Understanding Trajectories of Screening for Adverse Childhood Experiences Among Clinics Serving Medi-Cal Beneficiaries

In January 2020, Medi-Cal began reimbursing clinics for screening for and responding to Adverse Childhood Experiences (ACE) as part of an effort to promote trauma-informed health care (TIHC). Since that time, ACE screening and response has grown rapidly, but unevenly, across primary care clinics across the state. In this evaluation, we examine the factors that have contributed to this variation in ACE screening across clinics that serve Medi-Cal beneficiaries. By improving our understanding of the reasons clinics differ in screening practices, we aim to help tailor and target efforts to continue the growth in TIHC.

The project had two interrelated components. First, we used Medi-Cal claims data on screening to identify groups of clinics with different screening histories. Second, we conducted qualitative interviews with clinic representatives in each of those groups, as well as with representatives in clinics that have not yet begun screening, about the factors that influenced their screening practices. We aimed for diversity among the interviewees with respect to region of the state, rural versus non-rural locations, Federally Qualified Health Centers (FQHCs) versus private clinics, and clinics with versus without pediatric providers.

Screening Trajectory Groups

Our analysis of variation across clinics in ACE screening identified the following four screening trajectory groups:

1. early adopters: clinics that began screening soon after January 2020 and continued screening over time
2. late adopters: clinics that began screening later than the early adopters but continued screening over time after they started
3. non-sustainers: clinics that screened consistently for a period and then reduced the frequency of screening or ceased screening completely
4. never-screeners: clinics that never screened.

Reasons Clinics Have Different Screening Trajectories

We conducted 46 interviews with representatives of 44 clinics across the four screening trajectory groups. In our qualitative analysis, we found that the factors influencing screening were similar for early and late adopters, and we combined these two groups into a larger sustainer group, pointing out differences when they occurred. Summaries of the major themes related to screening trajectories are presented below.

Sustainers: Early and Late Adopters

Clinic representatives in the early and late adopter groups described both internal and external influences on their decisions to implement ACE screening. Internal influences included a strong motivation to address unmet health and health care needs among the most-vulnerable and most-underserved patient populations. External influences included pressure from a managed care organization (MCO) to implement screening, with monitoring screening required as part of a measure of quality of care. Sustainment of screening over time was supported by prospective monitoring of ACE screening (i.e., tracking which patients are due for screening), emailing the Pediatric ACE and Related Life Events Screener (PEARLS) form to patients prior to their visit, and making referral resources (most often behavioral health care providers) available. The most common reason that late adopters implemented screening later than early adopters was because they lacked awareness of screening. In most cases, late adopters indicated that they began screening soon after hearing about it.

Non-Sustainers

Most clinics in the non-sustainer group had not decided to deliberately curtail or cease screening. Interviewees suggested several possible explanations for why screening had declined, including that they see only adults, had already screened most of their patients, or lacked sufficient referral resources. Among the clinics that deliberately decreased screening, the major factors interviewees gave were a lack of referral resources and difficulty getting reimbursement.

Never-Screeners

Most of the never-screener clinics were unaware of ACE screening before being contacted to participate in this evaluation. On hearing about ACE screening for the first time when they were recruited to this evaluation, interviewees saw the potential to use ACE screening to address unmet needs in their patient populations and were interested in learning more. Never-screeners also had questions and concerns about screening related to adequate referral resources, patient comfort with personal questions, and implementation of screening in the context of already complex clinic workflows.

Key Findings

In addition to our findings regarding reasons that clinics differed in their screening trajectories, six major themes emerged from our evaluation and became the basis for our recommendations.

Screening Differs Across Regions and by Presence of a Pediatric Provider

Clinics that did not screen differed from clinics that did screen with respect to their locations, whether they were FQHCs, and whether they listed a pediatric provider among their staff:

• Clinics in Southern California were more likely to screen than clinics in other regions, reflecting the history of early efforts to promote ACE screening that were concentrated in Southern California.
• Clinics in rural areas were less likely to screen for ACE than clinics in non-rural areas.
• Clinics with pediatric providers were more likely to screen for ACE than clinics without pediatric providers; this difference was possibly influenced by Medi-Cal's policy of reimbursing once per year for children and only once in a lifetime for adults.

Lack of Awareness Remains a Major Reason That Clinics Do Not Conduct ACE Screening

• When recruiting never-screener clinic representatives, we found that many simply did not know about ACE screening. Moreover, once they heard about it, many of these representatives saw the potential to improve how their clinics address health needs and wanted to learn more.
• Screening within the late adopter group began soon after administrators learned about it. Few had made a deliberate decision not to screen or to delay the initiation of screening.

The Perceived Ability to Respond to High ACE Scores Drives Screening Practices

• A lack of referral resources was commonly cited as a reason not to screen or to decrease or stop screening. Across clinic types, the most cited concern among interviewees was with the availability of specialty behavioral health care.
• To some extent, these concerns may reflect a lack of awareness on the part of providers that the primary goal of ACE screening is to improve the response to ACE-related physical health conditions in the primary care setting rather than to identify undiagnosed behavioral health conditions.
• Although the primary response to high ACE scores is meant to occur within primary care, referral resources, when needed, are limited because of shortages of behavioral health providers and fragmentation among health care and social service providers.

Sustaining ACE Screening Requires Clinic-Wide Efforts

• ACE screening involves a wide variety of staff, although the specific types of staff involved differ across clinics. Many clinics, particularly those that were FQHCs, emphasized the importance of shared responsibility across different types of staff in sustaining ACE screening.
• Changes to electronic health records (EHRs), workflows to coordinate staff roles and responsibilities, and the integration of workflows and EHR tools are often required, especially in larger clinics.
• Billing for ACE screening involves additional administrative staff and additional workflows, which may be facilitated by EHR systems.
• In clinics that make the most use of EHRs, data on screening are extracted by a quality improvement team to inform clinic quality–improvement efforts and quality reporting to MCOs.

Clinics Are Interested in Training Opportunities Related to ACE Screening and TIHC

Interviewees mentioned several types of training as potentially helpful for implementing and sustaining ACE screening:

• trainings for nonclinical staff on their roles in screening and response
• training programs for new hires to explain the reasons for ACE screening and how screening is implemented in their clinic
• refresher courses for staff who have previously completed training.

Many Clinics Have Developed Solutions to Common Implementation Challenges

• Clinics described intensive efforts to design their clinic screening workflows and to continuously improve their screening rates using data on past performance.
• Knowledge gained through these processes, such as the importance of prioritizing building trust with patients over simply completing a screening form, could be useful to clinics that are beginning to screen or working to streamline their own screening processes.

Recommendations

Conduct Targeted Outreach to Never-Screener Clinics

Because we found that many clinics were not conducting ACE screening simply because they were not aware of it, we recommend targeted outreach to never-screener clinics. Outreach should target clinics in areas where lower proportions of clinics are screening (i.e., rural areas and regions outside Southern California). Claims data could be used to identify never-screener clinics. Outreach efforts could include mailings (the evaluation benefited from sending FedEx letters), local gatherings of providers, offers to give implementation consulting, and opportunities for start-up grants to support clinic planning. Claims data could also be used to identify high-performing clinics that can be engaged in peer-to-peer dissemination and to characterize clinics' patient populations (e.g., clinics that see adults only) to tailor outreach materials. MCOs could be engaged to target messages about ACE screening to clinics in which their beneficiaries are treated.

Develop Additional Training Related to Sustaining ACE Screening

The UCLA/UCSF ACE Aware Family Resilience Network (UCAAN), which is a multi-campus initiative of the University of California, Los Angeles, and the University of California, San Francisco, should respond to clinics' needs for training related to ACE and TIHC by developing and disseminating additional training materials. UCAAN already has infrastructure for developing and providing training through its education and training department. New offerings should continue to address the science and theory of ACE and toxic stress while also covering practical matters that we found to be essential to ACE screening sustainment, such as screening workflow, use of technology (for example, tablets and advanced EHR integration), billing for ACE screens, responding to ACE screening results, and the ability to address concerns raised by patients. The trainings should be tailored to specific audiences, including nonclinical staff, staff with prior training who need refresher courses, and newly hired staff.

In providing additional training, UCAAN should tailor implementation strategies to different types of clinics. Although there is no gold standard for conducting ACE screening and response, UCAAN has a wealth of knowledge based on research into toxic stress and the practice-based knowledge gained from working in diverse clinical settings that can address clinics' concerns and promote implementation. The training and guidance should have specific information for clinics that

• see adults only versus those that see primarily children or both children and adults
• are private practices versus FQHCs
• are located in rural areas with limited referral resources versus better resourced non-rural areas.

Provide Detailed Guidance on Responding to High ACE Scores in Primary Care

UCAAN should address the concerns about how to respond to ACE scores by working both alone and in collaboration with clinics, MCOs, and the state to develop and disseminate information related to the implementation of ACE screening and TIHC.

• To address perceptions that ACE screening is primarily intended to identify patients in need of referrals for specialty treatment, guidance should emphasize that ACE screening is meant to improve treatment and outcomes for physical health conditions in the primary care setting.
• UCAAN should work with clinics that have demonstrated successful ACE screening performance to develop practical screening and response strategies, with detailed specifications of workflows and referral procedures, to serve as guides for clinics that are just starting or considering ACE screening. The guidance should include data-informed estimates of the proportions of patients who are likely to require referrals and solutions to commonly encountered barriers to TIHC.
• UCAAN should work with the state and MCOs to strengthen referral networks for primary care clinics that would make these clinics more comfortable conducting ACE screening.

Work with Medi-Cal MCOs to Promote ACE Screening and TIHC

Clinics often indicated that their screening practices were influenced by MCOs, either positively through encouragement or negatively through claims denials. UCAAN should work with MCOs to

• develop informational materials, such as newsletter articles or clinical briefs, on the value of ACE screening for distribution through MCO communications with clinics
• clarify MCO guidelines related to billing for ACE screening to reduce claims denials
• disseminate information on in-network referral resources to which clinics can refer patients
• conduct research on the impact of ACE screening to demonstrate reduced costs of care or improved quality of care.

Enhance Staff Engagement and Support for ACE Screening

Our findings highlight the importance of shared responsibility in starting and continuing ACE screening. Clinics should encourage a team-based approach to TIHC that is inclusive of ACE screening and involves staff across multiple roles and hierarchies, including clinic leadership, physicians, nurses, medical assistants, and support staff, each implementing distinct tasks in the ACE screening process. Such a comprehensive approach can help sustain ACE screenings if an initial champion leaves the clinic.

To facilitate the continuation of ACE screening, clinics should implement structured feedback systems to those individuals who are involved in the screening process. These systems should actively monitor ACE screening frequencies and responses to positive screens. Supervisors can then give providers their performance metrics on a routine basis and facilitate conversations with staff who are struggling to meet targets. This approach can help staff identify barriers and develop solutions to improve their ACE screening rates.

Conclusion

Since the beginning of Medi-Cal reimbursement for ACE screening and response in January 2020, clinics across the state have varied in their implementation of ACE screening in fulfillment of their mission of addressing the health care needs of low-income Californians. Many clinics have integrated ACE screening into their routine practices, gaining valuable lessons related to implementation and sustainment in the process. However, there are also clinics that have struggled to maintain screening levels and many clinics that have yet to consider screening. Promoting ACE screening at this stage, when there is such diversity across primary care clinics, will require careful assessment of the needs and interests of different types of clinics. This evaluation is intended to address this variation and point the way toward more-tailored and more-targeted approaches, which will be necessary in the next phase of statewide promotion of TIHC in Medi-Cal.