ACEs Screening to Treatment - Integrated Primary Care and Behavioral Health Model

ACEs Screening and Triage
to Treatment Model
Treatment and Triage of
Health and Mental
Health Impacts of ACEs.
Secondary and Tertiary
Prevention.

Primary Care ACEs Treatment Response Big Picture
1. STRESS REDUCTION/
MANAGEMENT &
2. RESILIENCY
ENHANCEMENT
A
1. HEALTH
BEHAVIORS &
2. TREAMENT
ENGAGMENT
B
1. ACE SPECIFIC RISK
REDUCTION &
2. ACE SPECIFIC DISEASE
TREATMENT.
C
A + B + C = Secondary & Tertiary ACEs Prevention
STRESS & RESLIENCY HEALTH BEHAVIORS ACE SPECIFIC Tx.

Four Part ACEs Screening to Triage and
Treatment Model
1
2
3
4
Resiliency Factors: Assess for what helps someone survive and
thrive. Identify strengths that are resources on the path to transform
adversity.
ACE Domains: The three main ACEs domains are Neglect,
Abuse and Household Dysfunction. Develop a treatment pathway that
focuses on these three domains using existing evidenced based
treatments.
ACEs Risk Level: There is an increased risk at each level of increased
ACE score. Assessing for risk levels can help you prioritize intensity of
treatment, need for treatment and help define when watchful waiting
is the best solution.
ACEs Functional Impacts (Triangle): ACEs can manifest in three
levels 1. Social emotional and cognitive impairment; 2. Negative
health behaviors, self-care and life-functioning; 3. Disease, Disability
and Social Problems.
Support existing
resilience and develop
increased resiliency
promoting skills.
Treatment
Goal
Connect the individual
(child/adult), family to
existing evidenced
based interventions for
Identified ACE
Treatment
Goal
Prioritize interventions
based on risk level e.g.
treat diabetes at an
earlier stage more
aggressively.
Treatment
Goal
Develop interventions at
primary, secondary or
tertiary prevention e.g.
change health behaviors
before they manifest as
disease.
Treatment
Goal

Four Part ACEs Screening to Triage and
Treatment Model
1
2
3
4
Resiliency Factors & Personal Strengths
(8 Resiliency Factors)
ACE Domains/Specific ACEs Tx.
(1. Neglect, 2. Abuse and 3. Household Dysfunction)
ACEs Risk Level
(Level I, Level II, Level III, Level IV)
ACEs Functional Impacts (Triangle)
(e.g. Social/Emotional/Cognitive Functioning,
Health Risk Behaviors, Disease & Disability)
Support existing
promoting skills.
Treatment
Goal
existing evidenced
Identified ACE
Treatment
Goal
earlier stage more
aggressively.
Treatment
Goal
disease.
Treatment
Goal

Resiliency Factors and
Personal Strengths
1
Support existing
promoting skills.
Treatment
Goals

1 Resiliency Factors and Personal
Strengths
Support existing
promoting skills.
Treatment
Goal
(8) Mental Health Resilience
(7) Trauma Understanding & Resilience
(6) Values, Vision & Meaning
(5) Health Behaviors & Treatment Engagement
(4) Cognitive Capacity & Problem Solving
(3) Emotional Regulation & Coping Skills
(2) Family Resiliency, Social Support & Social Skills
(1) Community, Connection, Cultural Value
BuildingCapacityand
Long-TermHealth

1 Resiliency Factors and Personal
Strengths
Support existing
promoting skills.
Treatment
Goal
Medical Provider
Case Management &
Community Health Worker
Community
Mental Health Referral
Health Education & Nutritionist
Wrap Around Support Services
Medical Home Team
Members Community, Connection,
Cultural Empowerment
Social Support & Social Skills
Emotional Regulation & Coping Skills
Cognitive Capacity &
Problem Solving
Health Behaviors & Treatment
Engagement
Values & Meaning
Trauma Informed Resilience
Mental Health Resilience
Resiliency FactorsInterventions
ACEs Screening
Family Health & Parenting Skills
ACEs Education & Beh. ACEs
Session Menu
Community & Social Support
Enhancement
Social & Emotion Learning Emotion
Regulation Skills
Problem Solving & Cognitive Skills
Trauma Informed Understanding
and Guidance
Health Promotion Behaviors
(e.g., Exercise, Diet, Sleep)Health Psychology
Social Worker
Group Session Provider
Consult Liaison Psychiatry

3 ACE Domains
Abuse: Physical, Emotional, Sexual
2
existing evidenced
Identified ACE
Treatment
Goals

2
existing evidenced
Identified ACE
Treatment
Goal
3 ACE Domains – Abuse (Assessment)
Physical, Emotional, Sexual
Assessment Factor Specific Assessment Risk for ACE Domain
Mental Health
PTSD, Depression (Severity), Anxiety Symptoms, Impulsivity, Substance Use Disorders,
Suicide Risk/Safety Planning
Health Behaviors and
Treatment Impacts
Health Promotion Behaviors (diet, food coping); Treatment Impacting Behaviors
(Missed appointments, treatment avoidance, affect instability/aggression in treatment
relationship); Poorly managed chronic illness or illness promoting behaviors.
Sleep Sleep Disruption, Nightmares, Sleep Avoidance.
Social Support Social Isolation, Social Support, Boundaries and Limits
Learning/Cognitive
Challenges
Learning Disorders, Cog. Fx, Traumatic Brain Injury, Problem Solving, Internal & External
Locus of Control.
Family Functioning
(Adults & Children)
Parenting skills, family rhythms and organization, expressed affect/emotional
dysregulation.

2
existing evidenced
Identified ACE
Treatment
Goal
Health Factor ACE Specific Treatment
Mental Health
1. PTSD Positive: SSRI/SNRI, Mood Stabilizer, Individual Therapy, Seeking Safety Group,
2. Depression Positive: SSRI/SNRI, Individual Therapy, Mood and Emotions Group,
Seeking Safety Group
3. Anxiety: SSRI/SNRI, Buspirone, Atarax, Individual Therapy, Stress and Anxiety,
AVOID BENZOs
4. MH Factors: Anger management, Mood and Emotions Group, Individual therapy, Mood
Stabilizer/SSRI.
5. Suicide Risk Present: Safety Planning, Hospitalization, Therapy Referral and Group Skills, Consult
Liaison Psychiatry. Consider referral to MH ACCESS for Psychiatry, Consider walk in apt in Miller.
Health Behaviors &
Treatment
1. Health Beh: Referral to Health Psych to develop self-care, address neg cognitions, diet, exercise,
health risks, health related grief, and treatment adherence, poor management of chronic illness.
2. Treatment Impacting: Refer to Health Psych to develop plan of care, address anxiety/avoidance
in relationship, limit setting/behavioral contract, health psych attend session.
3 ACE Domains – Abuse
ACEs Specific Treatment (Part 1)

2
existing evidenced
Identified ACE
Treatment
Goal
3 ACE Domains – Abuse
ACEs Specific Treatment (Part 2)
Sleep
Disruption
1. Medication: Prazosin, Trazadone/Remeron, SSRI/SNRI to manage anxiety or depression
2. Health Psych/BH: CBT-I, Sleep Hygiene, Sleep Assessment,
SUDs Substance
Risk
1. SUD: Referral to Health Psych - Develop a treatment plan and connect to care; 12 Step Groups,
Outpatient, Inpatient, ACCESS Line, Medication assistance.
2. Substance Risk: Health behavior counseling addiction prevention
Social Support
1. Family Health: Family therapy, parenting skills classes, parenting behavioral health referral, CPS
report, STAND! (Family Violence)
2. Counseling/Individual: Interpersonal Therapy (evidenced based for depression), Health
Coaching: Co-dependency, boundaries and assertiveness.

2
existing evidenced
Identified ACE
Treatment
Goal
3 ACE Domains – Neglect (Assessment)
Physical and Emotional
Child &
Adolescence
1. Behavioral: Internalizing or externalizing behavior., conduct problems
2. Emotional Regulation: Lower affect regulation and emotional resiliency, Age
specific delays in emotional development.
3. Cog and Learning: Age specific delays in cognitive development.
Adults &
Families
1. Mental Health: Substance use disorder (SUD) and risker substance use, PTSD,
Assess for disruptions in attachment style (Avoidant, Anxious, Disorganized
attachment style), Risk of violence and aggression, Depression and Anxiety
Disorders, Suicide risk.
2. Work/Economic: Economic challenges, lower-financial literacy, lower economic
well-being
3. Health Behaviors: Sexual health challenges and risky sexual behavior, Self-neglect
behaviors and poor self-care (health care behaviors).
4. High-Risk: Risk of suicide

2
existing evidenced
Identified ACE
Treatment
Goal
3 ACE Domains – Neglect (Part 1)
Treatments & Interventions
Mental Health
1. Children/Teens Internalizing/Externalizing Behavior: Parenting skills groups, Individual Evidenced
Based Practice (Brief Strategic Family Therapy – BSFT), EBP Internalizing Treatment – e.g.
Adolescent Coping with Stress Course; PENN Resiliency Program.
2. MH Factors: PTSD Positive (SSRI/SNRI, Mood Stabilizer, Individual Therapy, Seeking Safety Group,
Consult Liaison Psychiatry), Depression Positive (SSRI/SNRI, Individual Therapy, Mood and
Emotions Group, Seeking Safety Group), Anxiety (SSRI/SNRI, Buspirone, Atarax, Individual Therapy,
Stress and Anxiety., Seeking Safety. AVOID BENZOs), Other (Anger management, Mood and
Emotions Group, Individual therapy, Mood Stabilizer/SSRI)
3. Suicide Risk Present: Safety Planning, Hospitalization, Therapy Referral and Group Skills, Consult
Liaison Psychiatry. Consider referral to MH ACCESS for Psychiatry, Consider walk in apt in Miller.
Health Behaviors &
Treatment
1. Health Beh. & Treatment Impacting: Referral to Health Psych to develop self-care, address neg
cognitions, health related grief, and treatment adherence, poor management of chronic illness.
2. Sexual Health/Risk: Evidenced based therapy; Counseling/Health Education on Sexual Health;
Assertiveness Skills; Sex and Love Addicts Anonymous (SLAA).

2
existing evidenced
Identified ACE
Treatment
Goal
3 ACE Domains – Neglect (Part 2)
Treatments & Interventions
Cognitive &
Emotional
Functioning
1. Cognitive/Developmental: IEP/504 Plan; Tutoring; Parenting skills cognitive delayed child;
Parental mental health; Caregiver skills; Academic testing; Cognitive testing, Treat learning
difference (ADHD/Dyslexia/Dyscalculia); Academic Enrichment.
2. Emotional Developmental Delay: Social and emotional learning curriculum; parental therapy;
family therapy; Child therapy; School readiness/emotional regulation skills; Mindfulness based
programs.
SUDs Substance
Risk
1. SUDs/Substance Risk: SBIRT Counseling about risk in use; Health Psych: develop a treatment
plan and connect to care; 12 Step Groups,
2. Other Referrals: Outpatient, In Patient, ACCESS Line, Medication assistance, Co-dependency,
boundaries and assertiveness.
Social Support
1. Family Health, Parenting Skills & Coping Promotion;
2. Anticipatory Guidance (Children/Adolescence); Increased social support.

2
existing evidenced
Identified ACE
Treatment
Goal
3 ACE Domains – Household Dysfunction
Assessment (Parental Incarceration, Mental Health, SUD, Divorce and IPV)
Mental Health
(Adults and Children)
PTSD, Behavioral/Conduct Problems, Substance Use Disorders, anxiety disorders,
relational/attachment challenges, ADHD), Externalization/Internalization.
Learning & Cognitive
Challenges
Assess for cognitive delays, learning disorders and their impact on school or work
functioning
Health Behaviors and
Treatment Impacts
Health care treatment avoidance dental care, T.V./internet, sugary drinks, cigarette
smoking, Using ED or urgent care not primary care, sexual health risk behaviors
High Risk ACEs
Household Disfunction:
Cholesterol, Asthma, Migraines, HIV/AIDS, Higher health complaints, eating challenges,
sleeping challenges, pain problems
Impact of Bias and Stigma
(Family and Children)
Mental health bias, bias against incarceration,.
Family Functioning
(Adults & Children)
Patterns of conflict promote disfunction and increased risk of ACEs, Parenting skills,
family rhythms and organization, expressed affect/emotional dysregulation.

2
existing evidenced
Identified ACE
Treatment
Goal
Treatments & Interventions (Part 1)
Mental Health
1. PTSD Positive: SSRI/SNRI, Mood Stabilizer, Individual Therapy, Seeking Safety Group,
2. Depression Positive: SSRI/SNRI, Individual Therapy, Mood and Emotions Group,
Seeking Safety Group
3. Anxiety: SSRI/SNRI, Buspirone, Atarax, Individual Therapy, Stress and Anxiety., Seeking Safety.
AVOID BENZOs
4. MH Factors: Anger management, Mood and Emotions Group, Individual therapy,
Mood Stabilizer/SSRI.
5. Suicide Risk Present: Safety Planning, Hospitalization, Therapy Referral and Group Skills,
Consult Liaison Psychiatry. Consider referral to MH ACCESS for Psychiatry, Consider walk in apt
in Miller.
Health Behaviors &
Treatment
1. Health Beh: Referral to Health Psych to develop self-care, address neg cognitions, health
related grief, and treatment adherence, poor management of chronic illness.
2. Treatment Impacting: Refer to Health Psych to develop plan of care, address anxiety/avoidance
in relationship, limit setting/behavioral contract, health psych attend session.

2
existing evidenced
Identified ACE
Treatment
Goal
Treatments & Interventions (Part 2)
Sleep
Disruption
1. Medication: Prazosin, Trazadone/Remeron, SSRI/SNRI to manage anxiety or depression
2. Health Psych/BH: CBT-I, Sleep Hygiene, Sleep Assessment,
SUDs Substance Risk
1. SUD: Referral to Health Psych - Develop a treatment plan and connect to care; 12 Step Groups,
Outpatient, Inpatient, ACCESS Line, Medication assistance.
2. Substance Risk: Health behavior counseling addiction prevention
Social Support
1. Services/Groups: Connect to treatment groups, 12 step programs, support groups,
church/religious, refer to health coaching to develop social support plan for trauma/chronic
illness/health behavior/health,
2. Counseling/Individual: Interpersonal Therapy (evidenced based for depression), Health
Coaching: Co-dependency, boundaries and assertiveness.

ACEs Risk Level & Interventions
Level I, Level II, Level III, & Level IV
3
Prioritize interventions based
on risk level e.g. treat
diabetes at an earlier stage
more aggressively.
Treatment
Goals

3
ACEs Risk Level & Interventions
Level I, Level II, Level III, Level IV
earlier stage more
aggressively.
Treatment
Goal
ZONE I Low Risk
0 ACEs
ZONE II Mild Risk
1 ACEs
ZONE III Mod Risk
2 – 3 ACEs
ZONE IV High Risk
4 + ACEs
No Action
ACEs Patient Education, Promotion of Stress Management, Increase
Health Behaviors and Resiliency Factors, Screen and Treat for Illness
ACEs Patient Education, Promotion of Stress Management, Increase
Health Behaviors and Resiliency Factors, Screen and Treat for Illness,
Team Based Care, Enhanced Primary Care I, Health Promotion
Focus/Resiliency Goals, Strengthen Social Support.
ACEs Patient Education, Stress Management, Increase Health Behaviors and
Resiliency Factors, Risk Assessment, Lower Threshold Screening, More
Aggressive Treatment, Team Based Care, Enhanced Primary Care II, Health
Promotion Focus/Resiliency Goals, ACEs Focused Care
38%
22%
23%
16%

3 ACEs Risk Level & Interventions
Level I, Level II, Level III, & Level IV
earlier stage more
aggressively.
Treatment
Goal
RISK ZONE CLINICAL ACTIONS ASSESSMENT AND INTERVENTION
ZONE I - 0 ACEs
Low Risk
• No actions
ZONE II - 1 ACEs
Mild Risk
• Assess presence of PTSD or other Common Mental Health, Assess treatable resilience factors, Assess and treat individual
ACEs, Children: Family support needs assessment, Adults: Health risk behaviors, problem solving and social connection,
Trauma informed clinical relational skills.
ZONE III - 2-3 ACEs
Mod. Risk
• Individual ACE specific treatment pathway referral, ACEs education and collaboration PCP with patient, Risk assessment
for suicide, CVD, Stroke, Addiction, Sexual health assessment and Health Psych referral, Addiction risk and prevention,
Psychiatry referral and medication management, Resiliency assessment and setting resiliency goals, ACEs Chronic Illness
assessment and aggressive care (including team-based care), Family support services (BH referral, Case Management,
PHN, enhanced pregnancy care), ACEs Health Psychology Menu of Health Promotion Sessions and Activities
• Zone III Enhanced Primary Care: (Lower threshold screening, more aggressive treatment)
ZONE IV – 4+ ACEs
High Risk
• Individual ACE specific treatment pathway referral, ACEs education and collaboration PCP with patient, Risk assessment
for suicide, CVD, Stroke, Addiction, Sexual health assessment and Health Psych referral, Addiction risk and prevention,
Psychiatry referral and medication management, Resiliency assessment and setting resiliency goals, Family support
services (BH referral, Case Management, PHN, enhanced pregnancy care), ACEs Health Psychology Menu of Health
Promotion Sessions and Activities (ACEs Health Ed, Resiliency Enhancement, Diet and Exercise Enhancement, Self-Care
and Stress Management for ACEs, Mental Health First Aid for ACEs, Trauma 101 Session).
• Zone IV Enhanced Primary Care: (BH Team Based Care, Lower threshold screening, more aggressive treatment).

Zone II – Provider Focused
earlier stage more
aggressively.
Treatment
Goal
Risk Level Provider ACEs Assessment Provider ACEs Interventions
ZONE II
1 ACEs
Mild Risk
22% of Patient
Population
1. Resiliency Assessment (See attached resiliency
checklist)
2. Social Functioning/Support (see attached).
3. Health Behaviors (see attached).
4. Individual ACEs Treatment: Individual ACE specific
treatment pathway referral (see attached)
5. ACE Related Assessment of High-Risk Factors: e.g.,
Risk assessment for suicide, CVD, Stroke, Addiction.
6. Mental Health: Common ACEs mental health
assessment (Anxiety, Depression and PTSD).
1. ACEs Patient Ed: PCP patient ACEs education and
collaborative goal setting.
2. Resiliency Goals: Consider setting resiliency goals.
3. BH ACEs Sessions from Menu: Referral to BH warm
handoff ACEs Session, social support assessment
and triage, other ACEs menu of treatments.

3 ACEs Risk Level & Intervention
Zone II – Health Psychology
earlier stage more
aggressively.
Treatment
Goal
Risk Level Health Psych. ACEs Assessment Provider ACEs Interventions
ZONE II
1 ACEs
Mild Risk
22% of Patient
Population
treatment pathway referral (see attached).
2. Behavioral Health & Resiliency Assessment: Brief
mental health and resiliency assessment (short
assessment see attached).
3. Social Support Assessment (short assessment see
attached)
1. Individual ACEs Treatment Plan: Develop
treatment plan with patient and triage pathway.
2. Behavioral Health Interventions: ACEs Health
Psychology Menu of Health Promotion Sessions
and Activities.
3. Social Support Interventions: Targeted assessed
social support intervention see list.

Zone III – Provider Focused
earlier stage more
aggressively.
Treatment
Goal
ZONE III
3-4 ACEs
High Risk
23% of Patient
Population
checklist)
treatment pathway referral
Risk assessment for suicide, CVD, Stroke, Addiction)
4. Health Behaviors: Health promoting behaviors
assessment (see attached)
5. Mental Health: Common mental health assessment
(Anxiety, Depression and PTSD).
6. Social Functioning/Support (High impact targets):
Family functioning and conflict, Loneliness &
engagement, Access to time of need social network
support, Emotional support, Communication and
2. Resiliency Goals: Setting resiliency goals.
3. Enhanced primary care (Zone III): BH Team Based
Care activated, consider case management or other
services for support, lower threshold screening
common health conditions, more aggressive/early
treatment treatment for common associated ACEs
health conditions).

Zone III – Health Psychology
earlier stage more
aggressively.
Treatment
Goal
ZONE III
3-4 ACEs
High Risk
23% of Patient
Population
2. Behavioral Health Assessment: 1. Common mental
health condition; 2. Health behaviors assessment;
3. Sexual health assessment; 4. Addiction risk,
treatment and prevention; 5. Sleep; 6. Exercise and
health; 7. Resiliency assessment.
3. Social Support Assessment: Family functioning and
conflict, Loneliness risk assessment, time of need
social network support assessment, Emotional
support assessment, Communication skills and
conflict management.
and Activities (e.g. ACEs Health Ed; Resiliency
enhancement session; Diet and exercise
enhancement; Self-Care and stress management
for ACE; Mental health first aid for ACEs; Trauma
101 session for self-care and treatment).
3. Social Support Interventions: Family support
services; Family therapy; BH referral individual
treatment (see attached referrals list); BH group
treatment (see attached referrals list); Case
Management (PHN, CCHS, Medical Social Work);
Enhanced pregnancy care, Couples communicate
and conflict skills class).

Zone IV – Provider Focused
earlier stage more
aggressively.
Treatment
Goal
ZONE IV
4+ ACEs
High Risk
16% of Patient
Population
checklist)
Risk assessment for suicide, CVD, Stroke, Addiction)
4. Sexual health assessment (see attached)
5. Health Behaviors: Health promoting behaviors
assessment (see attached)
6. Mental Health: Common mental health assessment
(Anxiety, Depression and PTSD).
7. Social Functioning/Support (High impact targets):
Family functioning and conflict,
Loneliness/engagement, Access to time of need social
network support, Emotional support, Communication
and conflict skills.
2. Resiliency Goals: Setting resiliency goals.
3. Addiction Treatment/ACEs Addiction Risk
4. Enhanced primary care (Zone IV): BH Team Based
Care activated, consider case management or other
services for support, lower threshold screening
common health conditions, more aggressive/early
treatment treatment for common associated ACEs
health conditions).

Zone VI – Health Psychology
earlier stage more
aggressively.
Treatment
Goal
ZONE IV
4+ ACEs
High Risk
16% of Patient
Population
2. Behavioral Health Assessment: 1. Common mental
health condition; 2. Health behaviors assessment;
3. Sexual health assessment; 4. Addiction risk,
treatment and prevention; 5. Sleep; 6. Exercise and
health; 7. Resiliency assessment.
3. Social Support Assessment: Family functioning and
conflict, Loneliness risk assessment, time of need
social network support assessment, Emotional
support assessment, Communication skills and
conflict management.
and Activities (e.g. ACEs Health Ed; Resiliency
enhancement session; Diet and exercise
enhancement; Self-Care and stress management
for ACE; Mental health first aid for ACEs; Trauma
101 session for self-care and treatment).
3. Social Support Interventions: Family support
services; Family therapy; BH referral individual
treatment (see attached referrals list); BH group
treatment (see attached referrals list); Case
Management (PHN, CCHS, Medical Social Work);
Enhanced pregnancy care, Couples communicate
and conflict skills class).

ACEs Functional Impacts
1. Social/Emotional/Cognitive; 2. Health Risk Behaviors;
3. Disease and Disability
4
primary, secondary or tertiary
prevention e.g. change health
behaviors before they
manifest as disease.
Treatment
Goals

4
1. Social/Emotional/Cognitive; 2. Health Risk Behaviors; 3. Disease
and Disability
disease.
Treatment
Goal
Level 1 – Interventions: Generational/Historical Trauma
Level 2 – Interventions: Social Location/ Local Context
Level 3 – Interventions: ACEs Prevention, Screening, Tx.
Level 4 – Interventions: Neuro. Cognitive Dev. Support
Level 5 – Interventions: Social, Emotional and Cog.
Level 6 – Interventions: Reduction of Health Risk Beh.
Level 7 – Interventions: Disease, Disability, & Social Prob.
2
1
3
4
5
6
7

4
1. Social/Emotional/Cognitive; 2. Health Risk Behaviors; 3. Disease
and Disability
disease.
Treatment
Goal
Level I
Level II
Level III
Level IV
Level V
Level VI
Level VII
Generational Trauma – As a field we are still developing ways to address… Some current indications are therapy that
promotes cultural identity validation and empowerment, psychological skills development, social support and culturally
responsive treatment systems.
Social Location/Cultural Trauma: Increased level of care, support services and culturally validating treatments, increased social
support, addressing impact of racism or bias related stress. Developing culturally responsive systems.
ACEs: ACEs Prevention, Screening, Resiliency Promotion programs, ACEs specific treatment interventions (see
attached).
Neuro. Cog. Development: Family support/Family Therapy, Health Coach ACEs Session, Address family mental
health and risk factors, family resiliency and parenting support, Addressing mental health impacts on learning.
Emotional, Cog, Social Fxn. – Social and emotional learning programs for children and families, Referral to
individual or family therapy, family communication classes, Emotional skills groups, family resiliency programs.
Health Risk/Resiliency Beh. – Health Risk Behaviors and Health Literacy, Resiliency Promotion, Addressing
Mental Health Diagnosis and Trauma/Depression.
Chronic Illness and Disease Management – Enhanced Primary Care I or & (risk based), Increased screening,
education on ACEs resiliency and chronic illness, collaborative treatment team.

ACEs & Resilience Initial
Screening Workflow
Registration, Nursing, Provider and Behavioral Lanes

ACEs PCP and BH
Initial Appointments
Screening and Building Resilience

PCP ACEs & Toxic
Stress Initial
Session
(7 Min ACEs Apt.)
• Motivational Interviewing:
• Use Motivational Interviewing (MI) ASK-EVOKE-ASK to
open discussion on ACEs and Toxic Stress.
• Provide basic education on ACEs, Resilience & Health
• Offer Warm H/O to BH: Recommend warm H/O to BH
provider for ACEs health session (Same Day Apt or
Scheduled Consult for Follow Up).
• Aces Plan Development
• Talking Points: “I am very grateful to know you better
and to see how you were able to make it through these
profound difficulties. While we can’t do it all today, let’s
start to make a plan to help you live your best life. Talking
about these things is an important first step. Overtime
let’s develop a plan to support your long-term health.
Let’s create a plan to support you to heal.”
• Plan Components: 1. Stress Reduction & Resilience, 2.
Action and health empowerment, 3. Help you get the
right professionals to treat and conditions related to ACEs
(Discuss appropriate conditions).

Behavioral Health Provider Same
Day Warm Handoff 30 Min
ACEs Appointment
Behavioral Health Provider Same
Day Introduction to BH provider
with Scheduled Consult for
Follow Up with Provider in
> 1 Month. 30 Min ACEs
Appointment
Behavioral Health ACEs Initial Consult Appointment
PCP Referral - Option 2PCP Referral - Option 1

BHC ACEs &
Toxic Stress
30 Min
Warm Handoff
Consult Session
or Scheduled
Consult
5 Min Use Motivational Interviewing
ASK-EVOKE-ASK to open
discussion on ACEs and Toxic Stress.
5 Min Provide Basic Psychoeducation on
ACEs, Toxic Stress, Resilience and
Empowerment for Health.
10 Min Explore impact of ACEs and identify
strengths that patients had to
survive difficulty.
10 Min Review and Discuss Basic 3 Part
Model of ACEs Health Promotions
and using MI Skills develop ACEs Tx.
and Resiliency Plan.
1. Review ACEs Session and Intervention Menu.
2. Develop Referral Plan and ACEs Goals
3. Offer ACEs Information Packet (Patient Ed,
Online Videos, Self-Care Apps List and Support
Services)

ACEs Clinical Tools
and Enhanced
Primary Care

ACEs Clinical
Tools In
Development
• ACEs Menu of Services (Guiding Values –
1. Simple and clear, 2. Beautiful and Intuitive, 3.
Easy connection to services, 4. Promotes
discussion with providers).
• Social functioning checklist
• Resiliency checklist
• Health behaviors checklist
• ACEs Patient Information Packet
• ACEs Focused Sessions: Family Health, Couples
Communication, Resiliency Planning, Stress
Reduction and Skills, Building Health Actions
Plan.
• ACEs Referral List and ACEs Tare Sheet

Enhanced
Primary Care I
(Zone III)
Definition
• BH Team Based Care activated and referral for assessment
and ACEs screening
• Development of common BH and PCP ACEs goals
• Strengthening families and communities approach (Five
Protective Factors).
• Lower threshold screening common health conditions &
More aggressive/early treatment treatment for common
associated ACEs health conditions
• ACE Based Team Communication Strategies I - Used for
Collaborative Care
• Three Part ACEs Plan developed with BH sent through
inbasket to provider.
• Provider developed plan for ACEs inbasked to BH
team member.
• Follow up upon ACEs session by BHP and discuss
patient ACE three-part plan with primary BH provider
and document plan.
• ACE based follow up call by BH provider to assess
access to care at one month, 6 months and 1 year.

Enhanced
Primary Care II
(Zone IV)
Definition
• BH Team Based Care activated and referral for assessment and ACEs
screening
• Development of common BH and PCP ACEs goals
• Strengthening families & communities approach (Five Protective Factors).
• Connection with Health Leads & Consider referral to case management,
wrap around services, or medical social worker for ACE based navigation.
• Lower threshold screening common health conditions. More
aggressive/early treatment treatment for common associated ACEs health
conditions
• ACE Based Team Communication Strategies II – Medical Home Plan
• ACE care team defined and including patient identified referrals.
• Menu Selection and plan documented by PCP and BH.
• ACE risk mitigation Plan (3 Parts) developed
• Increased support for care continuity and support to access services
(Care Management, Case Management and BH Tracking)
• Follow up upon ACEs session by BHP and discuss patient ACE three-
part plan with primary BH provider and team. Discuss coordinated
clinical interventions.
• ACE based follow up call by BH provider to assess access to care at
one month, 6 months & 1 yr.

ACEs Referral Pathway
Adult, Child, & Family

Referral & Triage
Pathway Adult
PRIMARY CARE
(Referral/Actions)
• Assess High-Risk Health and Mental Health Factors e.g. Suicide, HTN, Stroke
• Medication management of MH symptoms e.g. SSRI/SNRI, Mood Stabilizer,
Neuroleptic, Consult Liaison Psychiatry
• Warm Handoff to BH ACEs Session Provider or Scheduled BH ACEs Consult.
• Develop resiliency plan and stress management plan
• Develop ACEs pathway
• Develop Health Behaviors Plan to Address Adherence/Utilization
Challenges
• Universal Behavioral Health Referral Queue for ACCESS Assessment
• If Addiction present
• If MH Dx Present
• If ACE Domaine associated with trauma or depression present
• Staying Health Assessment Review and Referral
• If gaps in positive health behaviors or risks are present refer for Warm
Handoff or Scheduled Consult with BH for health behavior and resiliency
planning session
• If diet challenges exist consider wellness focused referral to nutritionist
• If sleep problems exist consider referral to BH for sleep skills, CBT-I or CBT-I
App first line and second line medication management for short-term.
• (In development) Enhanced Primary Care (Level I & II) Aggressively screen &
Chronic Illnesses Tx.
• (In development) Give ACEs Referral and Information Sheet as well as ACEs
menu of services.

Referral & Triage
Pathway
Adolescents and
Children
PRIMARY CARE
(Referral/Actions)
• Assess High-Risk Health and Mental Health Factors e.g. Suicide, abuse
• Mobile Crisis support, safety planning, crisis line referral, abuse services and safety for IPV victims, when
appropriate CPS report and crisis childcare.
• 211 Crisis line and access to crisis care; national hotline 1 (800) 273.8255; Crisis Nursery (925) 566.8050 ages
0-5; Dahlstrom House (925) 685.3695 ages 6-11; Safe Families (925) 566.8050 ages 0-18.
• Warm Handoff to Child Trained BH ACEs Session Provider or Scheduled BH ACEs Consult.
• ACEs child and family appointment – parent skills, child skills and consider mayo clinic Road to Resilience:
Raising Healthy Kids Game introduction and session.
• Develop family focused ACEs plan (see family pathways) e.g. in appointment review needed referrals for
housing parenting support, food and other SDOH and use 211 to develop a plan with family.
• Develop ACEs pathway: Develop resiliency plan and stress management plan, Develop Health Behaviors Plan
to Address Adherence/Utilization Challenges.
• Referral to child and family therapy developed e.g. Contra Costa BH Universal Queue; Familias Unidas
1.510.412.5930, A Step Forward (925) 685-9670; Center for Human Development (925) 687-8844; Child and
Family Therapy – ECMHP (510) 412-9200; Community Health for Asian Americans (CHAA) – Richmond; West
Contra Costa Family Justice Center (510) 412-9200; Wraparound Support – ECMHP (510) 412-9200
• If Addiction present
• Staying Health Assessment Review and Referral
• If gaps in positive health behaviors or risks are present refer for Warm Handoff or Scheduled Consult with BH
for health behavior and resiliency planning session
• If diet challenges exist consider wellness focused referral to nutritionist for child and family
• If sleep problems exist consider referral to BH for sleep skills and child and family sleep improvement (Infant
& Parent, Child and Parent, Teen Sleep and Family Skills)
• Medication management of MH symptoms if appropriate (Consider Counseling or Therapy as First Line) e.g.
Consider ACEs informed attention treatment for children with high ACEs and ADHD, Consult Liaison Psychiatry to
Support Medication Management.
• (In dev.) Enhanced Primary Care (Level I & II) Early screening & Active Early Chronic Illnesses Tx.
• (In dev.) Give ACEs Referral and Information Sheet as well as ACEs menu of services.

Referral & Triage Pathway Families
• Medication management of MH symptoms – Warm Handoff to BH for medication education for
family and mental health management skills for family.
• Warm Handoff to BH ACEs Session Provider/Scheduled BH ACEs Consult (Service & Referrals).
• ACEs Menu: (1) Family resiliency session, (2) Couples communication skills, (3) Family
education on medication and mental health treatment.
• Parenting Skills: CRISIS CHILD CARE Services, West County First 5, Second Nature Behavioral
Health, Primeros Nuestros Niños, C.O.P.E. Family Support Center,
• Abuse Hx or Current: Stand! (If hx of abuse of abuse is present): 1-888-215-5555
• Therapy: Brighter Beginnings - Family Health Clinic, Contra Costa Crisis Center, Familias
Unidas Counseling, Family Advocate Mental Health, The Hume Center
• Medication Management: George Miller Center
• MH Family Support: National Alliance for the Mentally Ill (NAMI), Autism – (1) Second
Nature Behavioral Health, (2) Regional Center, BH family education session related to
managing mental health.
• If Addiction present (e.g. SUD and pregnancy Ujima West)
• Staying Health Assessment Review and Referral: Family health ed. & family health behaviors
• (In development) Give ACEs Referral and Information Sheet; as well as ACEs menu of services.

ACEs Menu of Evidenced
Based Behavioral
Appointments

Menu of Integrated ACEs Focused Primary
Care Behavioral Health Sessions
• ACEs Empowerment 101: “Taking Back My Power from Adversity” For Adults,
Adolescents, Children and/or Families. In this one-on-one or family appointment
you will learn about ACEs, develop a personalized ACEs recovery pathway, and
develop some basic skills for reduced stress.
• ACEs Resiliency Map: “Making Map to Your Health and Best Life” For Adults,
Adolescents, Children and/or Families. In this appointment you will learn about
your body’s innate ability to bounce back
from stress, to heal and how you can help it!
• ACEs Stress Busting: “The Key to Health and Inner Power” For Adults,
Adolescents, Children and/or Families. You will work with your health coach to
develop a stress management plan, tools
that can help you thrive and pick support services that can help your take this to
the next level.

Menu of Integrated ACEs Focused Primary
Care Behavioral Health Sessions
• ACEs Communication for Couples or Families: “Thrive together in any weather” For
Parents/Caregivers, Couples, Families. Learn tools to reduce family and or conflict in
your couple, communicate from your
heart and make the home a sanctuary. In this monthly group you will learn tools
based in research to help your family or couple thrive.
• ACEs Health Action Plan: “Your Health is Your Wealth” For Adults, Adolescents, Children
and Families. ACEs and just life in general make it difficult to live your own health vision.
But with the right support and help you can make your best health.
• Individual ACEs Health and Behavior Sessions or ACEs Health and Behavior Attachment
Based Skills Groups. For Adults, Adolescents, Children and Families. Individual and
group health coaching sessions can help you reach your health goals, heal trauma, fight
depression and address overwhelm. Sometimes you just need some support from
someone who understands. ACEs can lead to trauma, depression and overwhelm.

ACEs Screening and
Triage to Treatment
Model
References

References
• Anda, R. F., Fleisher, V. I., Felitti, V. J., Edwards, V. J., Whitfield, C. L., Dube, S. R., & Williamson, D. F.
(2004). Childhood abuse, household dysfunction, and indicators of impaired adult worker
performance. The Permanente Journal, 8(1), 30.
• Arango, C., Díaz-Caneja, C. M., McGorry, P. D., Rapoport, J., Sommer, I. E., Vorstman, J. A., ... &
Carpenter, W. (2018). Preventive strategies for mental health. The Lancet Psychiatry, 5(7), 591-604.
• Browder, D. M., Wood, L., Thompson, J., & Ribuffo, C. (2014). Evidence-based practices for students
with severe disabilities. CEEDAR Document NO. IC-3. CEEDAR Center. Retrieved on August, 31, 2015.
• Collins, P. Y., Pringle, B., Alexander, C., Darmstadt, G. L., Heymann, J., Huebner, G., ... & Sretenov, D.
(2017). Global services and support for children with developmental delays and disabilities: Bridging
research and policy gaps. PLoS medicine, 14(9), e1002393.

References
• Constantino, J. N. (2018). Prevention of child maltreatment: strategic targeting of a curvilinear
relationship between adversity and psychiatric impairment. World psychiatry, 17(1), 103.
• Crnic, K. A., Neece, C. L., McIntyre, L. L., Blacher, J., & Baker, B. L. (2017). Intellectual disability and
developmental risk: Promoting intervention to improve child and family well-being. Child
Development, 88(2), 436-445.
• Demir-Dagdas, T., Isik-Ercan, Z., Intepe-Tingir, S., & Cava-Tadik, Y. (2018). Parental divorce and
children from diverse backgrounds: Multidisciplinary perspectives on mental health, parent–child
relationships, and educational experiences. Journal of Divorce & Remarriage, 59(6), 469-485.
• Geller, A., Garfinkel, I., Cooper, C. E., & Mincy, R. B. (2009). Parental incarceration and child
well-being: implications for urban families. Social science quarterly, 90(5), 1186-1202.

References
• Heard-Garris, N., Winkelman, T. N., Choi, H., Miller, A. K., Kan, K., Shlafer, R., & Davis, M. M. (2018).
Health care use and health behaviors among young adults with history of parental
incarceration. Pediatrics, 142(3), e20174314.
• Hjemdal, O., Friborg, O., Stiles, T. C., Rosenvinge, J. H., & Martinussen, M. (2006). Resilience predicting
psychiatric symptoms: A prospective study of protective factors and their role in adjustment to stressful
life events. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 13(3),
194-201.
• Lee, R. D., Fang, X., & Luo, F. (2013). The impact of parental incarceration on the physical and mental
health of young adults. Pediatrics, 131(4), e1188-e1195.
• Li, L., Denholm, R., & Power, C. (2014). Child maltreatment and household dysfunction: associations
with pubertal development in a British birth cohort. International journal of epidemiology, 43(4), 1163-
1173.

References
• Murray, J., & Farrington, D. P. (2008). The effects of parental imprisonment on children. Crime and
justice, 37(1), 133-206.
• Murray, J., Farrington, D. P., & Sekol, I. (2012). Children's antisocial behavior, mental health, drug
use, and educational performance after parental incarceration: a systematic review and meta-
analysis. Psychological bulletin, 138(2), 175.
• Patrick, P. M., Reupert, A. E., & McLean, L. A. (2019). “We Are More than Our Parents’ Mental
Illness”: Narratives from Adult Children. International journal of environmental research and
public health, 16(5), 839
• Pears, K. C., Kim, H. K., Healey, C. V., Yoerger, K., & Fisher, P. A. (2015). Improving child self-
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References
• Plass-Christl, A., Haller, A. C., Otto, C., Barkmann, C., Wiegand-Grefe, S., Hölling,
H., ... & Klasen, F. (2017). Parents with mental health problems and their children
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• Powell, N. Adverse Childhood Experiences: A Public Health Crisis That is Treatable
and Preventable Adverse Childhood Experiences: A Public Health Crisis That is
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• Roberts, M. Y., & Kaiser, A. P. (2015). Early intervention for toddlers with language
delays: a randomized controlled trial. Pediatrics, 135(4), 686-693.

References
• Turney, K. (2014). Stress proliferation across generations? Examining the relationship between
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319.
• Velleman, R., & Templeton, L. J. (2016). Impact of parents' substance misuse on children: An
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• Viswanathan, M., Fraser, J. G., Pan, H., Morgenlander, M., McKeeman, J. L., Forman-Hoffman, V.
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