Whole Population Well-Being When our science, lived experience and - - PowerPoint PPT Presentation

Whole Population Well-Being

When our science, lived experience and policies meet

Ours is a social brain. Preventing and healing developmental trauma is a matter of public health. Knowledge about the biology of human relationships, brain plasticity, epigenetics and social determinants of health making doing so imperative.

Advances in the sciences of human development create unprecedented

• pportunities to proactively advance child

well-being. Breakthrough findings across disciplines point to a new science of thriving that illuminate often untapped capacities for the promotion of healthy development and healing despite adversity. Given high rates of adversity, healing is prevention.

Key to this possibility are policies and practices that enable and support families and communities to recognize and learn to heal and flourish in the face of stress and adversity.

Prioritize Possibilities

Leveraging Existing Policies to Promote Child and Family Well-Being and Address Adverse Childhood Experiences

Christina Bethell, Johns Hopkins University, CAHMI Mark Wietecha, Children’s Hospital Association Lacy Fehrenbach, Washington State Department of Health Richard Antonelli, Harvard-Pilgram Health System Jeffrey Schiff, Minnesota Department of Human Services, Medicaid

The presenters document that they have no financial relationships to disclose or conflicts of interest to resolve.

National Health Policy Conference, February 5, 2018

Mark Wietecha-Children’s Hospital Association “Cannon to the right of them Cannon to the left of them Cannon in front of them Volleyed and thundered Stormed at with shot and shell Boldly they rode and well…” Tennyson

Richard Antonelli – Harvard-Pilgram Health System, Boston Children’s Hospital “The woods are lovely, dark and deep, But I have promises to keep, And miles to go before I sleep, And miles to go before I sleep. Robert Frost

Lacy Fehrenbach- WA State Department of Health “An open door days, ‘Come in.’ A shut door says, ‘Who are you?’ Shadows and ghosts go through shut doors. If a door is shut and you want it shut, why open it? If a door is open and you want it open, why shut it? Doors forget but only doors know what it is doors forget. Carl Sandburg

Jeffrey Schiff, Minnesota Department of Health, Medicaid “All the ‘woulda-coulda-shouldas’ layin’ in the sun Talkin’ bout the things they woulda-coulda- shoulda done But those woulda-coulda-shouldas all ran away and hid From one little ‘did’.

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Panel Agenda

2:45-3:00: Introductions and Laying the Groundwork for Dialogue 3:00-3:25: Question #1: Why are hospitals, state agencies and health systems interested? Impications for existing policies and payment and practice transformation efforts? 3:25-3:45: Question #2: What’s in the way? What’s possible now? Policy actions and opportunities? 3:45-4:00: Panel Dialogue 4:00-4:15 Audience Dialogue

Child and Adolescent Health Measurement Initiative

The 7C’s of Policy and Practice Translation

Coverage & Coding Costs and Payment Contracting, Accountability, Data Capacity & Training Credentialing & Integration Coordination Within and Across Communication Within and Across Partners and Patients

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

9

Truth About ACESs Infographic Robert Wood Johnson Foundation.

ACEs are a risk factor for trauma, toxic stress and neuro-endocrine-immune effects

Source: Bethell, C 2016

http://www.acesconnection.com/collection/aces-101

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

ACEs

Skeletal Fractures Relationship Problems Smoking General Health and Social Functioning Prevalent Diseases Sexual Health Risk Factors for Common Diseases Hallucinations Mental Health

ACEs Impact Multiple Outcomes

Difficulty in job performance Married to an Alcoholic High perceived stress Alcoholism Promiscuity Illicit Drugs Obesity Multiple Somatic Symptoms IV Drugs High Perceived Risk of HIV Poor Perceived Health Ischemic Heart Disease Sexually Transmitted Diseases Cancer Liver Disease Chronic Lung Disease Early Age of First Intercourse Sexual Dissatisfaction Unintended Pregnancy Teen Pregnancy Teen Paternity Fetal Death Depression Anxiety Panic Reactions Sleep Disturbances Memory Disturbances Poor Anger Control Poor Self- Rated Health

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

When a baby feels safe, they explore and if a baby explores, they learn. The neuroendocrine immune biology of stress is understood…

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

ACEs and Toxic Stress: Impact Pathways

“You can go good places with your mind if you can’t go good places with your

• body. “

Stephen Porges, PhD

Professor Emeritus, University of Illinois at Chicago. Director, Brain Body Center in the Department of

• Psychiatry. Author: The Polyvagal Theory

“Without mindfulness, there is no therapy. Mindfulness is a necessary state to be in to live your life. All growth occurs because you are in a state of mindfulness. Without mindfulness, there is no growth.” Bessel van der Kolk

Professor of Psychiatry, Boston University. Author : Treating Traumatic Stress in Children and Adolescents “The Body Keeps the Score”

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Event(s) Experience Effects Trauma

The event(s) or circumstance(s) causing actual or perceived physical

• r psychological harm

One’s experience of the event – differs across individuals – depends on beliefs, availability of supports, developmental stage, meaning making The resulting effects or symptoms – neurobiological and behavioral adaptations

Source: SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach (2014)

Creating an empowered relationship to adversity…… It’s not what’s wrong with you, it’s what happened to you. It’s not what happened to you, it’s how did it impact you? It’s not how did it impact you, it’s what can we do now to heal?

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

36.10% 26.00% 15.90% 9.50% 12.50% No ACEs 1 ACE 2 ACEs 3 ACEs 4+ ACEs

Prevalence of ACEs Among Adults in 18 States Assessing ACEs Statewide BRFSS

http://acestoohigh.com/got-your-ace-score/

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Source: Harvard Center for the Developing Child, 2018

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Diseases

• f

Dispair

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Those with two or more ACEs varies from15.0% (NY) to 30.6% (AZ). Most children with any

• ne ACE had at

least one other, ranging from 54.4% to 95.4%.

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

55.4% 46.3% 38.7% 29.5% 53.8% 64.2% 75.6% 82.9% 24.8% 20.9% 21.7% 16.0% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0% None of 9 ACEs 1 ACE 2-3 ACEs 4+ ACEs Flourishing At least 1 health problem Flourishing w/Health Problem

Minimal Measure of Flourishing (based on factors possible for parents to

• bserve):

1.Motivation: Curious and interested in learning new things 2.Resilience: Stays calm and in control when faced with a challenge 3.Attention: Follows through and finishes tasks

Flourishing, Health Problems and Adverse Childhood Experiences (US Children Age 6-17)

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Equally Unequal: Similarities of Impact Across Income Groups

Prevalence of Emotional, Behavioral of Developmental Problems Among Children with 4+ ACEs: By Household Income 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% Prevalence of Emotional, Behavioral or Developmental Problem

14.2%

37.2% 35.4% 37.7% 41.8%

All Children 400% Federal Poverty Level 200-399% Federal Poverty Level 100-199% Federal Poverty Level 0-99% Federal Poverty Level

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Source: Bethell, C 2016

“Led by a new paradigm, scientists adopt new instruments….and see new and different things when looking with familiar instruments.” Thomas Kuhn, The Structure of Scientific Revolutions, 1962

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Prevalence of emotional, mental

• r behavioral conditions 3.6 times

lower among children who experience 2 or more Adverse Childhood Experiences when they are taught resilience (all US children ages 6-17)

Chicken or egg questions—is it trauma or is it ADHD?

1.3% 2.1% 4.8%

11.9% 17.4% 28.5%

0% 5% 10% 15% 20% 25% 30%

No ACEs 1 ACE 2+ ACEs

Usually/always bounces back quickly when things don't go his/her way (has this aspect of resilience) Never/sometimes bounces back quickly when things don't go his/her way (no resilience)

Prevalence of Emotional, Mental or Behavioral Problems Identified by the CSHCN Screener, by Resilience and ACEs, age 6-17 years

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Close Relationships

• Effective parents and

caregivers

• Connections to other

competent and caring adults Child Capacities

• Self regulation, awareness
• f sensations, feelings,

meaning

• Problem solving skills
• Positive beliefs about self
• Beliefs that life has

meaning

• Spirituality and faith

Community & Environment

• Socioeconomic sufficiency
• Pro-social culture and peers
• Effective teachers/schools
• Safe and effective

communities

Adaptive Systems: The Short List for Resilience (Masten, ‘14)

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Child and Adolescent Health Measurement Initiative

Child and Adolescent Health Measurement Initiative

Difficulty Value Descriptive Analytics Diagnostic Analytics Predictive Analytics Prescriptive Analytics

What happened? Why did it happen? What will happen? How can we make it happen?

Child and Adolescent Health Measurement Initiative

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Translate the science of ACEs, resilience, and nurturing relationships Fuel “launch and learn” research, innovation, and implementation efforts

1 3

Priorities to Address ACEs and Promote Child Well-Being

Cultivate the conditions for cross-sector collaboration to incentivize action and address structural inequalities Restore and reward safe and nurturing relationships and self-, family-, and community-led prevention and healing

2 4

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Prioritize early and periodic screening, diagnostic, and treatment (EPSDT) and prevention Focus hospital community benefit strategies Advance and test Medicaid policy implementation Establish enabling organization, payment, and performance measurement policies (e.g. through CMMS, Title V, Head Start, etc.)

Priority Opportunities to Leverage Existing Policy-Driven Systems, Structures, and Innovation Platforms

Inform and track legislation to accelerate translation into policy

Key Short-Term Opportunities and Actions

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Leverage medical/health home and social determinants of health “movement” Build effective peer/family to peer/family support capacity Enable, activate, and support child, youth, and family engagement Empower community-based services and resource brokers (e.g. early childhood, school health, youth, & after school programs) Leverage existing commitments and focus areas in child and family health

Priority Opportunities to Leverage Existing and Evolving Practice Transformation Efforts

Key Short-Term Opportunities and Actions

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Leverage Existing Research and Data Platforms, Resources, and Opportunities

Key Short-Term Opportunities and Actions

Optimize existing federal surveys and data (including creation of follow-back surveys) Optimize state surveys Liberate available data (facilitate access and remove barriers to use) Build crowdsourcing, citizen science, and “N of 1” methods Integrate common-elements research modules for longitudinal studies Link to collaborative learning and research networks

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Findings from this agenda- setting process reflect the palpable hope for prevention, mitigation and healing of individual, intergenerational and community trauma associated with ACEs found in this work and provide a road map to do so.

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Question #1 Why are hospitals, state agencies and health systems interested? Implications for existing policies and payment and practice transformation efforts?

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Question 2

What’s in the way? What’s possible now? Policy actions and opportunities?

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Specify and test family- and youth-centered methods to assess and discuss ACEs and foster essential self-care, resilience, and relationship skills in clinical and other settings. Clinical Protocols Define and cultivate provider, health care system, and community-based core competencies related to ACEs, and the training, payment, and accountability models that will be effective in establishing these competencies. Capacity Building and Accountability

Priority Areas for Research

Evaluate the effects of alternative clinical and self-care interventions, including effects on health outcomes, utilization, and health care costs. Outcomes and Costs Promote and examine the effects of provider self-care related to ACEs, resilience, and relationship skills on quality of care and other

• utcomes.

Provider Self-Care

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

• Assessment – need to be clear about

purpose, focus (adults, children, or both), & differentiating from other assessments

• Need for methods for assessing

consequences of ACEs & positive health, resilience, and well-being

• Allow for common variations in language

around these topics, ensure discussions with families are relationship-centered Assessment, Measurement, and Language

Areas for Further Discussion

• Need for clarity around the appropriate role
• f children’s health services in addressing

ACEs

• Health care is often viewed through a

disease-focused lens, but pediatrics has a long-standing role in promoting healthy development,& serve a similar role in promoting positive health and addressing social determinants of health The Role of Health Care Providers & Systems

• More research needed into whether

providers need to address own ACEs and trauma before addressing ACEs among patients

• Need for clarity around roadmap for

follow-up or provision of resources after ACEs assessment

• Increased effort to promote self-care and

prevent burnout among providers Importance of Personal Engagement and Healing among Providers

Company name - Presentation

History is not destiny

“In my beginning is my end.” (?) T .S. Eliot, Four Quartets “What if the sun waited for me to rise?”

Thousand Pieces of Soul

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

Christina Bethell, cbethell@jhu.edu Visit us at childhealthdata.org For General Inquiries, email us at info@cahmi.org Connect with us on social media! Like us at www.facebook.com/childhealthdata Follow us on Twitter @childhealthdata

Contact Information

Thank You!

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

NHPC 2018-Leveraging Policy for Well-Being and Addressing ACEs

• Stable,

Responsive Relationships

• Safe,

Supportive Environments

• Appropriate

Nutrition

• Time and

Commitment

• Financial,

Psychological, and Institutional Resources

• Skills and

Knowledge

• Primary

Health Care

• Public Health
• Child Care

and Early Education

• Child Welfare
• Early

Intervention

• Family

Economic Stability

• Community

Development

• Private Sector

Actions Gene- Environment Interaction

Health-Related Behaviors Educational Achievement and Economic Productivity Physical and Mental Health

Psychological Adaptations or Disruptions Cumulative Over Time Embedded During Sensitive Periods

Policy and Program Levers for Innovations Caregiver and Community Capacities Foundations of Healthy Development Biology of Health and Development Outcomes in Lifelong Well-Being

Ecology Biology Health and Development

An Ecobiodevelopmental Framework for Policies and Programs