3
Current Adolescent Health Services, Settings, and Providers

SUMMARY

A Systems Perspective

  • Five objectives identified by the World Health Organization provide a basis for assessing the quality of current and future systems of health services for adolescents: accessibility, acceptability, appropriateness, effectiveness, and equity.

Primary Care Services

  • Evidence shows that while private office-based primary care services are available to most adolescents, those services depend significantly on fee-based reimbursement and are not:

    • accessible to adolescents who are uninsured or underinsured.

    • offered in acceptable settings that foster open communication of sensitive behaviors or health conditions.

    • provided by personnel who are skilled in addressing health conditions and behaviors that are appropriate for this stage of development.

    • effective at fostering health promotion or addressing risky behaviors that are prevalent among adolescents, such as substance use and unsafe sexual activity.



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3 Current Adolescent Health Services, Settings, and Providers Summary a Systems Perspective • Five objectives identified by the World Health Organization provide a basis for assessing the quality of current and future systems of health services for adolescents: accessibility, acceptability, ap- propriateness, effectiveness, and equity. Primary Care Services • Evidence shows that while private office-based primary care ser- vices are available to most adolescents, those services depend significantly on fee-based reimbursement and are not: – ccessible to adolescents who are uninsured or underinsured. a – ffered in acceptable settings that foster open communication o of sensitive behaviors or health conditions. – rovided by personnel who are skilled in addressing health p conditions and behaviors that are appropriate for this stage of development. – ffective at fostering health promotion or addressing risky be- e haviors that are prevalent among adolescents, such as sub- stance use and unsafe sexual activity. 5

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 ADOLESCENT HEALTH SERVICES • Evidence shows that safety-net health services for adolescents are – ccessible to many adolescents who are uninsured or do not a find private office-based services acceptable for their needs. – requently more acceptable to adolescents who are uncomfort- f able with private office-based primary care providers, especially when they can establish relationships with providers who are sensitive to their needs and promote open communication. – ometimes able to offer a more appropriate mix of skills and s counseling services that address risky behaviors. – ble to provide effective disease prevention and health pro- a motion services while also addressing issues related to risky behavior. However, such centers often can become unstable during times of fiscal uncertainty and may experience frequent personnel transitions. They also face unique challenges associ- ated with financing of prevention and health promotion services that cannot be reimbursed. – mportant mechanisms for resolving the disparities and inequi- i ties that exist within private office-based primary care. Specialty Care Services • Evidence shows that specialty care services for the adolescent population are not accessible to most adolescents. Existing spe- cialty services in the areas of mental health, sexual and repro- ductive health, oral health, and substance use treatment and prevention are generally insufficient to meet the needs of many adolescents. While evidence-based therapies are available in a number of these areas, they are not integrated into many practice settings. • Even when specialty services are accessible, many adolescents do not find them acceptable because of concerns about disclo- sure of treatment in sensitive areas (such as substance use or sexual health). • Many specialty providers lack appropriate training to address the needs of adolescent patients, and certification programs for treating adolescents are frequently unavailable in many specialty areas. • The lack of appropriate specialty services that are suitable for adolescents means that effective treatment is often delayed, care is of limited duration, and services are poorly reimbursed. • Limitations in the quality of or access to specialty services are especially prevalent among at-risk adolescents in whom problems

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7 CURRENT ADOLESCENT HEALTH SERVICES in the above areas frequently co-occur, contributing to health care inequities and disparities. Prevention and Health Promotion • Routine screening for risk factors and unhealthful behaviors that emerge during adolescence is not available or accessible for most adolescents. • Many health care providers who treat adolescents fail to adhere to recommended prevention guidelines, to screen for appropriate risk factors and unhealthful behaviors that emerge during adoles- cence, and to provide effective counseling that would reduce risks and foster health promotion. racial and Ethnic Disparities • Disparities and biases affect the quality of health services for adolescents and deserve serious consideration in any efforts to improve access to appropriate services and reduce inequities in the health system. Confidential Services • Evidence shows that health services that are confidential increase the acceptability of services and the willingness of adolescents to seek them, especially for issues related to sexual behavior, reproductive health, mental health, and substance use. • Existing state and federal policies generally protect the confiden- tiality of adolescents’ health information when they are legally allowed to consent to their own care. T his chapter introduces a framework for examining the strengths and limitations of current health system approaches for adolescents. This framework comprises five major objectives—accessibility, accept- ability, appropriateness, effectiveness, and equity—that serve as criteria for assessing the use, adequacy, and quality of adolescent health services. The chapter then reviews the current array of mainstream and safety-net primary care services, as well as specialty services, that respond to the ado- lescent health needs identified in Chapter 2; a brief discussion of inpatient hospital services for adolescents is also presented. This review is followed by a discussion of what is known about adolescents’ use of health services.

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 ADOLESCENT HEALTH SERVICES The chapter then considers how context matters—that is, how such factors such as income, race and ethnicity, and community affect access to and utilization of adolescent health services. Next is a discussion of consent and confidentiality and their influence on the acceptability of health ser- vices to adolescents. The chapter ends with a summary of the gaps between adolescents’ health service needs and the services and settings that exist to address those needs. This chapter deals with several important issues: the overall inadequacy of preventive screening, counseling, and health education for adolescents, which are crucial to high-quality care for this population; the value of hav- ing health services available in diverse locations; the lack of an integrated health system that recognizes and reflects the particular needs and interests of adolescents; and the importance of confidentiality and privacy of visits between adolescents and providers. Chapter 4 responds to the findings presented in this chapter by exploring elements of improved health services within an adolescent health system that would be more accessible, accept- able, appropriate, effective, and equitable relative to adolescents’ current health status, health service needs, and population variations. OBJECTIVES OF HEALTH SERVICES FOR ADOLESCENTS An array of studies has emerged describing the types of health services frequently used by adolescents in the United States and other countries, as well as gaps between the nature of these services and the health needs of adolescents, as identified in Chapter 2 (Chung et al., 2006; Tylee et al., 2007; U.S. Congress and Office of Technology Assessment, 1991). While evidence is insufficient to indicate that any one particular setting or prac- tice structure meets the complex needs of all U.S. adolescents better than others, a variety of national and international organizations studying both adolescents and health care providers (Donovan et al., 1997; Ford et al., 1997; Ginsburg et al., 1995; Kang et al., 2003; Veit et al., 1996) have (1) defined critical elements of health services that would improve adolescents’ access to appropriate services, (2) highlighted design elements that would improve the quality of those services, and (3) identified ways to foster patient–provider relationships that can lead to better health for adolescents. This research from various sources and the experiences of adolescents and health care providers, health organizations, and research centers have di- rected attention to the importance of designing primary care services that can attract and engage adolescents, create opportunities to discuss sensitive health and behavioral issues, and offer high-quality health services as well as guidance on both disease prevention and health promotion. Through a series of reports and consultations, the World Health Orga- nization focused attention on the importance of adolescent-friendly health

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 CURRENT ADOLESCENT HEALTH SERVICES services (Brabin, 2002; Tylee et al., 2007; World Health Organization, 1999, 2001). These activities led to a general consensus on five objectives that promote responsive adolescent health services: • Accessible. Policies and procedures ensure that services are broadly accessible. • Acceptable. Policies and procedures consider culture and relation- ships and the climate of engagement. • Appropriate. Health services fulfill the needs of all young people. • Effective. Health services reflect evidence-based standards of care and professional guidelines. • Equitable. Policies and procedures do not restrict the provision of and eligibility for services. These objectives provided the committee with a valuable framework for assessing the use, adequacy, and quality of adolescent health services; com- paring and contrasting the extent to which different services, settings, and providers address the health needs of young people in the United States; identifying the gaps that keep services from meeting these objectives; and recommending ways to fill those gaps. Using such a framework is superior to relying solely on process measures, such as rates of utilization, profes- sional licensure standards, or anecdotal reports of institutional reputations. This framework could be used to inform future local, state, and national as- sessments of adolescent health and health services, and to monitor progress toward achievement of the 21 Critical Health Objectives for adolescents and young adults (a subset of the Healthy People 2010 goals, as described in Chapter 2 [U.S. Department of Health and Human Services, 2007]), as well as the oral health objectives for adolescents (U.S. Department of Health and Human Services, 2000). It and the framework of behavioral and contextual characteristics presented in Chapter 1 complement each other and together help to provide a more comprehensive picture of the features of the health system that should be improved to provide adolescents with high-quality care and thus improve their health status, addressing the health needs of all adolescents while also attending to the needs of specific, often underserved, subpopulations and high-risk groups. The committee compared the five WHO objectives with the fundamen- tal aims for the health system set forth by the Institute of Medicine (IOM, 2001) as described in Box 3-1. Table 3-1 summarizes this comparison and illustrates that while there is considerable overlap between the two frame- works, there are important differences that merit consideration. The IOM framework reflects concerns about how to improve quality and reduce inefficiencies in services received by patients who have access to health care providers, especially those who need specialty care for chronic conditions

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0 ADOLESCENT HEALTH SERVICES BOX 3-1 Characteristics of Two Frameworks for Delivering Health Services World Health Organization Framework for Delivering adolescent-Friendly Health Services (as summarized by Tylee et al., 2007) • Accessible—Policies and procedures ensure that services are broadly accessible. • cceptable—Policies and procedures consider culture and relationships and the A climate of engagement. • Appropriate—Health services fulfill the needs of all young people. • ffective—Health services reflect evidence-based standards of care and professional E guidelines. • Equitable—Policies and procedures do not restrict the provision of and eligibility for services. Institute of medicine Framework for Delivering Quality Health Services (as set forth in Institute of medicine, 2001) • Efficient—Services are designed to reduce unnecessary time and costs. • Timely—Waiting times between assessment and treatment are reduced. • Patient-centered—Services are sensitive to the needs and preferences of the patient. • Equitable—Services do not reflect disparities within the general population. • Effective—Services reflect accepted standards of clinical care. • Safe—Protocols are in place to reduce medical errors and foster quality assurance. (such as diabetes or eating disorders, which generally involve coordina- tion of multiple specialty services). By contrast, the WHO framework is focused on how to improve access to and engagement with appropriate primary care services. Since all adolescents need to interact with primary care providers and fewer need specialty services, the WHO framework of- fers a more appropriate conceptual design for an analysis of the adolescent health system. With the WHO framework in mind, the committee reviewed compo- nents of the current adolescent health system—adolescent health services, the settings where these services are delivered, how services are delivered in these settings, and by whom. The committee considered the extent to which these services are accessible, acceptable, appropriate, effective, and equitable. Health services for adolescents in the United States are delivered through two sectors: primary care and specialty care. Each sector involves

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TABLE 3-1 Comparison of Criteria of the Institute of Medicine and World Health Organization Frameworks for Delivering Health Services IOM Framework Efficient Timely Patient-Centered Equitable Effective Safe WHO Framework Accessible X Acceptable X Appropriate X Effective X X Equitable X NOTES: IOM = Institute of Medicine; WHO = World Health Organization. SOURCES: Institute of Medicine (2001); Tylee et al. (2007). 

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2 ADOLESCENT HEALTH SERVICES multiple providers and institutions, and some providers work with specific subpopulations of youths. Primary care programs strive to meet the basic health needs of all adolescents, including routine checkups, immunizations, anticipatory guidance, and screening and assessment for disorders and risk factors. Specialty care programs serve adolescents with specific health needs (for example, those with chronic illnesses such as diabetes or asthma, those with eating disorders, those needing reproductive health services or treat- ment for sexually transmitted infections [STIs], those with clinical mental health needs, or those with substance use disorders). In some situations, specialty health services may be offered through primary care settings, and primary care services may sometimes be available within specialty clinics. Examples include the primary care services offered by Planned Parenthood clinics (which specialize in reproductive health care), as well as mental health services that are offered within certain types of community health or hospital-affiliated primary care clinics. Assessing the relative merits of various care settings requires close at- tention to the nature of their interactions and their experience with differ- ent health conditions and subpopulations of adolescents. It also requires consensus on the criteria that should be applied in weighing the strengths and limitations of particular service settings. The adolescent health system shares the same basic problems as those embedded in the organization of adult health services: the lack of communi- cation, collaboration, and system-level planning among various private and public health services, settings, and providers (Institute of Medicine, 2003). As noted in the IOM (2003) report, the vast array of clinicians, hospitals, other health care facilities, insurance plans, and purchasers operate in vari- ous configurations of groups, networks, and independent practices that are collectively termed “the health care delivery system.” However, this phrase suggests an order, integration, and accountability that do not exist, and whose absence results in barriers to and gaps in care. In some areas, such as the organization of mental health services for adolescents, the system of ser- vices is in substantial disarray because of financial barriers, eligibility gaps, the limited availability of providers, and concerns about confidentiality and privacy that impede smooth transitions across health service settings. Finding: • ive objectives identified by the World Health Organization pro- F vide a basis for assessing the quality of current and future systems of health services for adolescents: accessibility, acceptability, ap- propriateness, effectiveness, and equity.

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 CURRENT ADOLESCENT HEALTH SERVICES PRIMARY CARE SERVICES Traditional primary care encompasses provider-based services offered in private practices, such as pediatric, family medicine, and dental offices, as well as safety-net programs that include community health centers or hospital-affiliated primary care services. School-based health centers are also generally considered part of the primary care sector. Some primary care settings are structured to serve the health needs of specific populations with unique profiles (such as those who are homeless or runaways; those who are involved in the foster care or juvenile justice system; or those who are lesbian, gay, bisexual, or transgender1 [LGBT]). Private Office-Based Care The majority of adolescents have private insurance through family plans offered by one or both parents’ employers. These adolescents com- monly receive their primary medical care from private provider offices, usually a pediatrician, family physician, general internist, or nurse prac- titioner, or for older female adolescents, a gynecologist. Adolescents with public insurance (such as Medicaid or the State Children’s Health Insurance Program [SCHIP]) also routinely interact with provider offices in the private or public sectors that accept their insurance plans. Private office-based primary care services frequently cover the follow- ing: health maintenance or well-care visits (the scope of which is often guided by local school board policies), basic diagnostic tests (such as height, weight, and blood pressure), vision and hearing screening, and brief con- sultation on health concerns or health promotion. The administration of recommended vaccines may or may not be included in an annual office visit, depending on local school requirements, state programs for free vaccines, insurance coverage, and reimbursement practices. Significant variations frequently occur in private and public health plans that limit or influence the nature and duration of services eligible for reimbursement in private office-based primary care settings. For example, traditional plans allow reimbursement for health maintenance visits, labo- ratory tests, care for certain categories of acute and chronic medical condi- tions, and prescription medications. They generally do not cover extended or periodic counseling services beyond the brief contact associated with a health maintenance visit, nor do they reimburse many of the counseling or case management expenses associated with treatment of a number of 1 The group referred to as “lesbian, gay, bisexual, and transgender” sometimes also encom- passes the term “questioning” and is commonly referred to by the acronym LGBT (or GLBT) or LGBTQ (or GLBTQ). For the purposes of this report, the identifier “lesbian, gay, bisexual, and transgender” or LGBT is used.

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 ADOLESCENT HEALTH SERVICES behavioral problems, such as anorexia or bulimia, substance use, sexual or reproductive health practices, trauma, or behavioral or emotional problems that fail to meet the threshold criteria for a clinical disorder (Fox, Limb, and McManus, 2007; Fox, McManus, and Reichman, 2003; see Chapter 6 for more detail). A review of several studies found that 70 percent of adolescent mor- bidity and mortality involves consequences from such behavior as unsafe sexual activity, violence, substance use, tobacco use, poor nutritional habits, risky driving, and inadequate physical activity (National Research Council, 1999). Yet even though this age group is at significant risk for the onset of many health conditions that may persist into adulthood, only a minority of adolescents receive developmental or psychosocial services through routine assessment (Chung et al., 2006). While clinician surveys indicate that most private providers perform routine surveillance for risky behaviors, diet, and exercise, fewer than half of adolescents responded affirmatively to survey items asking whether they had spoken with their provider about sexual activity, other risk behaviors, STIs, diet, exercise, and emotional health (Bethell, Klein, and Peck, 2001; Chung et al., 2006; Ellen et al., 1998; Halpern-Felsher et al., 2000; Millstein and Marcell, 2003; Millstein, Igra, and Gans, 1996). Several factors account for the lack of appropriate private office-based health services for adolescents that are tailored to their behavioral and developmental needs. For example, insurance reimbursements are often inadequate to compensate for the time it takes to offer adequate health pro- motion or disease prevention services for adolescents (McManus, Shejavali, and Fox, 2003; O’Connor, Johnson, and Brown, 2000). This and other finance issues are discussed in more detail in Chapter 6. Another challenge involves the nature and skills of the workforce that is available to address the health needs of adolescents. According to the National Medical Ambulatory Survey and the National Hospital Ambula- tory Medical Care Survey, 40 percent of health visits for adolescents aged 11–14 were to pediatricians during 1994–2003. As adolescents matured and reached adulthood, they encountered a more diverse array of providers, moving from pediatricians to family physicians, internal medicine physi- cians, and gynecologists. For example, among females and males aged 18– 21, only 4 percent and 7 percent, respectively, had met with pediatricians. For the two age groups, 22 percent and 29 percent of visits, respectively, were to family physicians. Half of female and 70 percent of male health maintenance visits in the older age group were to family physicians. After age 18, females were more likely to visit obstetricians/gynecologists than any other type of physician (Rand et al., 2007). In some cases, adolescents are able to interact with a specialist in adolescent medicine in a private office-based primary care setting. An ado-

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5 CURRENT ADOLESCENT HEALTH SERVICES lescent medicine specialist has received extensive training in the particular health conditions and concerns of adolescents, as discussed later in this chapter and further in Chapter 5. These specialists may be more prepared than other practitioners to address multiple health problems faced by ado- lescents, identify specific behavioral disorders, and offer guidance on health promotion and disease prevention. But access to adolescent specialists is se- verely limited, since these practitioners are commonly available only in aca- demic health centers. According to one recent estimate, just 466 certificates in adolescent medicine were issued from 1996 to 2005 (for a population of about 40 million people aged 10–19), compared with 2,839 certificates issued in geriatric medicine during the same period (Hoffman, 2007). In addition to difficulties associated with insurance conditions and the shortage of specialists, opportunities to engage adolescents in discussions pertinent to their particular needs and circumstances and to monitor their general health status are severely constrained by a lack of continuity with a clinician or place of care, a lack of privacy, a lack of clinical awareness or skill, racial and ethnic barriers, language-related barriers, clinician and patient gender-related barriers, and a lack of time to provide comprehen- sive preventive care even if adolescents attend their recommended visits (Chung et al., 2006). In their review of the literature, Chung and colleagues (2006) found that fulfilling only the most conservative (i.e., evidence- and cost/benefit-based) counseling recommendations of the U.S. Preventive Care Task Force would take an average clinician nearly 40 minutes per adoles- cent per year. Both national surveys of pediatricians and case studies have found that insurance reimbursements are inadequate to cover the necessary time (McManus, Shejavali, and Fox, 2003; O’Connor, Johnson, and Brown, 2000). Several group plans and managed care organizations have recognized the importance of offering primary care services tailored to the needs of adolescents. These plans and organizations tend to provide greater oppor- tunity for adolescents and their parents to engage with providers who are specially equipped to address their concerns and are skilled in discussing sensitive health issues, such as pubertal changes, sexual activity, behavioral and mental health conditions, and substance use. More commonly, however, providers in private office-based primary care settings believe they are inadequately trained in adolescent health, and they are uncomfortable with discussing sensitive health issues of particular concern to adolescents and their families (as discussed further in Chapter 5). Moreover, few of these providers are aware of the Guidelines for Ado- lescent Preventive Services (discussed in Chapter 4) or the Healthy People 2010 objectives for adolescents and young adults (described in Chapter 2) (American Medical Association, 1997; U.S. Department of Health and Hu- man Services, 2007). They fail to recognize the importance of incorporating

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 CURRENT ADOLESCENT HEALTH SERVICES to ongoing change (U.S. Congress and Office of Technology Assessment, 1991). Nevertheless, the overall trend, with the exception of abortion, has been to protect the confidentiality of adolescents’ health information when they are legally allowed to consent to their own care. When exceptions are made, such as to grant health professionals discretion to disclose informa- tion to parents even when the minor has consented to the care and objects to disclosure, they are usually grounded in the importance of protecting the health of adolescents or others. Findings: • vidence shows that health services that are confidential increase E the acceptability of services and the willingness of adolescents to seek them, especially for issues related to sexual behavior, repro- ductive health, mental health, and substance use. • xisting state and federal policies generally protect the confiden- E tiality of adolescents’ health information when they are legally allowed to consent to their own care. SUMMARY This chapter has presented a review of current health services for adolescents and the settings where those services are typically received, with a focus on both the array of mainstream and safety-net primary care services and specialty services. It has also proposed the five objectives of accessibility, acceptability, appropriateness, effectiveness, and equity as a valuable framework for assessing health services and health care models that serve adolescents. Available evidence shows that health services for all adolescents, including those who are particularly vulnerable because of their demographic characteristics or other circumstances, do not reliably and consistently meet these objectives. Evidence also shows the lack of a system that provides coordinated health promotion, disease prevention, and behavioral health services for adolescents—all important elements for ap- propriately and effectively addressing the adolescent health needs discussed in Chapter 2. REFERENCES Aarons, G., Brown, S., Hough, G., Garland, A., and Wood, P. (2001). Prevalence of adolescent substance use disorders across five sectors of care. Journal of American Academy of Child and Adolescent Psychiatry, 0, 419–426. Adebimpe, V. R. (1981). Overview: White norms and psychiatric diagnosis of black patients. American Journal of Psychiatry, , 279–285.

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