Adverse Childhood Experiences (ACEs)
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.
Note: While ACE’s Aware billing and payment information is specific to Medi-Cal providers, funded by Proposition 56, the ACE’s Aware training materials and resources still apply to non Medi-Cal Providers. Non Medi-Cal providers can still get trained and use the workflows and tools. This article outlines how non Medi-Cal providers (that are trained and attest to training) can receive the $29 payment.
Prevent
Addressing trauma in primary care pediatrics can help patient remove discomfort for discussion of trauma histories. It can help connect patients and families and provide a way to prevent future trauma experiences from one generation to the next. Click here to learn more on Preventing Childhood Toxic Stress.
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:
Positive Parenting and Resilience Building
Parents and caregivers look to providers for reliable resources, information and help to address childhood trauma. Providers can offer help by assessing parental ACE’s, practicing trauma informed care to address childhood trauma and toxic stress and offer the following resources, focused on development and positive parenting skills.
- ACEs Connection: News and information on ACEs and how to become more trauma-informed in practice.
- The Center for Youth Wellness: Led by Nadine Burke-Harris, MD, the Center for Youth Wellness is an international leader in addressing ACEs in practice.
- Centers for Disease Control and Prevention (CDC): Helpful tip sheets for positive parenting at different ages.
- ZERO to THREE: This organization works to ensure that babies and toddlers benefit from the early connections that are critical to their well-being and development.
- Parenting Beyond Punishment: No cost parenting webinars for positive discipline in everyday parenting.
- Build resilience to cope with trauma
- Mind Yeti: A research-based digital library designed to help kids and their adults calm their minds, focus their attention, and connect better to the world around them.
- Stress Health: Learn how the stress that humans live with can have adverse effects if there is too much for too long.
- American Academy of Pediatrics: A presentation on Identifying Toxic Stress in Pediatric Practices at the 2015 American Academy of Pediatrics Event.
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 caregiver
- PEARLS for teenagers ages 12–19, to be completed by a 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 | Not given more than once during a 12-month period, per provider, per member |
18 or 19 | ACEs or PEARLS | Not given more than once during a 12-month period, per provider, per member |
20-64 | ACEs screening portion of the PEARLS tool (Part 1) can also be used. | Not given more than once during a 12-month period, per provider, per member under age 21. Not given more than once per lifetime, per provider, per member ages 21 and older. |
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:
Treat and Heal
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. |
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.
MHN
For Health Net:
Health Net members can obtain individual and group mental health evaluation and treatment. Providers can call MHN member services. MHN is Health Net’s behavioral health administrator. It is recommended providers call member services with the member to facilitate the referral and obtain member consent for treatment. Providers and members can also access more information at the MHN website. Crisis support is available 24 hours a day, 7 days a week. Members can call MHN to talk to someone right away.
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
Health Net Community Connect is powered by Findhelp formerly known as 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 healthnet.findhelp.com, enter a ZIP code and click Search.
myStrength
For members with ACEs, the myStrength program can provide an additional resource. Providers should call MHN if a member needs emergent or routine treatment 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 my Strength, then click Sign Up and complete the myStrength sign-up process with a brief wellness assessment and personal profile.
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
References
For more information, refer to:
ACE Training and Self-Attestation Requirement for Billing
Effective July 1, 2022, 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.
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.
How to receive payments for ACE screenings
Providers will need to complete the ACEs Aware training and must self-attest to receive payment. To get started, you must:
- Register for the “Becoming ACEs Aware in California” core training.
- Self-attest. Complete the ACEs Provider Training Attestation form.
- Note. The ACEs Aware provider directory is optional for commercial providers.
- Submit claims for ACEs screening with dates of service on or after January 1, 2022, and proof of completion certificate. Claims eligible for payment must be submitted within one year from the date of service.
- Use CPT codes 96160 and 96161 when billing for ACE screenings.
- Claims must also include an ICD-10 code (e.g., T and Z codes around child maltreatment). In California, some ICD-10 codes have been identified as being related to ACEs screening in the state. Examples are:
- Z59.4: Lack of adequate food or safe drinking water
- Z63.0: Relationship problem between spouse or partners
- Z62.819: History of abuse in childhood
- Z63.5: Family disruption due to divorce or legal separation
- Z63.32: Absence of family member
- Z81.9: Family history of mental and behavioral disorder
- Z63.72: Alcoholism and drug addiction in family
- Z63.9: Problem related to primary support group
- Providers must document the following information and ensure the documents remain in the member’s medical record and available upon request:
- The screening tool that was used.
- Date the completed screen was reviewed.
- Results of the screen.
- Interpretation of the results.
- What was discussed with member and/or family.
- Include any appropriate action taken.
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 ACEs Aware site.