Addressing Psychosocial Adversity Within the Patient-Centered Medical Home: Expert-Created Measurable Standards

Abstract

The Patient-Centered Medical Home (PCMH) may be improved by embedding identification and response for patients’ experiences with psychosocial adversity, but how this might optimally occur in practice has not been well-specified. We sought input from an expert panel to define feasible elements that could adapt the PCMH to adequately respond to patients’ experiences with psychosocial adversity. From December 2012 through September 2013, we used a Delphi process to systematically obtain expert opinions and reach consensus. We invited 37 experts to participate in three successive and iterative rounds of questionnaires, with each round based on aggregated, de-identified data from the prior round. We first asked experts to generate elements to adapt the PCMH, using the National Committee for Quality Assurance (NCQA’s) established six PCMH standards as the foundation. We then asked the experts to rate these elements on a 5-point Likert scale, and finally specify what they considered the most and least valuable elements. Eighteen of the 37 (49%) invited experts responded to the first survey, and constituted our sample. Experts identified 35 elements that fell under the six NCQA standards. The top rated elements included using a screening tool to identify adversity; training providers to address psychosocial adversity; having a team member with mental health expertise; providing culturally-competent care; and having written patient information related to adversity and coping. This study derived key elements that may enhance the PCMH’s ability to improve patient outcomes by purposefully identifying and responding to their psychosocial adversity.

Pediatric ACES assessment within a collaborative practice model: Implications for health equity.

“…These findings are in contrast to those of our study, which suggest that the CPM builds in enough dedicated time, follows a workflow that allows for all domains of inquiry, and has a multidisciplinary team for consultation that includes behavioral health experts. The characteristics identified in this study as contributing to acceptability also align with expert recommendations for identifying and responding to psychosocial adversity in patient-centered medical homes (Bair-Merritt et al, 2015), which include having a standardized tool to capture adversity, training providers on how to address adversity experiences, having a team member with expertise in mental health, and providing culturally responsive care. These are important factors to consider for any model of primary care practice, regardless of whether a CPM is being utilized or not.…”

Screening for Childhood Adversity: Contemporary Challenges and Recommendations

“…Professional development and training in TIC holds promise for making a meaningful difference in service providers' comfort and competence when engaging in the screening process. Critical areas for training include the following: (a) the impact of trauma on children and families, including intergenerational trauma; (b) selecting, administering, scoring, and interpreting standardized screening tools that are appropriate for the age and culture of those being screened; (c) determining who should be the primary informant(s) (e.g., parent, foster parent, youth, both caregivers and youth); (d) assessing adversity in ways that do not require recounting details that may be re-traumatizing; (e) adjusting the screening process when issues of gender, race/ethnicity, culture, language, and family challenges may affect the results (e.g., a female adolescent who is reluctant to report a history of sexual abuse to a male physician); (f) explaining the purpose, use, and result of screening to families; (g) making appropriate referrals to evidence-based, trauma treatment and other services (e.g., child welfare, homeless shelters, domestic violence services) following a positive screen; (h) engaging families in the process of determining next steps (e.g., by asking families what strategies have been effective in relieving trauma symptoms); (i) ensuring that children and families feel safe before ending the screening session; and (j) using self-care practices to prevent and address secondary traumatic stress due to working with families highly impacted by trauma (Bair-Merrit, Mandal, Garg, & Cheng, 2015;Fallot & Harris, 2001;Litz, Miller, Ruef, & McTeague, 2002;SAMHSA, 2014). In addition, close collaboration with mental health professionals (e.g., training, consultation, ongoing support) has had success in improving service providers' knowledge, skills, and comfort level in working with families affected by adversity (e.g., Boris, Larrieu, Zeanah, Nagle, Steier, & McNeill, 2006).…”

Screening of adverse childhood experiences in preschoolers: a systematic review

“…Table 1 describes those that were included in this review, indicating the name of the main author, objective, year, country, type of publication, language, and journal. [41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60] The origin of the selected articles corresponds to the United States (80%), the Netherlands (10%), Colombia (5%) and Israel-USA (5%). In total, 90 authors were identified, ranging from 1-8 in the different publications.…”