January 21, 2021

COVID-19 has exacerbated public health and economic crises, raising concerns about the unmitigated effects of pandemic-related stress on families and the potential for adverse childhood experiences (ACEs) to increase. ACEs are traumatic events that occur before the age of 18, including physical and emotional abuse, neglect, caregiver mental illness, and household violence, among other things, that can result in long-term negative effects on behavioral, physical, and mental health. With more than 60% of Americans reporting at least one ACE in their life, according to the Centers for Disease Control and Prevention (CDC), it is critical that families, medical providers, and policymakers come together to create solutions to this challenge that promote the lifelong health of their communities, especially in response to COVID-19.

Understanding the Disproportionate Toll of Toxic Stress on Health

Currently, there are ten recognized ACEs that fall into three categories – abuse, neglect, and household dysfunction. Data from the Center for Youth Wellness shows that if a child experiences several ACEs, it can cause what is known as toxic stress. Although every person encounters stress during childhood, and some stress can help build resilience, toxic stress occurs when the brain is in a state of severe or frequent stress. Over time, this prolonged state of “fight or flight” has a similar effect on the body as running too many simultaneous programs for days or weeks on a computer – it overtaxes the nervous system in ways that can lead to poor health outcomes or reduced quality of life.

Toxic stress can be particularly damaging to children because it can significantly alter the way that they develop – mentally, emotionally, and physically. According to a recent report from the California Department of Public Health, one in six Californians have experienced four or more ACEs, with a disproportionate number of these individuals identifying as members of racially marginalized, low income, and uninsured communities. The data also show that a person with four or more ACEs is:

• 3.5 times as likely to report frequent mental distress
• 1.5 times as likely to have heart disease
• 1.4 times as likely to have diabetes
• 1.9 times as likely to have a stroke
• 1.5 times as likely to be obese
• 3.2 times as likely to have chronic obstructive pulmonary disease
• 2.3 times as likely to have asthma
• 2.8 times as likely to be a current smoker
• 2 times as likely to be at risk for acute drinking

Early detection and intervention is critical to address these negative health outcomes and support families in crisis—particularly during the COVID-19 pandemic, which has taken a disproportionate toll on the health and prosperity of communities of color.

In response to this growing health equity challenge, the California Surgeon General released a blueprint calling for the reduction of toxic stress and ACEs through a cross-sector approach called the ACEs Aware initiative. The initiative aims to establish routine ACEs screening in primary care through grants and reimbursement, so that providers have the support to reach the greatest number of patients through early detection and family-based intervention.

Helping Providers Break the Cycle

With financial support from Blue Shield of California, OCHIN has integrated a new suite of tools that allow providers to screen patients for ACEs and toxic stress directly from their electronic health record (EHR) platform, OCHIN Epic EHR. First launched in September 2020, these California state-recommended child, adolescent, and adult screening tools were among the first to be integrated directly into an EHR nationally, giving providers at community health centers (CHC) unprecedented access to electronic screening tools and patients’ results within their EHR, whether they were seen in-person or via telehealth.

The integrated screening tools, which were developed by the Center for Youth Wellness and UCSF Benioff Children’s Hospital Oakland, are being used by six OCHIN Epic EHR members in California, with most utilizing the California Surgeon General’s recommended Pediatric ACEs and Related Life-events Screeners (PEARL). The advantage of having validated child- and adolescent-focused screening tools integrated directly into a young patient’s EHR is that it helps providers identify toxic stress early and break cycles of generational poverty, abuse, and/or neglect by coordinating appropriate counseling, behavioral health services, or community-based resources for things like food or housing assistance.

Additionally, OCHIN Epic EHR has made it easier for providers in California to get reimbursed for these valuable services through the ACEs Aware initiative by linking the screening to appropriate codes for reimbursement.

By easing provider access to ACEs screeners, OCHIN hopes that providers will be encouraged to have these conversations with patients and their families, offer depression and anxiety screens, make referrals to integrated behavioral health staff, or make external referrals to behavioral health specialists and community-based organizations using social service resource locators (SSRLs), like those that OCHIN offers through partners, such as Unite Us and Aunt Bertha.

Enhancing EHR Tools to Build Healthier Generations

While integrating ACEs screening tools into OCHIN Epic EHR helps clinics holistically address toxic stress, increasing adoption of these tools among already overburdened providers remains a challenge. Just over 2,000 patients have been screened for ACEs and/or toxic stress within the OCHIN Epic EHR thus far. In 2021 and beyond, OCHIN hopes to support members in dramatically growing that number by raising awareness about these screening tools, which are available to all OCHIN members across the country.

As OCHIN moves into the next phase of this work, it remains dedicated to making ACEs and toxic stress screening tools widely available to help providers standardize assessment and coordinate holistic care by providing a complete picture of a patient’s overall health within the EHR. Addressing these challenges and prioritizing preventive health services like ACEs and toxic stress screening could have a positive impact on the health system by supporting improved patient health outcomes and driving towards broader health equity.

If you are an OCHIN member and are interested in learning more about the ACEs screening or SSRL tools, please contact your OCHIN member care team.