Clinics in San Mateo County - one of the nine San Francisco Bay Area counties - have been working to identify and provide support to protect against the Adverse Childhood Experiences, or ACEs, that our families are facing. ACEs are traumas experienced during childhood and if they are experienced continuously can result in toxic stress which can damage a child’s developing brain and their overall health. In 2020, Fair Oaks Health Center (FOHC) became the latest clinic in San Mateo County to start this process through a three-year grant awarded by Resilient Beginnings Network (RBN). Our RBN team consisted of members from across our County Health division, including Family Health Services (FHS), Behavioral Health and Recovery Services (BHRS), Medical Center Administration and FOHC clinic staff. Taking the implementation plan used by another one of our County clinics, FOHC had the goal to implement the Pediatric ACEs and Related Life Events Screener (PEARLS) screening tool and support families with the ACEs they may be experiencing.
Our implementation plan was to gradually rollout this new process and to start by training a small group of staff to screen pediatric patients ages 0-12 who were coming in for their annual Well Child exam. This plan had several steps: First, our staff was trained in the short-and-long term effects of ACES, to establish why we were screening, how to intervene to reduce the effects of toxic stress and how to support each other at FOHC. This training was provided by our BHRS partners and was given to FOHC staff including PSAs, Nursing, and Providers. All Providers completed a 2-hour online educational training which is needed to bill for and receive reimbursements for completing the PEARLS screener with patients/families. Next, we developed the standard work that our staff would follow. FOHC had the additional challenge to start screening during COVID restrictions. After participating in the Resilient Beginnings Network for three years, we wanted to share our experience and highlight some of the lessons learned during rollout – especially as our other clinics are planning to follow with ACEs screening soon.
Original Idea and What Happened
When it comes to the workflow process for the new PEARLS screener, our initial idea was for Nursing Staff and MAs to provide screener to patients/families during the rooming process and prior to the family meeting with their Provider. The expectation was that staff would use this time to walk the patient/family through the PEARLS screener and be able to address any questions they had.
We began to pilot this process in February 2022 and after almost several months of piloting, we identified several issues coming up. Staff noted that many questions on the PEARLS screening tool were duplicated in the Staying Healthy form, so patients were being asked the same questions more than once. Secondly, Nursing Staff and MAs were feeling pressure to complete everything before the family meets with their Provider and there was a feeling that both staff and families might be overwhelmed with the addition of yet another form. The ACES screen is just one of many forms that parents may receive during rooming, including depression screens, developmental screening tools, Autism screening tool and others. Additionally, Nursing staff are also tasked with clinical intake, vitals, history of concerns etc. We felt that this workflow needed to be changed to better match our team’s process.
Change and Recommendation
We were able to track the numbers of completed PEARLS screenings using a Power BI dashboard and the data showed that we were not reaching the numbers we had hoped. From February to December 2022, we were completing a monthly average of 20 screenings. Based on feedback from the FOHC Pediatric staff, in January 2023 we changed our workflow and are now having PSAs distribute the PEARLS screener to families at registration. A very short script was also developed for the PSAs when handing out the form. If the parent had any concerns, the PSAs advise parents that completion is optional, and they could discuss with their Provider during the visit.
The rationale for this change was that our clinic team felt that it fits better within the overall patient/staff interaction. PSAs already are excellent at making sure families have all required paperwork at registration and we found they were much more successful in getting the PEARLS screener to parents rather than adding it as part of the rooming process. The results of changing the workflow were an increase in the number of PEARLS screenings. Between January 2023 when our workflow process was updated through August 2023, the monthly average of completed screenings was 135. For our Nursing and MA staff, the updated workflow allows for them to focus on the main tasks needing to be done during rooming. They can still answer questions the family has, but without the pressure of having to complete this additional screener during the rooming process – a small window of time that is already full of other assessments that need to be done prior to the family meeting with their Provider.
For our clinic to begin screening for ACEs, we overlayed the process that was done at another site and while it worked for that clinic, in hindsight it did not align with the day-to-day duties of our clinic site (I.e., more patients being seen overall in a given day, a larger group participating in the implementation process, etc.). We identified what wasn’t working and pivoted to a new strategy and our recommendation is to take time to review the workflow process and not be afraid to make changes if needed. We also recommend having a way to track the numbers in place so that there is data to confirm if your strategy is indeed working.
Which Patients to Screen
The second area that changed over the course of our RBN grant was which patients would be screened at the clinic. Again, our original idea was to use a similar implementation plan that was used at another clinic site and have a smaller, more focused rollout. Knowing that it would take time for staff to incorporate a new tool into their work, we wanted the team to be able to pace themselves and not get overwhelmed.
Original Idea and What Happened
A small group of clinic staff would be the first group to train on administering the PEARLS screener to families of children 0-12 who were coming in for their annual Well Child visit. We felt that starting with a smaller pilot group would allow for faster troubleshooting of any issues that may arise. We also knew that it would take time for staff to incorporate a new tool into their work and wanted the team to be able to pace themselves and not get overwhelmed. The expectation was that over time, this pilot group could train and support the rest of the clinic team when it was time to expand.
The clinic team screened this small patient population for 11 months. However, focusing on a smaller target population meant that there would be differences among staff in terms of practice time. For example, if a staff person didn’t have any Well Child appointments that fell into our target screening population in a given day, then they wouldn’t have an opportunity to practice whereas another staff person may get 3-5 opportunities to practice in the same day. Another unintended consequence of starting small was that it led to confusion among the staff in who to screen. The limited huddle time between nursing and Providers was focused more on clinical needs, which vitals, which vaccines etc. Staff needing to remember, “Screen this patient, but not that patient” was an additional disruption to their normal routine.
Change and Recommendation
Coinciding with updating workflows around which staff will provide the PEARLS screener to families, we decided to expand the screening to more patients. Beginning in January 2023, our current process is to give PEARLS screener to all patients 0-18 coming in for annual Well Child visit. This resulted in several changes. As we mentioned above, the overall numbers of completed PEARLS screening greatly increased once this change was made. The confusion among staff over remembering which patients needed to be screened was also improved.
While our initial idea of a gradual rollout was meant to help support staff and give them time to pace themselves, there were unintended consequences. An increase of staff confusion and stress led us to change our process for who we will be screening. Staff burnout is very real and needs to be taken seriously and we recommend focusing more on staff comfortability and confidence when rolling out the PEARLS screener.
In addition to implementing a new tool to screen for ACEs, FOHC also wanted to address the patient experience from a more strength-based lens. This was important for our team because our team has seen cases where children repeatedly come in for the same complaints – something that can continue if we don’t shift our focus to the underlying ACEs the child may be experiencing. This meant needing to help educate families on what ACEs and their impact on childhood health are as well as helping link to appropriate resources.
We began by updating the materials given to patients to include education around ACEs. We utilized our connection to the greater Resilience Beginnings Network as well as the various programs participating in this grant to share relevant, easy to understand handouts that we can give to families. These handouts help to explain what ACEs, potential long-term impacts, and examples of how seemingly unrelated things such as strong social connections can help to mitigate these impacts. We’ve also purchased children’s books that discuss the subject of being afraid and encourage parents to use this to have discussions with their children around fear and how it’s okay to be afraid and seek help when needed.
Another area of focus was the resources we refer our families to. A new resource we are also utilizing in our practice with families is nature therapy, including Park passes and prescriptions for time in nature. SMMC clinics have long recognized the importance of time in nature to promote both physical and mental well-being. During the pandemic, the Peninsula Open Space Trust made a cabin in the hills in San Mateo County available to spend a free night and our Providers can refer a family for a free stay. Families have been very enthusiastic about this resource, which helps provide a break from stressors of the home environment and gives families time to bond together. It is especially important for the children, as they may not have many opportunities to be in nature.
In the past year, our clinic has also hired a Community Worker who has helped to coordinate community resource days onsite. At these events, community resources representatives attend to make their services known to patients and staff. This has been very helpful in also strengthening the relationship between our clinic and the community. We are also working towards having our Community Worker be able to provide more one on one support to families with resource linkage and provide more in-depth assistance as needed.
Moving towards becoming a Healing Organization doesn’t stop with introducing a new screener to patients. That is just one part of the patient experience when they come in for an appointment. It is important to look at other aspects of the clinic as potential areas for improvement. This could be having a dedicated staff person who can help follow up around resource linkages. Providing resources such as children’s books that discuss important subjects and nature therapy helps to reinforce the education around protective factors. Increasing staff awareness of the resources that are available in the community is important as well.
A positive ACEs score does not always mean that big interventions and outside services are needed. Sometimes, just this act of sharing knowledge around protective factors can empower them to take control of their own health with great results. 11-year-old “Ryan" is a good example:
Ryan came to FOHC frequently with complaints of headaches and abdominal pain. A full work up and several interventions did not lead to improvement. Ryan's PEARLS screening was positive for several ACES. After some education his family chose several protective actions to take, including dedicated family walks and joining a soccer team. At a follow-up Tele-Visit, Ryan's mother reported his symptoms had resolved. His mom also shared that she felt happy knowing she was able to improve the health of her child.
At FOHC, our overall goals were to implement the PEARLS screening tool for pediatric patients and begin to address the ACEs that they are or have been experiencing. Though our clinic has always recognized how the hardships and barriers our patients face can affect their health, implementing this screening tool has provided structure and a team of providers who are better able to support patients through education around the effects of toxic stress and protective factors. During our three-year participation in the Resilient Beginnings Network, our team had several learnings that we feel other clinics can learn from as they consider beginning to screen for ACEs. These include:
- Be flexible with your standard work and willing to re-evaluate and make changes as needed. It is okay if your original idea isn’t ideal and to pivot to new strategies.
- Consider focusing less on a gradual rollout with a smaller population and more on staff comfortability. Recognize that everyone wants to do a good job and is working hard. Acknowledge the impact of toxic stress on staff and provide ways to support your team.
- Try to work within already existing roles. Our PSAs were better equipped to distribute the PEARLS screeners rather than working it into the rooming process.
- Having staff who can focus on resource linkage and using more strength-based materials and referral supports are a tremendous asset.
- Have a way to track progress and share progress with the team. This can include a data dashboard and a bulletin board that shows the progress made.
Moving towards becoming a more Healing Organization can be a long journey and we will continue to find new ways to help our families thrive. Progress sometimes seemed slow for our clinic, but looking back on the past three years, it is easier to see how far we’ve come. Our staff is much more aware of ACEs and their health effects on the families they serve and on themselves. The updates we’ve made to our standard work provides for a smooth distribution of the PEARLS screener and our data reflects this through increased numbers of completed screenings. Patients and their families have been receptive to this new screener. They have expressed gratitude for interest in the hard things that happen in their lives and are genuinely interested in the ways to decrease the effects of ACEs. We are proud of the progress our clinic has made over the past three years and hope these lessons learned are helpful to other clinics who are planning to screen for ACEs.