ACEs Aware Overview

March 17, 2021

ACEs Aware Mission

To change and save lives by helping providers understand the importance of screening for Adverse Childhood Experiences and training providers to respond with trauma-informed care to mitigate the health impacts of toxic stress.

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ACEs Aware Leadership

• Dr. Nadine Burke Harris California Surgeon General

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• Dr. Karen Mark Medical Director

Department of Health Care Services

What are Adverse Childhood Experiences (ACEs)?

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• Stressful or traumatic experiences people have by age 18 that were identified in the landmark 1998 study by the Centers for Disease Control and Prevention and Kaiser Permanente
• They relate to 10 categories of adversities in three domains: abuse, neglect, and/or household dysfunction

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10 Categories of Adverse Childhood Experiences

Copyright 2013. Robert Wood Johnson Foundation. Used with permission from the Robert Wood Johnson Foundation.

Prevalence of ACEs in California

Sources: California Department of Public Health, Injury and Violence Prevention Branch (CDPH/IVPB), University of California, Davis, Violence Prevention Research Program, California Behavioral Risk Factor Surveillance System (BRFSS), 2011-2017.

Prevalence of ACEs in Fresno County

Sources: California Department of Public Health, Injury and Violence Prevention Branch (CDPH/IVPB), University of California, Davis, Violence Prevention Research Program, California Behavioral Risk Factor Surveillance System (BRFSS), 2011-2017.

Annual Cost of ACEs to California

Cardiovascular disease

Smoking

Heavy Drinking

Obesity

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Asthma

Arthritis

COPD

Depression

Data source: Miller TR, Waehrer GM, Oh DL, Purewal Boparai S, Ohlsson Walker S, Silverio Marques S, et al. (2020) Adult health burden and costs in California during 2013 associated with prior adverse childhood experiences. PLoS ONE 15(1): e0228019. https://doi.org/10.1371/journal.pone.0228019

ACEs Dramatically Increase Risk for �at least 9 of the 10 Leading Causes of Death in U.S.

Source of causes of death: CDC, 2017; Sources of odds ratios: Hughes et al., 2017 for 1, 2, 4, 7, 10; Petrucelli et al., 2019 for 3 (injuries with fracture), 5; Center for Youth Wellness, 2014 for 6 (Alzheimer’s or dementia); Center for Youth Wellness, 2014 and Merrick et al., 2019 for 9.

ACEs Aware

The ACEs Aware initiative offers Medi-Cal providers training, screening tools, clinical protocols, and payment for screening children and adults for ACEs.

Screening for ACEs, assessing for toxic stress, and responding with evidence-based interventions can significantly improve the health and well-being of individuals and families.

• Effective January 1, 2020, qualified Medi-Cal providers are eligible for a $29 payment for screening patients up to age 65 with full-scope Medi-Cal using a qualified screening tool.
• Beginning July 1, 2020, to receive payment, providers must have completed a certified training and self-attested to completing it.

Steps for Providers

Providers should follow these steps to receive Medi-Cal payment from the Department of Health Care Services (DHCS) for ACE screenings:

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Steps for Providers

Follow these steps to receive Medi-Cal payment for ACE screenings:

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• Step 1: Get Trained & Attest to Completing Training. Take a free 2-hour, online training for 2 CME or MOC credits and self-attest to completing the training.

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• Step 2: Screen for ACEs, Assess Risk for Toxic Stress, Respond with Evidence-Based Interventions, and Implement Trauma-Informed Care. Learn about screening for ACEs and clinical assessment and treatment planning.

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• Step 3: Receive Medi-Cal payment. Submit one of two billing codes based on the results of the screening, and document certain information. Payment is in addition to the payment for the accompanying office visit – get payment information.

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• Step 4: Help Advance the Health Care System. ACEs Aware is hosting a series of activities and providing grants to promote shared learning and quality improvement among Medi-Cal providers.

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ACEs Aware Online Provider Training

• Certified provider training is available on training.ACEsAware.org
• Free, 2-hour online course that offers CME and MOC credits
• Includes information on:
• DHCS policies and requirements for providers
• Science of trauma and toxic stress
• How to screen for ACEs using PEARLS and ACE Questionnaire for Adults
• How to implement trauma-informed care
• Additional certified trainings will become available over time

Benefits of Screening

By screening for ACEs, providers can:

• Better determine the likelihood a patient is at increased health risk due to a toxic stress response.
• Better identify ACE-Associated Health Conditions that may benefit from a trauma-informed intervention.
• Identify which patients may be at risk of vertical transmission of ACEs and toxic stress and target prevention efforts.
• Empower patients to achieve better health by addressing potential toxic stress physiology.

Screening Tools

Different screening tools are used for children/adolescents and adults. The tools are available in 17 languages and de-identified and identified formats:

• For Children & Adolescents: The Pediatric ACEs and Related Life-Events Screener (PEARLS) was developed by the Bay Area Research Consortium on Toxic Stress and Health (BARC), a partnership between the Center for Youth Wellness, the University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital Oakland.
• PEARLS child tool, for ages 0-11, to be completed by a caregiver
• PEARLS adolescent tool, for ages 12-19, to be completed by a caregiver
• PEARLS for adolescent self-report tool, for ages 12-19, to be completed by the adolescent

Find screening tools at

ACEsAware.org/screening-tools

Pediatric ACEs and Related Life Events Screener (PEARLS) ��De-Identified for ACEs and Identified for Social Determinants of Health

Pediatric ACE Screening Clinical Workflow

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Available at: ACEsAware.org/clinical-assessment

ACEs and Toxic Stress Risk Assessment Algorithm – Pediatrics

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Available at: ACEsAware.org/clinical-assessment

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ACE-Associated Health Conditions – Pediatrics

For more details, see the ACEs and Toxic Stress Risk Assessment Algorithms at: ACEsAware.org/clinical-assessment

Screening Tools

• For Adults Ages 18 and Older: The ACE Questionnaire for Adults was adapted from the work of Kaiser Permanente and the Centers for Disease Control and Prevention (CDC).
• For the ACE Questionnaire for Adults recommended by the Office of the California Surgeon General and the Department of Health Care Services, visit ACEsAware.org/screening-tools.
• If an alternative version of the ACE Questionnaire for Adults is used, it must contain questions on the 10 original categories of ACEs to qualify for Medi-Cal payment.

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ACE Questionnaire for Adults — De-Identified

Adult ACE Screening Clinical Workflow

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Available at: ACEsAware.org/clinical-assessment

ACEs and Toxic Stress Risk Assessment Algorithm – Adults

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Available at: ACEsAware.org/clinical-assessment

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ACE-Associated Health Conditions – Adults

For more details, see the ACEs and Toxic Stress Risk Assessment Algorithms at: ACEsAware.org/clinical-assessment

Screening Frequency

• Medi-Cal payment is available for ACE screenings based on the following schedule:
• Children and Adolescents (Under Age 21)

Permitted for periodic ACE rescreening as determined appropriate and medically necessary, not more than once per year, per provider (per managed care plan).

• Adults (Age 21 through 64):

Permitted once per adult lifetime (through age 64), per provider(per managed care plan).

Screenings completed while the person is under age 21 years do not count toward the one screening allowed in their adult lifetime.

Trauma-Informed Care Framework

Trauma-informed care is a framework that involves:

• Understanding the prevalence of trauma and adversity and their impacts on health and behavior;
• Recognizing the effects of trauma and adversity on health and behavior;
• Training leadership, providers, and staff on responding to patients with best practices for trauma-informed care;
• Integrating knowledge about trauma and adversity into policies, procedures, practices, and treatment planning; and
• Resisting re-traumatization by approaching patients who have experienced ACEs or other adversities with non-judgmental support.

Trauma-informed care recognizes and responds to the signs, symptoms, and risks of trauma to �better support the health needs of patients who have experienced ACEs and toxic stress.

Trauma-Informed Care Principles

• 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 �and mental health
• Promote patient-centered, evidence-based 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 patient’s racial, ethnic, and cultural background, and gender identity

Clinical Response Overview

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

• Applying principles of trauma-informed care, including establishing trust, safety, and collaborative decision-making
• Identification and treatment of ACE-Associated Health Conditions by supplementing usual care with patient education on toxic stress and strategies to regulate the stress response, including:
1. Supportive relationships, including with caregivers (for children), other family members, and peers
2. High-quality, sufficient sleep
3. Balanced nutrition
4. Regular physical activity
5. Mindfulness and meditation
6. Mental health care, including psychotherapy or psychiatric care, �and substance use disorder treatment, when indicated

Clinical Response Overview

California Surgeon General’s Stress Busters

Clinical Response Overview

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

• Validation of existing strengths and protective factors
• 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 six pillars listed earlier
• Follow up as necessary, using the presenting ACE-Associated Health Condition(s) �as indicators of treatment progress

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For information on the clinical response to ACEs and toxic stress, �visit ACEsAware.org/assessment-and-treatment

Certification & Payment

• Conducting ACE screenings is voluntary; Eligible Medi-Cal providers who conduct qualified ACE screenings will be paid.
• Beginning on July 1, 2020, Medi-Cal providers must self-attest to completing certified ACE training to continue receiving payment for screening.
• Providers can find and submit an ACE Training Attestation Form at ACEsAware.org/certification-payment.

Guidance

All Plan Letter (APL) 19-018

Frequently Asked Operational Questions

Types of Providers Eligible for Medi-Cal Payment

Additional Policy Guidance

Key DHCS Requirements

Provider Toolkit��Information on the ACEs Aware initiative, how to screen for and respond to ACEs, and how �Medi-Cal providers can get �trained and receive payment �for conducting ACE screenings.��Visit ACEsAware.org/toolkit

ACE Resources��Free resources for providers on ACE screening and clinical response. ��Includes clinical resources for pediatric and adult providers, patient/family handouts, and policy/research/advocacy briefs.��Visit ACEsAware.org/resources

COVID-19 & Stress��Resources on managing stress related to COVID-19 and mitigating the impact of stress �on mental and physical health.��Visit ACEsAware.org/COVID19

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