Adverse Childhood Experiences (ACEs)
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The following information is intended to provide a general guide to help you implement screening for adverse childhood experiences (ACEs) and better determine the likelihood a patient is at increased health risk due to a toxic stress response. Screening for ACEs helps inform patient treatment and encourage the use of trauma-informed care. For more information, visit ACEs Aware.
Prevent
Trauma Informed Care
ACEs are stressful or traumatic experiences people have by age 18, such as abuse, neglect and household dysfunction. By screening for ACEs, providers can better determine the likelihood a patient is at increased health risk due to a toxic stress response. This is a critical step in advancing to trauma-informed care.
Follow the principles of trauma-informed care. Use these key principles as a guideline:
- Establish the physical and emotional safety of patients and staff.
- Build trust between providers and patients.
- Recognize the signs and symptoms of trauma exposure on physical, psychological and behavioral health.
- Promote patient-centered, evidence-based care.
- Train leadership, providers and staff on trauma-informed care.
- Ensure provider and patient collaboration by bringing patients into the treatment process and discussing mutually agreed-upon goals for treatment.
- Provide care that is sensitive to the racial, ethnic, cultural and gender identity of patients.
References
For more information, refer to:
Toxic Stress
Everyone experiences stress. Stress can show up in our bodies, emotions and behavior in many different ways. Too much of the wrong kind of stress can be unhealthy and, over time, become “toxic” stress and harm physical and mental health. An adult who has experienced significant adversity in the past, especially during the critical years of childhood, may be at higher risk of experiencing health and behavioral problems during times of stress.
References
For more information, refer to:
Screen for ACEs
Screening for ACEs can help determine if a patient is at increased health risk due to a toxic stress response and provide trauma-informed care. Identifying and treating cases of trauma in children and adults can lower long-term health costs and support the well-being of individuals and families.
The California Department of Health Care Services (DHCS) has identified and approved specific screening tools for children and adults for the 10 categories of ACEs grouped under three sub-categories: abuse, neglect and household dysfunction.
For children and adolescents, use PEARLS .
PEARLS is designed and licensed by the Center for Youth Wellness and are available in additional languages. There are three versions of the tool based on age:
- PEARLS for children ages 0–11, to be completed by a parent/caregiver
- PEARLS for ages 12–19, to be completed by a parent/caregiver
- PEARLS for teenagers ages 12–19, self-reported
For adults, use the ACE assessment tool .
The ACE assessment tool is adapted from the work of Kaiser Permanente and the Centers for Disease Control and Prevention (CDC). Other versions of the ACEs questionnaires can be used, but to qualify, questions must contain the 10 categories mentioned above.
Use of tools
AGES | USE THIS TOOL | TO RECEIVE DIRECTED PAYMENT |
|---|---|---|
0-17 | PEARLS | Permitted for periodic ACE rescreening as determined appropriate and medically necessary, not more than once per year, per clinician (per managed care plan). Children should be screened periodically to monitor the possible accumulation of ACEs and increased risk for a toxic stress physiology.1 |
18 or 19 | ACEs or PEARLS | Permitted for periodic ACE rescreening as determined appropriate and medically necessary, not more than once per year, per clinician (per managed care plan). Children should be screened periodically to monitor the possible accumulation of ACEs and increased risk for a toxic stress physiology.1 |
20-64 | ACEs screening portion of the PEARLS tool (Part 1) can also be used. | · Age 20: Permitted for periodic ACE rescreening as determined appropriate and medically necessary, not more than once per year, per clinician (per managed care plan). Children should be screened periodically to monitor the possible accumulation of ACEs and increased risk for a toxic stress physiology. · Adults ages 21 through age 64: Permitted once in their adult lifetime (through age 64), per clinician (per managed care plan). Screenings completed while the person is under age 21 do not count toward the one screening allowed in their adult lifetime. Adults should be screened at least once in adulthood, and though ACEs occur in childhood (by definition) and therefore do not change, patient comfort with disclosure may change over time, so re-screening for adults may be considered.1 |
1https://www.acesaware.org/learn-about-screening/billing-payment. Copyright ©️ 2023 by the State of California Department of Health Care Services.
The approved tools are available in two formats:
- De-identified screening tool: Patients have the option to choose a de-identified screening, which counts the numbers of experiences from a list without specifying which adverse experience happened.
- Identified screening tool: Patients can opt in for an identified screening in which respondents specify the experience(s) that happened to their child or themselves.
Providers are encouraged to use the de-identified format to reduce the fear and anxiety patients may have.
Administering the screening
There are several ways to administer the screening. Providers are encouraged to use the tools appropriate for their patient population and clinical workflow. Before administering, providers should consider the following:
- Identify which screening tools and format to use for adults, caregivers of children and adolescents, and adolescents.
- Determine who should administer the tool, and how.
- Determine which patients should be screened.
It is recommended that the screening be conducted at the beginning of an appointment. Providers or office staff will provide an overview of the questionnaire and encourage the patients (adolescent, adults or caregivers) to complete the form themselves in a private space to allow members to disclose their ACEs without having to explain their answers. Patients may take up to five minutes to complete the screening tool.
References
For more information, refer to:
Treatment
The ACE score determines the total reported exposure to the 10 ACE categories indicated in the adult ACE assessment tool or the top box of the pediatric PEARLS tool. ACE scores range from 0 to 10 based on the number of adversities, protective factors and the level of negative experience(s) that have impacted the patient. Providers will obtain a sum total of the number of ACEs reported on the screening tool.
For children and adults, two toxic stress risk assessment algorithms based on the score were developed to determine the level of risk and referral needs. According to the algorithm, risk and scores are determined as follows:
Risk | Score | Action |
|---|---|---|
Low | 0 | If a patient is at low risk, providers should offer education on the impact of ACEs, anticipatory guidance on ACEs, toxic stress and buffering factors. |
Intermediate | 1 – 3 | A patient who scores 1–3 has disclosed at least one ACE-associated condition and should be offered educational resources. |
High | 1 – 3 with associated health conditions, or a score of 4 higher | The higher the score, the more likely the patient has experienced toxic stress during the first 18 years of life and has a greater chance of experiencing mental health conditions, such as depression, post-traumatic disorder, anxiety and engaging in risky behaviors. |
References
For more information, refer to:
Heal: Referral and Resources
As part of the clinical workflow, providers should be prepared with a treatment plan and referral process so patients who have identified behavioral, social or trauma can be connected to trained professionals and resources. Building a strong referral network and conducting warm hand-offs to partners and services are vital to the treatment plan. In addition, it is critical to build a follow-up plan to effectively track the patient’s process to ensure they get connected to the support needed.
ACEs resources
Free ACEs resources for providers on screening and clinical response.
Behavioral Health Services
Health Net Medi-Cal members enrollees can obtain individual and group mental health evaluation and treatment. Providers can call Behavioral Health Provider Services.
CalViva Health Medi-Cal members can obtain individual and group mental health evaluation and treatment. Providers should call Health Net if a member needs emergent or routine treatment services. Members should call CalViva Health Member Services if they need these services.
For Community Health Plan of Imperial Valley (CHPIV) Medi-Cal members:
CHPIV Medi-Cal members can obtain individual and group mental health evaluation and treatment. Providers should call Health Net if a member needs emergent or routine treatment services. Members should call CHPIV Member Service if they need these services.
Case Management
If your patient is uncertain about next steps or would like to learn more, please refer them to the health plan’s behavioral health Case Management Department.
Health Net Community Connect & CalViva Community Connect
Health Net Community Connect and CalViva Community Connect are powered by Aunt Bertha, which is the largest online search and referral platform that provides results customized for the communities you and your health care staff serve or where members live. To use the tool:
- Health Net members should go to https://healthnet.auntbertha.com, enter a ZIP code and click Search .
- CalViva Health Medi-Cal members should go to https://calviva.auntbertha.com, enter a ZIP code and click Search .
myStrength
For members with ACEs, the myStrength program can provide an additional resource. Providers should call Health Net if a member needs emergent or routine treatment services. CalViva Health Medi-Cal members should call CalViva Health Member Services if they need these services. To refer a member to the myStrength program, members can visit myStrength.com to sign up online or download the myStrength app at Google Play or the Apple Store.
To join online, visit the site indicated below, then click Sign Up and complete the myStrength sign-up process with a brief wellness assessment and personal profile.
- Health Net Members: my Strength
- CalViva Health Medi-Cal members: my Strength CalViva
Health Education Materials
You can request materials on many key topics from Health Net's Health Education Department utilizing the form located in the Provider Library under Forms and References.
Consider ordering the below materials to support your ACEs treatment plan:
- Exercise
- Nutrition
- Parenting (stress reduction)
- Lower toxic stress
- Parenting Prevent ACEs
- Understanding ACEs
- Stress Management
ACE Training and Self-Attestation Requirement for Billing
Effective July 1, 2020, Medi-Cal providers who have completed the two-hour online ACE training and submitted their self-attestation to DHCS can continue or begin billing for ACE screenings. Providers who missed the July 1 deadline can still complete the training, self-attest and begin billing the month of completing the attestation.
- To get started, register for the online training.
- To self-attest, complete the Department of Health Care Services (DHCS) Trauma Screening Training Attestation form.
You must attest with a valid NPI number, or you will not be eligible to receive payment. Our support teams at Provider Services and Provider Relations Department will have the latest DHCS Prop 56 ACEs Provider Training Attestation List and be able to look up the customer/provider to see if DHCS has received their ACEs training attestation online form.
Existing and future trainings on ACEs
ACEs Aware offers a variety of trainings on ACEs and Trauma Informed Care. To access and view existing trainings or register for future trainings to support your work with ACEs, visit the ACE Aware site.