Increasing Screening and Referrals in Primary Care for Adults with Adverse Childhood Experiences

Background: Adverse Childhood Experiences (ACEs) are common and have been linked to many adverse health outcomes. Despite this evidence, only 33% of primary care providers screen for ACEs; subsequently patients are often unaware of the health impacts and less likely to be referred to psychotherapy. Primary care has been identified as an appropriate setting to address ACEs. The purpose of this project was to increase screening and referrals for psychotherapy and provide educational materials for patients with ACEs in a primary care setting. Local Problem: ACEs rates in Utah (63%) are comparable to ACEs rates in the United States (64%) as a whole. Methods: A quality improvement project was developed to help increase screening and referrals for ACEs. Pre-intervention and post-intervention surveys were sent to clinicians to identify ACEs screening and referral rates, barriers, knowledge, confidence, attitudes towards ACEs screening and satisfaction with ACEs resources. Data from the electronic health record (EHR) was also collected for the number of patients screened and the ICD-10 code for history of ACEs. Interventions: An education presentation was delivered to clinicians about ACEs, their health impacts, the abbreviated two-question ACEs screening tool and providing trauma-informed care. The screening tool was then implemented into the EHR with a patient education handout, list of providers for psychotherapy and providers were also sent a provider education handout. Results: Post-intervention, the clinician survey found that 100% of clinicians (n=7) reported an increase in ACEs screening rates. The EHR data collection showed that 290 patients were screened for ACEs. Of those who participated in the pre- and post-intervention surveys (n=7), 71% reported providing the patient education handout or referring for psychotherapy for at least 1 patient. Thirty patients had the ICD-10 code for history of ACEs added to their problem list. Clinician satisfaction with resources for ACEs increased from 1 clinician reporting being satisfied (9%) to 3 clinicians reporting being satisfied (28%). Conclusion: The short two-question ACEs screening tool, educational materials and list of psychotherapy providers appear to be valuable resources to increase ACEs screening rates and referrals. Replication of this quality improvement project with a larger sample size is needed to evaluate if significant changes are evaluated. Further work is needed to address ongoing barriers to ACEs screening and referrals at this institution.