The authors examine factors that contribute to variation in screening for adverse childhood experiences across clinics that serve Medi-Cal beneficiaries by identifying clinics with different screening trajectories and conducting qualitative interviews with staff from a diverse clinic sample. By understanding the reasons clinics differ in screening practices, the authors aim to help tailor and target efforts to promote trauma-informed health care.

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

Priya Gandhi, Joshua Breslau, Ryan K. McBain, Jonathan S. Levin, Avah Mousavi, Elizabeth Roth, Megan S. Schuler, Ben Senator, Danielle Schlang, Nicole K. Eberhart

ResearchPublished Apr 15, 2025

In January 2020, Medi-Cal began reimbursing clinics for screening for and responding to adverse childhood experiences (ACEs) 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 report, the authors examine factors that have contributed to variation in ACE screening rates across clinics that serve Medi-Cal beneficiaries. By improving understanding of the reasons clinics differ in screening practices, the authors aim to help tailor and target efforts to promote continued growth in TIHC.

This evaluation had two interrelated components. First, the authors used Medi-Cal claims data on screening-related reimbursements to identify groups of clinics with different screening trajectories. Second, they conducted qualitative interviews with clinic representatives in each of those trajectory groups about the factors that influenced their screening practices. Clinics were selected to ensure diversity 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 was found to vary based on clinic location and the presence of a pediatric provider. Common barriers to screening included lack of awareness and concerns about the availability of referral resources. The authors make recommendations, based on their findings, for actions that address barriers to screening and TIHC for pediatric and adult primary care clinics serving Medi-Cal beneficiaries.

Key Findings

  • 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.
  • Lack of awareness remains a major reason that clinics do not conduct ACE screening. Many never-screener clinics simply did not know about ACE screening. Among the late adopter group, most of the clinics began screening soon after learning about it.
  • The perceived ability to respond to high ACE scores drives screening practices. Concerns about the availability of referral resources were 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.
  • Sustaining ACE screening requires clinic-wide efforts. ACE screening involves a wide variety of staff, changes to electronic health records (EHRs), workflows to coordinate staff roles and responsibilities, and the integration of workflows and EHR tools are often required.
  • Clinics are interested in training opportunities related to ACE screening and TIHC, including trainings for nonclinical staff on their roles in screening and response, trainings for new hires to explain the reasons for ACE screening and how screening is implemented in their clinic, and refresher courses for staff who have previously completed training.
  • Many clinics have developed solutions to common implementation challenges, including through their clinic screening workflow designs and continuous improvement of their screening rates using data on past performance.

Recommendations

  • Health leadership and policymakers advocating for TIHC should conduct 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). Managed care organizations (MCOs) could be engaged to target messages about ACE screening to clinics in which their beneficiaries are treated.
  • The UCLA-UCSF ACEs Aware Family Resilience Network (UCAAN) should respond to clinics' needs for training related to ACEs and TIHC by developing and disseminating additional training materials. 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, and are located in rural areas versus better resourced non-rural areas.
  • 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.
  • UCAAN should work with Medi-Cal MCOs to promote ACE screening and TIHC. Specifically, it should work with MCOs to develop informational materials on ACE screening, clarify MCO guidelines related to billing for ACE screening, disseminate information on in-network referral resources, and conduct research on the impact of 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. They should also implement structured feedback systems to help maintain or improve ACE screening rates.

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Citation

RAND Style Manual

Gandhi, Priya, 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 30, 2025: https://www.rand.org/pubs/research_reports/RRA2152-6.html

Chicago Manual of Style

Gandhi, Priya, 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. Santa Monica, CA: RAND Corporation, 2025. https://www.rand.org/pubs/research_reports/RRA2152-6.html.
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This research was funded by the UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN) through a contract with the California Department of Health Care Services (DHCS) and carried out within the Quality Measurement and Improvement Program in RAND Health Care.

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