California's ACEs Aware Initiative Has Made Substantial Early Progress, but Sustained Investment Is Needed

Adverse Childhood Experiences (ACEs) are a major public health issue facing California. ACEs are traumatic childhood experiences, such as abuse, neglect, and household challenges. ACEs may trigger toxic stress, a prolonged activation of an individual's stress response system that can lead to long-term disruptions in brain development and immune, hormonal, and metabolic systems — especially when ACEs occur in the absence of protective factors, such as nurturing relationships and safe, stable environments. Centers for Disease Control and Prevention studies found that people who have experienced ACEs are significantly more likely to have many common chronic physical health conditions in adulthood, such as hypertension, diabetes, cardiovascular disease, and cancer.^[1] In fact, nine of the ten leading causes of death in the United States are linked to ACEs.^[2] ACEs are common: As many as 64 percent of California adults have experienced at least one ACE. ACE-associated health conditions lead to an estimated financial burden to California of $1.5 trillion annually — $24.6 billion in direct medical costs alone, in addition to the high cost of lost healthy life-years.^[3]

To address these pressing challenges, in 2020, California launched ACEs Aware, the first initiative in the nation to identify and address ACEs in health care settings. Clinicians who have taken a certified training course are now able to be reimbursed for ACEs screening and response for Medi-Cal beneficiaries. Screening is conducted by using a validated questionnaire to ask patients or their caregivers about experiences of ACEs. Response to ACE screening involves discussing how ACEs affect health, promoting protective factors that can buffer the impacts of ACEs, supplementing usual care with strategies to address toxic stress physiology, and, when appropriate, referring patients to trauma-informed interventions or support services. ACE screening can be reimbursed for children annually and for adults only once per provider (because adults can no longer accumulate ACEs).

RAND was asked to conduct an independent evaluation of ACEs Aware programming, including the California ACEs Learning and Quality Improvement Collaborative and the UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN). This brief presents key evaluation findings and provides recommendations for building on ACEs Aware's early successes.

The evaluation findings from California clinics showed that ACE screening is feasible, is acceptable, and benefits patients.^[4] Clinicians reported that they were able to incorporate ACE screening into their practice and found screening useful to build trust and inform patient care. Electronic health record (EHR) data revealed that ACE screening results influenced patient care: Clinicians provided more referrals and took other actions to support patients with higher levels of ACEs. Patients and caregivers generally felt comfortable discussing ACEs as a routine part of care and reported benefits of ACE screening, such as building a trusting relationship with their health care providers. Despite concerns about retraumatization, no clinicians or patients reported any lasting adverse effects of ACE screening. Although providers and patients alike saw the potential benefits of ACE screening, further evaluation is critical to determine whether ACE screening leads to improved health.

ACE screening of Medi-Cal beneficiaries has scaled rapidly, but important gaps persist. Between the start of reimbursement for ACE screening and response in January 2020 and March 31, 2024 (the most recent date for which data are available), Medi-Cal reimbursed a total of 3,688,710 screening and response claims for 2,187,040 individual beneficiaries.^[5] An impressive 31 percent of children and teenage Medi-Cal beneficiaries have been screened. Overall, 16.5 percent of Medicaid beneficiaries have been screened, a remarkable accomplishment in just over four years. However, implementation has been uneven; only 6.3 percent of eligible adults have been screened. The RAND evaluation found that ACE screening varied widely among primary care clinics serving Medi-Cal beneficiaries. Primary care clinics were less likely to conduct screening if they were in regions other than Southern California, if they were in rural rather than suburban or urban areas, and if they did not have a pediatric clinician on staff. This work found that lack of awareness about ACEs and ACE screening remains a major reason that clinics are not conducting ACE screening and response.^[6]

Training has increased clinician knowledge and skills. Since December 2019, nearly 45,000 individuals have taken a course provided by UCAAN that teaches the fundamentals of ACE screening and trauma-informed health care. This course qualifies clinicians to receive reimbursement from Medi-Cal for screening and response. The course has been well received by learners, with over 90 percent of those who completed an evaluation immediately after the course rating it highly for being evidence based, enhancing knowledge, and informing clinical practice. Initial evaluations were corroborated by a follow-up survey conducted by RAND six to 12 months after the training. In the survey, 90 percent of clinicians indicated that they continue to screen their patients for ACEs, and 85.7 percent indicated that they pay more attention to information about their patients' ACEs than they did prior to the training.

Additional training is needed to sustain trauma-informed health care practice over time. In RAND surveys and qualitative interviews, respondents expressed a need for training beyond the initial basic course. Specifically, respondents emphasized the need for refresher courses in trauma-informed health care theory and practice for clinical and non-clinical staff, training on screening and response implementation in different types of clinics, and advanced training on responding to high ACE screening scores in primary care settings. Pilot projects have developed and tested approaches to ACE screening and response in clinical settings other than primary care (such as inpatient pediatric services) and among underserved populations (such as farmworkers). Investment is also needed to translate and disseminate knowledge from these pilot projects into clinical practice.

ACEs Aware has helped clinics build a strong foundation in trauma-informed health care, which is essential for ACE screening and response. There is increasing recognition that a trauma-informed health care approach that promotes safety, trust, and healing from trauma is critical in order to provide quality care.^[7] Indeed, in 2021, the American Medical Association officially adopted a policy recognizing the importance of trauma-informed care.^[8] In the California context, RAND evaluators found that clinics increased their readiness for trauma-informed health care through training and shared learning opportunities that were integral to the process of implementing ACE screening and response. The evaluation found that clinics with larger increases in readiness for trauma-informed health care also had larger increases in ACE screening.

RAND evaluations have found multiple barriers that will require investment in infrastructure to address. Within clinics, effective implementation is often limited by the capabilities of the clinic EHR system. In clinics with more-limited systems, manual work is required to track screening, to enter results into the record, and to scan and upload screening forms into the system for billing purposes. In contrast, more-sophisticated EHR systems have more-automated processes to ensure consistent screening by identifying eligible patients and collecting screening results prior to the visit, saving the results directly to the patient's record, preparing forms for billing, and monitoring screening rates over time to inform quality improvement. An issue identified across the evaluations has been the lack of referral resources; some clinicians expressed reluctance to conduct ACE screening because they do not have access to services to address issues that might be identified through the screen. Building referral networks, including behavioral health providers, could give clinicians more confidence that they can effectively respond to patient needs, making them more likely to conduct ACE screens.

Additional work is needed to disseminate implementation lessons to support continued scaling of California's ACEs Aware initiative. Through its evaluations and pilot projects, UCAAN has produced valuable knowledge about how to implement ACE screening and response and trauma-informed health care to Medi-Cal beneficiaries. In addition, clinics that have been conducting ACE screening and response have gained valuable experience in practical aspects of implementation. These lessons about implementation need to be described and translated into practical guidance for clinics that have yet to initiate ACE screening. Such guidance could lower the bar to participation by providing a clear pathway to successful implementation.

Understanding the impact of California's ACE screening and response initiative is critical. Now that ACE screening and response has been successfully implemented in clinical settings across the state and several million Medi-Cal beneficiaries have been screened, it is important to assess the impact that screening can have on health care utilization and health outcomes. Evidence regarding the initiative's impact to date can inform the state's future efforts to promote health.

In sum, California has launched a historic effort to improve the health of its residents through screening and response for ACEs and toxic stress. The state has trained almost 45,000 individuals to date, and RAND's evaluation provides evidence that training imparts the foundational knowledge and skills necessary for successful implementation of ACE screening and response. Millions of Californians have been screened in a relatively short time, but some populations (e.g., adults, people living in rural areas) have not been reached. Although there is promising early evidence that ACE screening benefits patients, further evaluation is needed to understand the extent to which screening improves health outcomes. For all these reasons, continued investment in training, screening, and evaluation is necessary to realize the full benefits of the initiative and ensure that it reaches its goal of improving the health and well-being of all Californians.

This brief highlights key findings from the following publications:

Notes

• [1] Melissa T. Merrick, Derek C. Ford, Katie A. Ports, Angie S. Guinn, Jieru Chen, Joanne Klevens, Marilyn Metzler, Christopher M. Jones, Thomas R. Simon, Valerie M. Daniel, Phyllis Ottley, and James A. Mercy, "Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention—25 States, 2015–2017," Morbidity and Mortality Weekly Report, Vol. 68, November 8, 2019.
• [2] ACEs Aware, "The Science of ACEs & Toxic Stress," webpage, undated (as of March 28, 2025: https://www.acesaware.org/ ace-fundamentals/the-science-of-aces-toxic-stress/).
• [3] Cora Peterson, Maria V. Aslam, Phyllis H. Niolon, Sarah Bacon, Mark A. Bellis, James A. Mercy, and Curtis Florence, "Economic Burden of Health Conditions Associated with Adverse Childhood Experiences Among US Adults," JAMA Network Open, Vol. 6, No. 12, 2023.
• [4] Gabriela Alvarado, Ryan McBain, Peggy Chen, Ingrid Estrada-Darley, Charles Engel, Nipher Malika, Edward Machtinger, Brigid McCaw, Shannon Thyne, Nina Thompson, Amy Shekarchi, Marguerita Lightfoot, Anda Kuo, Darcy Benedict, Lisa Gantz, Raymond Perry, Indu Kannan, Nancy Yap, and Nicole Eberhart, "Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics," Annals of Family Medicine, Vol. 21, No. 5, September–October 2023; Ingrid Estrada-Darley, Peggy Chen, Ryan McBain, Gabriela Alvarado, Charles Engel, Nipher Malika, Deborah Kim, Edward Machtinger, Brigid McCaw, Shannon Thyne, Nina Thompson, Amy Shekarchi, Marguerita Lightfoot, Anda Kuo, Darcy Benedict, Lisa Gantz, Raymond Perry, Nancy Yap, and Nicole Eberhart, "Patient and Caregiver Perspectives on Implementation of ACE Screening in Pediatric Care Settings: A Qualitative Evaluation," Journal of Pediatric Health Care, Vol. 37, No. 6, November–December 2023; J. Scott Ashwood, Nipher Malika, Stephanie Williamson, Charles Engel, Edward Machtinger, Nina Thompson, Amy Shekarchi, Shannon Thyne, Brigid McCaw, Marguerita Lightfoot, Anda Kuo, Eric Fein, Darcy Benedict, Lisa Gantz, Raymond Perry, Nancy Yap, and Nicole Eberhart, "Clinician Actions in Response to Adverse Childhood Experience (ACE) Screening," Preventive Medicine Reports, Vol. 47, November 2024; and Ingrid Estrada-Darley, Gabriela Alvarado, Alejandro Roa Contreras, Cristina Glave, Yoselín Mayoral, Peter Mendel, and Nicole K. Eberhart, Addressing Adverse Childhood Experiences in Clinics Serving California Farmworker Communities: NACES Pilot Project Evaluation, RAND Corporation, RR-A2152-2, 2024 (as of March 28, 2025: https://www.rand.org/pubs/research_reports/RRA2152-2.html).
• [5] ACEs Aware, Quarterly Progress Report: ACE Screening and Clinician Training Data, February 2025 (as of March 28, 2025: https://www.acesaware.org/wp-content/uploads/2025/02/ ADA_DRAFT-Feb-2025-Quarterly-Progress-Report-02122025-1_a11y.pdf).
• [6] Joshua Breslau, Graham DiGuiseppi, Gabriela Alvarado, Avah Mousavi, Elizabeth Roth, Suzanne Perry, Priya Gandhi, Cristina Glave, Vanessa Miller, and Nicole K. Eberhart, Evaluation of the Early Impact of the UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN), RAND Corporation, RR-A2152-4, 2025 (as of April 15, 2025: https://www.rand.org/pubs/ research_reports/RRA2152-4.html); Priya Gandhi, Joshua Breslau, Ryan K. McBain, Jonathan S. Levin, Avah Mousavi, Elizabeth Roth, Megan S. Schuler, Ben Senator, Danielle Schlang, and Nicole K. Eberhart, Understanding Trajectories of Screening for Adverse Childhood Experiences Among Clinics Serving Medi-Cal Beneficiaries, RAND Corporation, RR-A2152-6, 2025 (as of April 15, 2025: https://www.rand.org/pubs/research_reports/RRA2152-6.html).
• [7] Substance Abuse and Mental Health Services Administration, SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach, HHS Publication No. (SMA) 14-4884, 2014; Edward L. Machtinger, Yvette P. Cuca, Naina Khanna, Carol Dawson Rose, and Leigh S. Kimberg, "From Treatment to Healing: The Promise of Trauma-Informed Primary Care," Women's Health Issues, Vol. 25, No. 3, May–June 2015.
• [8] American Medical Association, "Adverse Childhood Experiences and Trauma-Informed Care," Policy H-515.952, 2023 (as of March 28, 2025: https://policysearch.ama-assn.org/policyfinder/detail/Adverse%20Childhood%20Experiences%20and%20Trauma-Informed%20Care%C2%A0%20H-515.952?uri=%2FAMADoc%2FHOD.xml-H-515.952.xml).

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Topics

• California
• Childhood Trauma
• Health Care Education and Training
• Health Interventions
• Health Screening
• Mental Health and Illness
• Primary Care
• School-Based Health Care Program Evaluation