Turning straw into gold, ACE screening for adult agricultural workers in primary care: a quality improvement project

Abstract

History of adverse childhood experiences (ACEs) is common among adults and associated with nine of the ten leading causes of death in the United States. ACEs screening, coupled with patient education and support from behavioral health promotes resilience and healing from trauma. ACEs screening was not a routine component of the annual assessment visit at the primary care clinic, a federally qualified health center serving agricultural workers and their families. The purpose of this project was to implement ACEs screening as a routine part of the annual assessment visit for adult agricultural workers, coupled with education and, for patients at increased risk, prompt referral to behavioral health. Prior to implementation, training was provided to clinical staff to prepare them for ACEs screening. During the ten-week data collection period, 75% of annual assessment visits included ACEs screening with documentation in the patient's medical history. 17% of the patients screened were determined to be at increased risk due to ACEs, and 57% of patients referred to behavioral health secondary to ACEs screening completed a visit with a behavioral health provider within two weeks of screening. Recommendations to increase ACEs screening and behavioral health referrals in this primary care clinic include adding ACEs screening to the organization's At-a-Glance Checklist for chart preparation, adding ACE score documentation to peer review chart audit, and identifying ACE-specific diagnoses to list in the medical history to facilitate data extraction and meaningful use for population health.