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Adapting the Patient-Centered Medical Home to Address Psychosocial Adversity: Results of a Qualitative Study

      Abstract

      Objective

      The patient-centered medical home (PCMH) seeks to improve population health. However, PCMH models often focus on improving treatment of chronic diseases rather than on addressing psychosocial adversity. We sought to gather key stakeholder input about how PCMHs might feasibly and sustainably address psychosocial adversity within their patient populations.

      Methods

      We conducted 25 semistructured interviews with key stakeholders, such as physicians, nurses, medical assistants, and patients. The audiorecorded interviews focused on participants' perceptions of the best ways to modify the PCMH to address patients' psychosocial adversity. To facilitate information gathering, a fictional patient case was presented. Analyses were conducted using a 3-stage content-analysis process.

      Results

      Participants identified provider-related and systems-level changes necessary for addressing these psychosocial adversities effectively. On the provider level, participants thought that practitioners should foster trusting relationships with patients and should be emotionally present as patients describe their life experiences. Participants also emphasized that providers need to have sensitive conversations about adversity and resilience. On a systems level, participants discussed that documentation must balance privacy and include relevant information in the medical record. In addition, care should be delivered not by a single provider but by a team that has a longitudinal relationship with the patient; this care team should include behavioral health support.

      Conclusions

      Participants provided practical strategies and highlighted provider and systems level changes to adequately address patients' prior psychosocial adversity. Future studies need to assess the degree to which such a trauma-informed approach improves patient access, outcomes, and care quality, and reduces cost.

      Keywords

      What's New
      Medical home models often focus on improving treatment of chronic diseases rather than on addressing psychosocial adversity. This study gathered key stakeholder input via interviews about how medical homes might feasibly and sustainably address psychosocial adversity for their patients.
      Psychosocial adversity, defined as significant stressors such as poverty or violence, is alarmingly prevalent. For example, 1 in 3 women has experienced rape, physical violence, or stalking by their partner over their lifetime.
      Centers for Disease Control and Prevention; NISVS Summary Reports
      National intimate partner and sexual violence survey—2010 summary report.
      The Adverse Childhood Experiences (ACE) studies found that two thirds of adults had experienced some childhood adversity, one particularly important type of psychosocial adversity with known detrimental effects on lifelong health.
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study.
      Growing evidence demonstrates that ACEs and other psychosocial adversity can disrupt physiological systems and increase risk-taking behaviors, thereby increasing morbidity and mortality.
      • Keeshin B.R.
      • Cronholm P.F.
      • Strawn J.R.
      Physiologic changes associated with violence and abuse exposure: an examination of related medical conditions.
      Trauma also can have an intergenerational effect. Parents with histories of psychosocial adversity report high rates of depression and parenting stress, and they are more likely than other parents to report using harsh child discipline.
      • Banyard V.L.
      • Williams L.M.
      • Siegel J.A.
      The impact of complex trauma and depression on parenting: an exploration of mediating risk and protective factors.
      The health-related costs of psychosocial adversity are significant. Intimate partner violence (IPV) exposure alone was estimated to cost $4.1 billion in 2003
      Centers for Disease Control and Prevention
      Costs of intimate partner violence against women in the United States.
      ($5.3 billion today), in part because women who have experienced IPV have 20% higher health care utilization than women without such history.
      • Rivara F.P.
      • Anderson M.L.
      • Fishman P.
      • et al.
      Healthcare utilization and costs for women with a history of intimate partner violence.
      There is need, therefore, within the developing national agenda to address ACEs and promote resilience, to gain understanding about how medical providers and health care delivery systems can adapt to best support patients with ACEs and other psychosocial adversities.
      The patient-centered medical home (PCMH) represents one innovative, increasingly implemented health care model that seeks to improve the delivery and quality of patient care. Key components include a continuous patient-provider relationship, access to comprehensive and evidence-based care, and care coordination.
      • Van Cleave J.
      • Okumura M.J.
      • Swigonski N.
      • et al.
      Medical homes for children with special health care needs: primary care or subspecialty service?.
      In August 2014, the Affordable Care Act announced $35.7 million of funding to support PCMHs among 147 health centers in 44 states.
      US Department of Health and Human Services
      The Affordable Care Act supports patient-centered medical homes in health centers.
      Emphasizing the need for care that comprehensively addresses patients' needs, the Institute of Medicine called for medical homes to consider patients' ecological context, including family, neighborhood, and cultural level influences on health. However, to date, PCMH models focus predominantly on improving medical treatment of chronic diseases rather than on addressing psychosocial adversity. This focus likely reflects practice constraints including time, lack of appropriate training, and need for additional infrastructure.
      • Schickedanz A.
      • Coker T.R.
      Surveillance and screening for social determinants of health—where do we start and where are we headed?.
      The health of millions of US residents may improve if the PCMH model used a “trauma-informed” approach to address physical and emotional health in an integrated way, using predetermined standards. We previously presented the results of a Delphi process we conducted to obtain expert consensus on the key elements necessary to enhance the PCMH's ability to address psychosocial adversity.
      • Bair-Merritt M.H.
      • Mandal M.
      • Garg A.
      • et al.
      Addressing psychosocial adversity within the patient-centered medical home: expert-created measurable standards.
      However, these recommendations came from experts such as researchers or leaders within nonprofit organizations who were only partially engaged in clinical practice. A well-documented chasm exists between scientific evidence and clinical practice, and priorities from academia may not be fully concordant with those of practitioners.
      • Baker A.
      Crossing the quality chasm: a new health system for the 21st century.
      Thus, it is unclear which action steps are appropriate or feasible to implement during day-to-day practice in health care settings.
      Therefore, following the guiding principles of implementation science, we conducted semistructured interviews with key PCMH stakeholders to understand perspectives and organizational cultures that serve as barriers or facilitators to implementing a trauma-informed approach to care. We sought to explore actionable strategies about how PCMHs might best address psychosocial adversity with their patient populations, ideally in a manner that is feasible and sustainable.

      Methods

      Study Design, Sample, and Setting

      Between June and September 2015, we conducted 25 semistructured interviews with key stakeholders, defined as physicians, nurses, medical assistants, office managers, quality improvement specialists, and patients, as well as one representative from a payer organization. All participants were recruited from a Wisconsin-based health system with over 1 million outpatient visits per year. This health system prioritizes preventive medicine, population health, and trauma-informed care by providing diverse services to address these issues and by offering training to departments within the system.
      Participants had to be: 1) a hospital/clinic employee, or a patient on the Patient/Family Advisory Board, 2) ≥18 years of age, and 3) English speaking. Interested participants informed a member of the study team, who provided them with information and the interview questions. A graduate-level research assistant (RA) with public health background conducted interviews by telephone, at which time participants gave verbal consent. The audiorecorded interviews focused on ways to modify the PCMH to better address patients' histories of psychosocial adversity. All participants were instructed, “When you are answering the questions, please think about whether your responses would be possible within your practice.”
      To facilitate information gathering, the RA presented a fictional patient case and participants discussed how the hospital or a provider might respond (Figure 1, Figure 2). Transcripts were professionally transcribed. The research team discussed transcripts concurrent with data collection, with recruitment continuing until data saturation was reached. This study was considered exempt by the authors' committees for the protection of human subjects.
      Figure thumbnail gr1
      Figure 1Fictitious case study presented to participants.

      Analysis

      Transcribed interviews were uploaded to Dedoose software, an electronic platform that allows for organization and analysis of qualitative data. Analyses were conducted using a 3-stage content analysis process. First, 2 research team members read all interview transcripts to get a sense of the whole and to develop a coding dictionary. One is a public health graduate student and the other a pediatrician and researcher. These 2 team members then developed 15 codes to encompass the emerging themes. Second, 4 RAs (2 medical students and 2 public health students) coded the interviews, with 2 coders per interview. The coders worked independently, and then reviewed each interview together to discuss disagreements and reach a final decision. Finally, the RAs and the pediatrician came to consensus on overarching themes.

      Results

      Participants

      Twenty-five participants were interviewed. Demographic data are presented in Table 1.
      Table 1Demographic Data of 25 Study Subjects
      Characteristicn%
      Gender
       Male520
       Female2080
      Race/ethnicity
       White2496
       Black/African American14
      Age (years)
       18–30416
       31–401040
       41–50312
       51–60832
      Education
       Did not graduate high school14
       Graduated high school14
       Trade school832
       College and beyond1560
      Profession
       Physician520
       Nurse936
       Medical assistant312
       Quality improvement312
       Patient416
       Payer14

      Interview Themes

      Themes with additional illustrative quotes are presented in Table 2.
      Table 2Themes and Illustrative Quotations
      ThemeIllustrative Quotation
      Trusting relationships focused on holistic well-beingIt's going to take a cultural transition for health care providers, because I think that we've always seen our role as when that patient comes in to the clinic or the hospital or whatever, and not necessarily as our role being much broader than that. And so in order to do this well, we're going to have to really transition the mindset that this patient is, you know, our responsibility from start to finish, not just when they're in this building.
      Conversations, not screening questionnaires, for psychosocial adversityDoes she have family that she can go to? Does she have support within her family or within her community besides us? Is there somebody there that Annie can turn to?…I think Annie needs support, so if there is not that in her life, then we need to figure out a way to support her more.
      Full-team approach to compassionate careI think that a comfort level for most patients is always being able to see the same provider of course, and same staff. Being here 21 years, I've been in one department my whole time, so a lot of the patients know me and they get used to you, and when I'm not here or when those people aren't there, it gives them a little more anxiety, because it's somebody new putting them in, so I think just making them feel comfortable that they know everybody that is working with them is in their medical home group.
      Documentation and privacy of sensitive informationA patient may have a high level of comfort with you as one provider versus another in discussing those things. Say she has abuse at home and I put that on her problem list or her medical history, she may not want that there because she may not want other people aware of that because that is a private issue for some people. I think before you put anything on the problem list or medical history, I think you need to talk to patients because you have to be aware that other people likely will talk to her and look at her different because of that documentation.
      Need for behavioral health supportI think behavioral health and counseling and social services are things that if you're a medical home, you should have ready access to, and if you don't, then you're going to struggle, because it sometimes feels like 25–30% of the things you deal with in a day-in and day-out situation are psychosocial. And so if you don't have those resources available to you as a medical home, you're going to miss out on a lot of things that you can do to help alleviate some of the pain and suffering associated with psychosocial distress.
      Calming office environmentI don't know how they're going to be when they check me in…and then they are nice, and then they end up having this medical assistant or LPN, whoever is going to be rooming the patient, and then they get that welcoming environment. It makes them actually feel, “Oh, okay, it doesn't matter where I go. I'm not seeing my primary care provider, [but] I'm still taken care of.” So patients usually want to have that security, and a welcoming environment that they can trust someone.

      Trusting Relationships Focused on Holistic Well-being

      Participants mentioned that earning patient trust was crucial to facilitate discussions about psychosocial health. Some remarked that the provider–patient power dynamic, or embarrassment or shame may preclude trust building. Participants stressed that the patient should receive individualized attention. Others noted the importance of staff being fully mentally present when listening to patients' histories, demonstrating sincerity and willingness to listen. Being present and listening nonjudgmentally seemed to be especially relevant for patients with complicated histories. One female patient explained:for that time frame, it's just really all about Annie [the case patient]…and she's the focus. So, the provider or [the health system] itself is kind of, you know, present at the moment that Annie is the patient here. They're not worried or focused about anything else.…So, if that is the feeling Annie gets from the experience, then that increases her comfort level every time she needs to return here.
      Participants also emphasized the need for a holistic approach, considering patients' needs comprehensively rather than focusing only on the chief complaint. However, participants commented that caring for the full patient may require a shift in current medical culture.

      Conversations, Not Screening Questionnaires, for Psychosocial Adversity

      Most participants suggested that they preferred to ask open-ended questions (vs using validated screening instruments) about sensitive topics. One patient noted:I know in the hospital they always ask you, “Do you feel safe at home?” Barriers I think would go up right away for Annie, and in order to protect her children and herself she might [say], “Oh, yep, yeah.” She's going to lie through her teeth, but if you skirt around it—and I'm not sure, because again, the legal things I don't know—but asking her, “What kinds of things do you like to do in the evening? Do your children like those, too?” You know, talking about her home life and see what kind of community her husband and her children and she have together.
      Participants supported asking questions in a conversational tone that avoid judging, like “Are there currently any stressors in your home or life?” or “How are you handling stress?” The patient then can lead the conversation, and the provider can ask more specific questions. Some participants also noted the importance of watching the patient's body language to gauge comfort level and how much to probe. Providers recognized that having sensitive conversations was a skill that did not necessarily come naturally but that could be learned (see Magen and DeLisser
      • Magen E.
      • DeLisser H.M.
      Best practices in relational skills training for medical trainees and providers: an essential element of addressing adverse childhood experiences and promoting resilience.
      ).
      Participants emphasized that staff should not only ask about adversity but should also get information about social support and self-care. For example, health care providers could ask about how patients handle stress, whether they exercise, and whether they have family they can depend on.

      Documentation and Privacy of Sensitive Information

      Participants discussed the precarious balance between putting relevant information in the medical record for care providers while assuring confidentiality by limiting information to those who need to know it to improve patient care. Some noted that access to this information could help to connect health care departments, allowing them to work as a united team. However, one physician predicted that patients may be reluctant to have their psychosocial histories documented as a result of privacy concerns. Accordingly, he suggested that providers communicate explicitly to patients how this information will be recorded and who has access to it.A patient may have a high level of comfort with you as one provider versus another in discussing those things. Say she has abuse at home and I put that on her problem list or her medical history, she may not want that there because she may not want other people aware of that because that is a private issue for some people. I think before you put anything on the problem list or medical history, I think you need to talk to patients because you have to be aware that other people likely will talk to her and look at her different because of that documentation.

      Full-Team Approach to Compassionate Care

      Participants emphasized consistently that compassionate care was the responsibility of every person on the health care team, not solely the physician. Several added that everyone had a role in forming a strong relationship with the patient. Participants also noted that all members of the health care team were well positioned to ask patients about psychosocial adversity. One physician stated:It really starts with the whole care team participating in getting a good social history. I could list many examples of where my medical assistant, after rooming a patient, says, “You know what, you really need to ask them about this—he kind of opened up about something and started to cry, and I think there's something going on,” and you know, without that input, I might miss the cues. Hopefully I don't, but you know, when everyone on the team is paying attention, that happens more frequently, and you can provide more holistic care for the patient.
      Participants suggested that team-based care may be more effective when there is continuity over time. For example, one medical assistant stated that her many years working at the same clinic made patients comfortable coming to appointments, which indirectly lessened anxiety.

      Need for Behavioral Health Support

      Almost all participants (n = 24) noted the limited communication between primary care and the behavioral health services most needed by their patients. They stressed that if the primary care provider is assessing for psychosocial concerns, she must have the right resources to respond, including behavioral health and social work. For example, participants thought that social workers were invaluable because they served as gateways to community resources, especially if the primary care team was unaware of the resources or lacked time to counsel the patient about options. One physician explained,I think behavioral health and counseling and social services are things that if you're a medical home, you should have ready access to, and if you don't, then you're going to struggle because it sometimes feels like 25–30% of the things you deal with in a day-in and day-out situation are psychosocial. And so if you don't have those resources available to you as a medical home, you're going to miss out on a lot of things that you can do to help alleviate some of the pain and suffering associated with psychosocial distress.
      Some participants commented that patients would be more willing to use behavioral health services if they were directly embedded in primary care. By having these services available immediately and in a familiar context, it is probable that more patients would make initial appointments.

      Calming Office Environment

      Participants' perception was that the overall office atmosphere was essential for establishing the relationships required to address psychosocial adversity. Several participants noted that front desk staff were important in setting the office tone. One medical assistant stated,I don't know how they're going to be when they check me in…and then they are nice, and then they end up having this medical assistant or LPN, whoever is going to be rooming the patient, and then they get that welcoming environment. It makes them actually feel, “Oh, okay, it doesn't matter where I go. I'm not seeing my primary care provider, [but] I'm still taken care of.” So patients usually want to have that security, and a welcoming environment that they can trust someone.
      Participants highlighted the importance of office aesthetics such as comfortable chairs, soothing paint colors, and restful exam rooms.

      Discussion

      This qualitative study focused on how to best and most feasibly address patients' psychosocial adversity within the medical home from the perspectives of medical providers, staff/employees, and patients within a single health system. Participants identified provider-related and systems-level changes necessary for addressing these issues effectively, with several themes warranting further exploration. On the provider level, participants thought that practitioners should foster trusting relationships with patients, and should be emotionally present. Participants also emphasized that providers need to have sensitive conversations about adversity and resilience rather than using validated screening questionnaires.
      On a systems level, participants discussed that documentation must be developed to balance privacy and the need to include relevant information in the medical record. In addition, care should be delivered not by a single provider but by a team that has a longitudinal relationship with the patient; this care team should include (or include access to) behavioral health support. Participants also reinforced the importance of a calming office environment; while this goal is ubiquitous in medical homes, in part related to studies that cite enhanced recovery for patients cared for in serene settings,
      • Choi J.H.
      • Beltran L.O.
      • Kim H.S.
      Impacts of indoor daylight environments on patient average length of stay (ALOS) in a healthcare facility.
      a quiet and reflective environment may be of particular importance for patients who are at higher risk than their peers of being triggered as a result of prior adverse experiences.
      • Elliott D.E.
      • Bjelajac P.
      • Fallot R.D.
      • et al.
      Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women.
      Participants emphasized the need to develop trusting provider–patient relationships and for providers to be present when having conversations with patients. While these relationships ideally are an essential component of any PCMH, establishing trust is particularly important for patients who have faced adversity.
      • Green B.L.
      • Saunders P.A.
      • Power E.
      • et al.
      Trauma-informed medical care: patient response to a primary care provider communication training.
      This emphasis on relationship building between providers and patients parallels literature that suggests that safe, stable, and nurturing relationships are an essential component of resilience. Specifically, to overcome the adverse impact of ACEs and other adversities, adults, just like children, need stable relationships to reduce stress and improve wellness; our results indicate that medical providers and staff may be important sources of support.
      • Thornberry T.P.
      • Henry K.L.
      • Smith C.A.
      • et al.
      Breaking the cycle of maltreatment: the role of safe, stable, and nurturing relationships.
      • Henry K.L.
      • Thornberry T.P.
      • Lee R.D.
      The protective effects of intimate partner relationships on depressive symptomatology among adult parents maltreated as children.
      The importance of empathy is consistent with prior literature focused on individuals with a history of abuse.
      • Rhodes K.V.
      • Frankel R.M.
      • Levinthal N.
      • et al.
      “You're not a victim of domestic violence, are you?” Provider–patient communication about domestic violence.
      For example, one study audiotaped discussions between patients and providers about abuse history. Results supported that empathetic conversations—including active listening and validation—facilitated the disclosure of abuse, while closed-ended questions or a focus on biomedical concerns were not effective in creating a safe space.
      • Rhodes K.V.
      • Frankel R.M.
      • Levinthal N.
      • et al.
      “You're not a victim of domestic violence, are you?” Provider–patient communication about domestic violence.
      Medical staff and providers may require training to develop these relational skills.
      • Green B.L.
      • Saunders P.A.
      • Power E.
      • et al.
      Trauma-informed medical care: patient response to a primary care provider communication training.
      Participants reported feeling more comfortable having open-ended conversations about both adversity and resilience, as opposed to using validated questionnaires. This approach stands in contrast to evidence-based recommendations from organizations like the United States Preventive Services Task Force that emphasize using well-validated screeners for individual psychosocial stressors like IPV and behavioral health concerns like depression.
      • US Preventive Services Task Force (USPSTF)
      • Siu A.L.
      • Bibbins-Domingo K.
      • Groosman D.C.
      • et al.
      Screening for depression in adults: US Preventive Services Task Force recommendation statement.
      • US Preventive Services Task Force
      • Moyer V.A.
      Screening for intimate partner violence and abuse of elderly and vulnerable adults: US Preventive Services Task Force recommendation statement.
      Considering screening for adversity more generally, some practices have begun using the ACE screening, but these have not yet had adequate psychometric validation.
      • Bair-Merritt M.H.
      • Zuckerman B.
      Exploring parents' adversities in pediatric primary care.
      Future studies should explore the benefits and limitations as well as the sensitivity and specificity of a general screening tool compared to more open-ended conversations.
      Participants discussed the challenges of balancing medical record documentation and privacy concerns. Experts in our Delphi study commented that providers should record details about psychosocial adversity and the resultant care plan in the medical record, but they did not propose best practices about where this information should be documented or whether it should be restricted to specific providers.
      • Bair-Merritt M.H.
      • Mandal M.
      • Garg A.
      • et al.
      Addressing psychosocial adversity within the patient-centered medical home: expert-created measurable standards.
      The National Academy of Medicine recommends recording social and behavioral data related to health outcomes in the electronic medical record.
      National Academy of Medicine
      Capturing social and behavioral domains in electronic health records: phase 1.
      Prior work in IPV screening demonstrated that the electronic medical record has the potential to facilitate standardized screening, provide linkages to practice guidelines, and improve communication between providers.
      • Miller E.
      • McCaw B.
      • Humphreys B.L.
      • et al.
      Integrating intimate partner violence assessment and intervention into healthcare in the United States: a systems approach.
      Patient privacy and confidentiality is paramount, however, and may be strengthened at the practice and the system level. At Kaiser Permanente, IPV documentation is present in the health record but does not appear on billing statements or patient portals.
      National Academy of Medicine
      Capturing social and behavioral domains in electronic health records: phase 1.
      Many electronic systems are now capable of producing reports with encrypted individual data and deidentified clinic- or population-level data that can be used for quality improvement.
      National Academy of Medicine
      Capturing social and behavioral domains in electronic health records: phase 2.
      The PCMH model promotes a team approach to care. This may be advantageous when treating survivors of psychosocial adversity. Many participants noted that all clinical staff who develop strong connections with patients are well positioned to discuss psychosocial adversity. This could be a critically important driver of health and patients' engagement in health care; the sequelae of psychosocial adversity are well documented and include psychological and behavioral problems,
      • Price M.
      • Higa-McMillan C.
      • Kim S.
      • et al.
      Trauma experience in children and adolescents: an assessment of the effects of trauma type and role of interpersonal proximity.
      physiological stress,
      • Heim C.
      • Ehlert U.
      • Hellhammer D.H.
      The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders.
      and a need for healthy coping strategies and resources.
      • Bonanno G.A.
      • Mancini A.D.
      The human capacity to thrive in the face of potential trauma.
      The PCMH team-based approach may enhance system capacity to identify trauma survivors and create comfortable interactions for patients, ultimately promoting better treatment adherence and medical follow-up.
      • Marsac M.L.
      • Kassam-Adams N.
      • Hildenbrand A.K.
      • et al.
      Implementing a trauma-informed approach in pediatric health care networks.
      When practices assess for psychosocial adversity, it appears to be important to have close alliance with behavioral health providers; both our participants and experts queried in the Delphi study commented on the need for enhanced behavioral health support within primary care.
      • Bair-Merritt M.H.
      • Mandal M.
      • Garg A.
      • et al.
      Addressing psychosocial adversity within the patient-centered medical home: expert-created measurable standards.
      Integrated behavioral health has recently received much empirical attention.
      • McCue Horwitz S.
      • Storfer-Isser A.
      • Kerker B.D.
      • et al.
      Do on-site mental health professionals change pediatricians' responses to children's mental health problems?.
      In adult medicine, primary care providers who are trained to detect and treat depression or who incorporate a mental health specialist into their practice are more likely to improve depressive symptoms and reduce suicide ideation in patients.
      • Bruce M.L.
      • Ten Have T.R.
      • Reynolds III, C.F.
      • et al.
      Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial.
      In pediatric medicine, a meta-analysis by Asarnow et al
      • Asarnow J.
      • Rozenman M.
      • Wiblin J.
      • et al.
      Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis.
      showed that children exhibit better outcomes if they receive integrated care rather than traditional primary care. However, in our current health care system, colocation of services may be challenging; building strong relationships with community-based agencies may be a more realistic option for some practices. Some states, such as Massachusetts, have developed telephone consultation services to support primary care decision making about behavioral health.

      ACEs too high: pediatricians screen parents for ACEs to improve health of babies. Available at: https://acestoohigh.com/2015/08/03/pediatricians-screen-parents-for-aces-to-improve-health-of-babies/. Accessed January 4, 2017.

      Future studies must explore how to modify reimbursement and develop sustainable funding streams that allow for billing of primary care visits and behavioral health visits during the same encounter.
      There are several limitations to our study. First, qualitative studies gain understanding of a topic from a specific group of stakeholders, and are not designed to be generalizable. Our sample was drawn from a health care system in the Midwest, and most of our participants were white women. Health care staff and providers from other systems may have different viewpoints. Second, participants may have felt compelled to provide socially desirable responses. Despite these limitations, our interview questions avoided responses specific to the site's patient population. Rather, our questions focused on provider–patient interaction and the resources hospitals can offer to patients. The problem of balancing psychosocial against other health demands is a problem that is independent of geography and demography. We believe our findings and recommendations are relevant across a variety of health care settings.
      Participants provided practical strategies and highlighted provider- and systems-level changes that would be required to address patients' histories of psychosocial adversity. While the case study that was presented to participants focused on an adult patient's current psychosocial adversity rather than childhood trauma, the same strategies recommended by the study participants can be used to address ACEs. Considering a national agenda to address ACEs and promote resilience, our results support a number of priorities: 1) while the PCMH represents forward movement in care delivery, it must be redesigned to include trauma-informed principles
      • Flynn A.B.
      • Fothergill K.E.
      • Wilcox H.C.
      • et al.
      Primary care interventions to prevent or treat traumatic stress in childhood: a systematic review.
      ; the Substance Abuse and Mental Health Services Administration provides guidance about these principles; 2) team-based care allows for multiple touch points to assess for psychosocial adversity and support resilience; and 3) primary care medical providers have the ability to form safe, stable, and nurturing relationships with patients who have experienced psychosocial adversity. Future research should focus on identifying best practices and assessing the degree to which addressing psychosocial adversity, including colocation of mental health services, improves access and quality and reduces cost. For example, one approach would be to design a randomized trial in which intervention practices make fundamental trauma-informed systems changes, such as staff trauma trainings, training on relational skills (see Magen and DeLisser,
      • Magen E.
      • DeLisser H.M.
      Best practices in relational skills training for medical trainees and providers: an essential element of addressing adverse childhood experiences and promoting resilience.
      this supplement), development of reflective supervision practices, implementation of routine screening for trauma and for resilience, and integrated behavioral health services. Key outcomes would be patient experience, health improvement over time, and cost-effectiveness.

      Acknowledgments

      We acknowledge the work done by our graduate student coders, Ashleigh Pezzoni, Heather DeHaan, and Paul George.
      Financial disclosure: Publication of this article was supported by the Promoting Early and Lifelong Health: From the Challenge of Adverse Childhood Experiences (ACEs) to the Promise of Resilience and Achieving Child Wellbeing project, a partnership between the Child and Adolescent Health Measurement Initiative (CAHMI) and Academy-Health, with support from the Robert Wood Johnson Foundation (#72512).

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