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Provider Toolkit Screening and Responding to the Impact of ACEs and Toxic Stress

May 2020

Cover Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i Dr. Nadine Burke Harris and Dr. Karen Mark

ACEs Aware Initiative ACEs Aware Initiative: Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The Science of ACEs and Toxic Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

01 Screen: Training and Payment Screening Tools Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Suggested Clinical Workflows for Screening . . . . . . . . . . . . . . . . . . . . 18 Medi-Cal Certification and Payment . . . . . . . . . . . . . . . . . . . . . . . . . . 22

02 Treat: Clinical Practice Trauma-Informed Care Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Clinical Response to ACEs and Toxic Stress . . . . . . . . . . . . . . . . . 33

03 Heal: Resources and Support Patient Tools and Informational Handouts . . . . . . . . . . . . . . . . . 38 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

For more ACEs Aware information and resources visit the ACEs Aware website at ACEsAware.org.

Contents This Provider Toolkit provides information on the ACEs Aware initiative, including how to screen for and respond to ACEs, and how Medi-Cal providers can get trained and receive payment for conducting ACE screenings. This toolkit is composed of a series of fact sheets that are designed to be read individually.

May 2020

Dear Providers, Adverse Childhood Experiences (ACEs) and toxic stress represent a public health crisis that has been, until recently, largely unrecognized by our state’s health care system and society. A consensus of scientific research demonstrates that cumulative adversity, especially when experienced during critical and sensitive periods of development, is a root cause to some of the most harmful, persistent, and expensive health challenges facing our state and nation. But there is hope. We can take action now to change and save lives. The impacts of ACEs and toxic stress are treatable. We can screen for ACEs, respond with evidence-based trauma-informed care, and significantly improve the health and well-being of individuals and families. These efforts can also reduce the risk of intergenerational transmission of the significant health and societal consequences of toxic stress. As a provider, you are on the frontlines of administering ACE screenings and interventions, but you are not alone in this effort. That is why we are so pleased to share our ACEs Aware Provider Toolkit, created in partnership between the Office of the California Surgeon General (CA- OSG) and the California Department of Health Care Services (DHCS). The toolkit offers information and resources that providers will find useful as we join forces to screen, treat, and heal patients. This includes how to get trained to screen for ACEs, assess risk for toxic stress, implement evidence-based interventions, receive payment from Medi- Cal for screenings, and help advance our state’s systems of care to be more effective and efficient. The time to act is now. Effective January 1, 2020, DHCS began paying Medi-Cal providers for conducting ACE screenings for children and adults up to age 65 with full-scope Medi-Cal. Together, we can address this public health crisis, advance our health care systems, and lead a national movement to ensure everyone is ACEs Aware. We hope you will join us by using the information in this toolkit and by going to the ACEs Aware website at ACEsAware.org to take action.

Sincerely, Karen E. Mark, MD, PhD MEDICAL DIRECTOR California Department of Health Care Services

Nadine Burke Harris, MD, MPH, FAAP CALIFORNIA SURGEON GENERAL

i

This fact sheet explains Adverse Childhood Experiences (ACEs), the impact of ACEs and toxic stress on health, and steps for providers to screen for ACEs and receive Medi-Cal payment.

ACEs Aware Initiative: Overview

The term Adverse Childhood Experiences (ACEs) comes from the landmark 1998 study by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente. It describes 10 categories of adversities in three domains experienced by age 18 years: abuse, neglect, and/or household dysfunction (Figure 1).1

Data show that 62% of California residents have experienced at least one ACE and 16% have experienced four or more ACEs.2

Figure 1: 10 Categories of Adverse Childhood Experiences (ACEs)

Abuse: physical, emotional, and sexual abuse

Neglect: physical and emotional neglect

Household dysfunction: parental incarceration, mental illness, substance use, parental separation or divorce, and intimate partner violence

ACEs cross ethnic, socioeconomic, gender, and geographic lines. Children are uniquely vulnerable to the effects of an overactive stress response due to ACEs because their brains and bodies are still developing.

ACEs Aware Initiative: Overview • ACEsAware.org • 1

A consensus of scientific research demonstrates that cumulative adversity, especially when experienced during critical and sensitive periods of development, is a root cause to some of the most harmful, persistent, and expensive health challenges facing our state and nation, including at least 9 of the 10 leading causes of death in the United States.

ACEs Aware in California

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 for conducting ACE screenings:

For more information, visit the ACEs Aware website at ACEsAware.org.

Step 1 Step 2 Step 3 Step 4

Get Trained Screen for ACEs, Assess Risk for Toxic Stress, Respond with Evidence-Based Interventions, & Implement Trauma- Informed Care

Receive Medi-Cal Payment

Help Advance the Health Care System

ACEs Aware Initiative: Overview • ACEsAware.org • 2

This fact sheet explains Adverse Childhood Experiences (ACEs) and the impact of ACEs and toxic stress on health.

The Science of ACEs and Toxic Stress

The term Adverse Childhood Experiences (ACEs) comes from the landmark 1998 study by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente. It describes 10 categories of adversities in three domains experienced by age 18 years: abuse, neglect, and/or household dysfunction (Figure 1).1

Data show that 62% of California residents have experienced at least one ACE and 16% have experienced four or more ACEs, using 2011-2017 Behavioral Risk Factor Surveillance System (BRFSS) data from a random-digit-dialed telephone survey.2

Figure 1: 10 Categories of Adverse Childhood Experiences (ACEs)

Abuse: physical, emotional, and sexual abuse

Neglect: physical and emotional neglect

Household dysfunction: parental incarceration, mental illness, substance use, parental separation or divorce, and intimate partner violence

The Science of ACEs and Toxic Stress • ACEsAware.org • 3

The Science of ACEs & Toxic Stress • ACEsAware.org • 8

Key findings of the ACE Study and subsequent body of research include:

• ACEs are highly prevalent. Two thirds of respondents in the Kaiser Permanente/CDC study reported at least one ACE and one in eight reported four or more ACEs.1, 3,4 Subsequent studies have shown a rate of four or more ACEs that is closer to one in six.5,6

• ACEs are strongly associated, in a dose-response fashion, with some of the most common and serious health conditions facing our society today, including at least nine of the 10 leading causes of death in the U.S. (Figure 2). Find the ACE-Associated Health Conditions as part of the ACE Screening Workflows, Risk Assessment and Treatment Algorithms, and ACE-Associated Health Conditions at ACEsAware.org/assessment-and-treatment.

• ACEs affect all communities. The original ACE Study was conducted among a population that was mostly Caucasian, middle class, employed, college educated, and privately insured.1,3,4 Subsequent studies have found higher prevalence rates of ACEs in people who are low-income, of color, justice-involved, and/or part of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community.5-10

The Science of ACEs and Toxic Stress • ACEsAware.org • 4

Overview • ACEsAware.org • 9Trauma-Informed Care Overview • ACEsAware.org • 9The Science of ACEs & Toxic Stress • ACEsAware.org • 9

Leading Causes of Death in the U.S., 2017

Odds Ratios for > 4 ACEs (relative to no ACEs)

1 Heart disease 2.1

2 Cancer 2.3

3 Accidents (unintentional injuries) 2.6

4 Chronic lower respiratory disease 3.1

5 Stroke 2.0

6 Alzheimer’s or dementia 11.2

7 Diabetes 1.4

8 Influenza and pneumonia Risk unknown

9 Kidney disease 1.7

10 Suicide (attempts) 37.5

Figure 2: Leading Causes of Death in the U.S.

Source of causes of death: CDC, 2017.11

Sources of odds ratios: Hughes et al., 2017 for 1, 2, 4, 7, 10.12 Petrucelli et al., 2019 for 3 (injuries with fracture), 5.3,5,13 Center for Youth Wellness, 2014 for 6 (Alzheimer’s or dementia).14 Center for Youth Wellness, 2014 and Merrick et al., 2019 for 9.5,14

The Science of ACEs and Toxic Stress • ACEsAware.org • 5

Overview • ACEsAware.org • 10Trauma-Informed Care Overview • ACEsAware.org • 10The Science of ACEs & Toxic Stress • ACEsAware.org • 10

Toxic Stress Several decades of scientific research have identified the biological mechanisms by which early adversity leads to increased risk of negative health and social outcomes through the life course. Repeated or prolonged activation of a child’s stress response, without the buffering protections of trusted, nurturing caregivers and safe, stable environments, leads to long-term changes in the structure and functioning of the developing brain, metabolic, immune, and neuroendocrine responses, and even the way DNA is read and transcribed. This is known as the toxic stress response (Figure 3).15-18

These biological changes play an important role in the clinical progression from ACE exposure to negative short- and long-term health and social outcomes. Further, both the disrupted biology and the associated negative outcomes demonstrate a pattern of high rates of intergenerational transmission. Development of the toxic stress response is influenced by a combination of cumulative adversity, buffering or protective factors, and predisposing vulnerability.

In addition to ACEs, social determinants of health (SDOH), such as poverty, discrimination, and housing and food insecurity, are associated with health risks and may also be risk factors for toxic stress. While validated odds ratios are available in large, population-based studies utilizing the 10 standardized ACE criteria, the strengths of associations between SDOH and health outcomes have not been similarly standardized.

The Science of ACEs and Toxic Stress • ACEsAware.org • 6

The Science of ACEs & Toxic Stress • ACEsAware.org • 11

Figure 3: Toxic Stress Response

Adapted from Bucci et al., 201616

Endocrine Metabolic

Reproductive

Neurologic Psychiatric Behavioral

Neurological Psychiatric Behavioral

Immune Inflammatory

Cardiovascular

TOXIC STRESS

CHRONIC DYSREGUL ATION

CLINICAL IMPLICATIONS

EARLY LIFE ADVERSITY

Protective Factors

NEURO

ENDOCRINE IMMUNE

Epigenetic

Predisposing Vulnerability

The Science of ACEs and Toxic Stress • ACEsAware.org • 7

The Impact of ACEs and Toxic Stress on Health ACEs are associated with increased risk of a wide range of negative health conditions in both pediatric and adult populations. The life expectancy of individuals with six or more ACEs is 19 years shorter than that of individuals with none.20 Find a list of ACE-Associated Health Conditions for pediatrics and adults as part of the ACE Screening Workflows, Risk Assessment and Treatment Algorithms, and ACE- Associated Health Conditions at ACEsAware.org/assessment-and- treatment.

Pediatric Health The effects of toxic stress are detectable as early as infancy. In babies, high doses of adversity are associated with failure to thrive, growth delay, sleep disruption, and developmental delay. School-aged children may have increased risk of viral infections, pneumonia, asthma, and other atopic diseases, as well as difficulties with learning and behavior.

Among adolescents with high ACEs, somatic complaints — including headache and abdominal pain, increased engagement in high-risk behaviors, teen pregnancy, teen paternity, sexually transmitted infections (STIs), mental health disorders, and substance use — are common.

Adult Health As noted above, ACEs are associated with some of the most common and serious health conditions facing our communities. Learn more about ACE-Associated Health Conditions for adults at: ACEsAware.org/ assessment-and-treatment.

The Science of ACEs and Toxic Stress • ACEsAware.org • 8

Mental and Behavioral Health The higher the ACE score, the greater the likelihood an individual may experience mental health disorders such as depression, post-traumatic stress disorder, anxiety, and sleep disorders, and engage in risky behaviors such as early and high-risk sexual behaviors and substance use.5,12,13 High doses of childhood adversity are associated with increased risk of engaging in high-risk behaviors that can lead to negative health outcomes.

However, even in the absence of health-damaging behavior, strong associations between cumulative childhood adversity and increased risk of serious health conditions persist. Evidence suggests that the toxic stress response likely plays a role in mediating both behavior-related and non-behavior-related pathways.

Cost of ACEs in California Considering just five ACE-Associated Health Conditions (asthma, arthritis, COPD, depression, and cardiovascular disease) and three health risk factors (lifetime smoking, heavy drinking, and obesity), the annual total cost of these health-related impacts of ACEs in California is $112.5 billion. This includes direct healthcare expenditures ($10.5 billion), and the cost in disability and years of productive life lost to ACEs ($102 billion).21,22

In sum, ACEs are common, highly consequential for health and well- being, and very costly—and thus constitute a major and under- addressed public health crisis of our era.

For information on the clinical response to ACEs, see the "Clinical Response to Adverse Childhood Experiences and Toxic Stress" fact sheet at ACEsAware.org/toolkit/clinical-response.

The Science of ACEs and Toxic Stress • ACEsAware.org • 9

01 Screen: Training and Payment Screening Tools Overview

Suggested Clinical Workflows for Screening

Medi-Cal Certification and Payment

NEW

PHOTO

NEEDED

ACE Screening Tools The tools used to screen children, adolescents, and adults for ACEs are available in de-identified and identified formats:

For Children and Adolescents (Ages 0–19) 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.

Screening for ACEs and toxic stress and providing targeted, evidence-based interventions for toxic stress can: • Improve efficacy and efficiency of health care; • Better support individual and family health and well-being; and • Reduce long-term health costs.

This fact sheet explains why providers should screen for ACEs and describes the tools that should be used to screen children, adolescents, and adults for ACEs.

Screening Tools Overview

Overview • ACEsAware.org • 18Screening Tools Overview • ACEsAware.org • 10

Overview • ACEsAware.org • 19Screening Tools Overview • ACEsAware.org • 19

Part 1: ACE screen—10 questions that screen for history of abuse, neglect, and household dysfunction (Figure 1). The ACE score refers to the total number of ACE categories experienced, rather than the severity or frequency of any one category. The total score ranges between 0 and 10. Part 2: It is recognized that social determinants of health (SDOH) other than ACEs are associated with health risks and may also be risk factors for toxic stress. These include community violence, food and housing insecurity, bullying, discrimination, and a caregiver’s physical illness or death.

The PEARLS includes an ACE screen (Part 1) as well as a social determinants of health (SDOH) screen (Part 2) — for a total of 17-19 questions, depending on child age (Figure 4). Only Part 1 is used to calculate a child's ACE score. Below is more information about the two parts:

The social determinants of health also should be addressed with appropriate services as indicated, but they should not be added to the ACE score for the purpose of the toxic stress risk assessment, treatment planning, and billing. While validated odds ratios are available in large, population-based studies utilizing the 10 standardized ACE criteria, the strengths of association between these SDOH and health outcomes have not been similarly standardized.

Overview • ACEsAware.org • 19Screening Tools Overview • ACEsAware.org • 11

There are three versions of the tool, based on age and reporter, for a total of 17-19 questions (10 ACE categories and seven to nine SDOH categories):

• 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

Providers receive a single Medi-Cal payment if the adolescent OR their caregiver completes the PEARLS adolescent tool. However, the best practice is for both the adolescent and the caregiver to each complete a tool. When these yield different scores, the higher score should be used in toxic stress risk assessment, treatment planning, and billing.

Overview • ACEsAware.org • 20Screening Tools Overview • ACEsAware.org • 12

Overview • ACEsAware.org • 21Screening Tools Overview • ACEsAware.org • 21

Figure 4. PEARLS – De-Identified for ACEs and Identified for SDOH

Overview • ACEsAware.org • 21Screening Tools Overview • ACEsAware.org • 13

Overview • ACEsAware.org • 22Screening Tools Overview • ACEsAware.org • 22

Figure 4. PEARLS – De-Identified for ACEs and Identified for SDOH

Overview • ACEsAware.org • 22Screening Tools Overview • ACEsAware.org • 14

Overview • ACEsAware.org • 23Screening Tools Overview • ACEsAware.org • 23

Figure 5. ACE Questionnaire for Adults — De-Identified

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). A version of the tool (Figure 5) has been compiled by the Office of the California Surgeon General and the Department of Health Care Services, in consultation with the ACEs Aware Clinical Advisory Subcommittee.

Overview • ACEsAware.org • 23Screening Tools Overview • ACEsAware.org • 15

Overview • ACEsAware.org • 24Screening Tools Overview • ACEsAware.org • 24

Figure 5. ACE Questionnaire for Adults — Identified

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 (Figure 1). For 18- and 19-year-olds, either tool may be used. For patients 20 years and older, the adolescent self-report version of the PEARLS is also acceptable.

Overview • ACEsAware.org • 24Screening Tools Overview • ACEsAware.org • 16

Find the ACE Screening Tools at ACEsAware.org/screening-tools.

Tool Formats Both tools are available in de-identified and identified formats:

1. De-Identified: Respondents count the number of ACE categories on the screening tool that they or their child has experienced, and indicate only the total score — without identifying which ACE(s) they or their child experienced.

2. Identified: Respondents count the number of ACEs categories on the screening tool that they or their child has experienced and specify which ACE(s) they or their child experienced.

For information on the clinical response to ACEs and toxic stress, see the "Clinical Response to Adverse Childhood Experiences and Toxic Stress" fact sheet at ACEsAware. org/toolkit/clinical-response.

For information on Medi-Cal payment, see the "Medi-Cal Certification and Payment" fact sheet at ACEsAware.org/toolkit/ certification-and-payment.

Overview • ACEsAware.org • 25Screening Tools Overview • ACEsAware.org • 17

Overview • ACEsAware.org • 26Screening Tools Overview • ACEsAware.org • 26

At the beginning of an appointment, the age-appropriate screening tool should be given directly to adult patients, caregivers for children and adolescents, and adolescent patients for completion in a private setting when possible. The Clinical Advisory Committee and the Office of the California Surgeon General have developed the following suggested workflows for incorporating ACE screening and response into clinical care, adapted for pediatric and adult practices. These ACE Screening Clinical Workflows can also be found as part of the ACE Screening Workflows, Risk Assessment and Treatment Algorithms, and ACE-Associated Health Conditions at ACEsAware.org/assessment- and-treatment.

This fact sheet provides suggested workflows for implementing ACE screening and explains how to calculate the ACE score.

Suggested Clinical Workflows for Screening

Overview • ACEsAware.org • 26Suggested Clinical Workflows for Screening • ACEsAware.org • 18

*PEARLS is recommended to be completed once per year.

tHealthcare Common Procedure System (HCPCS) billing codes for ACE scores: G9919: ACE score ≥ 4, high risk for toxic stress G9920: ACE score of 0 – 3, lower risk for toxic stress. For purposes of coding, scores of 1-3 with ACE-Associated Health Conditions should be coded as G9920, even though patient falls into the high-risk category of the clinical algorithm.

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