Adverse Childhood Experiences: A Model for Effective 21st-Century Clinical–Community Partnerships

The recrafting of the American health care system is not for the faint of heart. The existing structures of care represent a $4 trillion enterprise with well-established systems of operation, finance, and development. International rankings suggest that the nation could improve outcomes by incorporating social determinants of health into the system’s scope of services. Adjusting the existing infrastructure provides both the opportunity for and significant inertia against the expansion of clinical–community collaborations as supported by the US Preventive Services Task Force as useful in providing evidence-based preventive interventions.¹

CLINICAL–COMMUNITY PARTNERSHIPS

The development of clinical–community partnerships is one of the more intriguing strategies of contemporary health system reform. The goal of this strategy is to achieve better value in health care through prevention and population health. Its implementation has been enabled by components of the Affordable Care Act that allowed for the development of accountable care organizations and value-based purchasing arrangement, and organizational restructuring, such as the establishment of population health units, in the private health sector health care organizations. This transition of hospitals from islands of care to integrated systems of health can be seen in the expansion of required community health assessments and improvement plans from a clinical focus toward the identification of community resources addressing social determinants of health (i.e., the conditions in which people are born, grow, live, work, and age).

Clinical–community partnerships are generally applicable to social determinants of health: for instance, introducing violence prevention programs in schools, banning soda-vending machines, creating bicycle lanes, or introducing farmers’ markets to combat food deserts. But in so doing, strong partnerships should ensure that allies in community and public health organizations are fully engaged.²

ADVERSE CHILDHOOD EXPERIENCES MODEL

Leadership in this evolutionary process of combining clinical and population health can be found in the area of pediatrics and early childhood development. Emerging from the considerable discussion of brain development in the 1980s and 1990s was the study conducted by the US Centers for Disease Control and Prevention and Kaiser-Permanente identifying adverse childhood experiences (ACEs) as a factor affecting a child’s healthy development.³ Subsequent research, documented by the Child and Adolescent Health Measurement Initiative, has deepened an understanding that ACEs “can lead to trauma and toxic stress and impact children’s brain development and physical, social, mental, emotional, and behavioral health and well-being.”⁴ Therefore, the consequences of ACEs must be the concern of health providers, but as Jones et al.⁵ acknowledged, while describing how clinical practice must appropriately adapt, ACEs also present a fundamental “societal and community challenge.” How can this broader challenge be met?

As described by the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Population Health Improvement, because “education influences health outcomes and community well-being,” it should be “explored how health sector capabilities could be used to help improve educational outcomes from pre-kindergarten through 12th grade.”⁶

A classic principle of public health is that health outcomes are the result of direct and indirect contributors of the type that ACEs research has identified. As health systems establish broader community partnerships to address population health goals, the development of clinical–community partnerships involving the educational system to address ACEs can help describe a vision for a population- and community-based 21st-century health system. This challenge should resonate with health system planners, school administrators, policymakers, and community leaders because the clinical–community partnership enabled by a health system–school alliance can address threats to a child’s ability to succeed in school and have a successful life.

IOWA CITY SCHOOL DISTRICT APPROACH

One recent local discussion of the potential effect of clinical–community partnerships on ACEs occurred in August 2019 at a roundtable of educational administrators and community representatives from across eastern Iowa and researchers from the University of Iowa. Led by the superintendent of the Iowa City Community School District, the group used information from attendance records, school food programs, and vaccination records, as well as demographic information, to evaluate how the existing kindergarten to 12th-grade data system was being used to develop student programs and infrastructure. School administrators asked how additional health status information, such as ACEs, might be incorporated into these school information systems so that administrators could better identify individual student needs and, at the district level with the use of geo-mapping, establish school boundaries and develop new resources.

This discussion made clear the importance of clinical–community partnerships. However, it also made clear that there is no easy path forward to a consistent and universal approach to the use of the type of patient- and student-specific information that surveys such as ACEs and other health assessments might provide. Among the challenges identified were questions about issues such as the following:

• •How strong are the infrastructure and governance?
• •How could these new partnerships be organized and led?
• •How would the systems be set up, and who would carry out the day-to-day work?
• •Can categorical confidentiality provisions be overcome to enable patient-centered benefit?
• •What will be the metrics, and how will accountability, results, and value be addressed and used in a continuing effort to improve health outcomes?
• •What national, state, or other policies will enable the use of data analytics to inform local collaborative practice?
• •How will positive change be sustained?

AN OPPORTUNE TIME

In the two decades since the ACEs study,³ ACEs have been firmly established as leading indicators for a range of social, emotional, and physical outcomes, including chronic disease, mental health, and substance abuse. The nation is at an opportune time to address these interconnected priorities as an evolving health care system business model aims at addressing factors leading to poor patient health outcomes. However, the ability of the clinical sector alone to address population health is limited. Involving community organizations, such as schools, through clinical–community partnerships, provides greater opportunities for success, especially for the prevention and mitigation of the effects of ACEs.

Advocates for a better American health care system should seize on the best examples of work on ACEs as a model for an inclusive strategy for population health. Perhaps, just as the Flexner report⁷ set forth a new model for personal health care 110 years ago, the leaders of this century’s health care system might establish the standards, systems, and mechanisms to fully achieve a new vision for the 21st century, one marked by prevention and population health.