Implementation of Adverse Childhood Experiences (ACEs) Policy
Study Details
Study Description
Brief Summary
Adverse Childhood Experiences (ACEs) are pervasive among children with 45% experiencing at least one ACE and 10% experiencing three or more, placing them at high risk for toxic stress and symptomatology. Yet, ACEs often go undetected in primary care settings during well-child visits due to unclear policies and tested implementation strategies. This pilot study will use mapping methodology, guided by the EPIS framework, to refine a multi-faceted strategy supporting the implementation of the state of California's 2020 policy promoting universal ACE screening in community clinics, and a stepped-wedge trial to test the impact of the strategy on implementation and child-level outcomes.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
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N/A |
Detailed Description
Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accident, harsh migration experiences or exposure to violence. ACEs are pervasive, with 45% experiencing at least one ACE and 10% experiencing three or more ACEs, placing them at high risk for negative life outcomes. ACEs are more prevalent among minority and immigrant communities due to exposure to poverty, discrimination, community violence, national disasters, and refugee experiences. ACEs screenings have potential value in identifying children experiencing toxic stress and the physical and mental health conditions associated with it such as asthma, ADHD and anxiety. Yet, they are seldom used in primary care during well-child visits. The Surgeon General of the state of California have addressed this care gap by issuing an ACEs screening policy. Starting January 2020, MediCal, California's Medicaid health care program, will reimburse primary care settings ($29) for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children for ACEs during wellness visits. Despite significant investment in California and nationwide, evidence of the public health value of universal child screening policies is unclear. Increased screening efforts often do not translate into higher access to care for children and may even exacerbate disparities by increasing stigma and reinforcing a deficit view of marginalized groups. These results have been attributed to a lack of rigorous studies testing implementation strategies suited for pediatric screening policies. This mixed-method study will fill this gap by refining and testing an implementation strategy using a multi-site controlled trial within a Federally Qualified Health Center in Southern California. Using the EPIS framework, we will employ a hybrid (type 2), randomized controlled trial using a stepped-wedge design (n=5 clinics) to test to test THE central hypothesis that clinics employing a multifaceted implementation strategy will have higher fidelity and reach of the ACEs screening policy. A secondary hypothesis will examine the public health impact of the ACEs policy on child patient-level mental health service and symptom outcomes. Specific aims are: Aim 1. Refine a multifaceted implementation strategy to support the implementation of the ACEs screening policy in community-based clinics, and Aim 2. Pilot test the feasibility, acceptability, fidelity and reach of the implementation strategy and the impact of the ACEs policy on child patient-level outcomes. This project capitalizes on a rare opportunity to pilot test an implementation strategy to maximize the impact of a state-wide policy intended to improve child health in under-resourced settings.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Active Comparator: Multifaceted Implementation Strategy The core implementation strategy components are: 1) short video-trainings for clinic personnel (care team staff and providers) on the administration of caregiver-reported screening tools; 2) technical implementation support using an approach comprised of external academic consultants, and internal FQHC personnel to increase inner context capacity, 3) use of a validated clinical screening tool - Pediatric Symptoms Checklist (PSC-17), used in pediatric primary care settings to assess behavioral and social/emotional development. For this study, we will use the PSC tools that are tailored to children ages 0 to 5 years old with the Baby Pediatric Symptomatology Checklist (BPSC) for ages 0 to 18 months, and the Preschool Pediatric Symptom Checklist (PPSC) for ages 18 to 60 months. This screening tools is needed as the PEARLS only assesses ACEs exposure and not mental health symptomatology; and 4) use of a technology based tailored ACEs algorithm that incorporates multiple data sources. |
Other: Implementation Strategy of ACEs Screenings
We will use implementation mapping, guided by the EPIS framework, to promote a co-created process and refine the strategy comprised of online training videos, a customized ACEs algorithm and use of technology to improve workflow efficiency, implementation technical assistance/coaching, and written implementation protocols.
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| Other: ACEs Screening Adverse Childhood Experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment, harsh migration experiences or exposure to violence. ACEs screening are increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. To promote ACEs screening uptake, the state of California issued the "ACEs Aware" 2020 policy; a fee-for-service health policy that provides a financial incentive to Medicaid-serving clinics to promote yearly ACEs pediatric screenings in primary care settings. This study will focus on screening children ages 0-5, in line with the partnering FQHC's ACEs screening priorities. |
Other: Usual Care
The ACEs Aware policy goal is to "equip providers with training and clinical protocols to screen children and adults for ACEs, detect ACEs early, and connect patients to interventions, resources, and other support to improve patient health and well-being." ACEs screenings are comprised of: a) a 2-hour on-line provider training; b) the Pediatric ACEs and Related Life-events Screener or PEARLS tool; c) an ACEs associated health conditions checklist; and d) complete a wellness exam. The primary care provider uses multiple sources of information to identify a child's need for follow-up services.
Other Names:
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Outcome Measures
Primary Outcome Measures
- Reach of the intervention [7.5 months]
proportion of eligible children screened for ACEs
- Feasibility of the intervention and strategy [7.5 months]
Participants perceive the ACEs policy and implementation strategy as feasible in their clinic
- Aceptability of the intervention and strategy [7.5 months]
Participants perceive the ACEs policy and implementation strategy as acceptable
- Fidelity of the screening process [7.5 months]
Adherence to screening protocols and competence of performance
Secondary Outcome Measures
- Mental health service referrals [7.5 months]
Number of mental health referrals (behavioral analysis, behavioral health, care coordinator, care management, child development/development center or social work) divided by the total # of eligible children in a 10-week trial period.
- Changes in BPSS / PPSC [7.5 months]
Mean score differences from eligible child visits in each 10-week period. Compare those means in pre vs post implementation periods. No threshold as we will test a two-tail hypothesis for this measure given mixed evidence on the impact of screening policies on access to care and clinical outcomes
Eligibility Criteria
Criteria
Inclusion Criteria:
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Children ages 0-5 scheduled for wellness visit for upcoming week
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Caregiver of child is 18 years or older with legal custody or authority to arrange care for child
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Caregiver provides informed consent; signs consent form and HIPAA release form as well as COVID information sheet
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Caregiver agrees to complete the Pediatric Symptoms Checklist or PSC
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Caregiver provides permission for socio-demographic information about their child to be pulled from EMR records, de-identified, and shared with PI
Exclusion Criteria:
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Children ages 0-5 scheduled for wellness visit for upcoming week
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Caregiver declines to provide signed informed consent, HIPAA release, or permission for socio-demographic data to be pulled from EMR, de-identified and shared with PI; or declines to respond to 17 questions for the PSC
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Children ages 6-18 scheduled for wellness visits
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Children ages 0-5 scheduled for wellness visits outside the study data collection windows or at clinics not providing pediatric care
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Caregiver does not have legal guardianship or written authority to arrange care for the child
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Borrego Health | Desert Hot Springs | California | United States | 92240 |
Sponsors and Collaborators
- University of Southern California
Investigators
- Principal Investigator: Monica Perez Jolles, PhD, University of Southern California, Los Angeles
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- UP-21-00009