Learn About Screening

Using early detection and intervention to improve health outcomes

female doctor showing a young female patient notes on a tablet

Preventing the lasting impacts of ACEs

The purpose of a complete ACE screening is to rapidly identify which patients are at highest risk for toxic stress and perform the next steps of a more complete, individualized assessment for each of them.

A complete ACE screening involves assessing for the triad of:

  • Adversity (the ACE score)
  • Clinical manifestations of toxic stress (ACE-Associated Health Conditions)
  • Protective factors

Clinical teams should use the ACEs and Toxic Stress Risk Assessment Algorithm to assess whether a patient is at low, intermediate, or high risk for having a toxic stress physiology. A patient’s risk of toxic stress helps inform the treatment strategy.

See more information on toxic stress treatment >

Once the risk has been assessed, a treatment strategy consisting of education can help patients recognize and respond to the role that past or present stressors may be playing on their current health conditions. Addressing toxic stress physiology is a core component of treating ACE-Associated health conditions.

Image for smiling doctor with child

It is important to note that exposure to ACEs does not determine or foretell an individual’s future health or life outcomes. Fortunately, exposure to ACEs does not always lead to toxic stress. The presence of protective factors – like supportive relationships – can alter the risk of toxic stress and related health and social outcomes.

The health care setting offers a unique opportunity to help patients and families understand the impact of ACEs on health and to prevent and treat toxic stress. Effective January 1, 2020, California began providing a $29 Medi-Cal payment for conducting qualifying ACE screenings for pediatric and adult patients (up to age 65) with full-scope Medi-Cal, as part of the ACEs Aware initiative. This payment is intended to incentivize clinical teams to learn about and adopt ACE screening and the principles of trauma-informed care into their practices.

ACE screening:

  • Supports health promotion and prevention of illness.
  • Helps clinical teams and patients form stronger therapeutic relationships.
  • Improves clinical decision-making and treatment of serious and difficult-to-treat health conditions.
  • Promotes an intergenerational cycle of health by reducing the transmission of ACEs and toxic stress.

This section provides more information on the benefits of ACE screening, how to get certified to screen for ACEs, the screening tools, and the Medi-Cal billing codes with payment information.

FAQs

The training is available to any clinician team or staff members, but it is particularly geared towards primary care clinicians. Clinicians who will implement ACE screening in their practice should take the training and attest to completing it to qualify for Medi-Cal payment. Other clinicians and staff may also benefit from taking the training, but are not required to attest.

For more information on eligibility to receive Medi-Cal payment for ACE screenings, view eligible provider types.

Yes. You can earn 2.0 Continuing Medical Education (CME) credits and 2.0 Maintenance of Certification (MOC) credits by taking the “Becoming ACEs Aware in California” training. You can earn additional education credit by completing additional cases.

  • The Postgraduate Institute of Medicine accredited the “Becoming ACEs Aware in California” training for:
    • 2.00 American Medical Association (AMA) Physician’s Recognition Award (PRA) Category 1 Credit™
    • 2.00 American Academy of Family Physicians (AAFP) Prescribed credits
    • 2.00 American Nurses Credentialing Center (ANCC) contact hours
    • 2.00 American Academy of PAs (AAPA) Category I CME credits
    • 2.00 American Psychological Association (APA) Continuing Education (CE) credits
    • 2.00 Association of Social Work Boards (ASWB) CE credits
    • 2.00 NAADAC (the Association for Addiction Professionals) credits
    • 2.00 American Board of Internal Medicine’s (ABIM) points in the MOC II program
    • 2.00 American Board of Pediatrics’ (ABP) points in the MOC program

Learners may also take the course for attendance only. More information about credit types is available on the “Becoming ACEs Aware in California” training page.

Yes. Eligible Medi-Cal providers who screen Medi-Cal patients for ACEs can receive payment as of January 1, 2020. Beginning on July 1, 2020, Medi-Cal providers must have taken a certified Core Training and self-attested to completing the training to continue to receive Medi-Cal payment for ACE screenings. There is currently one Core Training available, Becoming ACEs Aware in California.

For children, the screening tool required for use is the Pediatric ACEs and Related Life-events Screener (PEARLS) tool. There are versions of the tool based upon age: PEARLS for children ages 0-11, to be completed by a caregiver; PEARLS for teenagers 12-19, to be completed by a caregiver; and PEARLS for teenagers 12-19, self-reported. All versions of PEARLS are available as identified and de-identified screeners. The ACE score refers only to Part 1 of PEARLS (Part 2 asks about social determinants of health and is not required).

In total, there are eight versions of the PEARLS tool:

  • PEARLS for children ages 0-11, to be completed by a caregiver with identified responses
  • PEARLS for children ages 0-11, to be completed by a caregiver with de-identified responses
  • PEARLS for children ages 0-11, with de-identified responses in Part 1 and identified responses in Part 2
  • PEARLS for adolescents 12-19, to be completed by a caregiver with identified responses
  • PEARLS for adolescents 12-19, to be completed by a caregiver with de-identified responses
  • PEARLS for adolescents 12-19, self-reported with identified responses
  • PEARLS for adolescents 12-19, self-reported with de-identified responses
  • PEARLS for adolescents 12-19, self-reported with de-identified responses in Part 1 and identified responses in Part 2

Eligible providers will be paid for the screening if any of the versions are used. The ACEs screening portion (Part 1) of the PEARLS tool is also valid for use to conduct ACEs screening among adults age 20 and older. Access the screening tools.

 

For adults, the screening tool required for use is the ACE Assessment Tool adapted from the work of Kaiser Permanente and the Centers for Disease Control and Prevention. Access the Identified and de-identified versions of the screening tools. If an alternative version of the ACE questionnaire for individuals age 20 and older is used, it must contain questions on the ten original categories of ACEs (and be available in an identified and de-identified response format) to qualify for payment.

 

Qualifying ACE screenings are eligible for payment in any clinical setting in which billing occurs through Medi-Cal fee-for-service or to a network provider of a managed care plan. For services provided on or after January 1, 2020, the following enrolled Medi-Cal provider types are eligible to receive payment:

  • Certified Nurse Midwife
  • Certified Nurse Practitioner
  • Group Certified Nurse Practitioners
  • Early and Periodic Screening, Diagnostic, and Treatment Services Providers
  • Licensed Clinical Social Worker – Individual, Group
  • Licensed Nurse Midwife
  • Licensed Professional Clinical Counselor – Individual, Group
  • Marriage and Family Therapist – Individual, Group
  • Physician
  • Physician Group
  • Psychologist
  • County Hospital – Outpatient
  • County Clinics not associated with a Hospital
  • Indian Health Services (IHS)/Memorandum of Agreement
  • Otherwise Undesignated Clinic
  • Outpatient Heroin Detox Center
  • Rehabilitation Clinic
  • Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC)
  • In-state and border providers

To receive payment through Medi-Cal managed care, the provider also needs to be a network provider of a Medi-Cal managed care health plan billing for services provided to a member of that health plan.

ACE screenings are eligible for payment in any clinical setting in which billing occurs through Medi-Cal fee-for-service or to a network provider of a medical managed care plan. In most cases, ACE screenings are most appropriately delivered in an outpatient primary care setting.

Resources

END USER SUBLICENSE AGREEMENT

PLEASE READ CAREFULLY: This End User Sublicense Agreement (the “Agreement” or “Sublicense”) is a legally binding agreement between you (an individual or an entity, hereinafter “You” or “Sublicensee”) and the Department of Health Care Services (“DHCS”) for the use of the Pediatric ACEs and Related Life-events Screener (“PEARLS”) for children and adults up to the age of 21.

BY WAY OF DOWNLOADING, COPYING, ACCESSING, OR OTHERWISE USING THE PEARLS TOOL, YOU ARE AGREEING TO BE LEGALLY BOUND BY THE TERMS OF THIS AGREEMENT. IF YOU DO NOT AGREE TO BE BOUND BY THE TERMS OF THIS AGREEMENT, THEN YOU HAVE NO RIGHTS TO THE PEARLS TOOL AND MAY NOT DOWNLOAD, COPY, ACCESS, OR OTHERWISE THE PEARLS TOOL.

THE PEARLS TOOL IS PROTECTED BY COPYRIGHT LAWS AND IS OTHERWISE PROTECTED INTELLECTUAL PROPERTY. THE PEARLS TOOL IS LICENSED AND IS NOT SOLD.

    1. The PEARLS Tool. The PEARLS tool is a unique tool that assess for both Adverse Childhood Experiences (“ACEs”) such as abuse, neglect, and household challenges, and related events, such as discrimination, food insecurity, and community violence, thought to be risk factors for toxic stress. The PEARLS tool was made in the course of research under the auspices of the Children’s Hospital Research Center at Oakland (“BCHO”) and the University of California, San Francisco. BCHO has licensed the PEARLS tool to DHCS and provided DHCS with the right to sublicense the PEARLS tool.
    2. Sublicensee Attestation. By agreeing to this Agreement, You attest that You are a provider of health care services to Medi-Cal beneficiaries, a Medi-Cal Managed Care Plan, a Medi-Cal beneficiary, a parent or guardian of a Medi-Cal beneficiary, or an Electronic Health Records (“EHR”) vendor.
    3. The Sublicense. Subject to the terms of this agreement, DHCS hereby grants to Sublicensee a non-exclusive, royalty-free, non-assignable, non-transferable sublicense (the “Sublicense”) to the PEARLS tool. Under the Sublicense, Sublicensee may use the PEARLS tool as directed, and may save, download, print, copy, reproduce, or distribute the PEARLS tool to facilitate such use.
    4. Use in a Remote Patient Portal. The PEARLS tool was developed as a screener of risk for toxic stress and has been tested for safe, reliable screening when used during in-person (i.e., synchronous) visits. The questions and responses of the PEARLS tool may be administered using the EHR as structured data fields to facilitate record and follow-up. Because the PEARLS tool was never studied under asynchronous screening formats, DHCS cannot provide recommendations regarding its use in a remote patient portal. This includes information around safety and adequate windows of response. Sublicensee acknowledges that DHCS is not responsible for providing any recommendations regarding the use of the PEARLS tool in a remote patient portal, and that DHCS is not responsible for overseeing implementation and use of the PEARLS tool in a remote patient setting. This includes information around safety and adequate windows of response.
    5. Disclaimer of Warranty. This Sublicense and the associated PEARLS tool are provided WITHOUT WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR ANY OTHER WARRANTY, EXPRESS OR IMPLIED. DHCS MAKES NO REPRESENTATION OR WARRANTY THAT THE PEARLS TOOL WILL NOT INFRINGE ANY COPYRIGHT, PATENT, OR OTHER PROPRIETARY RIGHT.
    6. Limitations of Liability.
      1. IN NO EVENT WILL DHCS BE LIABLE FOR ANY INCIDENTAL, SPECIAL OR CONSEQUENTIAL DAMAGES RESULTING FROM EXERCISE OF THIS SUBLICENSE OR THE USE OF THE PEARLS TOOL.
      2. DHCS WILL NOT BE LIABLE FOR ANY LOST PROFITS, COSTS OF PROCURING SUBSTITUTE GOODS OR SERVICES, LOST BUSINESS, ENHANCED DAMAGES FOR INTELLECTUAL PROPERTY INFRINGEMENT OR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR OTHER SPECIAL DAMAGES SUFFERED BY SUBLICENSEE, JOINT VENTURES, AFFILIATES, OR DEVELOPMENT PARTNERS ARISING OUT OF OR RELATED TO THIS AGREEMENT. DHCS WILL NOT LIABLE FOR ANY CAUSES OF ACTION OF ANY KIND (INCLUDING TORT, CONTRACT, NEGLIGENCE, STRICT LIABILITY, AND BREACH OF WARRANTY) EVEN IF DHCS HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
    7. Indemnity and Duty to Defend. Sublicensee shall indemnify, defend, and hold harmless DHCS from and against all claims, actions, damages, losses, liabilities (or actions or proceedings with respect to any thereof), whether or not rightful, arising from any and all actions or claims by any third party or expenses related thereto (including, but not limited to, all legal expenses, court costs, and attorney’s fees incurred in investigating, preparing, serving as a witness in, or defending against, any such claim, action, or proceeding, commenced or threatened) to which DHCS and/or any employee, contractor, or agent acting on DHCS’s behalf may be subject, whether or not Sublicensee is a party to any pending or threatened litigation, which arise out of or are related to (i) claims and losses accruing or resulting to any person, firm or corporation who may be injured or damaged by Sublicensee’s use, reproduction, manufacture, sale, offer to sell, distribution, import, export, modification, public and private  performance/display, license, and disposition of the PEARLS tool; (ii) the incorrectness or breach of any of the representations, warranties, covenant or agreements of Sublicensee pertaining the PEARLS tool; or (iii) any intellectual property infringement, or any other type of actual or alleged infringement claim, arising out of Sublicensee’s use, reproduction, manufacture, sale, offer to sell, distribution, import, export, modification, public and private performance/display, license, and disposition of the PEARLS tool. This indemnity obligation shall apply irrespective of whether the infringement claim is based on a patent, trademark or copyright registration that issued after the effective date of this Agreement. DHCS reserves the right to participate in and/or control, at Sublicensee’s expense, any such infringement action brought against DHCS.
    8. Governing Law. This Agreement is to be interpreted and construed in accordance with the laws of the State of California.
    9. Miscellaneous
      1. The relationship between DHCS and Sublicensee established by this Agreement is that of independent contractors. No joint venture or partnership is established by this Agreement. Neither party is the agent, broker, partner, employee, or legal representative of the other for any purpose.
      2. The headings of any sections are inserted for convenience of reference only and are not intended to be part of, or to affect the meaning or interpretation of this Agreement.
      3. This Agreement embodies the entire understanding of DHCS and Sublicensee and supersedes all previous communications, representations or understandings, either oral or written, between them relating to the subject matter of this Agreement.
      4. In the event that any provision of this Agreement is unenforceable or held to be unenforceable, all other provisions of this Agreement have force and effect and will not be affected thereby.
      5. This Agreement may only be amended, modified, or supplemented by an agreement in writing signed by each party hereto.