An Upstream Intervention 

Open Door Community Health Centers will be fortifying efforts to help providers regularly screen for adverse childhood experiences and streamline access to support systems for Humboldt and Del Norte County children, thanks to a grant from the California Department of Health Care Services.

Specifically, Open Door received a Preventing and Responding to Adverse Childhood Experiences-Associated Health Conditions and Toxic Stress in Clinics through Community Engagement (PRACTICE) grant that is aimed at "increasing the workforce and services needed for primary care clinics to expand and sustain screening and response to [adverse childhood experiences (ACEs)] and toxic stress in local communities." The grant will be implemented at Open Door's Del Norte and Eureka clinics.

Open Door Vice President of Operations Sarah Ross, who is supervising implementation of the PRACTICE grant, said screening for ACEs is a type of "upstream intervention."

"The idea being going to the source and the root of the problem to prevent disease and unhealthy outcomes later in life," Ross told the Journal. "If we can help support pregnant women, postpartum women, children earlier in their journey, the more tools they'll have for resiliency and for a healthier life."

Adverse childhood experiences, or ACEs, are traumatic events experienced in childhood. The U.S. Centers for Disease Control and Kaiser Permanente quantify "adverse childhood experiences" with 10 different categories of stressful, traumatic experiences that include experiencing sexual, emotional or physical abuse, or emotional or physical neglect; living in a household with someone who suffers from mental illness, domestic violence, substance abuse or divorce; or having an incarcerated relative. Each experience counts as one "ACE," with the cumulative total known as a person's ACEs score on a scale of one to 10.

First 5 Humboldt Executive Director Mary Ann Hansen previously told the Journal that ACEs go beyond the 10 outlined by Kaiser Permanente and the CDC. Any stressful situation in a child's life — like experiencing a natural disaster and losing their home or being discriminated against — can have far-reaching impacts on their life if they don't have the coping skills to ease stress.

In 2014, through the Center for Youth Wellness, former California Surgeon General Nadine Burke Harris found when children are exposed to a variety of stressful experiences, their bodies create an overwhelming amount of cortisol, a stress hormone, putting them in a constant fight-or-flight mental state. A large, constant amount of cortisol produced in growing bodies has been found to cause higher rates of poor physical and mental health outcomes in adulthood, including heart disease, diabetes, substance abuse and depression, among others. These conditions are now known as "ACE-associated health conditions."

The Center for Youth Wellness report found that Humboldt and Mendocino counties combined have the highest childhood trauma rate in California, with roughly 75 percent of residents having experienced one or more ACEs and 30 percent having experienced four or more. Meanwhile, 69 percent of residents in Plumas, Sierra, Siskiyou, Lassen, Modoc, Trinity, Del Norte and Shasta counties combined have experienced one or more ACEs, with 23 percent having experienced four or more ACEs.

Harris found the best way to overcome toxic stress is to build resiliency for traumatic situations by teaching children and adults the coping skills needed to manage their stress in healthy ways, like forming and maintaining healthy relationships, exercising and eating healthy. She also noted another way to help reduce stress in children and families would be to provide them with needed social services, like food pantries, access to secure housing, parenting classes, counseling and more.

Since the release of the CYW report, the state and Humboldt County have been working to reduce high rates of childhood trauma. Local schools are enacting more trauma-informed approaches to discipline, while other organizations are creating more resources for families and kids in need. Local health clinics, including Open Door and Redwood Pediatrics in Fortuna, have started screening for ACEs using a survey called Pediatrics ACEs and Related Life-events Screener (PEARLS), which asks patients questions about their living situation, whether they have seen domestic violence in their home and other ACE-related questions.

Once patients complete the survey, clinicians and providers document their experiences and connect them with appropriate resources. For example, if a patient indicates they are food insecure, their providers can refer them to a nearby food pantry. Or if a patient needs counseling, clinics can refer them to a behavioral therapist, or refer parents to a parenting class or sibling support groups if they need it.

Connecting patients to proper resources is the most important step in the ACEs screening process, as it can exponentially help families and children build skills needed to handle stressful situations and alleviate toxic stress.

Open Door implementation specialist Deja Kono said the PRACTICE grant will help Open Door create a pilot software system to guide the clinical workflow of screening for ACEs and making referrals to organizations using a "closed-loop" system in which the clinic, local nonprofits and other health organizations connect to easily document when patients are referred to resources, and whether they actually received services.

The idea of the "closed-loop" software referral system has been discussed by the California Surgeon General Office's ACEs Aware Initiative and one of Open Door's champions of the ACEs efforts locally, pediatrician Mike Mangahas.

In previous ACEs coverage, Mangahas told the Journal it's difficult for physicians to oversee referrals and ensure patients are getting the services they need without a software system in place to track them.

This "closed-loop" system ensures patients get the care they need outside of the clinic and creates a clear network between organizations and Open Door.

In addition to the creation of the software system, the grant will also fund efforts to audit Humboldt and Del Norte's available social services to identify gaps in care and services.

"This is referencing the resources, programming and workforce that we currently do not

have that has been identified as a need in our community. For example, childcare not having enough affordable options, [adding] more parent support groups and transportation options," Kono said, adding that through a statewide learning collaborative, Open Door and other organizations will be able to leverage existing and new sources of state funding to fill in these gaps.

In collaboration with Open Door through the PRACTICE grant, First 5 Humboldt, First 5 Del Norte and Partnership HealthPlan of California will spearhead efforts to expand "evidence-based" buffering services and integrate other community-based organizations into Open Door's referral network.

First 5 Humboldt and First 5 Del Norte will also employ two "community health workers" to support Open Door in creating a comprehensive, team-based network of care and act as a type of case manager who helps families address unmet basic needs, navigate referrals, monitor patient needs and ensure follow-up and provider communication.

All in all, the PRACTICE grant is intended to help the Humboldt and Del Norte Open Door clinicians regularly screen for ACEs and help communities create more buffers through necessary services to protect children and reduce the effects of ACEs and toxic stress, an upstream intervention hoped to have a great impact in an area with the worst rates of childhood trauma in the state.

Open Door's partners and clinicians are excited to implement the grant to help North Coast children build resiliency, according to Mangahas.

"This grant says, 'We are all in this together.' This is an amazing opportunity to build and strengthen relationships with our community partners already doing this important work," Mangahas said in an Open Door press release. "It will make such a difference to Open Door as we integrate mental and behavioral health into our clinics, and help our families raise resilient children and reduce family trauma."

Iridian Casarez (she/her) is a staff writer at the Journal. Reach her at (707) 442-1400, extension 317, or [email protected].