ACEs Screening in Rural California: Exploring Provider Perspectives & Experiences

Through nine key informant interviews with Medi-Cal providers in rural Northern California, this paper identifies barriers and solutions to implementing ACEs screening.

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The impact of Adverse Childhood Experiences (ACEs) can be seen in communities across the state of California and beyond. The prevalence of ACEs varies across counties yet, rural Northern California has a toxic stress crisis that affects not only the current well-being of the communities but also future generations: the region has the highest rate of ACEs in the state, per capita.

This research focuses on the six-county region in rural Northern California served by the PHI Population Health Innovation Lab’s (PHIL) Northern ACEs Collaborative through a multisector collaborative of 28 agencies, which include Butte, Colusa, Glenn, Shasta, Tehama, and Trinity counties. Through nine key informant interviews with Medi-Cal providers in rural Northern California, this paper identifies barriers and solutions in the implementation of ACEs screening; and best practices for trauma-informed care in the region. Additionally, the interviews explored the impact of the COVID-19 crisis on the screening process, particularly with respect to referral resources and supportive interventions.

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As a rural community, I think we might be more in touch with our patients than in urban settings. Even though we see a lot of patients, we pretty much now who they are. That's helpful. We often know if they are having hard times and we want to help them. Rural Family Practice Provider
In our clinic, there are very rarely patients with a score of 0. For the most part the numbers are between 1 and 7, a few 9s. Rural Pediatric Provider
Time is the main barrier we face. It is already hard to fit in all that needs to be fit into the time of one visit. Adding another form just adds one more thing. Rural Family Practice Provider
You also fear that you will uncover something you can't handle in the time of the visit. You won't know where to send them or have time to ensure they are referred to the appropriate service. Rural Family Practice Provider
Patients from one county go to certain places and patients from another county go to certain places and Medi-Cal makes it so they can't utilize certain services in other areas. So, the services might be there, but they can't use them. Rural Pediatric Provider

Through interviews with nine pediatric and family practice physicians, nurse practitioners and physician assistants, the paper identifies common factors that helped support screening practices, including: the presence of a champion that strongly advocates for ACE screening; and having an inventory of referral resources readily available.

The paper also identifies common barriers, including: lack of time, lack of referral resources, difficulty navigating referrals across county lines, clinical infrastructure and workflow limitations, and shortage of skilled support staff.

Key Opportunities

Rural providers need resources and support to establish successful screening, referral, and treatment processes for patients across the region. Key opportunities include:

  • Leveraging a regional approach to address ACEs through a regionally connected trauma-informed network of care
  • Increasing access to, and availability of, local referral resources for patients with high ACE scores
  • Sharing best practices that are specific to the rural context
  • Expanding the local health workforce

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