MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

The mission of St. Joseph´s is to promote healing and recovery for individuals, as well as their families, suffering from substance use disorders and problem gambling. We offer these services with a commitment to providing effective, professional and quality treatment. Our services are enhanced by our belief in the spiritual nature and inherent dignity and worth of each individual.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

Trauma is defined as: "

1. an injury (such as a wound) to living tissue caused by an extrinsic agent,
2. a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury,
3. an emotional upset."

Adversity is defined as: "a state or instance of serious or continued difficulty or misfortune."

According to research and years of experience from the likes of Sanctuary Model founder Dr. Sandra Bloom, trauma expert Bessel van der Kolk M.D. and many others in the field, trauma and adversity, while personal and unique in circumstances, are universal experiences throughout society. Everyone, at some point in time, will be faced with some form of adversity (physical, mental, emotional, spiritual). Based on the ever–growing research on the physiological, mental, emotional, and spiritual effects of trauma and adversity during an individual´s lifespan, particularly during early childhood, Kaiser Permanente and the Centers for Disease Control and Prevention created the Adverse Childhood Experience (ACE) Questionnaire. Studies show that basically, the higher one´s ACEs score is, the higher propensity the individual has to engage in high risk behavior and experience unhealthy side effects of poor health choices as they age (i.e. nicotine use, substance use, COPD, early sexual behavior, suicide attempts, rape and domestic violence perpetration, chronic depression, etc.).

Regardless of age, ethnicity, gender, faith–system, education level, and any other social construct used to identify people and groups, studies show that traumatic experiences and adverse events, especially when experienced during developmental childhood, can be strong indicators of unhealthy trajectories of individuals as they develop and age. One of the strongest mitigating sources that can be identified, honed, and applied to reduce the amount of negative life consequences due to high ACEs scores is the prevalence of resiliency factors. As a solution–focused, strength–based response to the ACEs Questionnaire, supported by over 40 years of research, study and literature from Emmy Werner and others, the Resilience Questionnaire was created and introduced by the Southern Kennebec Healthy Start.

Introducing the Adverse Childhood Experience (ACE) Questionnaire, followed by the Resilience Questionnaire, into more social service providers (Mental Health, Doctors and Primary Care Physicians, Substance Use Disorder, etc.) will enrich and inform service providers with potential insight into the five key areas of SDH and how best to respond with services, insurance coverage and other supportive resources. When coupled and administered at appropriate times after a therapeutic relationship is sustained, service providers will be enabled to recognize a significant factor for all areas of SDH and introduce intrinsic resilience factors to the individuals that they can begin to utilize. Coupling these two questionnaires that need minimal training to administer, score, and document, will act as a preventative measure and as an awareness indicator that helps service providers respond in order to build off the intrinsic resiliency factors and reduce the potential negative consequences of the preceding trauma and adversity.

Being able to identify an ACEs score earlier in a person´s lifespan will allow service providers and caregivers to refer to appropriate resources sooner leading to faster, lower level service provision and less acute dysfunction and disruption that would result in more costly interventions. Based on studies referred to above, the results of adverse childhood experiences have the strong propensity to negatively affect all five areas of SDH; most often resulting in the individual becoming one of the costliest consumers in the Medicaid/MCO realm in terms of entering the social service system at the most expensive entry points (i.e. Emergency Department, Crisis Care Management, Detox/Inpatient SUD treatment, Psychiatric emergencies, etc.). Offering the ACEs Questionnaire more often and in more healthcare, settings will allow service providers to respond sooner with appropriate interventions that will likely decrease costs.

Coupling the Resilience Questionnaire with the ACEs Questionnaire will offer an immediate, strength–based response to the information identified by the ACEs score. Oftentimes when an individual is presented with the evidence of adverse childhood experiences and how it can negatively impact the trajectory of one´s quality of life, they experience emotional disruption that may result in unhealthy impulsive behaviors. By following the ACEs Questionnaire with the Resilience Questionnaire, service providers can help individuals identify positive, strength–based resiliency factors they have intrinsically and can apply to their daily lives immediately. This will also serve as the foundation for identifying what referrals or resources would be ideal to connect to the person in need (i.e. housing, social services, substance treatment, etc.) leading to SDH stability.

The ACEs and Resilience Questionnaires have been utilized for years in the Behavioral Healthcare field. It is simple, easily administered in paper form or built into Electronic Medical/Health Records and does not require significant, costly training to become versed in the language and content. The potential return on investment is almost invaluable in terms of the relatively inexpensive incorporation of these questionnaires in comparison to the cost savings that could result in identifying the significant risk factors that accompany adverse childhood experiences, educating service recipients and engaging support services sooner; reducing the quantity of costly acute services required to react to the results of trauma and adversity.

The scalability of utilizing these questionnaires throughout the healthcare field are twofold and practical. Both questionnaires utilize a simple, objective scoring system in order to identify both adversity and resiliency factors which can be recorded as a simple, single digit and used for monitoring and data analytics without sharing the confidential, intimate information that is being asked (the research is based on the amount of compounding adverse childhood events, not on the specific events themselves). This information can be collected and shared on an agency, county, State, even Federal level which will offer service providers, insurance companies, government entities and policy–makers priceless information about micro and macro trends in ACEs scores and resiliency factors. This information will not only assist in identifying specific trends and needs for individuals served, it will also allow service providers to recognize the collective needs of the communities served and more capably assign resources for those areas.

The feasibility of enriching current healthcare provider´s services with these questionnaires is high as the only requirements for including these questionnaires into a service provision practice is to either administer them as paper documents and report to collecting agencies or have them built in their Electronic Medical/Health Records. Training requirements to administer and speak to the contents of the questionnaires is minimal as well (could be trained via webinar or in–person in an hour). The information gained from these questionnaires well exceeds the minimal cost to incorporate them into current practices and it can be used by all to recognize strengths of individuals, communities and identify more specifically appropriate resources required to stabilize individuals in all SDH areas.

While the specific arena of traumatic experiences, adverse events and becoming more trauma–informed as healthcare providers is just starting to "wake up," the research and study of the effects of trauma and adversity on individuals and communities has been happening for decades. The benefit of this is that there is extensive evidence–based support for the value in identifying and tracking ACEs and resiliency scores as a way to prevent costly healthcare issues or respond to them before they become acute services that are costly, inefficient and do not typically lead to reduced recidivism in service delivery.

The relevance of this innovation to the Medicaid population is that, based on research in trauma and adversity, the Medicaid population have the highest collective ACEs score and are in need of identifying their internal resiliency factors. ACEs measures the following areas: Physical abuse, Sexual abuse, Emotional abuse, Physical neglect, Emotional neglect, Intimate partner violence, Mother treated violently, Substance misuse within household, Household mental illness, Parental separation or divorce, Incarcerated household member. By starting to collect the ACEs score in a widespread effort, more research and direct correlations can be made between the ACEs score and those in the Medicaid population; offering specific insight into how best to serve and connect those in the population to relevant services.

The speed in which these questionnaires could be introduced into the market, trained and used to collect data is relatively fast. Since the questionnaires are already based on research evidence and in circulation within parts of the healthcare field, all it would take to circulate and introduce en masse is a collaborative effort. The incentive for the service providers would be an additional treatment/service factor qualifying their specific services. The incentive for healthcare companies would be a specific data set that can establish medical/service necessity in which to provide coverage for. The incentive for the local, regional and federal governments would be a simple tool to gain information from and begin to assess trends and correlations between the cost of healthcare based on SDH and early childhood events which can lead to demographic–specific interventions on small and large scales.

1. Merriam–Webster Dictionary. (2018, May 7). Definition of trauma.
2. Merriam–Webster Dictionary. (2018, May 9). Definition of adversity..
3. Bloom, S. L. (2013). Restoring Sanctuary. Oxford University Press.
4. Van der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. Viking Press.
5. Bloom, S. L. (2013). Restoring Sanctuary. Oxford University Press.
6. Retrieved from here.
7. Retrieved from here.
8. Van der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. Viking Press.
9. Retrieved from here.
10. Rains, M. and McClinn, K. (2013). RESILIENCE Questionnaire.
11. Retrieved from here.
12. Retrieved from here.

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