California health care providers will soon begin to learn how many of the 13.2 million California children and adults in the state’s MediCal program have been exposed to adverse childhood experiences (ACEs). But the state’s proposed decision to reimburse only one of three recommended options for screening children has drawn mixed reactions from pediatricians.
“If we have mandated legislation that only looks at one screening tool, it really limits the opportunity to improve that screening tool over time and it also doesn’t take into consideration that there are a number of tools that are applicable and work really well right now,” said Dr. Kate Williamson, a pediatrician in private practice in Ladera, Calif. Her clinic is part of a larger consortium associated with Children’s Hospital of Orange County. Williamson also serves as vice president of the Orange County chapter of the American Academy of Pediatrics.
The AB 340 Workgroup of pediatricians and other health care providers, legal services and social service agency representatives was convened by the California Department of Health Care Services (DHCS) to recommend options for screening for trauma. It made its recommendations in November 2018.
The three options for screening children are the PEARLS tool, the Whole Child Assessment tool, and a tool that meets the same criteria as the PEARLS tool.
These three options would provide the flexibility necessary to enable pediatricians and health care providers in a variety of clinics to screen the state’s children for trauma in the MediCal program, according to a letter detailing the recommendations. (see the attached letter).
Katharine Weir, a spokesperson for the Department of Health Care Services (DHCS), said that the DHCS “will allow any of the three options to be used for screening children pursuant to the AB340 workgroup.”
But only those health care providers who choose the PEARLS (Pediatric ACEs Screening and Resiliency Study) tool will get paid a supplemental fee of $29, according to the DHCS. Reimbursements are slated to begin July 1st under the CPT code 96160, according to the DHCS.
Dr. Jonathan Goldfinger, chief medical officer of the Center for Youth Wellness, says that he hopes that the DHCS “has weighed or will weigh the pros and cons when offering more than one tool.” This includes, he explained, giving health care providers greater autonomy.
But Goldfinger, a pediatrician who is a member of the AAP’s National Advisory Board on Screening in Practices, posits that the DHCS “would be on the hook for implementation, recognizes that developing and maintaining two types of training, two types of technical assistance, two types of data collection systems, two metrics, etc., are exceedingly difficult.”
PEARLS was developed by the Bay Area Research Consortium on Toxic Stress and Health, which includes the University of California at San Francisco (UCSF), UCSF Benioff Children’s Hospital in Oakland, Calif., and the San-Francisco-based Center for Youth Wellness. (See this article about PEARLS).
The PEARLS tool includes 10 questions from the original Adverse Childhood Experiences Study (ACE Study). These include questions about physical or emotional abuse, living with a parent who’s alcoholic, or witnessing a parent being abused. It also asks seven other questions, about bullying, racism, homelessness, community violence, involvement with the foster care system or lack of food. (To see the PEARLS survey questions, please see the attached document.) And it gives parents filling out the survey the option of identifying which ACEs apply to their child or simply reporting the number of ACEs their child has experienced.
A small pilot study testing whether the language and types of questions were understandable and acceptable to parents and health care providers and staff appeared in the December 2018 issue of the journal Plos One.
Over seven weeks, researchers used feedback from participants to refine the survey. For example, researchers changed the wording in one of the survey questions from asking if a caregiver is “depressed, mentally ill,” to whether a caregiver has “mental health issues.”
A randomized controlled study of PEARLS is underway in a safety net clinic associated with UCSF Benioff Children’s Hospital in Oakland, Calif., according to an article on its website. Of the 555 patients and their families participating, 367 patients were screened, the remaining patients receive usual primary care as a comparison, according to Sara Marques, the director of strategic partnerships at the Center for Youth Wellness (CYW). Marques says that the PEARLS tool is very similar to CYW’s ACE-Q screener used at the Bayview Child Health Center since 2015 in items and format. The CYW ACE-Q screener has screened more than 2,250 patients at the Bayview Clinic and among the pilot sites of the National Pediatric Practice Community on ACEs, a project of the Center for Youth Wellness, according to Marques. It’s also been downloaded thousands of times from the NPPC site, she said. (In response to several interview requests over many months to do an article about PEARLS, at the Children’s Hospital site, ACEs Connection has been continually advised to check back in the coming months.)
Williamson’s clinic has not yet implemented ACEs screening, but she is among members of the AAP Orange County chapter leading the way to raise awareness about ACEs at a regional conference on April 5-6, 2019.
Like other pediatric practices, her clinic already distributes the required questionnaire, the Staying Health Assessment (SHA). It’s a tool that has versions for different ages from birth to 17 years. It asks about everything from a child’s nutrition and physical activity to mental health, safety and substance use. It includes between 16 and 36 questions, depending on a child’s age.
Form fatigue is a concern for Williamson, who says that if ACEs questions could be added to the SHA, that would be the most workable way of integrating trauma screening.
“Each time you add another tool it’s one more thing for the parents to fill out. It’s one more thing for the provider to separately grade and screen. If it’s in one tool, it will be utilized more widely.”
“In the pediatric clinic, you have to have things that are easy to fill out for a parent who has several kids,” said Dr. Suzanne Frank, a pediatrician who helped implement ACEs screening in January 2017 at Kaiser Permanente in San Jose, Calif. “Because I think sometimes, some of the people weren’t filling out the forms because I think they didn’t have the energy and the bandwidth to fill them out in the clinic.” After 30 years at Kaiser, Frank will begin serving as a pediatric director for the School Health Clinics of Santa Clara County.
In fact, there’s already a tool that combines SHA and ACEs questions, the Whole Child Assessment, developed by Dr. Ariane Marie-Mitchell and colleagues at Loma Linda University. It has been used to screen about 29,000 pediatric patients since 2017, according to Marie-Mitchell, who was also part of the AB 340 Workgroup, which was convened by the DHCS. The workgroup recommended the WCA as another option for ACEs screening.
Marie-Mitchell said she learned the hard way about the difficulties of separate questionnaires. “I started with a separate screening tool for ACEs, and immediately ran into challenges from families and providers about having one more questionnaire,” she recalls.
The WCA tool is now in its second iteration, which was approved in Nov. 2018 by the DHCS. A provider can review it with a patient during a 15-minute well child visit, according to Marie-Mitchell (see stories about the WCA’s first and second iterations).
Catherine Tan, the medical director for the Department of Pediatrics at SAC Health Systems, which includes Loma Linda, says the use of the WCA has changed the way that providers interact with patients.
“It’s been helpful to know if kids are having a traumatic experience, if there’s a divorce and the patient is having to go back and forth between two different homes, or a parent is in jail,” said Tan, whose clinics offers onsite counseling and other resources for patients. Noting the experience of questionnaire fatigue, Tan also said the WCA 2.0 has helped to reduce paperwork for the families they serve.
The integration of SHA into the WCA 2.0 might help with form fatigue. But because it functions as more than just a trauma screen, it wasn’t selected as a reimbursable option, according to the DHCS. It was not selected because the “DHCS will not fund assessments that go beyond trauma,” noted DHCS spokesperson Weir.
However, the department's decision was not based on any language handed down to them. DHCS’ Weir wrote: “There was no language that directly required the Department to fund any screening or assessment."
A third option proposed by the AB 340 Workgroup would have allowed researchers to seek approval from the DHCS for a trauma-screening tool that includes at a minimum, all of the items in the PEARLS trauma screening tool.
Several questions remain unanswered. Beyond those who are quoted in this article, other people have commented about the choices made by the Department of Health Care Services, which solicited public comments about its decision. ACEs Connection filed a public-records request last week for those public comments and was told they’d be provided early this week. They have not yet been received. We will publish them when they become available.
And beyond screening for trauma, Williamson said that the screening is only going to be helpful if practices have something to do with the results of that screen. “So, it’s important for pediatricians to partner with resources in their local community to address the concerns they find on these screening tools,” she said.
Another pressing question is how clinics will be trained to use the PEARLS screener in a way that’s efficient for their workflow and in the most beneficial way for their patients. The DHCS’s Weir said it will offer a webinar on how to use the PEARLS screener. A bill introduced this February by Assemblymember Ash Kaira, AB-741,would provide training “to ensure the success and sustainability of trauma screenings for children.”
The irony is that while DHCS selected only one screening tool for reimbursement in pediatrics, doctors who plan to screen adults for trauma will be entitled for reimbursement for using “the ACEs assessment or a similar tool,” according to a DHCS document.
Reflecting on the DHCS’s decision to restrict reimbursement to one tool for children, Marie-Mitchell said, “They’re showing flexibility for adults. They are not showing the same flexibility for screening kids, which is really where the opportunity for prevention is.”