By Jennifer Ryan & Sarah Tocher, Pathways to Resilience

California’s ACEs Aware initiative – authorized by a series of legislative and policy actions (AB 340 and Proposition 56) – leverages state and federal Medicaid funding to support a multi-faceted approach to educating the health care community about Adverse Childhood Experiences (ACEs) and toxic stress. The focus of the initiative is to encourage primary care providers to screen their patients for ACEs, use the knowledge they have gained to provide trauma-informed care, and follow-up with evidence-based interventions and connections to needed supports.

In the three years since its launch, the ACEs Aware initiative has been successful in many ways – nearly 27,000 individuals have completed the free on-line training offered through ACEs Aware, more than 12,000 Medi-Cal clinicians are certified to screen for ACEs and toxic stress, and 900,000 Californians have been screened. Although these are significant milestones, the full potential of the initiative has yet to be realized — systemic change takes years, if not decades. However, there are many lessons that can be learned from this unprecedented investment in advancing trauma-responsive policies and programs.

As we conceived of the fundamental elements of the Pathways to Resilience initiative, the team was guided by our experience supporting the ACEs Aware initiative on behalf of the Office of the California Surgeon General (CA-OSG) and the Department of Health Care Services (DHCS) from July 2019 through June 2022. The journey was not without its challenges, but the vision for and importance of the work inspired us to take what we learned and apply it through a national lens. Following are some reflections on the experience we hope will help inform other states’ efforts to prevent and address adversity and trauma on a system-wide level.

Background

California’s ACEs Aware initiative first received funding through Proposition 56, an increase in the tobacco tax that voters approved in 2016 to fund various services for those enrolled in Medi-Cal, the state’s Medicaid program. To be certified to bill Medi-Cal for screening and receive a $29 supplemental payment, providers need to complete the free two-hour Becoming ACEs Aware in California online training. Providers are expected to use the screening results as part of a complete assessment of their patients’ health status in the context of the toxic stress that often results from exposure to adversity and trauma. ACEs are known to contribute to the leading causes of death nationally. The trauma-informed response includes, where appropriate, clinical interventions in primary care, as well as referrals to trauma-informed networks of care made up of health care providers and community-based organizations that provide a range of supports to patients and families.

Making Medi-Cal the foundation for ACEs Aware provided a clear pathway to connect the work to other statewide efforts, but there is more work to be done. Following are some of the key elements that contributed to the successful launch of ACEs Aware, as well as some of the challenges to its long-term sustainability.

Critical Ingredients for Success

A Champion

Nadine Burke Harris was appointed the first Surgeon General of California in the spring of 2019 and served until the spring of 2021. The creation of this new position in state government provided a platform upon which Dr. Burke Harris would translate more than a decade of her own efforts to screen patients for ACEs and incorporate trauma-informed care concepts into a statewide initiative. Dr. Burke Harris had already made a name for herself both in the medical and research fields, but also more broadly as an author and through a TED talk filmed in 2015 that has since received more than 15 million views across various platforms.

With a dynamic presence and infectious passion for her work, Dr. Burke Harris served as the spokesperson for ACEs Aware as well as the clinical and scientific expert behind the program. Her ability to connect with a wide range of audiences also helped build momentum for the initiative – she could easily transition from deep scientific discussions about neurological development to a more philosophical New York Times interview to a small group meeting with community grantees across California in the same afternoon. The presence of a champion like Dr. Burke Harris was a huge contributing factor to the program’s early success.

Rooted in Medicaid

While Dr. Burke Harris was the driving force behind ACEs Aware, it needed the support of the Governor’s office, DHCS, and the state legislature to get off the ground and to become sustainable. The state’s decision to leverage state Medicaid funding to support a $29 supplemental payment for primary care and a range of other providers who conduct ACE screenings during a clinic visit was critical to long-term sustainability. California’s Medi-Cal program serves 14 million low-income people, including populations that are disproportionately affected by ACEs and trauma, so it was easy to make the case that ongoing payment for ACE screenings could be made permanent in the Medicaid state plan.

Rooting the program in Medi-Cal has provided the opportunity to incorporate ACE screenings and trauma-informed care into the state’s Medi-Cal transformation effort known as CalAIM. For example, ACE screening results can be used by Medi-Cal managed care plans to identify members for the new enhanced care management benefit, which provides intensive care coordination for high-need enrollees. Similarly, DHCS lists ACE screenings as one of the data sources that plans should be using to understand member risk as part of CalAIM’s population health management effort. Finally, as part of the Children and Youth Behavioral Health Initiative (CYBHI), ACE screening results can help facilitate more immediate access to mental health services without requiring a formal diagnosis. The state has also expanded the types of providers who can receive the supplemental payment to include some school settings and now provides Medi-Cal funding for community health worker services (CHWs). CHWs play a critical role in connecting families to services and supports to mitigate toxic stress.

Government/Community Partnerships

A third key element of success for ACEs Aware has been the state’s decision to distribute a significant portion of the available funding for the initiative to communities that serve the Medi-Cal population. In 2020 and 2021, the ACEs Aware initiative awarded $45 million in community grant funds to organizations across the state. The influx of resources directly to community-based organizations, health clinics, and local government agencies helped promote awareness of the initiative and the availability of the provider training.

The funding awarded in 2021 supported the establishment of community-based “networks of care” – relationships among health care providers and community-serving organizations designed to help families navigate the system and access needed supports. The grants were guided by a Network of Care Roadmap and an ACE Screening “How To” Guide; accompanied by extensive and hands-on technical assistance and monthly shared learning opportunities, which continued to advance the overall goals of the initiative. Using grants as a vehicle to get money directly to community providers and their partners provided an effective method of encouraging practice change that might have taken much longer to gain traction if promoted only from the state level.

Lessons Learned

As the first statewide initiative of its kind, with a significant financial investment (even by California standards), ACEs Aware offers a blueprint with extensive resources that other states can leverage at no cost. Like all programs, particularly those with short timeframes between passage of legislation, funding, and implementation, there are several lessons learned about how the program could have been implemented differently to achieve broader reach and greater sustainability.

Investing in Cross-Sector Collaboration

Because families’ experience with trauma and adversity can affect all aspects of their daily lives, it is important for states to take a cross-sector approach when designing strategies for preventing and addressing ACEs. Although the initiative was supported across leadership levels in the state, there was never a mandate that other agencies work collaboratively with DHCS and CA-OSG to devise and implement policy approaches. In one case, the Department of Social Services worked in partnership with OSG and DHCS to develop and release a joint guidance letter elaborating on existing guidelines for mandatory reporting of child abuse and neglect. However, state agencies could have worked together to more broadly to release more joint guidance highlighting the state’s commitment to addressing ACEs and trauma and the tools available for doing so as well as opportunities to promote broader cross-sector uptake of the initiative.

As an example, health and education agencies could have worked together to expand access to, or tailor, the free, online ACEs Aware training to teachers, school administrators, and others who would have benefitted from the information. It would have been particularly helpful for educators given the challenges that the COVID-19 pandemic brought. With funding through the CYBHI, the state is starting to focus on training educators, but ACEs Aware could have achieved broader reach with a prioritized partnership with education from the outset.

Providing a Well-Resourced Organizational Home

While it is not uncommon for initiatives to start small within the Governor’s office, it is important for long-term success that they have an organizational home and governance structure, with staff resources to carry out the work in a meaningful way. Because state agencies are already very busy and have clear lines and limitations of authority, when new offices are established, it is important that executive leaders champion alignment of resources and mission to serve the needs of both new and existing programs. The ACEs Aware initiative was publicly housed in the newly formed Office of the Surgeon General, a small office with limited resources, and oversight of Medi-Cal dollars for the initiative was located at the Medicaid agency. A more formal governance and staffing structure that unified both policy direction and funding oversight might have resulted in a more effective long-term positioning for the policy opportunities that have emerged from the initiative.

Align with Other Policy Priorities

Burke Harris departed from her position in the fall of 2021, after two years of juggling the heavy responsibility of managing the state’s COVID-19 response with leadership of ACEs Aware. While the work will continue through the University of California system, the absence of a champion in state government will undoubtedly have an effect on the long-term sustainability of the initiative. The Medi-Cal program itself is embarking on large scale transformation through the Medi-Cal initiative. Even though several elements of ACE screening have been successfully incorporated into the policymaking around CalAIM, it is just one of many competing policy priorities and implementation projects. These are all occupational hazards in state policymaking but important considerations for those looking to make trauma-informed care a priority in their state.

Conclusion

California’s historic investment in trauma-informed care through the ACEs Aware initiative can provide valuable lessons for policymakers hoping to prevent trauma and promote healing in their own states and communities. Although it may not be feasible for most states to implement an initiative of the same scale, ACEs Aware filtered an unprecedented state-level funding commitment through the Medicaid program, providing valuable experience others can learn from.

A strong champion in Dr. Burke Harris and support from the Governor and legislature helped get ACEs Aware off the ground, but the development of community partnerships and a foundation in the state’s Medicaid program made the initiative sustainable. States should consider Medicaid and other existing programmatic vehicles that might serve as a pathway for authorization and funding of system-wide strategies for addressing trauma. The federal Center for Medicare & Medicaid Services (CMS) has signaled increasing flexibility in use of Medicaid dollars to pay for services designed to address the social drivers of health, and trauma-responsive policymaking fits squarely within these priorities. Pathways to Resilience will continue to use these lessons learned in offering considerations for other states looking to prevent and address trauma and promote well-being.