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Mean Std. Dev. Years at Participating CHC 5.3 5.2 Count Percentage Clinical roles Clinic leadership 15 38.5% Allied health professionals 14 35.9% Licensed clinicians 10 25.6% Gender Woman 32 82.1% Man 6 15.4% Non-binary 1 2.6% Race and ethnicity Asian or Pacific Islander 4 10.3% Black or African American 3 7.7% Hispanic/Latine 17 43.6% Multi-racial 2 5.1% White 13 33.3% Languages spoken English and Spanish 22 56.4% English only 8 20.5% English, Spanish, and at least one other language 6 15.4% English and one other language (excluding Spanish) 3 7.7% Note: Sixty percent of clinic leaders were also licensed clinicians (n = 9).
Abbreviations: CHC, Community health center.
Count Percentage Years receiving care at CHC Less than 1 year 3 30.0% 1 to 2 years 2 20.0% 3 years or more 4 40.0% Unknown 1 10.0% Age 18 to 24 3 30.0% 25 to 44 5 50.0% 45 to 64 2 20.0% Gender Woman 8 80.0% Man 1 10.0% Prefer not to answer 1 10.0% Race Black or African American 1 10.0% Multi-racial or other 2 20.0% Prefer not to answer 1 10.0% White 6 60.0% Ethnicity Non-Hispanic/Latine 6 60.0% Hispanic/Latine 3 30.0% Prefer not to answer 1 10.0% Highest level of education Some high school 1 10.0% Graduated high school/GED 2 20.0% Some college 4 40.0% Graduated college or graduate degree 3 30.0% Household income 0 to 25K 4 40.0% 25K to 50K 4 40.0% 50K to 100k 1 10.0% Unsure 1 10.0% Abbreviation: CHC, Community health center.
Topics Description Supporting Quotes Benefits Interconnection between ACEs and SR ACEs and SR are correlated.
Childhood trauma shapes current life stressors.
“They all work so hand in hand with each other. It's impossible to take one out from the other.” – primary care clinician
“The ACEs questionnaire, the original adult 10 question questionnaires, is just not, in and by itself, as useful as when we combine it with more social determinants of health questions. And even just the PEARLS tool that we use for kids is so much more helpful, because it has these additional categories that are really crucial for us to know about.” – clinic leader and primary care clinician
“I believe it's absolutely necessary to have both. If you're opening a wound and not addressing it… It's not trauma informed, it's not patient-centered. And I believe it defeats the purpose of the conversation… As we look at social determinants of health, these are things that people live, experience, work. All these conditions impacted their family from their childhood, impacted their teenage selves or adult selves, the kids that they're raising and the families that they're starting. If we're talking about ending cycles of ACEs, it means giving them support.” – ACEs navigator
Building Trust ACEs and SR screening can have positive impact on patient-clinician relationships.
Screening may elicit trust and open communication.
“I think it opens so many beautiful doors. I've never ever felt it hindered my connection with my patients… I would say 90% of the time it leads to an opening and… a deeper connection with the patient.” – primary care clinician
“I feel that it does open things up, it does open a gateway to be able to interact and understand your patients more and see where they're coming from, as well as for the patient, who realizes that the provider does care.” – medical assistant
“I could see it definitely being triggering for some people… it perhaps creates a barrier between the provider and the patient. But I think at the end of the day, opening the dialogue and also, it does create a sense of trust if asked appropriately. And then with some sensitivity, knowing that they can trust their primary care provider.” – patient
Drawbacks Overwhelming to patients and staff ACEs screening can trigger emotional responses from patients – Addition of SR screening could overwhelm patients.
“What I'm afraid would happen is that people would start to deny their economic needs that we could help with… Because they're like, ‘Every time you ask me these questions, it re-traumatizes me. I don't want to talk about this anymore.’ They're like, ‘No, I'm fine. I have enough food.’ ‘No, I'm fine. I don't need transportation.’” – primary care clinician
“I feel like the ACEs is very personal and if you ask those personal questions, sometimes it brings up bad memories. They tend to get emotional, it just brings up their past… And then if you turn around and you're like, ‘Okay, well are you homeless? Are you, this?’ And then it's kind of like, ‘No, I don't want to talk about it.’ So like, ‘I'm done with the conversation, I don't want to talk about anything else.’ So I feel like one thing at a time, instead of bombarding them with 20 million questions, I think would be better.” – medical assistant
“It would feel like… a job interview instead of a doctor's appointment.” – patient
Abbreviations: ACEs, Adverse childhood experiences; SR, Suicide risk.
Topics Description Supporting Quotes Advantage Efficiency More effective and efficient to complete one integrated screening.
Reduce discussion of overlapping topics.
Offer more resources for referrals.
“I would say that the shorter the better, the quicker the better for everybody.” – primary care clinician
“We see a lot of patients a day… sometimes over 30 patients a day… So to be honest, yes [integrated screening] will be helpful, if it's shorter screening, or less time-consuming, especially for adult patients, they have a lot of comorbidities.” – primary care clinician
“That could definitely be harder for some people. If I had gotten all of that at the same time, I think that would've been fine. Especially if you're a new patient…it'd just kind of be nice to get that out of the way.” – patient
Barriers Screening Frequency Data collection frequency for ACEs and SR differs.
ACEs screening are generally administered once a lifetime.
SR screening varies (e.g., during new patient intake, every visit, or annually).
“We were talking about the frequency because it's like, ‘Okay, do you do the social determinants, every visit every time or how do you do it?’ With ACEs it's easy after the age of 18, you only do it once in a lifetime because it never changes. Right? So with social determinants that can change in a day. Right? You could lose your job.” – clinic leader
“I feel if we ask both of them together every year, we can probably miss out on a opportunity to help out somebody that's in need before the year hits.” – medical assistant
Time Constraints Brief visit time (10 to 15 minutes).
Clinic staff have competing needs to address.
Clinic staff may feel hesitant to “open a can of worms”.
"I guess my input is that for it to happen at the same visit isn't totally necessary. Would both of that information be useful? Absolutely. I'm just not certain that getting all of that done in one swoop is totally advisable in terms of the timing.” – primary care clinician
“It's more conversation around what the patient is facing both in their past and their present, and an opportunity to intervene if we have the resources to do so. So I think it's a good idea. Whether it's feasible is the only piece that you would have to really think about, just because our visits are 15 minutes.” – clinic leader and primary care clinician
“There's just so many things that have to be done and it could become overwhelming for staff, the provider and the patient… So I think that's where we get less compliance because it's like, ‘Now I have to do this, now I have to do that.’ It's like some of them say, ‘I don't even want to fill out this paperwork anymore. Why is there so much paperwork?’” – clinic leader
“Those are delicate subjects, and they're delicate things that people go through in life. It's not just something that you can put somebody in a room and say, ‘Oh, yeah, we'll do this for half an hour,’ and then send them on their way.” – patient
Workforce- related Concerns High staff turnover and burnout impacts morale and results in fewer staff trained in ACEs/SR.
Differences in clinic staff responsible for administering ACEs and SR screening (e.g., medical assistants, ACEs navigators, social workers, clinicians).
Sustainability of grant-funded roles (e.g., ACEs navigator)
“I mean we try to fill the gaps as much as we can on the areas that we can, but the way that I look at it is that we can't be everything to all because it takes a village in some regards. And we got in this business being focused on this particular area and now it's kind of grown into, okay, we got to be your primary care provider, we got to be your mental health provider, we got to be your electric company, we got to be your taxi cab, we got to be your food bank, your grocery store, we got to be your landlord. That's a lot.” – clinic leader
“From front desk to MAs to medical clinicians, we had gone through an incredible rotation of clinicians. So that's a huge challenge. So whoever you train or whoever you have conversation about this, you have to retrain because we getting new clinicians and who knows, these new clinicians may be gone in a year or so.” – clinic leader
- Table 5.
Clinic Staff and Patient Recommendations to Improve ACEs and SR Screening Programs
Recommendations Description Clinic staff should fully explain why both screenings are administered and how they relate to current health. Although the majority of patients seen at study clinics completed the ACEs screening when there was hesitancy, staff observed that patients were more likely to complete the ACEs screening when staff had adequate time and training to provide context. Healthcare teams should take the type of visit into consideration before administering ACEs surveys to minimize potential re-traumatization. Clinic staff had differing approaches to what kinds of visits ACEs screening should be conducted. For example, many sites did not administer ACEs screening during telehealth visits. One medical assistant firmly suggested that ACEs screening should not be administered before a well-woman exam. Clinicians should always discuss screening results and offer resources. Many study participants highlighted the importance of discussing ACEs and SR screening results and offering referrals and resources accessible to patients at home. Many acknowledged that it takes time to accept or realize the impact of trauma. Some patients may initially decline referrals but may be interested later. One clinic staff member therefore recommended that referrals are always offered. Clinics should be clear about the availability of referrals and provide context for accessing resources with longer waiting periods. ACEs and SR-related resources and referrals should be provided whether or not formal screening takes place. A patient recommended posting SR resources on bulletin boards. This would allow patients to find community organizations or clinic resources (e.g., on-site food pantry) even when SR are not discussed in a visit. Abbreviations: ACEs, Adverse childhood experiences; SR, Suicide risk.
ACEs Screening Workflows Description Variability Screening Frequency Clinics varied on frequency of screening ranging from once a year to once a lifetime. Most clinics conducted ACEs screening once in a lifetime. Few clinics collected ACEs once a year. Workforce Clinics varied on who administered the screening. Most clinics had medical assistants distribute ACEs screening; one had dedicated ACEs navigators who distributed ACEs screening forms. Clinicians discussed the results of ACEs surveys with patients. Behavioral health clinicians sometimes readminister ACEs surveys for referred patients. Screening type Clinics varied in the type of ACEs survey they administered. Most clinics used a de-identified screening; one used an identified survey. There was variation in the version of the ACEs survey administered (e.g., ACE-10 or ACE-8 plus “resiliency questions”). Referrals Clinic staff varied on the type of resources or referrals offered and the criteria for offering referrals. Most clinics had access to on-site behavioral health care. The criteria for referrals were widely variable (e.g., no ACEs, 1 or more ACEs, or 4 or more ACEs). Abbreviation: ACEs, Adverse childhood experiences.
SR Screening Workflows Description Variability Method Clinics varied on offering formal surveys (paper or digital) or informal conversations to discuss SR. Most clinics had informal discussions about SR instead of formal screening. SR screening was conducted during new patient intake or regular office visits. Screening type Clinic staff varied on the type of SR they discussed. There was variation in the types of SR discussed. Formal surveys included PRAPARE, Staying Healthy Assessment, and a clinic-specific checklist. Informal discussions were tailored to individual patients’ SR or available referral resources. Workforce Clinics varied on who administered the screening. There was wide variation in clinic staff administering formal surveys or informal conversations including front desk staff, MAs, clinicians, social workers, and ACEs navigators. Referrals Clinic staff varied in the type of resources they offered after SR screening. There was high variability in the types of resources and referrals offered (e.g., collaboration with 211 San Diego’s Community Information Exchange, Unite Us platform, on-site food banks). Abbreviations: ACEs, Adverse childhood experiences; SR, Suicide risk; PRAPARE, Protocol for responding to and assessing patients' assets, risks, and experiences; MAS, Medical assistance services.
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