Introducing ACEs and social need screening

“As we get you ready to see your provider, we would like to have you complete these screening questions in order to make your time with your provider as efficient as possible. You do not need to answer all the questions if you do not want to. This will not affect any part of your visit with your provider. The following questions are about potentially stressful experiences that can impact yours and your family’s health and well-being. Your answers can help your provider support you to prevent long-term health issues related to these stressful experiences. Your answers to all of the screening questions are kept confidential, unless you or your family is at risk for harm. You have the right to decline to answer or skip any question at any time.“

Privacy when screening adolescents and adults

• For adolescents, a caregiver should initially be present during the encounter. The caregiver can and should be asked to give the adolescent privacy for confidential parts of the telehealth encounter.

“Similar to in-person visits, it is our clinic’s policy that patients 12 years and older answer the screening questions themselves. Is [patient’s name] available to answer these questions in a private and safe place?“

• Confirm privacy when performing sensitive screens.

 “[Introduce yourself and your role if you have not already- see above] Are you in a private place where you can answer these questions without someone else hearing what you say? [wait for answer] Are you and I the only ones on the phone right now? [wait for answer].” If patient answers “Yes” to both questions, proceed to screening.

Patient/caregiver hesitancy See the Hesitancy Response chart in the Appendix.

During screening

• Complete one screening tool in its entirety before moving on to the next screening tool.

After screening

• Thank the patient/caregiver for their time.
• Notify the patient/caregiver that their provider will review results and next steps during their upcoming phone visit. Be sure to add that they will have a chance to talk with their provider about anything that concerns them or upsets them during the screen. NOTE: Trauma screens can be rough and if a patient is retraumatized, consider the following:
  • Ask the patient/caregiver if they have support at home
  • Offer a warmline
• Ask them what the rest of their day looks like and suggest/discuss the benefits of taking a walk. Enter the results into the appropriate ad hoc forms. LA County DHS: See job aids and screening tool charts.
• Scan any paper versions of the screening tools into the patient’s electronic medical record per your facility’s guidelines.

Gauging patient/caregiver understanding

• There is a purpose for all of the screenings. It is the screener’s job to convey that idea, but there still may be participants who do no not fully understand the questions being asked or the screenings themselves.
• Do not overcomplicate/over-explain ideas and concepts.
• Do not assume that a clear “yes” or “no” = question comprehension.
• Give complete attention to the patient and try to read their tone through the phone.
• Be alert to patients who may be confused or hesitant to answer. This may indicate lack of understanding, compromised privacy, or a patient who is not yet ready to share.

Key components to telehealth screening

• Building and preserving trust
• Ensuring patient confidentiality and family safety
• Developing appropriate responses
• Retaining the purpose of screening

Asking supplemental questions

If it seems the patient/caregiver is answering passively or not answering completely, ask questions that are rephrased or supplemental to the question on the screen. See the example table below.

Breaking down questions

It may be hard to keep the attention of patients/parents over the phone. This can be for a number of reasons, but it is important to limit confusion and maintain attention by completing the screens thoroughly AND in a timely manner.  See the example table below.

• Avoiding repetition – if a question has been answered on one screen and is asked similarly on a separate screen, confirm the original answer, verbally omit the question, and use the answer from the first response.

General screeners

• Document into ORCHID screening results as appropriate. This includes calculating and documenting the ACEs Risk Score. LA County DHS: See charting job aids.
• Do not interpret screening results for the patient/caregiver.
• Do let patients know that their provider will review the details of the patient’s results and next steps at their upcoming phone visit.
• Support patients who have experienced adversity/toxic stress. See Adversity Response table for General Screeners in the Appendix.
• Offer general resource/health education material from pre-approved list. Pre-approved materials can be accessed ACES-LA’s Project Resource page (on DHS Sharepoint).
• Share responses with providers.

Providers and designated staff

• Review screener’s risk assessments and adjust scoring as needed. For ACEs Risk Score, utilize the risk stratification chart to determine appropriate risk stratification.
• Disclose and discuss risk score with the patient/caregiver. See Adversity Response table for Providers and Designated Staff in the Appendix.
• Treat and provide referrals as appropriate.