Beginning in 2007, practitioners from around the Bay Area of California came together to have informal conversations about how to address the ongoing issue of toxic stress and trauma that children and youth in San Francisco face on a daily basis. We define toxic stress here as resulting from “strong, frequent, or prolonged activation of the body’s stress response systems,” impacting the brain and other physiological responses to stress [1]. Knowing that exposure to this type of stress—stemming from abuse, neglect, witnessing community or interpersonal violence, and the challenges of growing up in poverty—had deleterious effects on individuals’ health and well-being, we formed a multidisciplinary group determined to create a coordinated approach to the issue. Our partnership was made up of an unlikely group of researchers, health practitioners, child abuse prevention specialists, and other service providers whose work focused on alleviating poverty or improving juvenile justice systems. In traditional health care models, these various practitioners and advocates work separately, often focused on similar, overlapping systemic problems. We wanted to bring together voices across disciplinary lines to address this complex reality.

After narrowing in on the problem of early childhood stress and its associated conditions, the central question in our group became whether to (1) integrate services under one organization, (2) refer patients across various coordinated providers, or (3) collocate separate partners under one roof. We knew that such a complex issue needed a variety of coordinated services, innovative care, and sustainability. Originally we conceived of the Center for Youth Wellness as a single entity, with three main partner organizations sharing the Center for Youth Wellness identity. This arrangement, however, proved to work against the aim of the model—to provide trauma-informed, holistic, and innovative care to patients and families experiencing chronic stress and trauma. Given the intricacies and power of each suborganization’s work, an urgent timeline to get services to families, and the need for enough funding for essential programs in a competitive environment, the arrangement of a fully integrated, one-organization model threatened the possibility of no Center for Youth Wellness at all.

Ultimately, we decided upon a collocated approach, which has allowed the partner organizations to maximize their areas of expertise while coordinating care in one accessible location for families. They are able to independently and fully implement programs that serve their respective missions while retaining the opportunity to work collaboratively with one another in service of the community. Now, three organizations are collocated in the Center for Youth Wellness building, offering pediatric, mental health, child abuse prevention, and wellness programming for children and families in the Bayview Hunters Point neighborhood of San Francisco.

Chronic stress and trauma affect an extensive number of people across the country. Whether due to interpersonal, community, or institutional violence, the heightened strain that comes with living in poverty, such as the insecurity of one’s ability to put food on the table or find safe housing, or experiencing daily microaggressions and decreased opportunity as a person of color in an institutionally racist society, we knew that ongoing stress negatively impacts mental and physiological health. Particularly for children and youth, the results of enduring such chronic adversity may follow them throughout their lives in the form of academic challenges, long-term health conditions such as asthma or diabetes, or anxiety and depression.

In the United States, for example, children and youth are exposed to extraordinary rates of violence. In 2010, among youth aged 15–24 years old, homicide was the second highest cause of death generally and, in particular, the number one reason for death for African Americans, second for Latinos, and third for American Indians and Alaska Natives aged 10–24 years old [2].

Traditional responses to such widespread conditions have their own set of challenges and limitations, among which include lack of financial opportunities. For example, funding for community health centers has continuously declined for over the past 4 or more years [3]. Additionally, researchers have identified a lack of evidence-based interventions in approaches for early childhood interventions and youth psychology [4, 5].

Among resource-scarce communities in urban areas there is a great need for accessible, community-based, and coordinated care to support children and their families. Research has shown a strong connection between urban planning and public health disparities, citing segregation and other social or physical environment factors in urban areas leading to health inequalities, such as housing, mobility, and other factors traditionally placed solely in the social domain [5, 6]. An example of such a community, Bayview Hunters Point was our center site to develop and implement a trauma-informed, one-stop, integrative model working to address not only individual but also family, community, and social needs.

Bayview Hunters Point is a long-standing residential neighborhood of San Francisco that has experienced high rates of poverty, community violence, and toxic environmental exposure. Historically an African American neighborhood, Bayview has experienced a significant amount of adversity from economic challenges, lack of quality housing and healthy food options, institutionalized racism and isolation from the remainder of San Francisco, and exposure to environmental toxins left behind when the Hunters Point Shipyard and power plant closed [7]. As a result, Bayview residents experience much higher rates of chronic illnesses like diabetes, asthma hospitalization rates [7], ischemic heart disease, cancer, and other cardiovascular illnesses. Violence, however, is the number one cause of lives lost in Bayview Hunters Point [8]. Given these factors, we saw a need for a holistic approach to health care in the neighborhood, one that addressed health outcomes stemming from seemingly nonmedical factors.

Researchers have been calling for the expansion of clinical medicine into the social space for some time. An example of this is the difference between a “medical home” and “health neighborhood” [9]. By creating health neighborhoods, which utilize “community-based, nonmedical services that promote the health of patients and families” and incorporate the “identification of basic needs and facilitation of referrals, care coordination, co-location, and centralization of services” [9], health care providers support the whole person, the whole family, and the whole community. Doing so, however, requires multiple stakeholders offering different services to partner in order to support individuals, families, and entire communities.

Specifically, federally qualified health centers act as a “safety net provider” [10] in underresourced communities and offer primary care, housing, or other services. Often known as community health centers, they must fit the following requirements to be federally qualified: (1) retain private nonprofit or public organization status; (2) offer extensive primary care services; (3) offer services to low-income communities with limited access to resources; (4) provide sliding fee scale to uninsured patients; and (5) obtain an independent and community-based board of directors [11].

Reflecting national approaches, health services in San Francisco and the greater Bay Area have traditionally focused on clinical disease only [12], not the issues that were deemed social problems, such as exposure to violence or scarce housing, leading to a lack of resources in the clinical space devoted to addressing social inequities. Because these challenges exist in both the traditional health care and other social settings, such as schools, there is a need to combine these sectors to effectively target the problem [12]. In developing the Center in Bayview Hunters Point, it became critical to work with stakeholders around the community, such as juvenile justice and other community-based public service providers, in order to scale interventions from individuals and families to the community systems level.

The Center for Youth Wellness is a collocated pediatric and mental health care model in Bayview Hunters Point. Made up of a number of partners from different spheres of the nonprofit and public sectors, the Center for Youth Wellness is an approach to address the high prevalence of adversity that children and youth, especially those living in poverty, face in the southeast sector of San Francisco. Low-income families and communities of color in the city experience ongoing toxic stress and trauma due to a multitude of external stressors. Specifically, the Center for Youth Wellness utilizes the Adverse Childhood Experiences (ACEs) diagnostic tool, derived from the renowned Kaiser ACEs study [13], to understand how patients experience toxic stress.

For some background context, the Kaiser ACEs study showed a dose–response relationship between exposure to ACEs and adult risk of chronic disease [13]. The ACEs categories include (1) physical abuse; (2) emotional abuse; (3) contact sexual abuse; (4) physical neglect; (5) emotional neglect; (6) someone chronically depressed, mentally ill, institutionalized, or suicidal; (7) mother treated violently; (8) one or no parents, parental separation, or divorce; and (9) substance abuse in the household [14]. One of the central findings of the ACEs study revealed a high prevalence of ACEs even within a college-educated, middle-class, white majority San Diego population—factors which generally put individuals at less risk for chronic illness.

We applied this approach to a chart review of Bayview children in a primary care setting in 2010–2011 and found that 67 % of children (mean age 8.13) had one or more ACEs and that 12 % had four or more ACEs. Fifty-one percent of the children with four or more ACEs were identified as experiencing learning and behavioral problems. Forty-five percent of those with four or more ACEs were overweight or obese. In comparison, only 3 % of children with zero ACEs experienced learning and behavioral problems, and 31 % were overweight or obese [14]. It became clearer that a response and further prevention was needed to address ACEs in the children from the Bayview community [14].