Abstract
Background: Adverse Childhood Experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to community or school violence. ACEs screenings are recommended in primary care settings to identify psychosocial needs and address ACEs-associated physical and mental health conditions early on. To promote its uptake, the State of California, United States, issued the 2020 “ACEs Aware” policy that reimburses clinics for screening patients annually. Yet, there is no guidance on how to successfully embed psychosocial screening practices in clinical workflows, and rigorously evaluate its impact. In partnership with a Federally Qualified Health Center system, we describe a participatory co-creation approach, called Implementation Mapping (IM), used to design and test a strategy to support the implementation of ACEs Aware policy for children ages 0 to 5 years old.
Methods: IM is a collaborative six-step iterative process to co-create multi-level implementation strategies. Sessions were conducted between May and October of 2020. We included the active participation of Hispanic caregiver mothers (n=13), and clinics’ personnel (n=22) representing roles from clinical management to front-line staff (e.g., pediatricians, medical scribers, medical assistants, promotoras, and reception desk). Mapping tasks focused on conducting a needs assessment, identifying performance goals (who, what, when and why), developing a matrix of change (how will the strategy activities bring about change), and practical applications (e.g., manuals). We fostered a co-created group process by including clinical partners in the grant proposal, and by co-creating the ACEs screenings’ implementation strategy.
Results: Twenty-five partners (52% non-White; 64% female) representing service providers, managers, departments of medical health records, technology and quality assurance, patient support, and caregivers participated in the mapping process to refine the strategy’s core goals and develop steps to carry out those goals. Five sub-groups were formed based on system characteristics: Medical Health Records system, Technology deployment, Clinic workflow, Patient/Family Experience, and Training. Study clinics serve mostly racial/ethnic minority patients. This iterative process fostered the development of tailored protocols during pre-implementation. The implementation strategy was comprised of online training videos, the use of technology (iPads) and team-based screenings to improve clinic workflow, ongoing coaching between researchers and care teams, use of peer support during implementation, and procedure protocols. Caregivers shared feedback on ways to improve families’ ACEs screening experience such as the use of scripts by screeners, with a focus on equity and reduced stigma. The resulting tailored implementation protocols are being pilot-tested using a randomized control trial.
Impact: We convened researchers, healthcare personnel, and caregivers to plan and allocate resources using a co-creation implementation mapping process. Our collaborative work with caregivers during the planning phase supports prevention to improve health and wellbeing among young children and promote equity and inclusion. This approach can contribute to efforts from other researchers and practitioners, in the United States and other countries, seeking to increase implementation capacity within community-based health systems serving low-income racial and ethnic minority children and families. Future efforts will scale up this participatory approach to implementing psychosocial screenings in primary care in the United States.