing is what’s called the “positive experiences,” talking about what are the positive strengths before we end the visit. Although we are not doing the HOPE or the positive questionnaire at this time, which I learned from Ken Epstein, one of your coaches and guides. He spoke about it several times in the Resilient Beginnings Network sessions that we had throughout from the second year onwards. Because the parents are already filling out so many questionnaires, we did not add another questionnaire. But the way we as pediatricians and the providers are ending a visit is talking about the positive strengths, which can bring resilience to our families.

For example, when they say, “I’m going through depression, anxiety,” for example, the teenagers when they talk about the COVID lockdown pandemic, how we were feeling, there was no social connections, not able to meet friends and so on. But then they’re speaking to a therapist, their parents are involved, they’re trying to involve them in sport teams or something. Every evening I talk about, “look at the positives you have in life.” So I ended with a positive message or a note to pointing out the strengths like, “You are seeing a therapist, your family is here to support you. You came in today to talk about this, so these are all your positive strengths and you are going in the right direction.”

Dayna Long:

You have to balance the adversity with the resilience and the HOPE framework. It sounds like that’s what you’re using a lot of, and I think that’s really awesome.

Shesh Seshadri:

Indeed. Yeah, yeah.

Dayna Long:

You’ve been part of the Resilient Beginnings Network for the last three years. What are you most proud of?

Shesh Seshadri:

I think collaborating with various team members, that’s what I’m proud of. I have met up with so many team members like Melissa and other medical assistants who have played different types of roles in this collaboration from front desk, to our providers, to new hires when they come in and I say, “This is all the trainings you need to do”, they’re ready. So, the enthusiasm that they all have to provide for our patients, the resources that they need, from screening to healing, is great.

And in this process, I have met so many wonderful leaders and role models and gotten guidance from the Resilient Beginnings Network, and learned from other community organizations who were involved in this learning. I still remember Dr. Suzanne Frank from school-based clinics of Santa Clara. She was far ahead of the curve, she had already screened and had the resources ready. She was doing the positive experiences screening and, for example, when she talked about what’s called No Hit Zone, where no adult shall hit another child, no adult shall hit a child, no child shall hit an adult, and no child shall hit another child. So we sometimes see in some of our patients, when I’m talking to the mom and she goes, “Hey, pow-pow, don’t do that,” and so on, like, “Oh no, look, these are the gentle parenting techniques, and this is how we do it”, and so on. So the amount of learning I’ve had and how everybody else is open to learning on our team and the connections I have made through this has been a proud moment.

Dayna Long:

Do you have advice for other clinics who are earlier on in their trauma-informed journey or haven’t yet started ACEs screening and response? What would you like them to know?

Shesh Seshadri:

I think you should just get started. We were very apprehensive to start with, and like I talked about a lot of administrative barriers or the process barriers, workflow barriers, what do we do when we have positive ACEs? So there are a lot of what ifs, what ifs, and assumptions that “this won’t go well” or, “we are not set up for success,” and so on. I think we should get started and baby steps will lead us there. And we are all learning.

Dayna Long:

Always learning, that’s for sure. In the spirit of always learning, what are the next steps for you all?

Shesh Seshadri:

We would like to have a dedicated pediatric care coordinator like Melissa in all of our clinics, or more of her in our clinics. We do have four big pediatric clinics here in – not family medicine clinics – but we have pediatrics centers as well here in Alameda County and four big ones in Santa Clara County. And she’s the only one for us at Alameda County. So we are trying to replicate the work she’s doing by hiring another care coordinator for Santa Clara County. I think that’s our first one.

And the second one is expanding this – expanding the screening to pregnant women. I recently spoke with the transgender and HIV team manager to perform the screening in that population. When we had the senior management team meeting, she was talking about how her population are so much more affected, has 10 times more ACEs than the general population. And I think that’s the next direction that we are going to go with to expand the ACEs screening with those. Also, to expand them for adults, which is once in a lifetime, but if we need, so we can always do it at every visit if we want to, but that’s what they say, once in a lifetime for adults. And of course hire bilingual, especially Spanish- and Mandarin- speaking behavioral health clinicians, especially to our south, to provide access to more patients in their language of preference, which has been challenging. So we are constantly on the lookout for recruiting these behavioral health clinicians.

Dayna Long:

I heard you all say that there are 40 providers at Bay Area Community Health, that’s a lot of providers for one care coordinator. How do you balance that?

Melissa Pereda:

It’s a little challenge, especially because I’m new in the role too. I try to balance, do a little bit of follow [up] of my positive ACEs. Like I do my follow-ups on my ABA referral. So I do a little bit of each every day as I go. And yeah, I mean I could only do what I can do in a day, but I try to balance by doing a little bit of each so I don’t leave my positive ACEs behind. And also the parents, they don’t stay also without hearing from us to see what’s going on with their referrals. So I do a little bit of each in a day.

Shesh Seshadri:

A little bit is a lot, I think. The little bit that she does is a lot, because I was talking about the CHCN Pediatric Care Coordinator pilot grant, they asked us to write the number of minutes she spends on each patient for data purposes. So we’ve been using smart forms, smart touches where she writes about… It gathers the data, how many minutes she spends with the patient. That just shows how many minutes she’s saving for us, for the providers, and how that’s preventing burnout for us. Which I don’t think she’s seeing, but that’s my perspective to this.

Dayna Long:

So how many minutes was it?

Shesh Seshadri:

She spends about 45 minutes to an hour per patient. 30 to 60 minutes per patient.

Dayna Long:

That’s a lot.

Melissa Pereda:

It’s depending on the screenings too. I mean a lot of families, they like to speak. I’ve gotten feedback like they’re happy that they have someone to speak to. They have vent out to me with a lot of things and I’m here to hear them out. I support them. I always offer them any resources they need. But yeah, these calls can take up to 45 to an hour sometimes. And like I said, that’s why we’re here to hear them out and support them. And it’s been a challenge, but I mean, we’re here. That’s why we’re here, the care coordinator, to help out and just offer them resources and whatever they need.

Dayna Long:

Can you share a case, in a de-identified fashion of course, where you felt as if you made a big impact on a family?

Melissa Pereda:

So I had a patient, I think it was one of my first patients when I was doing my first ACEs screenings, and there was an aunt that I had called for the screening and she mentioned that the parents had passed away of the child also, their grandma passed away right after the parents. And the aunt had to take over the child, she was a guardian now. And it was hard for her because she was of elderly age and these children were young and now these children stayed without a mom, without a dad, and without a grandmother.

So now the aunt had to lead and it was tough for her and she was just happy that she was able to express everything to me, talk to me, and then offer the resources that she needed. So I mean, she was very glad that she was able to talk to someone. And her story happened in Mexico, so she had to bring the children to the United States. So yeah, she became the guardian.

It was touching, just hearing, yeah, we get an impact of all these patients, the stories that they tell us. Like I said, we’re here to support. We’re here to support all the parents and the guardians.

Dayna Long:

I’m confident that you made a huge impact on her life, so thank you for the work that you do. It’s really important.

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!