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20-408 Use These Guidelines to Improve Trauma-Informed Care for Patients with ACEs

Date: 05/22/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.


Tips to help you provide care for patients dealing with adverse childhood experiences  

Adverse childhood experiences (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.

Speak with your patients to ease their fears

Start speaking about ACEs to your patients to reduce fear and anxiety they may have when answering the ACEs questionnaires. It may be uncomfortable at first, since screening tools collect personal information. It will help to start by explaining the following:

  • The screening asks personal questions because research has shown that our childhood events can have strongly negative, long-lasting effects on our bodies, behavior and mind.
  • Around two thirds of adults have experienced at least one ACE, and of those individuals, the majority have had two or more.
  • The ACEs questionnaire was developed to help doctors identify risks early in a child’s life and prevent or lower the risk of health problems.
  • Let the patient know that the goal of learning about family experiences is to provide better health care, treatment and more individualized support.

Avoid re-traumatization

Screening for trauma requires patients to reflect on and revisit upsetting topics, which may trigger distressing feelings or thoughts for patients and providers conducting the screenings. Therefore, it is important to administer screenings in a manner that avoids re-traumatization. You can do this by:

  • Adhering to a recommended time frame for ACE screening tools to maintain emotional safety for patients and providers.
  • Referring members to MHN at 1-888-327-0010 for evidence-based trauma therapy if the member wants to discuss traumatic events in detail. Providers can provide supportive, compassionate responses to trauma without focusing on specific details.
  • Practicing compassionate resilience to maintain provider and staff well-being, and to combat staff compassion fatigue, burnout, secondary traumatic stress, various trauma and other workforce concerns.
  • Allowing self-reporting or use of de-identified screeners to give patients more control over the screening process by allowing them to disclose the number of ACEs that apply to them, not which experiences apply.

What does a clinical response look like?

A clinical response to identification of ACEs and increased risk of toxic stress should include:

1     Applying principles of trauma-informed care, including establishing trust, safety and collaborative decision-making.

2     Identification and treatment of ACE-associated health conditions by supplementing traditional care with patient education on toxic stress and anticipatory guidance to regulate the stress response specific to the patient’s age. You can use anticipatory guidance to ask open-ended questions and help you and your patient have a timely, relevant and appropriate discussion that meets everyone’s needs. Topics include:

A     Supportive relationships.

B     High-quality, sufficient sleep.

C     Balanced nutrition.

D     Exercise.

E     Mindfulness and meditation.

F      Mental health care, including psychotherapy or psychiatric care, when indicated.

3     Validation of existing strengths and protective factors helps ensure patient has mechanisms in place to build resilience.

4     Referral to needed patient resources or interventions, such as educational materials, social work, care coordination, or patient navigation, community health workers, as well as the pillars A–F listed above.

5     Follow up as necessary, using the presenting ACE-associated health condition(s) as indicators of treatment progress.

Validating protective factors as strengths

Protective factors are personal, family and environmental factors that protect children and promote their healthy development and well-being, especially during times of stress associated with ACEs. Use this list of protective factors to validate your patient:

  • Resilient parenting
  • Social and emotional competence of children
  • Social connections
  • Knowledge of parenting and child development
  • Concrete support in times of need


Training and billing requirements

Contracted providers must train on trauma-informed care, including how to use the PEARLS tool and the ACEs questionnaire. The training requirement is waived for dates of service prior to July 1, 2020. Providers must complete mandatory training and submit attestation to get payments after June 30, 2020. For more information, see provider update 20-319, Receive Prop 56 Payments for ACEs Screenings.

To bill for ACEs screening, contracted providers must match the correct HCPCS code based on the score and description of the screening performed.

HCPCS code

Description of screening performed


ACEs screening score is…


Positive results and provision of recommendations given


4 or greater for high risk


Negative results


Between 0–3 for lower risk

Payments for HCPCS G9919 and G9920

Clean claims must be received within one year from the date of service. Payments for codes G9919 or G9920 are made within 90 calendar days of receipt.

  • The medical plan is financially responsible. All providers delivering ACEs services need to submit their claims to
    Health Net*, on behalf of CalViva Health.
  • Under age 21, payment is allowed once during a 12-month period, per member screened by that provider.
  • Age 21 and up to 65 (adult), payment is allowed once per lifetime, per member screened by that provider.

For more information on these approved directed payments for ACEs screening, refer to the DHCS All Plan Letter (APL)
19-018, distributed on December 26, 2019, and Medi-Cal Bulletin 547, dated January 2020. You can also visit the DHCS website at

More resources

Understanding ACE-associated health conditions

ACE-associated health conditions vary between adults and children. For a complete list of associated conditions, please visit:

Patient education through ACEs Aware

Educate your patients about how ACEs, as well as buffering practices and interventions, can affect health. Doing so offers patient/family the chance to discuss these topics and complete a PEARLS screen.

ACEs Aware has a library of resources that include print-on-demand patient handouts at

Aunt Bertha

If your patient needs supportive services, consider referring them to the Aunt Bertha Social Care Network at


For members with ACEs, the myStrength program can provide an additional resource. If a member needs emergent or routine treatment services, call MHN at 1-888-327-0010.

To refer a member to the myStrength program, members can visit to sign up online.

1     In a web browser enter

2     Click Sign Up.

3     Complete the myStrength sign-up process with a brief wellness assessment and personal profile.


If you have questions regarding the information contained in this update, contact CalViva Health at 1-888-893-1569.

Last Updated: 05/22/2020