Beginning in 2014 and continuing through 2017, Native American Health Center’s SBHCs incorporated social determinants of health questions into screening tools used with students. This presentation will provide an update on implementing these screening questions, specifically the challenges and strategies to responding effectively when students identify a need. The importance of leveraging internal resources, partnering with community agencies and building connections with school staff will be addressed in relation to specific identified needs. Models of clinic staff role expansion and internal capacity building, along with other challenges and adaptations will be shared as tools for helping participants plan for and engage in incorporating screening and evaluations of these important health indicators into their practices.

1. Social Determinants of Health:
Building Screening and Response Capacity at
School Based Health Centers
Jennifer Bryson-Alderman, MSN, FNP-C
Andrea Burrell, MA-C
Silvia Calderon, Program Manager I
Vanessa Puschendorf, MSN, PNP-C

2. No financial relationships or
conflicts of interest to disclose
DISCLOSURES

3. OBJECTIVES
• At the end of this presentation, participants will
be able to describe:
– The importance of social factors on health outcomes
– Some key measures for social determinants
– Important considerations for implementing screening
– Methods for ensuring team-based approach for
response to students’ identified needs

4. “ The social determinants of health are the conditions in which
people are born, grow, live, work and age. These circumstances
are shaped by the distribution of money, power and resources at
global, national and local levels. The social determinants of
health are mostly responsible for health inequities- the unfair
and avoidable differences in health status seen within and
between countries.” - World Health Organization (2012)
Social Determinants of Health (SDOH)

6. • Adverse Childhood Experience Questionnaire (ACE-Q)
• Rapid Assessment of Adolescent Preventative Services
(RAAPS)
• Guidelines for Adolescent Preventative Services (GAPS)
• Stay Healthy Assessment (SHA)
Let’s Talk About Screeners

7. ACEs & Toxic Stress
• Felliti and Anda, CDC and Kaiser
Adverse Childhood Events
(ACE) study examined data for
>17,000 members
• Findings: adults from all walks
of life were at greater risk for
long-term physical, mental and
behavioral health issues
resulting from exposure to
ACEs
• As ACE score increases so does
the risk for long-term health
complications
• Toxic Stress: Extreme and
repetitive stress

8. ACES Questionnaire
• CYW Adverse Childhood
Experiences Questionnaire (CYW
ACE-Q) is a clinical screening tool
that calculates cumulative exposure
to Adverse Childhood Experiences
(ACEs) in patients age 0 to 19
• The tool is available in three age-
specific versions, and in English and
Spanish. It takes approximately two
to five minutes to complete.
• Comprised of two sections: Section
1 of the CYW ACE-Q consists of the
traditional ten ACEs. Section 2
consists of items assessing for
exposure to additional early life
stressors identified by experts and
community stakeholders.

9. RAAPS
• 21 item questionnaire that can
be completed in approximately
5-7 minutes
• Identified as a reliable and
valid tool for identifying
adolescent risk behaviors
contributing to most
adolescent morbidity,
mortality, and social problems

10. GAPS
• Developed by the AMA in
1997
• Individualized
questionnaires for
younger adolescent and
middle-older adolescents
• 72 and 61 questions
respectively

11. SHA
•The SHA is the Department of
Health Care Services’ (DHCS)
Individual Health Education Behavior
Assessment (IHEBA)
•Used to identify and document
patients’ health education needs
related to lifestyle, behavior,
environment, and cultural and
linguistic background
•Available in many languages
•Required to use and administer to
all Medi-Cal beneficiaries as part of
the initial health assessment

12. • 8 clinics in the East Bay
– five in Oakland
– two in Alameda
– one in San Leandro
• 6 of 8 are Title I schools
• Free and reduced lunch from 72% - 94%
Native American Health Center (NAHC)
School-Based Health Centers

13. Involving the Whole Team:
Staff at Each SBHC
● Program Manager
● Program Coordinator
● Behavioral Health
Clinician
● Medical Assistant
● Nurse Practitioner The Skyline Team!

14. NAHC Teen Screen
• Developed by NAHC staff
• Consists of 64 questions from
aforementioned screeners, as well
as PHQ 9, trauma screener, and
CSEC question
• Given to students at initial visit to
health center and annually
• Available in English and Spanish

15. CAUTION:
Screening is only the beginning
● Primary care conundrum
○ high number of well-intentioned recommendations about
important health issues
○ pressure to increase clinic productivity
• Selecting screening priorities
○ local health risks and challenges
○ clinical expertise and leadership
○ available community resources

16. Areas of Focus for NAHC
• Food Insecurity
• Unstable housing/homelessness
• Commercial Sexual Exploitation of Children (CSEC)
• Newcomers
• Vicarious trauma

17. Nurse Practitioner
*In-depth review of screener *Red flags addressed with student
Medical Assistant
*Receives screener from student
*Brief review of screener for
completion and red flags; red flags
brought to attention of NP
Program Coordinator
* Teen Screen given to student to complete prior to medical visit
SBHC Work Flow

19. Food Insecurity - California
• All ages – 1 in 18 Californians does
not know where their next meal is
coming from
• Total 4.6 million w/food insecurity
• Children – 1 in 5 children lives
with unstable food supply
• Summer hunger when cut-off
from school lunch
• Obesity and food insecurity –
directly related

20. Food Insecurity – Local Area
• Alameda County
– One in seven overall
– One in six children
– One in three kids qualify for free lunch program
• Skyline High School (2016)
– Screened 70% of total school population
– One in six kids identified
– Three out of four kids on free/reduced lunch

21. Food Insecurity – Screening Questions
The Hunger Vital Sign™ identifies households as being at
risk for food insecurity if they answer that either or both of
the following two statements is ‘often true’ or ‘sometimes
true’ (vs. ‘never true’):
• Within the past 12 months we worried whether our
food would run out before we got money to buy more
• Within the past 12 months the food we bought just
didn’t last and we didn’t have money to get more

22. Food Insecurity – Clinic Process
• Every patient fills out universal screener every
school year
– Includes Hunger Vital Signs questions
• NP reviews for potential need
– Screen for false positive
– Determine urgency of need: today v. general need
– Refer to program manager for connection to
resources
– Problem list: Food Insecurity

23. Food Insecurity - Response
• Program Manager
– Warm Handoff/Private Session
– Identify specific need
– Individual/Family/Foster care
• Connect with Alameda County Food Bank services
– Many modes of connection
(800) 870-FOOD (3663) or (510) 635-3663
Or, visit FoodNow.net

24. Making it Work for Students
• 1st version: AC Food Bank hotline
– Good resource/not accessible for students
• Evolving the response
– Food delivered to school site weekly
• 1 bag/identified student – pickup at clinic
– Food bank discontinues program
– Partnership w/Youth Center
• Onsite food bank
• Students “shop” as needed
– SBHC program manager provides screening for all students
and provides access to youth center food bank

25. Making it Work for Students
• Fruit basket delivery weekly to classrooms at
teacher request
– Available for all students
– Helps support healthy snacking
• prevent “hot-cheetos gastritis”
– Immediate support for more effective learning
• Unintended benefits
– Increased visibility of partnership w/foodbank
– Large, supportive constituency (teachers) for work of
clinic and efforts to support students learning

26. Housing and Homelessness
In 2018:
– 130,000 homeless in
California
– almost ¼ of national total
– 33 per 10,000
residents/highest in the
country
– credit record/rental history
– down-payment (3x rent)
In 2017:
– Alameda County
experienced almost a
40% increase in
homelessness in two
years (5,600 people)

27. Housing- Screening Questions
• During the past year, have you moved (changed where you
live)?
• Do you live in foster care?
• Have you considered running away?
• Provider- HEADSSS Assessment

28. Housing- Clinical Process
● Program Coordinator
– Provides screeners
● Medical Assistant
– Gathers and assesses for red flags
● Nurse Practitioner
– Provides in-depth evaluation of housing situation of
students
● Program Manager and BH consult
– Case management
– Coordination of Services Team (COST) Referral
– Outside agency Case manager family referral

29. Housing- Response
● Verbal
- Contact 211 directly
-Sign families up for section 8 Waitlist
● Substantive
• Internal resources (BH referral)
• External resources (school, community partners,
legal assistance, for example Centro Legal de la Raza
and East Bay Community Law Center)
• Outside agency Case manager referral (Madison)

30. Barriers to Care
• Reluctant to disclose
– students
– families
– Trapped in high rent areas (family, childcare,
school choice)
• Lack of housing resources
-In 2014 there was a 58,680 units shortfall for
homes available
-New housing units grew by only 40,000
between 2010-2014 = 1 unit for every 8.5
people (Bay Area wide)

31. Commercial Sexual Exploitation of
Children (CSEC) – The Problem
• Up to 300,000 Americans under 18 are lured into the
commercial sex trade every year
• Top three states with the most human trafficking
activity are:
– California
– New York
– Texas
• Poor understanding of scope of problem d/t
reluctance to disclose

32. West Coast Children’s Clinic
CSE-IT Screener:
a validated four page risk assessment
1. Stability in Residential Status & Life Functioning
2. Relationships
3. Finances & Belongings
4. Use of Technology
5. Physical Health
6. Risk Behaviors
7. Trauma Exposures
8. Trauma Signs & Symptoms
9. Coercion and Grooming
10. Exploitation*

33. CSEC– Screening Question
• Over the years we’ve noticed that more and
more youth are turning to the streets to
make money for themselves or for other
people. Have you ever or do you trade sex or
“going on dates” for money, clothes, a place
to stay, drugs or other favors?

34. Risk Factors (partial list)
• Abuse in the home, including sexual abuse
• Runaway or Foster Care
• Drug use or addiction
• Alcohol addiction
• Mental or physical disabilities
• Homelessness

35. CSEC- Our Process
• Every patient fills out universal screener every school
year
– Includes CSEC question
• MA receives screener
– begins rapport building
– Report to NP: + screen and/or clinical instinct
• NP thorough review
– Follow-up on MA concerns
• Low bar for providing resources
• Problem list: High risk sexual behavior with note

36. Our Response:
Bay Area Community Partners
(partial list)
• MISSEY: Motivating, Inspiring, Supporting & Serving Sexually
Exploited Youth
• DREAMCATCHER YOUTH SERVICES: A program of Covenant
House California

37. Newcomers/Unaccompanied
Immigrant Youth
• > 200,000 unaccompanied
immigrant youth (UIY) have
come to the U.S. since 2014
• >28,000 living in California
with the majority in Los
Angeles and Alameda Counties
• End of FY 2019 (2/2019)
approximately 237 UIY
released to sponsors in
Alameda County

38. Unique Screening Needs
• Infectious Disease
– Tuberculosis
– Hepatitis
– HIV
– RPR
– Strongyloides
– STIs
– Skin infections (ex. scabies, lice)
• Nutritional Deficiencies (ex.Anemia)
• Toxic/Environmental Exposures (ex.Lead)
• Undiagnosed General Health Conditions
– Hearing, Vision, Dental
• Literacy issues
• Mental Health
• Legal Aid
• Health Insurance

40. Newcomers- Our Response
• Assessment for immediate risk/needs
• Resources in Health Center
– Food Bank resource/School Food Pantry
– Family Resource Center (available Th at 9am)
– Healthy Relationships Foldable Pamphlet
– Crisis Resource Card
– Sanitary Napkins/Hygiene Essentials
• Internal Referral to Newcomer Social Workers at BHMS
– Document include patient name/DOB, type of referral
– requesting, provider commentary section
– Document emailed to LCSW
– LCSW replies with follow-up plan (ex. Plan to check-in
today, COST referral, connect to external resources)
– Newcomer assistant teacher tutor/homework help
available daily
– Oakland Leaf afterschool program

41. Newcomers- Our Response
• Legal Assistance
– Review local resources (ex. Centro Legal de la
Raza)
– Offer letters of support
– Referral to Newcomer Liaison at Middle School
• Health Insurance Navigation
– Medi-cal Packet given at first appointment
– Eligibility worker
– Case Management

42. Newcomers- Barriers to Care
• Reluctant to disclose needs
- Fear of discrimination, deportation
• Language Barrier
• Not Enough Resources
• Accessibility / Confusion Navigating Healthcare
System

43. Vicarious Trauma
• Vicarious trauma is a transformation in the self
of a trauma worker or helper that results from
empathic engagement with traumatized clients
and their reports of traumatic experiences.
• Symptoms similar to PTSD:
- continuously worrying about wellbeing of
another
- lack of sleep
- feelings of hopelessness
- irritability, anger, or numbness

44. Vicarious Trauma- The Issue
• Responding to community need:
– 50% of California school children have
experienced some form of trauma due to
neglect, abuse, or violence
– Teachers - play a vital role in a child’s life as
counselors, parents, case managers, etc.
• More community circles to hold due to
high crime areas/shootings our students
face

45. Vicarious Trauma - Our Observations
• Increase teacher turnover rate
• Teachers yelling in classrooms → Students not
wanting to go back to class/ having physiological
reactions, stomachaches/headaches/anxiety
• Teacher’s Strikes across the nation due to large
class sizes, low pay, not enough support or
resources in the classroom

46. Vicarious Trauma- Our Process
• SBHC Director
– Grant proposals for trauma and resiliency
• Program Manager
– Connecting with school administration to
implement strategies for vicarious trauma
with staff
– Implementing peace corners in the
classrooms

47. Vicarious Trauma- Our Response
● Verbal - informal
● Internal resources
– Coordination of Services Team (COST) Referral
○ discuss students who needs more support
○ teachers can refer after trying different approaches
without success
– Grant funded trauma support group
– Revamp the Staff lounge
● External resources
– Health and Wellness Fairs for Staff/appreciation

48. Vicarious Trauma- Barriers
• Clinic based
– Unrecognized Issue
– Outside the usual scope of SBHC work
• Teacher based
– unrecognized issue
– Lack of time to meet or receive counseling for
themselves
– No self-care/staying late at night helping
students with college applications or
internships

49. Lessons Learned
• Identify priorities in your community
– Lack of capacity to respond to all possible issues
– Marriage of need + resource availability
• Importance of partnership relationships
– varying capacity and interests
– resources/priorities not under clinic control
– ongoing relationships ensure consistency for patients

50. Lessons Learned
• Utilize existing clinic process/flow patterns
• Think through staff training needs
– standardize v. localize
– recognize out of usual comfort-zone/practice
– leverage wisdom of all staff
• Flexibility
– Needs may not fit neatly into screener format

53. Citations
Ark of Hope for Children: https://arkofhopeforchildren.org/child-trafficking/child-
trafficking-statistics
Basson, D., (2017). Validation of the Commercial Sexual Exploitation-
Identification Tool (CSE-IT). Technical Report. Oakland, CA: WestCoast
Children’s Clinic.
California Association of Food Banks; http://www.cafoodbanks.org/hunger-
factsheet
Darling-Fisher, C.S., Salerno, J., Hwa Y. Dahlem, C., Martyn, K.K. (2014). The
Rapid Assessment for Adolescent Preventive Services (RAAPS): Providers
Assessment of Its Usefulness in Their Clinical Practice Settings. Journal of
Pediatric Health Care, 28(3), 217-226.
Hunger vital signs screener: Hager, E. R., Quigg, A. M., Black, M. M., Coleman,
S. M., Heeren, T., Rose-Jacobs, R., Cook, J. T., Ettinger de Cuba, S. E., Casey,
P. H., Chilton, M., Cutts, D. B., Meyers A. F., Frank, D. A. (2010). Development
and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity.
Pediatrics, 126(1), 26-32. doi:10.1542/peds.2009-3146.

54. Citations Continued
Garner, A.S., et.al. (2012). Early Childhood Adversity, Toxic Stress, and the Role of the
Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics., 129(1),
224-231.
Office of Disease Prevention and Health Promotion.
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
Overview Alameda County Housing Needs. 21 Jan. 2016,
www.acgov.org/board/bos_calendar/documents/DocsAgendaReg_TP_1_21_16/GENER
AL%20ADMINISTRATION/Regular%20Calendar/Housing_Needs_Overview_TP_%201_
21__16.pdf.
Yarnall, K. S., Pollak, K. I., Østbye, T., Krause, K. M., & Michener, J. L. (2003). Primary
care: is there enough time for prevention?. American journal of public health, 93(4), 635–
641.
World Health Organization., Social Determinants of Health.
https://www.who.int/social_determinants/sdh_definition/en/

55. Resources
AAP- Immigrant Child Health Toolkit
https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Immigrant-
Child-Health-Toolkit/Pages/Clinical-Care.aspx
Adverse Childhood Experiences & Toxic Stress
https://centerforyouthwellness.org/
https://www.aap.org/en-us/advocacy-and-policy/aap-health-
initiatives/resilience/Pages/ACEs-and-Toxic-
Stress.aspx?nfstatus=200&nftoken=95b9d741-56cb-460d-8e2f-
a5a281517f3f&nfstatusdescription=Set+the+cookie+token
California Homelessness Statistics
https://www.usich.gov/homelessness-statistics/ca/
CSEC- https://misssey.org/
https://www.westcoastcc.org/
Housing Resource Guide - Alameda County
https://www.achhd.org/documents/RAMP_HousingResourceGuide.pdf