Denyse Olson-Dorff - PsyD
Afton Koball - PhD, ABPP
As the landscape of healthcare changes, healthcare systems must respond with new approaches to improve the health of communities. Identifying and responding to social conditions that affect health have been suggested as important next steps in healthcare.
Now 20 years old, the landmark Adverse Childhood Experiences Study (ACE Study) (Felitti, et. al, 1998) was among the first to show evidence of actual relationships between toxic stress in childhood and long-term health outcomes. The ACE Study showed a close association between the number of categories of ACEs experienced in childhood (e.g. abuse, domestic violence) and the number and severity of illness risk factors (e.g. obesity), the number of health risk behaviors (e.g. smoking, alcohol abuse, etc.) and the presence of serious disease or other physical health problems (e.g. heart disease, cancer, etc.). The 10 ACEs identified in the original study were found to be common, yet largely unrecognized by healthcare providers. Most importantly, the research showed that repeated toxic stress levels have a biological and psychological effect on human development and also greatly affected future health. Despite these important findings, little change has occurred at the systems level in most healthcare institutions.
At Gundersen Health System in La Crosse, Wis., a variety of department and system-wide initiatives have been implemented because of the results of the original ACE Study (1998). These efforts are collectively referred to as ACE-informed practices and have been developed to prevent or lessen the effects of early adversity on long-term health. This list of initiatives includes workflows aimed at prevention, early intervention and/or specialized care. Several of these initiatives are described below.
To date, patients have been part of an ACE-driven workflow in the departments of Behavioral Health, Pediatrics and Family Medicine. Each department has developed different workflows (e.g. if, when and why a screening instrument is used) and screening tools (e.g. Safe Environment for Every Kid, 2013; Gundersen-developed ACE Conversation Card). Each department addresses toxic stress and health in the way that best fits that particular department.
In developing ACE-informed workflows, these are some initial questions to consider:
Deciding what you are looking for will determine the approach to use, a screening tool that may apply and when to use it in a medical appointment. It is important to have resources and support for patients once the workflow is complete so you are not screening for something, finding something and then not having help available for patients.
In the department of Behavioral Health, where previous research would suggest a higher incidence of toxic stress in childhood has occurred, all new patients are screened for ACEs. Behavioral Health uses a slightly revised set of the 10 questions used in the original ACE Study (Felitti, et.al., 1998), which asks about neglect, abuse, and household dysfunction before age 18. Patients complete this questionnaire during one of their first appointments with a mental health provider who is immediately available for support, if needed. This process was created to respond to any patients with a trauma history who might be triggered by answering the ACE questions. Adult patients answer the questions about themselves. If the patient is a child or adolescent, parents complete the questionnaire about their child. With a positive finding to any of the 10 questions, there is discussion with the patient about whether to add it to the list of objectives on the treatment plan. The treatment plan is a document created through a collaborative effort between the patient and provider. It identifies what will be worked on during treatment and how treatment will be approached.
A patient’s need for community referrals, to a women’s shelter or food pantry for example, can be expedited by the clinician. Completion of the questionnaire is optional for all patients (although less than 1 percent of patients have declined to date). Staff training included background education about the ACE Study and findings. It was followed by video-supported instruction on how to carry out the process. A clinical psychologist explained how to document in the electronic medical record. The next goal in this workflow is to standardize a process so screening results are forwarded to the primary healthcare provider in Family Medicine, Internal Medicine or Pediatrics for physician review. Physicians can then consider any ACE indicators in medical decision-making. A current research project is looking at the relationship between information on the ACE questionnaire and how patients enter as well as use the healthcare system.
The Pediatrics department uses the Safe Environment for Every Kid (SEEK) questionnaire (Dubowitz, 2013). It is completed by parents at well-child visits and screens for risk factors for abuse in an effort to prevent maltreatment. The SEEK Parent Questionnaire (PQ) was developed for use in pediatric primary care. It screens for targeted problems of parental depression, substance abuse, major stress, intimate partner violence, food insecurity and harsh punishment. Many of these problems were recognized as ACEs in the original ACE Study, so the SEEK as a screening tool can be thought of as an ACE-informed approach. The SEEK program includes training for professionals via online videos and the SEEK website. When a SEEK screening in Pediatric primary care at Gundersen indicates a problem, the pediatric social worker is available to connect the patient and family to community resources. A behavioral health consultant is available for additional support, if needed. Work on training and implementation of this workflow is ongoing.
In Gundersen’s Family Medicine Residency Clinic, a conversation about ACEs helps to improve patient care by addressing health and ACEs during well-child visits. The primary purpose of this workflow is to educate and raise awareness about the relationship between toxic stress, health outcomes and the positive effect of resilience. This workflow is simply a conversation with each family during a well-child visit in order to summarize the ACE data. The conversation includes evidence-based steps to raise resilience in families.
The ACE Conversation Card was developed to support this sensitive conversation by physicians and residents in the clinic with their patient families. Use of the ACE Conversation Card is universal for all patients in this clinic and occurs during a trusting patient-healthcare provider relationship. It recognizes patients’ strengths, encourages safe, stable and nurturing relationships, does not require disclosure, does not tally a score and recognizes common problems related to long-term health outcomes. The front of the card highlights major findings of the ACE Study and the back outlines steps to reduce toxic stress in families. Patients are given the card to take with them at the end of the appointment. To date, less than 1 percent of patients have disclosed abuse or maltreatment during these appointments, and physicians report that the conversation takes between three to five minutes. A doctoral level behavioral health consultant is available in the Family Medicine Residency Clinic for consultation, if needed. Staff training included presentation and education about the original ACE study, video practice scenarios of the ACE Conversation and implementation of the workflow. A current research project is assessing patient and provider satisfaction with the inclusion of the ACE data into primary care through this provider-patient conversation.
At Gundersen, a strong commitment from the institution and larger community around ACE-informed care has reinforced efforts to integrate assessment, evaluation, prevention and intervention around early experiences of adversity. As our work has demonstrated, differing approaches with varied assessments and overarching goals are needed to impact patient care. Continued work within our institution is planned and we look forward to learning more about the long-term benefits that may come from these ACE-informed efforts. It is our hope that other healthcare systems may follow suit to improve whole person care, resulting in improved health in the communities we serve.