2024 Performance Improvement: ACEs, Toxic Stress and Patient Education

Registration Closes June 15. Projects must be complete by July 15. Activity closes 11:59pm pacific time, July 15, 2024

Adverse Childhood Experiences (or ACEs) are associated with some of the most common, serious, and intractable health conditions facing our patients. Toxic stress from ACEs such as poverty, violence, and emotional or physical abuse can cause wear and tear on all body systems. In fact, ACEs are associated with increased risk for heart disease, cancer, accidents, respiratory disease, stroke, diabetes, kidney disease, and suicide.

ACEs are common across all populations. Over sixty-two percent of California adults have experienced at least one ACE and over sixteen percent have experienced four or more. Many of our patients do not realize that exposure to ACEs is associated with increased risk for health problems across their lifespan.

In this performance improvement (PI) project, physicians will survey a minimum of ten patients, distribute two educational flyers, survey a minimum of ten more patients, analyze survey data, and reflect on resulting practice improvement.

Learning Objective:

This PI project is designed to improve patient and physician awareness on ACEs and toxic stress, and to study the impact of educational materials on patients’ understanding of ACEs and its health impacts.

Target Audience:

This activity is designed for family medicine physicians.

Participation and Credit:

Learners must register by June 15, 2024 and complete by July 15, 2024 to participate in and receive credit for this performance improvement activity; Read the target audience, learning objectives, and author disclosures; and Study the educational content online and complete the activity evaluation. Your certificate will be available to you as a downloadable link. You may print the certificate, but you cannot alter it. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board. 

Participating with a Practice Team:

Multiple learners may participate from the same practice, analyzing a single set of survey data. Each learner must be enrolled in the PI project separately, and move through each step of the project, although the survey and education steps may be performed collectively by the team. This will be explained in more detail in the course materials.

Unlabeled Use Disclosure:

This activity will not include discussions of products or devices that are not currently approved for use by the Food and Drug Administration (FDA), and the curriculum clearly indicates this fact.


This activity is sponsored by the California Academy of Family Physicians and supported by the American Board of Family Medicine.


There is no charge for this activity.

Cultural/Linguistic Competency:

CAFP policy and California state law requires that each learning activity have elements of cultural and linguistic proficiency included in the content. The definition of cultural and linguistic competency is the ability and readiness of health care providers and health organizations to humbly and respectfully demonstrate, effectively communicate, and tailor delivery of care to patients with diverse values, beliefs, identities, and behaviors, in order to meet patients’ social, cultural, and linguistic needs as it relates to patient health. This activity meets these requirements.

Implicit Bias:

CAFP policy and California state law requires that all CME activities comprising a patient care element include either (1) examples of how implicit bias affects perceptions and treatment decisions of physicians and surgeons, leading to disparities in health outcomes and/or (2) strategies to address how unintended biases in decision-making may contribute to health care disparities by shaping behavior and producing differences in medical treatment along lines of race, ethnicity, gender identity, sexual orientation, age, socioeconomic status, or other characteristics. This activity meets these requirements.

Privacy Policy:

The California Academy of Family Physicians (CAFP) is committed to protecting the privacy of its members and customers. CAFP maintains safeguards to store and secure information it has about members and customers. The safeguards may be physical, electronic or procedural. For more information, contact cafp@familydocs.org.


For questions regarding the content of this activity or for technical assistance, contact cafp@familydocs.org.

The CAFP has made all reasonable efforts to ensure that information contained herein is accurate in accordance with the latest available scientific knowledge at the time of accreditation of this continuing education program. Information regarding drugs (e.g., their administration, dosages, contraindications, adverse reactions, interactions, special warnings, and precautions) and drug delivery systems is subject to change, however, and the learner is advised to check the manufacturer's package insert for information concerning recommended dosage and potential problems or cautions prior to dispensing or administering the drug or using the drug delivery systems.

Approval of credit for this continuing education program does not imply endorsement by CAFP of any product or manufacturer identified.

Any medications or treatment methods suggested in this CME activity should not be used by the practitioner without evaluation of their patient's condition(s) and possible contraindication(s) or danger(s) of use of any specific medication.


© 2023 California Academy of Family Physicians. No part of this activity may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embedded in articles or reviews.

Course summary
Available credit: 
  • 20.00 AAFP Prescribed
  • 20.00 AMA PRA Category 1 Credit™
Course opens: 
Course expires: 

Erika Roshanravan, MD

imageErika Roshanravan, MD is a family physician and serves as the Associate Medical Director at CommuniCare's Davis Community Clinic. Erika received her Doctor of Medicine degree from the University of Berne School of Medicine (Berne, Switzerland) and completed her Family Medicine Residency at University of Washington. Committed to spending her career serving the most vulnerable, she spent her first six years in practice at a community health center in Everett WA doing full-spectrum family medicine including obstetrics before moving to California in 2018. She is on the leadership team of CommuniCare’s Trauma-Informed, Resilience-Oriented Healing (TIROH) initiative and works with a county-wide team on the Trauma-Informed Network of Care. She is on the board of directors for the California Academy of Family Physicians (CAFP) as well as the Sacramento Valley Chapter of the CAFP. Erika is fluent in German, Spanish, French and English; and lives with her husband, three children and their dog in Davis, California.

Adia Scrubb, MD, MPP

imageAdia Scrubb, MD, MPP grew up in Oakland, California and currently practices full-scope Family Medicine in Solano County. Dr.Scrubb received her Doctor of Medicine degree from the David Geffen School of Medicine/ PRIME Program at UCLA and the Charles R. Drew University of Medicine and Science in Los Angeles. She earned a Master of Public Policy degree from the UCLA Luskin School of Public Affairs and completed Family Medicine training at John Muir Health along with the CAFP Susan Hogeland, CAE Health Policy Fellowship in 2020.   Dr. Scrubb's previous experience in juvenile restorative justice led to interests in resilience after trauma and serving on the California Surgeon General's ACEsAware clinical implementation committee.  Dr. Scrubb is now part of the CAFP Family Medicine Initiative in Trauma Informed Care (FIT) team as well as the CAFP JEDI Committee.


Brent Sugimoto, MD, MPH, AAHIVS, FAAFP

imageBrent K. Sugimoto, MD, MPH, AAHIVS, FAAFP is a family physician and HIV specialist. With a focus on care for adolescents and adults living with HIV at Kaiser Permanente in Oakland, California he worked to improve outcomes for this population. It was at Kaiser Permanente that Brent began efforts to screen and intervene for Adverse Childhood Experiences, which are over-represented in persons living with HIV. Brent is an educator and author of ACEs education for primary care, he serves on several of the California Surgeon General's ACEs Aware subcommittees, and he is currently the New Physician member on the AAFP Board of Directors. Brent is currently Chief Medical Officer for Decoded Health, a technology startup using artificial intelligence (AI) to achieve the Quadruple Aim. Brent received his MD from the University of California, San Francisco (UCSF), his MS as part of the University of California, Berkeley-UCSF Joint Medical Program, and his MPH from UC Berkeley. Brent lives with his husband and two children in Richmond, California.

Conflict of Interest Statements:

The Committee on Continuing Professional Development and CME will be responsible for mitigating any relevant financial relationships disclosed by an individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP. Mitigation may include learner notification, peer review of content before presentation, requirement of EB-CME, changing topics, or even dismissing a potential faculty member.

It is the policy of the CAFP to ensure independence, balance, objectivity, scientific rigor, and integrity in all continuing education activities. All individuals with potential to influence the content of this program have submitted Disclosure of Interest declarations that have been reviewed according to policy. Learner notification of declarations is below. All individuals with relevant financial relationships with ineligible companies have been contacted by CAFP staff or CCPD members, and issues of conflict have been discussed and mitigated.

Faculty Disclosure:

Brent Sugimoto is founder and Chief Medical Officer of Decoded Health, a clinical automation software company. This relevant financial relationship has been mitigated.

Remaining faculty have no financial relationships with ineligible companies to disclose.

CME Planners:

The following planners have no financial relationships with ineligible companies to disclose: Laurie Isenberg, MA, MILS

Successful completion of this activity enables the participant to earn twenty (20) Performance Improvement points in the American Board of Family Medicine (ABFM) Family Medicine Certification program.

The AAFP has reviewed ACEs, Toxic Stress and Patient Education and deemed it acceptable for up to 20.00 Performance Improvement AAFP Prescribed credits. Term of Approval is from 12/15/2023 to 07/15/2024. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 credit(s)™ toward the AMA Physician's Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

Available Credit

  • 20.00 AAFP Prescribed
  • 20.00 AMA PRA Category 1 Credit™
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