Adapting the Patient-Centered Medical Home to Address Psychosocial Adversity: Results of a Qualitative Study

Vu, Cecilia; Rothman, Emily F.; Kistin, Caroline J.; Barton, Kelly; Bulman, Barb; Budzak-Garza, Ann E; Olson-Dorff, Denyse; Bair-Merritt, Megan

doi:10.1016/j.acap.2017.01.014

Cited by 19 publications

(23 citation statements)

References 27 publications

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“…13,15,48,49 However, many questions and controversies exist, including whether and how to directly inquire about ACEs with children and youth in addition to ACEs of parents, ensuring assessment promotes trust and empowers families and children, other information to collect simultaneously, data protection and confidentiality, and feasibility and practice redesign implications. 12,27,50 Because assessing ACEs in clinical or community public health contexts is not yet well studied, we approached this study with neutrality as to the value, efficacy, and feasibility of ACEs assessment in practice.…”

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confidence: 99%

Methods to Assess Adverse Childhood Experiences of Children and Families: Toward Approaches to Promote Child Well-being in Policy and Practice

Bethell

Carle

Hudziak

et al. 2017

Academic Pediatrics

393

249

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Background Advances in human development sciences point to tremendous possibilities to promote healthy child development and well-being across life by proactively supporting safe, stable and nurturing family relationships (SSNRs), teaching resilience, and intervening early to promote healing the trauma and stress associated with disruptions in SSNRs. Assessing potential disruptions in SSNRs, such as adverse childhood experiences (ACEs), can contribute to assessing risk for trauma and chronic and toxic stress. Asking about ACEs can help with efforts to prevent and attenuate negative impacts on child development and both child and family well-being. Many methods to assess ACEs exist but have not been compared. The National Survey of Children’s Health (NSCH) now measures ACEs for children, but requires further assessment and validation. Methods We identified and compared methods to assess ACEs among children and families, evaluated the acceptability and validity of the new NSCH-ACEs measure, and identified implications for assessing ACEs in research and practice. Results Of 14 ACEs assessment methods identified, 5 have been used in clinical settings (vs public health assessment or research) and all but 1 require self or parent report (3 allow child report). Across methods, 6 to 20 constructs are assessed, 4 of which are common to all: parental incarceration, domestic violence, household mental illness/suicide, household alcohol or substance abuse. Common additional content includes assessing exposure to neighborhood violence, bullying, discrimination, or parental death. All methods use a numeric, cumulative risk scoring methodology. The NSCH-ACEs measure was acceptable to respondents as evidenced by few missing values and no reduction in response rate attributable to asking about children’s ACEs. The 9 ACEs assessed in the NSCH co-occur, with most children with 1 ACE having additional ACEs. This measure showed efficiency and confirmatory factor analysis as well as latent class analysis supported a cumulative risk scoring method. Formative as well as reflective measurement models further support cumulative risk scoring and provide evidence of predictive validity of the NSCH-ACEs. Common effects of ACEs across household income groups confirm information distinct from economic status is provided and suggest use of population-wide versus high-risk approaches to assessing ACEs. Conclusions Although important variations exist, available ACEs measurement methods are similar and show consistent associations with poorer health outcomes in absence of protective factors and resilience. All methods reviewed appear to coincide with broader goals to facilitate health education, promote health and, where needed, to mitigate the trauma, chronic stress, and behavioral and emotional sequelae that can arise with exposure to ACEs. Assessing ACEs appears acceptable to individuals and families when conducted in population-based and clinical research contexts. Although research to date and neurobiological findings compel early ide...

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confidence: 99%

Methods to Assess Adverse Childhood Experiences of Children and Families: Toward Approaches to Promote Child Well-being in Policy and Practice

Bethell

Carle

Hudziak

et al. 2017

Academic Pediatrics

393

249

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“…Team-based care has the potential to provide family support and care coordination, which has been shown to have positive impacts on the toxic stress resulting from ACEs in children and may even help prevent future ACEs. 29 As discussed in the article by Vu et al 30 in this supplement, a number of the ACA's reforms seek to transform primary care through the PCMH model. The health home for Medicaid enrollees with chronic conditions is a related concept that permits states to bring PCMH to chronically ill children; approximately 17 states now have state plan amendments that permit them to implement health homes.…”

Section: Primary Care Transformation Through Implementation Of Patienmentioning

confidence: 99%

Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities

Srivastav

Fairbrother

Simpson

2017

Academic Pediatrics

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Adverse childhood experiences (ACEs) occur when children are exposed to trauma and/or toxic stress and may have a lifelong effect. Studies have shown that ACEs are linked with poor adult health outcomes and could eventually raise already high health care costs. National policy interest in ACEs has recently increased, as many key players are engaged in community-, state-, and hospital-based efforts to reduce factors that contribute to childhood trauma and/or toxic stress in children. The Affordable Care Act (ACA) has provided a promising foundation for advancing the prevention, diagnosis, and management of ACEs and their consequences. Although the ACA's future is unclear and it does not adequately address the needs of the pediatric population, many of the changes it spurred will continue regardless of legislative action (or inaction), and it therefore remains an important component of our health care system and national strategy to reduce ACEs. We review ways in which some of the current health care policy initiatives launched as part of the implementation of the ACA could accelerate progress in addressing ACEs by fully engaging and aligning various health care stakeholders while recognizing limitations in the law that may cause challenges in our attempts to improve child health and well-being. Specifically, we discuss coverage expansion, investments in the health workforce, a family-centered care approach, increased access to care, emphasis on preventive services, new population models, and improved provider payment models.

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“…There is a growing body of literature that argues for relational skills training for medical trainees and providers as a necessity to addressing ACEs and promoting resilience, including a multi-model blend of experiential training in workshop format, self-paced individual learning, and small group work (Magen & DeLisser, 2017). Clinical settings, however, may encumber operationalizing an idealized vision to teach skills to promote resilience, and prior qualitative work has recommended that providers should address the sensitive topic of adversity, and that behavioral health support should be integrated with this approach (Vu et al, 2017). The overall office environment, including medical assistants and front desk staff, was important in setting the tone for a trusting relationship, especially when considering the feasibility of addressing patients’ psychosocial adversity (Vu et al, 2017).…”

Section: Introductionmentioning

confidence: 99%

“…Clinical settings, however, may encumber operationalizing an idealized vision to teach skills to promote resilience, and prior qualitative work has recommended that providers should address the sensitive topic of adversity, and that behavioral health support should be integrated with this approach (Vu et al, 2017). The overall office environment, including medical assistants and front desk staff, was important in setting the tone for a trusting relationship, especially when considering the feasibility of addressing patients’ psychosocial adversity (Vu et al, 2017). A transformative approach needs to value a comprehensive public health approach to preventing ACEs with programs that promote “a more nurturing society” (Biglan et al, 2017) that values resilience and prosocial behavior.…”

Section: Introductionmentioning

confidence: 99%

Providing trauma-informed pediatric care for underserved populations: Reflections on a teaching intervention

Jee

Conn

Milne-Wenderlich

et al. 2019

Developmental Child Welfare

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National organizations call for providing trauma-informed care (TIC) to those who have experienced adverse childhood experiences (ACEs) and to the population as a whole. All providers and staff are at risk for experiencing stress and burnout when they care for patients with multiple complex needs and insufficient resources. All are at risk but not all develop burnout. This study shares findings from a pilot project to implement training on ACEs and toxic stress in a busy urban pediatric primary care practice. Using a mixed-methods approach, we assessed pre and post self-reported knowledge and attitudes via surveys ( n = 52), baseline in-depth interviews ( n = 16), focus groups (three groups, n = 36), and follow-up interviews ( n = 13). After training, staff reported a marginally significant increase in rating the office as doing a good job meeting the needs of families around childhood trauma (72% vs. 46%, p = 0.057). Key themes from baseline in-depth interviews and focus groups identified the following: (1) pervasiveness of trauma and adversity among families in the practice, (2) empathy for families with significant social needs, (3) feelings of frustration to alleviate stressors identified during visits, (4) need for social support and coping mechanisms to alleviate workplace stress, and (5) receptiveness to enhance knowledge and understanding. Key themes from follow-up interviews and focus groups highlighted the impact of compassion fatigue and strategies to promote self-care. We discuss these findings and challenges in relation to providing TIC and professional development.

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Adapting the Patient-Centered Medical Home to Address Psychosocial Adversity: Results of a Qualitative Study

Cited by 19 publications

References 27 publications

Methods to Assess Adverse Childhood Experiences of Children and Families: Toward Approaches to Promote Child Well-being in Policy and Practice

Methods to Assess Adverse Childhood Experiences of Children and Families: Toward Approaches to Promote Child Well-being in Policy and Practice

Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities

Providing trauma-informed pediatric care for underserved populations: Reflections on a teaching intervention

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