Children - Key Activity 7B


Develop a Screening Process for Social Needs and Adverse Childhood Experiences (ACEs) that Informs Patient Treatment Plans


This key activity involves all seven elements of person-centered population-based care: behavioral health integration; address social needs.


This activity provides guidance on screening for health-related social needs and adverse childhood experiences (ACEs) and for beginning to use the data to inform patient treatment plans, including referral to community-based services.

Social needs are defined as individual material resources and psychosocial circumstances required for long-term physical and mental health and well-being, such as housing, food, clean water and air, sanitation and social support. ACEs are the potentially traumatic events that occur before the age of 18 years and are associated with toxic stress that can contribute to adverse health and social outcomes.[1] More specifically, the term ACEs refers to ten categories of adversities across three domains identified in the landmark 1998 study by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente.[2][3]

There is not yet consensus or uniform endorsement regarding screening for social needs, due at least in part to a lack of high-quality evidence on the risks, benefits and best practices of screening and response.[4] The AAP/Bright Futures currently includes select social needs in its recommendations. Findings from the recent Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities (AHC) Model indicate that the social needs screening and navigation services reduced ED utilization and may have reduced expenditures but did not appear to increase patient’s connection to community services or resolve the patient’s social needs.[5] Other possible ways social needs screening can support attending to social needs include strengthening the patient-provider relationship,[6] destigmatizing social services, tailoring care, and – at a population level – increasing social investment.[7]

Screening for ACEs is neither a recommendation of Bright Futures nor USPSTF. However, California Medi-Cal providers can be reimbursed for ACEs screening when they first complete a mandatory two-hour training. Additionally, DHCS encourages providers to conduct ACEs screening.

Increasing amounts of evidence demonstrates how social needs and ACEs impact physical and mental health outcomes[8][9] and, in turn, how physical and mental health conditions impact social stability.[10] Screening for and responding to unmet social needs and ACEs provides an opportunity to ensure medical care is provided in the context of patient and family life circumstances and as part of a more holistic, person-centered approach to care.

Health equity is advanced by addressing the underlying issues that prevent people from being healthy. At the population level this means addressing communitywide social drivers of health and structural determinants, and at the individual level this means acknowledging and beginning to address health-related social needs.[11]

Social needs screening asks questions about personal and potentially stigmatized aspects of patients’ lives (e.g., poverty, interpartner domestic violence).[12] See below about screening for and responding to unmet social needs and reported ACEs in a trauma-informed way. Also, be aware that staff may also experience trauma when screening for social needs and ensure essential, empathic support for their needs.

Technology-enabled screening can be utilized to screen patients for social needs through various channels: Directly in the EHR, in applications used by care coordinators, and directly to patients via patient-facing outreach and engagement technologies. Practices will need to determine a process to assure that externally generated screening information be incorporated into the patient record and used for care delivery, risk assessment and management and for managing relevant referrals. Social health information exchanges exist in some communities to identify where patients are getting social services and to help identify higher risk patients; these will develop over time.

Ability to link information in parents’ records to the child’s record is often not possible electronically in the EHR, requiring manual data collection.

Action steps and roles

1. Select one or more validated, standardized screening instruments to use and establish how screening results are documented.

Suggested team member(s) responsible: Clinical leadership.

Pick standardized screening tools that fit your organizational environment and the context of your patient population.

  • For health-related social needs, the Social Interventions Research and Evaluation Network (SIREN) conducted a review of social needs screening tools and provides a comparison and search tool for different tools for children including Income, Housing, Education, Legal Status, Literacy, Personal Safety (IHELLP) Questionnaire, Safe Environment for Every Kid (SEEK), Survey of Well-being of Young Children (SWYC) and WeCare, as well as tools that are nonspecific to an age including Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE), the screening toolkit by Health Leads and several others. The Center for Child Health Policy and Advocacy at Texas Children’s Hospital also has a helpful guide comparing and selecting a screening tool for a pediatric setting.
  • For ACEs, consider using a Medi-Cal qualified screener like Pediatric ACEs and Related Life-events Screener (PEARLS) provided for the caregiver for ages zero to 19 years and/or the patient for ages 12 to 19.

Work with your clinical informatics team to determine how staff will document screening results in your EHR. Consider documenting the results of screening for ACEs in a structured EHR field to facilitate reporting and trending at the practice level. Additionally, since screening for ACEs is reimbursable by both Medi-Cal and California commercial health plans since the passage of S.B. 428, ACEs Equity Act (CA 2021), providers should submit the appropriate billing code for reimbursement and to fulfill Medi-Cal managed care reporting requirements to DHCS. Specifically, HCPCS Code G9919 is used when screening yields an ACE score of four or higher; G9920 is used when the ACE score is between zero and three. Some EHR systems have screening tools already embedded and many are moving quickly to incorporate screening; some EHRs may be able to auto-populate Z codes based on screening results. Your managed care plans may offer additional guidance or support and can be a resource to connect your practice to other organizations who have experience with screening instruments and technology tools. By using the same screening tools and/or information technology platforms, the consistency and quality of care delivery can be enhanced.

For the patient’s problem list for health-related social needs, DHCS provides a list of 25 Priority Social Determinants of Health (SDOH) Codes to focus on. This shorter list of codes is intended to capture areas where the health system may have the greatest impact on identifying and addressing social needs.


2. Understand resources and community referrals for positive social needs screens.

Suggested team member(s) responsible: Referral manager, community health workers.

Through CalAIM, the California Department of Health Care Services (DHCS) has taken steps to ensure that Medi-Cal members have access to social support that can impact health outcomes. Connect with your managed care plan (s) (MCPs) and regional area consortia to understand what services and resources they have in place to support patient access to community-based social services. Many MCPs are developing relationships with social services agencies to meet the needs of their members. For Medi-Cal members with the highest level of social needs, MCPs offer Enhanced Care Management (see Key Activity 19: Provide Care Management) and some or all of 14 Community Supports: these provide resources to address social needs such as housing navigation, recuperative post-hospitalization care, and medically tailored meals. Some MCPs use the new CalAssist tool for Medi-Cal members to self-identify whether they are eligible for any of the 14 CalAIM Community Supports and generate a referral to the applicable provider.

Many patients will screen positive for social needs and will benefit from connection to resources that are not part of Community Supports. Contact your MCP to see if they have established relationships with providers who connect individuals to social services. Health plans may contract with an online provider or with a social services network lead entity that can connect you with existing community-based organizations and public agencies in the area. These contracted services will often include a process for making closed loop referrals, where the referring provider is notified if the patient has successfully accessed the referral. Closed loop referrals are a best practice in care coordination that leads to higher levels of patient and provider satisfaction.[13]

Key services to catalog include nutrition assistance, employment readiness, childcare support, postpartum paid family leave, rent and utility assistance, and resources for transportation. Other places to look to build sources for local community referrals include:

  • Your current social work staff and/or community health workers, who may have many go-to resources already identified.
  • Free online aggregators for local community services in California such as
  • 2-1-1, a free telephone number providing access to local community services for housing, utility, food and employment assistance.
  • Resource networks maintained by a local hospital or larger health system in your area.

For going deeper in this area, practices can consider prioritizing quality improvement activities that establish new or previously underutilized community resources to address specific social needs as part of your systematic approach to decrease inequities. See Key Activity 4: Use a Systematic Approach to Decrease Inequities for more information. Case studies provided in the resources linked below provide examples these improvement initiatives.


3. Establish a workflow for screening and referrals.

Consider screening before the patient meets with the PCP and have a workflow in place for follow-up of positive screen (e.g., meet with the care coordinator or care management staff who will facilitate referral). Take steps to flag the positive screen so the PCP is aware and can address any positive screen during the visits.

Train staff in the new workflows and how to provide trauma-informed screening. Several resources are provided below. Staff often initially resist screening if there is a sense they feel they don’t have the tools to help address positive screens.

Following screening, ask patients for their prioritized need and whether they would like assistance before making a referral. Providing a written script for staff and accompanying signage can build confidence in dealing with the challenging circumstances many patients experience.


4. Provide person-centered care that acknowledges social needs.

Suggested team member(s) responsible: PCPs, expanded care team.

Information about a patient’s social needs and ACEs can be used to provide tailored, person-centered care and treatment plans that patients are more likely to follow and benefit from. For example, if a patient and their family screen positive for food insecurity, that could influence details around advice given for healthy weight management.

ACEs Aware offers two asynchronous online courses as well as periodic live recorded webinars for safety net organizations to screen for ACEs and treat toxic stress.

In developing shared plans of care, use trauma-informed ways of engaging patients in their own care, including developing shared goals, providing self-management support, and using communication techniques such as motivational interviewing. See Key Activity 10: Implement Trauma-Informed Care Approach Across the Patient Journey.

The desires and goals of the patient will inform how and when to move ahead in addressing social needs. It is important to support patients through motivational interviewing and trauma-informed practices to create a person-centered care plan. Having processes in place to support ongoing person-centered care planning, such as a warm handoff to a care coordinator or a documented plan to follow up on issues discussed at the next visit, will help to build trust and support connection to community referrals when the patient is ready.

Implementation tips

  • Start by identifying the most common social needs (e.g., food, housing, income security) and map out an end-to-end process from identification to resolution for each need.
  • Practice coaches can be resources in this process of mapping, which can include:
    • Selection of screening tool.
    • Capture of data within the tool (e.g. Z codes for health-related social needs for future tracking and reporting.
    • Development of a referral pathway, including individuals and agencies responsible.
    • Defining success and resolution.
    • Ongoing periodic follow-up.
  • Seek input from patients, families, clinic staff and referral entities as you develop your process


  1. phqscreeners [Internet]. Available from: 
  2. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine 1998; 14: 245–58. 
  3. Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Preventive Medicine 2003; 37: 268–77. 
  4. Kaiser Permanente Research Affiliates Evidence-based Practice Center. Screening and Interventions for Social Risk Factors: A Technical Brief to Support the U.S. Preventive Services Task Force [Internet]. 2021. Available from: 
  5. Rojas L, Project S. Accountable Health Communities (AHC) Model Evaluation Second Evaluation Report RTI Point of Contact [Internet]. 2023 [cited 2024 Jan 16]. Available from: 
  6. Sınger A, Coleman K, Mahmud A, Holden E, Stefanik-Guizlo K. Assessing the Feasibility of an Empathic Inquiry Approach to Social Needs Screening in 10 Federally Qualified Health Centers. The Permanente Journal. 2023 Dec 15;27(4):136–42. 
  7. Byhoff E, Gottlieb LM. When There Is Value in Asking: An Argument for Social Risk Screening in Clinical Practice. Ann Intern Med. 2022;175(8):1181-1182. doi:10.7326/M22-0147 
  8. Alegría, M., NeMoyer, A., Falgàs Bagué, I., Wang, Y., & Alvarez, K. (2018). Social Determinants of Mental Health: Where We Are and Where We Need to Go. Current psychiatry reports, 20(11), 95. 
  9. Chavez, L. J., Tyson, D. P., Davenport, M. A., Kelleher, K. J., & Chisolm, D. J. (2023). Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care. Academic pediatrics, S1876-2859(23)00095-5. Advance online publication.  
  10. Califf, R. M., Wong, C., Doraiswamy, P. M., Hong, D. S., Miller, D. P., Mega, J. L., & Baseline Study Group (2022). Importance of Social Determinants in Screening for Depression. Journal of general internal medicine, 37(11), 2736–2743. 
  11. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 2, Social Determinants of Health and Health Equity. Available from: 
  12. Butler, AB ED, Morgan, MD, MSc, MSHP AU, Kangovi, MD, MS S. Screening for Unmet Social Needs: Patient Engagement or Alienation? NEJM Catalyst [Internet]. 2020 Jul 20; Available from: 
  13. American College of Physicians. Closing-the-Loop. Baltimore: Transforming Clinical Practice Initiative--CMS; 2015.