Implementation Intervention Example


Adverse childhood experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to violence. Adverse childhood experience screening is increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. This 2021-2024 study examines the implementation of a fee-for-service policy in California (ACEs Aware) promoting ACEs screenings and reimbursing clinics that:

  1. Complete a 2-hour online provider training in the administration and interpretation of ACE screening
  2. Use the Pediatric ACEs and Related Life-events Screener (PEARLS) tool
  3. Use an ACE-associated health conditions checklist (e.g., asthma, allergies, anxiety, depression)
  4. Complete a wellness exam

The service provider or care team uses a workflow provided by the state to score each source of information to determine a final child risk score and provide follow-up education to the family. 

    Why is it a complex intervention?

     CI DomainACEs study: Pediatric Screenings in Primary Care


    Green checkmark

    The intervention has multiple components that are dependent on each other

    The implementation of screenings by a care team in a clinical setting, use of screening scores to identify patients’ psychosocial needs, delivery of information on toxic stress to families, activation of a referral process to local Community-based Organizations (CBOs), and incorporation of screenings and referral information in the patient’s treatment plan — Referrals are dependent on screening scores, family/patient linkage to CBOs are dependent on a successful referral process.

    Green checkmark

    The individuals delivering and receiving the intervention often exhibit a high set of coordinated behaviorsThe implementation relies on coordinated action among team members of screenings, referrals, and linkage to outside clinic organizations. Families/patients participating in screenings are expected to disclose needs, and then participate in a multi-step service track comprised of care team members, referral personnel, and linkage to local Community-based Organizations or CBOs.
    Green checkmarkACEs screenings in primary care settings require changes at the organizational, workforce, and patient levelsClinic workflows need changes to embed ACEs screenings as standard practices, care team members need to increase their ACEs knowledge to provide support and information to families/patients on toxic stress and to activate suitable referrals to CBOs. Healthcare leadership needs to institute reimbursement procedures with the state and tracking practices in the patient health records system.
    Green checkmarkOutcomes are numerous and they can change over time

    Outcomes of ACEs screenings at the child and family level include Reach (i.e., percent of eligible children who have access to screenings and representativeness of those children screened), and referrals to support services based on needs identified. Outcomes at the organizational level include healthcare efforts to transform into a Trauma-informed Care system.

    Green checkmark There is a need for flexibility in how the intervention is implemented dailyACEs screenings are embedded in already strained workflows within primary care clinics and flexibility is needed such as the timing of the screenings (e.g., at specific child-age wellness visits to avoid new patients given the high paperwork caregivers already have to complete at those visits). 

    Key References:

    • ACEs Aware Website
    • Publication:
      • Pérez Jolles, M., Mack, W. J., Reaves, C., Saldana, L., Stadnick, N.A., Fernandez, M.E., Aarons, G. (2021). Using a participatory method to test a strategy supporting the implementation of a state policy on screening children for Adverse Childhood Experiences (ACEs) in a Federally Qualified Health Center system: A stepped-wedge cluster randomized trial. Implementation Science Communications Journal, 2, 143. 


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