On June 16, 2020, $14.3 million in ACEs Aware grants was awarded to 100 organizations across California to augment the work of the state’s ACEs Aware initiative. A Dec. 9, 2020 report, Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health, detailed how Adverse Childhood Experiences (ACEs) and toxic stress can impact learning and school success. Toxic stress can impede learning and affect relationships and other aspects of functioning in school by impairing the areas of the brain responsible for learning, memory, threat detection, emotional regulation, impulse control and executive functioning.
More than 20 ACEs Aware grantees were awarded funding to develop practice papers highlighting promising strategies and lessons learned, as well as new research around ACE screening and trauma-informed systems of care. The practice papers cover a broad range of topics, some of which apply to local educational agencies and the organizations they partner with. This CSBA series will highlight several of these reports.
Developed by Training and Research Associates and the California School-Based Health Alliance, this paper highlights emerging best practices, barriers and facilitators to implementing trauma-informed care, ACE screening and care coordination for the prevention and treatment of toxic stress in school-based health centers (SBHCs), which are well-positioned to coordinate care for some of the most medically underserved youth.
Ideally, in practice, SBHCs will employ multidisciplinary health and mental health professionals such as nurses, psychologists and social workers who consult regularly with school- and community-based supports for students to help identify and get them the services they need. Additionally, SBHCs should be convenient, culturally responsive and eliminate structural barriers to service, including transportation, cost, language barriers, available hours and lack of confidential services for adolescents. SBHCs also tend to have a schedule that allows for more time with patients and easier access to patients for follow-up care.
SBHCs have demonstrated the ability to increase school attendance, improve academic scores, decrease school dropout rates and provide high-quality care, according to the paper. There are currently almost 300 such centers in schools throughout California. These centers face several common barriers, according to SBHC stakeholders who participated in the research and interviews. Among them are a lack of agency leadership structure and buy-in.
Practices are often determined by the lead agency sponsoring the SBHC — be it a community health center, school district, county health department, hospital/medical center, nonprofit community-based organization or private physician group — and these lead agencies may adhere to different values and priorities, governing laws and policies, and billing mechanisms than an LEA. “Buy-in from the lead agency is necessary to establish policies and procedures that promote trauma-informed care and dedicate the time and resources for ongoing staff training,” researchers stated.
Reimbursement mechanisms and ongoing training for leadership, providers and staff at all levels of the clinic were also challenging, and only a small percentage of SBHCs were early adopters of ACE screening.
In light of the barriers and best practices outlined in the report, researchers call on the state to:
- Continue to fund and sustain an infrastructure to provide ongoing training and capacity building for trauma-informed systems and networks of care;
- Increase funding and sustainability of mental health providers in SBHCs to advance the goal of ACEs Aware to both prevent and address the impact of ACEs and toxic stress; and
- Expand tele-health resources and training for rural settings.
This paper from the San Diego Healthcare Quality Collaborative explores how Accountable Communities for Health (ACHs) can leverage their experience leading multi-sector partnerships to support the Network of Care Milestones for Communities set out in the ACEs Aware Trauma-Informed Network of Care Roadmap.
ACHs are well-positioned to provide the necessary leadership over the long term to create a community ACEs network of care through community-based partnerships across multiple sectors that develop a shared vision and take action to improve the health and well-being of a community. The San Diego ACH was established in 2016 to build new relationships between clinical and community partners. Its partners include community members, clinical providers, public health professionals, social service agencies, health plans, community-based organizations and many others.
Using a one-year provider engagement grant from the California ACEs Aware Initiative, the San Diego ACH launched an ACEs Aware Network of Care Learning Collaborative to improve cooperation and coordination across systems — including education — to prevent, treat and heal ACEs and toxic stress.
Responses to an open-ended question in the pre-session survey for the collaborative suggested more education and training were needed to improve referrals and strengthen the trauma-informed network of care.
“More providers need to access the ACEs Aware trainings about trauma-informed care and social-emotional development,” according to the report. “Teachers and parents also need to be educated about the impact of ACEs and toxic stress, as well as resources they can access to address them.”
Students benefit when schools participate in ACHs. For example, the paper spotlights the work of the Imperial County ACH, which reduced ER visits for children with asthma and improved school attendance by creating lines of communication between schools, primary care settings, emergency departments and home visiting services.