Implementing ACE Screening in a Primary Care Setting

Background: Adverse Childhood Experiences (ACEs) screening is the assessment of elements of child abuse, neglect, and household dysfunction. The estimated prevalence of ACEs among adults in the U.S. is 60% (Kalmakis & Chandler, 2015). ACE scores can predict current health risk behaviors, chronic diseases, and comorbidities. The correlation of high ACE scores with poor health status suggests that ACE screening should be done in primary care visits to identify high-risk patients and to intervene early to improve health status and outcomes. Despite the evidence, primary care providers treat patients without knowledge of their childhood history and do not routinely screen for ACEs. Methods:The purpose of this quality improvement project was to implement ACE screening in a primary care clinic with nurse practitioners, support staff, and students. Pre- and post-implementation surveys were given to assess provider and staff understanding, rate of screening, perceived barriers, and satisfaction with ACE screening. Pre-intervention data was not collected from support staff because support staff were included in the intervention based on provider input obtained from the pre-survey. Staff training was developed and presented to implement validated ACE screening method at the clinic. Results: The clinic employs two providers and both participated in the study. In addition, four support staff participated. The results of this quality improvement project demonstrated that after provider training and implementation of ACE screening, there was an overall increase on the 5-point Likert scale for recommendation, familiarity, preparation, satisfaction, and rate of ACE screening in a primary care setting for both providers. There was no change in provider understanding, comfort, and confidence with ACE screening after implementation. Both providers reported an increase in their use of formal/validated screening tools and rate of screening from none to 5-10 times per week. Both providers also reported an increase in familiarity with ACEs and preparation to make referrals for positive ACEs up to "somewhat [positive]" or "very [positive]" on the Likert scale. Views on support staff training inclusion were polarized among the providers and the support staff. Conclusions:The project data demonstrates the readiness of nurse practitioners and possibly other provider roles to implement ACE screening in family practice. The positive findings from this project include use of validated screening tools and overall increases in self-reported ACE screening. This quality improvement project focused on ACE screening implementation in a small family practice. This process could be translated to a larger practice or health system. Further studies on the implementation among other providers such as physician assistants and physicians could also be feasible in similar practice settings.