Universal Adverse Childhood Experience Screening in Primary Care

Adverse childhood experiences (ACEs) - defined as abuse, neglect, or household dysfunction before age 18 years - are consistently associated with a higher risk for many chronic health conditions and harmful health behaviors. Many organizations have recommended ACE screening to support preventive medical care and have provided examples of screening strategies. However, despite the consistent evidence linking ACEs with chronic health conditions and harmful health behaviors, routine ACE screening in primary care populations is rarely clinically implemented. The 1998 seminal Kaiser Permanente (KP)-Centers for Disease Control and Prevention ACEs study was born from ACE screening implemented in the Department of Preventive Medicine at KP San Diego in the 1980s. The goal of the 2018 initiative was to build on and advance that earlier work by implementing universal ACE screening in primary care at a KP Northern California site. The KP team included patient service representatives, medical assistants, nurses, physicians, and patients. Team members were first educated about ACEs and screening best practices. The workflow included directions on the ACE screener handout procedure, patient screener completion location, patient screening response documentation, and addressing the results with patients. Hurdles included concerns regarding the time it would take for patients to complete the screening and for providers to review and discuss with the patient, as well as the communication barriers related to topic discomfort among clinicians. Consistent with prior reports, patient resistance or discomfort was not a major hurdle. Metrics to measure implementation focused on ACE screenings completed by clinicians and patient screening refusal rates. Over the course of an 18-month pilot period, only 1% of patients declined screenings and more than 90% of physicians completed the screening process with their primary care patients. Team member education and recognition of ACEs as risk factors for chronic health conditions, a culture of trauma-informed care, and identifying team members who are passionate about ACE screening are necessary preludes to implementation of ACE screening.