4
Improving Systems of Adolescent Health Services

SUMMARY

Developing improved health systems for adolescents will require attention to several fundamental goals:

  • Emphasize the capacity of primary health care services to provide high-quality screening, assessment, health management, referral, and care management of specialty services, especially for behaviorally based health problems.

  • Coordinate behavioral, reproductive, mental health, and dental services in practice and community settings.

  • Incorporate health promotion, disease prevention, and youth development throughout the health system and within the community.

  • Focus attention on the health and health service needs of those adolescents who are most vulnerable to risky behavior and poor health.

  • Ensure consent and confidentiality for adolescents seeking care.

Chapter 3 described the current array of primary and specialty care health services for adolescents, with a particular emphasis on reviewing the evidence on the gaps and shortcomings in the accessibility, acceptability, appropriateness, effectiveness, and equity of these services. The evidence presented underscores the importance of adolescent health



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4 Improving Systems of Adolescent Health Services Summary Developing improved health systems for adolescents will require at- tention to several fundamental goals: • Emphasize the capacity of primary health care services to provide high-quality screening, assessment, health management, referral, and care management of specialty services, especially for behav- iorally based health problems. • Coordinate behavioral, reproductive, mental health, and dental services in practice and community settings. • Incorporate health promotion, disease prevention, and youth devel- opment throughout the health system and within the community. • Focus attention on the health and health service needs of those adolescents who are most vulnerable to risky behavior and poor health. • Ensure consent and confidentiality for adolescents seeking care. C hapter 3 described the current array of primary and specialty care health services for adolescents, with a particular emphasis on re- viewing the evidence on the gaps and shortcomings in the accessibil- ity, acceptability, appropriateness, effectiveness, and equity of these services. The evidence presented underscores the importance of adolescent health 

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5 IMPROVING SYSTEMS OF ADOLESCENT HEALTH SERVICES services that meet these quality objectives; the scarcity of current services that consistently do so; and the lack of systems that provide coordinated health promotion, disease prevention, and behavioral health services for adolescents. Whereas Chapter 3 focused primarily on findings with respect to problems with adolescent health services, this chapter focuses on ways to address these problems and achieve improved adolescent health systems that embody the above quality objectives. The strategies recommended are informed by three of the behavioral and contextual characteristics presented in Chapter 1. First, participation matters: effective health services for young people invite engagement with clinicians by adolescents and their families. Second, family matters: at the same time that adolescents are growing in their autonomy, families continue to affect their health and overall well- being and to influence what health services they use; young people without adequate family support are particularly vulnerable to risky behavior and poor health and thus require additional support in health service settings. Third, community matters: good health services for adolescents include population-focused as well as individual and family services since the en- vironment that adolescents live in as well as the supports provided in the community are important. Efforts to improve the availability of health services for adolescents and the accessibility of those services are insufficient by themselves to meet the health needs of today’s adolescents. Those needs increasingly involve health problems resulting from behaviors that can best be addressed before the onset of obvious morbidity or during the early stages of experimentation in such areas as diet and exercise, substance use (including tobacco and alcohol), driving, and sexual behavior. Therefore, adolescent health services need to do a better job of incorporating prevention and health promotion, while also being more tailored to the developmental stage of adolescents. Evidence is insufficient to suggest that one particular setting or practice structure for adolescents can achieve significantly better outcomes than other approaches. While a small number of comprehensive clinics and facilities focused on adolescents do exist, these service approaches are not easily applied to larger populations or most communities because of a lack of professionals specializing in adolescent health. However, the five criteria of accessibility, acceptability, appropriateness, effectiveness, and equity pro- vided the committee with a framework for assessing the use, adequacy, and quality of adolescent health services, and comparing and contrasting the extent to which different services, settings, and providers meet the health needs of adolescents in the United States. To meet these needs, improved systems of adolescent health services will be necessary. These systems must encompass (1) evidence-based and standardized screening tools and management and referral processes in adolescent-friendly primary care settings, including primary care provider

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 ADOLESCENT HEALTH SERVICES offices, community-based health centers, hospital-affiliated primary care services, and school-based health centers; (2) facilitated linkages between providers of primary and specialty care services, especially for specific sub- populations of more vulnerable adolescents; and (3) expanded connections between primary care settings and community agencies providing health promotion, disease prevention, behavioral health, and youth development services that are delivered by health professionals with appropriate training in adolescent medicine. In short, it will be necessary to modify the structure and design of primary care (including safety-net services), specialty care (including mental health, sexual and reproductive health, oral health, and substance abuse treatment and prevention services), organizational arrange- ments, workforce development, and financial systems so that adolescent health services can place greater emphasis on health promotion, disease prevention, and youth development. The latter three emphases are particu- larly lacking for the most underserved and high-risk groups of adolescents, such as those who are poor; are members of a racial or ethnic minority; are in the foster care system; are homeless; are in families that have recently immigrated to the United States; are lesbian, gay, bisexual, or transgender; or are in the juvenile justice system. This chapter describes elements of adolescent health services that can best meet the needs of all adolescents. It emphasizes the importance of in- tegrating efforts to identify and address risky behavior with interventions aimed at health promotion, disease prevention, and youth development in settings that serve adolescents. The first section identifies selected features of health services (including screening, assessment, health management, referral, and care management of specialty services) that, when incorpo- rated into primary care services, may enable those services to better address unhealthful habits and risky behaviors of adolescents. Next is a discussion of strategies that can be used for enhanced coordination of primary care services with more specialized behavioral, nutritional, oral, and sexual and reproductive health services. The third section examines strategies for fos- tering health promotion, disease prevention, and youth development, with the goal of improving the health of all adolescents. This section also consid- ers how public health objectives for adolescents (the 21 critical objectives within the broader set of Healthy People 2010 goals and the Healthy People 2010 adolescent oral health objectives) can be linked to the health system for adolescents through a population-based approach (U.S. Department of Health and Human Services, 2000, 2007). The ultimate goal is to identify strategies that can foster service integration and coordination across public and private health systems so the two sectors can complement each other in addressing the health needs of today’s adolescents, strengthen adolescents’ capacity to become healthy and productive adults, and ultimately achieve the objectives for adolescents of Healthy People 2010. The fourth section

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7 IMPROVING SYSTEMS OF ADOLESCENT HEALTH SERVICES reviews the roles and responsibilities of various stakeholders in ensuring adolescents’ access to confidential health services. This is followed by a discussion of innovations in adolescent health services, including the in- creasing use of health information technology, as well as some examples of current efforts to deliver health services to this population through a variety of approaches. IDENTIFYING AND ADDRESSING UNHEALTHFUL HABITS AND RISKY BEHAVIORS AMONG ADOLESCENTS As reviewed in Chapter 2, unhealthful habits and risky behaviors that are initiated during adolescence extend into adulthood and contribute directly to poor health conditions and significant morbidity and mortal- ity in the short and long terms (Kolbe, Kann, and Collins, 1993). Health systems can play a critical role in the early identification, management, and monitoring of adolescents who are already experimenting with unhealthful habits and risky behaviors or associating with peers who do so. Systematic efforts to identify and respond appropriately to these behaviors can delay their onset or reduce their severity and duration, as well as prevent the initiation of other, co-occurring behaviors, such as use of alcohol, drugs, and tobacco products; unprotected sex; violence; and hazardous driving. Designing interventions to address unhealthful habits and risky behaviors requires attention to several key components of primary care: screening, assessment, health management, referral, and care management of spe- cialty services. Each of these components is discussed below, with a focus on selected research findings that may influence the development of more effective health services for adolescents. Screening As discussed in Chapter 3, screening and counseling are critical for adolescents, since unhealthful and risky behaviors are the leading cause of morbidity and mortality among individuals in this age group and also affect their future health status as adults. A general physician inquiry, the screening method most frequently relied upon by health care practitioners, frequently falls short in screening for unhealthful habits and risky behav- iors. An alternative to a general physician inquiry is the use of standardized screening tools. Such tools, however, are used infrequently in primary care settings for adolescents (Gardner et al., 2003). Those that are used often focus on only a single risky behavior, such as sexual practices or substance use (McPherson and Hersch, 2000), so that clinicians must administer several screens to have a comprehensive battery. Internal factors, such as physician attitudes or inadequate training of personnel who must adminis-

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 ADOLESCENT HEALTH SERVICES ter the screens, and external factors, such as cost, time, inadequate referral resources, and a lack of guidance on the use of the tools, may be an addi- tional barrier to their use (Horwitz et al., 2007; Ozer et al., 2005). Several national organizations, including the American Medical Asso- ciation (AMA) and the American Academy of Pediatrics (AAP), recommend that, at a minimum, all adolescents receive routine structured screening for a variety of behavioral and health risks as part of the annual health main- tenance visit (Elster and Kuznets, 1994; Green and Palfrey, 2002). Not only do such tools increase the identification of targeted behaviors or symptoms, but they also may minimize disparities in care by increasing standardization of practice (Miranda et al., 2003). Numerous regulatory and advisory bod- ies are in general agreement on criteria for the use of standardized screening tools (Calonge, 2001; Feightner and Lawrence, 2001). These criteria in- clude the availability of practical, sensitive, and specific instruments; a high prevalence of morbidity or mortality associated with the target condition(s); access to effective intervention(s) for the condition(s); and positive benefits from the early initiation of intervention. Despite their infrequent use, a number of routine screening instruments for unhealthful habits and risky behaviors are available for use in primary care settings. Common instruments for alcohol and drug use include the Problem Oriented Screening Instrument for Teenagers (POSIT) (Rahdert, 1991), the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al., 2001), and the RAFFT (Relax, Alone, Friends, Family, and Trouble) (Riggs and Alario, 1989) and CRAFFT (Car, Relax, Alone, Forget, Family, Trouble) tests for adolescent substance use (Knight et al., 1999). Similar instruments are available for depression and suicidality. Routine urine tests for sexually transmitted infections (STIs), such as chlamydia, are recom- mended for all sexually active adolescents (American Medical Association, 1997). HEADSS (Home, Education, Activities, Drug use and abuse, Sexual behavior, Suicidality and depression; or Home, Education, Alcohol, Drugs, Smoking, Sex) has also been used for many years as a provider-driven questionnaire for assessing unhealthful habits and risky behaviors in adoles- cents (Cohen, Mackenzie, and Yates, 1991; Van Amstel, Lafleur, and Blake, 2004). Instruments for assessing nutrition and exercise for adolescents in primary care have not been extensively studied. An alternative to surveys or questionnaires completed by patients and families is semistructured questionnaires for clinicians to administer to pa- tients. An example, issued by the AMA, is Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (GAPS), which consolidates national guidelines of multiple professional organizations (e.g., AMA, AAP) for preventive screening, counseling, and health education services for both adolescents and children into one set of recommendations endorsed by all these organizations (American Medical Association, 1997).

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 IMPROVING SYSTEMS OF ADOLESCENT HEALTH SERVICES Recommendations for adolescents are organized into four types of services that address 14 separate topics or health conditions (see Box 4-1). These guidelines offer physicians recommendations for identifying ado- lescents at risk and helping them change or prevent unhealthful behaviors. They suggest specific questions providers can ask their young patients as gateways for addressing concerns in such areas as physical, social, and emotional development; oral health habits; and sexual practices. These guidelines emphasize periodic health care visits for health education and preventive screening to provide opportunities for counseling, anticipatory guidance, early identification, and referral for medical, behavioral, and emotional risks. According to the GAPS, health care providers should ask all adolescents about risky behaviors every year, including their use of to- bacco products, alcohol, and other substances; behaviors or emotions that indicate recurrent or severe depression or risk of suicide; and any sexual behavior that may result in unintended pregnancy or STIs. The guidelines further specify that at-risk adolescents should be counseled about how to reduce their risks. It should be noted that the GAPS are based on consensus among experts and are not required to be evidence based. In contrast, the U.S. Preventive Services Task Force (USPSTF) also issues recommendations for clinical preventive services, but does so only if evidence for the effective- ness of the counseling or screening is available, and only after using study results to weigh the benefits against possible harm. Because research-based evidence is often not available, the recommendations of the USPSTF are less extensive than the GAPS. For example, the USPSTF has not issued a recommendation with respect to preventing obesity because an evidence base to support the effectiveness of such counseling does not exist. On the other hand, the USPSTF does recommend both chlamydia screening and counseling on family violence (U.S. Preventive Task Force and Agency for Healthcare Research and Quality, 2004, 2007).1 As discussed previously, the unhealthful habits and risky behaviors tar- geted for screening in primary care are highly prevalent among adolescents and are associated with significant morbidity and mortality both during and after adolescence. Moreover, many of these behaviors could be mitigated by early treatment. Less clear, however, is whether adolescents who screen positive for these behaviors will have the insurance benefits, transportation access, or cultural predisposition to take advantage of such treatment. It is clear that most criteria for the implementation of screening for unhealthful habits and risky behaviors as part of adolescent primary care, especially those related to depression, substance use, and violence, are not met in most settings that treat large numbers of adolescents, but should 1 See www.ahrq.gov/clinic/prevenix.htm.

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200 ADOLESCENT HEALTH SERVICES BOX 4-1 Guidelines for adolescent Preventive Services (GaPS) GAPS recommendations are organized into four types of services that address 14 separate topics or health conditions: • hree recommendations pertain to the delivery of health care services. T • even recommendations pertain to the use of health guidance to promote S the health and well-being of adolescents and their parents or guardians. • hirteen recommendations describe the need to screen for specific con- T ditions that are relatively common among adolescents and that cause significant suffering either during adolescence or later in life. • ne recommendation pertains to the use of immunizations for the primary O prevention of selected infectious diseases. The 14 topics or health conditions addressed by GAPS are divided into those aimed at health promotion and those aimed at disease prevention: Promotion • Parents’ ability to respond to the health needs of their adolescents • Adjustment to puberty and adolescence • Safety and injury prevention • Physical fitness • Healthy dietary habits and prevention of eating disorders and obesity • ealthy psychosexual adjustment and prevention of the negative health H consequences of sexual behaviors Prevention • Hypertension • Hyperlipidemia • The use of tobacco products • The use and abuse of alcohol and other drugs • Severe or recurrent depression and suicide • Physical, sexual, and emotional abuse • Learning problems • Infectious diseases SOURCE: American Medical Association (1997). be a priority. Primary care systems must assess their capacity to process screening results, the prevalence of various problems in their community, and the capacity of local treatment services to respond before deciding whether to initiate screening in each risk area. With regard to expanding the capacity of local treatment services to respond, primary care providers

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20 IMPROVING SYSTEMS OF ADOLESCENT HEALTH SERVICES for adolescents may have a role to play, including direct management in the primary care setting. Changes in screening practices and treatment capac- ity are likely to benefit marginalized and more vulnerable adolescents the most since carefully worded instruments and standardized services would eliminate some barriers to inquiry about unhealthful and risky behaviors that are especially salient for these individuals. Such changes are unlikely to come about quickly or at all without major external impetus. Significant financing changes currently under way are es- pecially likely to move screening to the forefront. Specifically, the increased willingness of payors to reimburse primary care clinicians for screening and assessment activity and the rapid expansion of pay-for-performance con- tracting that rewards early detection, as well as the greater availability of automated screening tools and brief paper tools, are all likely to encourage clinicians to consider universal screening during adolescent visits. Assessment Research has identified a developmental sequence in the emergence of unhealthful habits and risky behaviors such as substance use. Yet the use of one drug does not inevitably lead to the use of more potent drugs (Golub and Johnson, 1994), nor does it mean that current use will extend indefinitely (Chen and Kandel, 1995). Uncertainty about the strength of the pathway hypothesis creates challenges for assessment of the meaning and implications of positive results of screening for unhealthful habits and risky behaviors, especially those involving substance use. The substantial heterogeneity of the adolescent population and the absence of predictive models make it difficult to distinguish adolescents who are at substantial risk of chronic or problematic substance use or dependency from those who engage in one-time or short-term experimentation with hazardous substances or behaviors as part of normal adolescent development and peer interaction. Positive results of a screen for substance use or other unhealthful habits or risky behaviors must therefore be carefully assessed to determine the characteristics, severity, and duration of the problem and to identify an appropriate course of treatment and follow-up. Many health care provid- ers feel ill equipped to provide detailed assessments of positive screens or suspicions of behavioral, reproductive, or developmental concerns for their adolescent patients (Horwitz et al., 2007). As a result, they tend to refer their patients to specialty practices that may focus on only one dimension of unhealthful habits and risky behaviors that frequently co-occur (treatment for alcohol use, for example, in the presence of smoking and unprotected sex). Substantial delays may occur between initial screening and assessment, during which other risk factors or behaviors may emerge that complicate

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202 ADOLESCENT HEALTH SERVICES the determination of a best course of action. Alternatively, new protective factors (such as family reunification, positive peer interactions, athletic suc- cess, or improved school achievement) may emerge that could mitigate the results of the initial screen and alter the preferred course of action. Concerns about privacy and confidentiality (discussed in detail later in this chapter) are particularly significant during screening and assessment, when sensitivity to stigma and bias may affect the adolescent patient’s will- ingness to trust and communicate with health professionals or return for follow-up care. Low-income and minority adolescents are at particular risk of being labeled with certain risk factors prior to an in-depth assessment of their overall health status and history. For example, African American youths are more likely to be diagnosed with conduct disorder and less likely to be diagnosed with depression than comparable white youths (Cuffe et al., 1995). High-risk populations also are especially likely to lack access to effective care management and treatment services, as discussed in later chapters. Health Management Health management of unhealthful habits and risky behaviors in pri- mary care settings has a limited research base except for some studies of specific domains or risks. For example, there has been considerable research on the prescription of psychotropic drugs for the management of depres- sion and attention-deficit hyperactivity disorder (ADHD) in primary care settings (Harpaz-Rotem and Rosenheck, 2006; Hoagwood et al., 2000; Murray et al., 2005; Rushton, Clark, and Freed, 2000; zito et al., 1999). Primary care clinicians are the most common prescribers of psychotropic drugs to adolescents, in part because of the large number of younger ado- lescents receiving stimulants for ADHD. Rapid growth was also seen in the prescribing of antidepressants for adolescents until the U.S. Food and Drug Administration issued recent warnings about possible associations with suicidal ideation (U.S. Food and Drug Administration, 2007). The provi- sion of effective services for adolescents with mental health and substance use disorders will continue to require that primary care clinicians manage psychiatric medications for large numbers of adolescent patients because there will never be a sufficient number of child psychiatrists to do so. To accomplish medication management effectively, primary care clinicians need specific training in the use of these medications and better processes for monitoring side effects and adherence, attendance at follow-up visits, and changes in symptoms and functioning. Such activities are almost impos- sible to conduct within a small primary care practice without additional staff. Multiple practices employing common records, in partnership with pharmacy benefit programs, disease management organizations, or health

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20 IMPROVING SYSTEMS OF ADOLESCENT HEALTH SERVICES plans, likely must coordinate such efforts through guild organizations or managed care plans. Since counseling takes time, new organizational structures and physician-extender professionals may be needed to permit a shift from treatment to prevention. Physicians and other health workers dealing with adolescents may need to acquire new skills in such promising techniques as solution-focused interviewing, the medication interest model, and motiva- tional interviewing (Cheng, 2007). The latter technique has been shown in college students to reduce risky behavior related to alcohol (LaBrie et al., 2007b), increase condom use (LaBrie et al., 2007a), potentially improve patient involvement in dental care and smoking cessation counseling by dentists (Koerber, Crawford, and O’Connell, 2003), and potentially enable patients to control diabetes (Dale et al., 2007). Although many physicians feel comfortable interviewing patients and families, formal physician train- ing in these manual-based techniques, including role play, has been shown to improve satisfaction and outcomes for patients (Wissow et al., 2008). While primary care management of mental health disorders such as ADHD and depression is fairly well documented, much less evidence exists on the primary care management of high-risk sexual activity, substance use disorders, adolescent obesity, or other nutritional problems. In part, this is attributable to the lack of pharmaceutical interventions for these problems, from which clear data for research on ADHD and depression management are generated. It is also true, however, that ideal services for primary care interventions for these other problems have not been well described. For example, few successful interventions for adolescent obesity have been documented in any settings (Hawley, Beckman, and Bishop, 2006; O’Brien, Holubkov, and Reis, 2004; Quintos and Castells, 2006). Similarly, primary care management strategies for adolescent substance use are largely unstudied. Because these problems are so understudied, many researchers have fo- cused on the importance of the clinician–patient relationship in adolescent primary care. Relationships between adolescents and parents, families, peers (especially best friends), and extrafamilial individuals play a significant role in adolescent development (Collins and Laursen, 2000). Although research in this area has not explicitly addressed relationships between adolescents and their health care providers, it offers intriguing opportunities to study the attributes and processes that attract (or repel) adolescents to certain providers and care environments. The presence or absence of supportive relationships provides a context for socialization and the inculcation of social norms, as well as models for future relationships, including the capacity to relate effectively to others (Hartup, 1986; Maccoby, 1984). The affective quality of the relationship between a health care provider and an adolescent can therefore be as im-

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20 ADOLESCENT HEALTH SERVICES portant as the content or quality of the service provided, especially if it reinforces the adolescent’s positive experience with a parent–child relation- ship or addresses dimensions that lie beyond the sphere of parent–child communications. Through their relationships with health care providers, adolescents can be encouraged to disclose health conditions and behaviors of concern and to become attentive to risks and protective factors that influence their current and future health status. Significant attention is therefore warranted to understand how supportive relationships can be cultivated and sustained in the provision of health services in ways that lead to positive health outcomes for adolescents, especially those in vulnerable circumstances. Of course, such relationships and their benefits are greatly enhanced by longitudinal care provided over many years to adolescents and their families. When care is less continuous and youths are seen only once every few years, the potential benefits are much more difficult. In addition to the establishment of close ties with adolescents, primary care management will increasingly require monitoring strategies. Adoles- cents are particularly vulnerable to low rates of attendance at follow-up appointments, failure to adhere to medication instructions, and inadequate communication with health care providers. Numerous strategies for im- proving communication and monitoring have shown promise. These range from better communication links, such as automated calls and messages through cell phones and the Internet (described later in this chapter), to contact that involves problem solving and motivational interviewing be- tween visits. As with other components of high-quality primary care for adolescents, regional coordination across multiple practices and settings can diminish the cost of such interventions for individual practices. Referral Once an adolescent patient has been screened and assessed, the provider must determine what course of action is most appropriate. In some cases, the patient may need to be referred to another care setting for treatment. In many situations, the primary care provider may not be familiar with community resources that are appropriate to address the behavior in ques- tion. This is the case especially for patients who have difficulty navigating traditional health service settings or those whose insurance panel provid- ers may not include the resource considered most appropriate. Indeed, primary care clinicians cite a lack of referral sources as a major barrier to their identifying and meeting the mental health needs of adolescents and their families (Horwitz et al., 2007). Strategies that may support providers in finding and engaging with community partners are described below. For purposes of efficiency, these strategies may be pursued by groups of clini- cians or practices in partnership.

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22 IMPROVING SYSTEMS OF ADOLESCENT HEALTH SERVICES and a 24-hour Kids Care telephone resource staffed by registered nurses for all-hours advice on medical needs. The provision of sports medicine and physical therapy is well suited to an adolescent-specific health center. The offsite adolescent eating disorders clinic uses an interdisciplinary approach for diagnosis and treatment, and is the only adolescent-specific eating dis- orders clinic in the state of Arkansas. Partnership with the school district provides payment for the sports medicine program, while other services are covered by SCHIP. The center’s medical staff make up the Adolescent Division of the Department of Pediatrics and enjoy considerable autonomy in the center’s management and planning. The center’s policies, procedures, strategic planning, and monitoring are largely within the purview of the Arkansas Children’s Hospital administration, with consultation from the medical staff of the Adolescent Division. The hospital submits all outpatient billing and returns collections on physician and other professional charges to the Department of Pediatrics through a contractual agreement. Jetson Center for Youth Through a contract with the Louisiana State Office of Youth Develop- ment, the Louisiana State University (LSU) Health Sciences Center’s Juve- nile Justice Program provides multidisciplinary health services for youths in the state’s long-term secure juvenile facilities. The Jetson Center for Youth is one of these long-term secure juvenile sites. It serves primarily the southern portion of the state of Louisiana, including New Orleans and Baton Rouge, and provides medical, dental, psychiatric, and psychological services, as well as other specialty services, including neurology, orthope- dics, gastroenterology, audiology, radiology, and ophthalmology. The center also provides educational and vocational services. Many of the center’s services are available onsite; however, youths have access to all LSU health services offsite as well. The services are fully funded by the state. All poli- cies, procedures, protocols, billing, quality assurance, staff development, strategic planning, grant management, and utilization review and outcome monitoring are managed through the Office of Youth Development in part- nership with LSU. The Jetson Center for Youth provides health services to 150 to 200 males aged 12–21, 80 percent of whom are African American and most of whom come from low-income rural communities. The most common health issues for adolescents served by the center are mental disorders (40 percent of these adolescents have a serious mental health problem), STIs, behavioral problems, and bruises and broken bones and teeth due to physical encoun- ters. A multidisciplinary health care team delivers the center’s onsite health services. The team includes registered, licensed practical, and administrative nurses; psychologists; psychiatrists; social workers; pediatricians; an oph-

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20 ADOLESCENT HEALTH SERVICES thalmologist; a dentist; a dental hygienist; and pediatric, physician assistant, and administrative personnel essential to the coordination of services. In addition to the onsite staff, there is access to other specialists, most notably an additional psychiatrist, who works offsite through telemedicine. This health team, employed by LSU and with several members available onsite at all times (24-hour nursing and on-call psychiatric/psychological staff), is eager to move from a correctional to a therapeutic model, particularly in dealing with serious mental illness, through ongoing planning, training, and evaluation with Office of Youth Development leadership. Mount Sinai Medical Center An adolescent health clinic associated with Mount Sinai Medical Cen- ter, established in 1968, is one of the largest and oldest examples of a free- standing health center that provides integrated, multidisciplinary services and also strives to help adolescents take responsibility for their own health. The center annually serves more than 10,000 youths (aged 12–22) in several sites, including one in East Harlem and two school-based health centers in other Manhattan neighborhoods (Sandmaier et al., 2007). About one- third of clients have public or private insurance, and the center helps young people enroll in such public insurance programs as Medicaid or SCHIP; even so, care is available to all patients without restriction. The center’s diverse and multiethnic staff operates as a collaborative team focusing on coordinated, comprehensive, and highly individualized care. It includes 6 adolescent medicine specialists; 20 clinical social workers; 3 health educa- tors; specialists in obstetrics/gynecology, mental and behavioral health, and nutrition; and nurse practitioners, physician assistants, and ambulatory care technicians (Sandmaier et al., 2007). The Mount Sinai adolescent health clinic is especially noteworthy for its emphasis on youth empowerment through intentional engagement with adolescents and partners in understanding and ownership of their health. The Youth Advisory Board, a peer education program called SPEEK (Sinai Peers Encouraging Empowerment through Knowledge), and skill-building components in both primary and specialty care programs all reflect the center’s focus on helping adolescents make healthy decisions and support- ing their overall growth through mentoring, tutoring, legal advocacy, and preparation for taking such key tests as the General Educational Develop- ment, a high school equivalency degree (Sandmaier et al., 2007). Erie Teen Health Center The mission of the Erie Teen Health Center in Chicago is “both simple and challenging: to provide comprehensive, integrated, teen-sensitive care,

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2 IMPROVING SYSTEMS OF ADOLESCENT HEALTH SERVICES focusing on helping adolescents to develop the strengths and skills that will allow them to become effective stewards of their own health” (Sandmaier et al., 2007, p. 12). The center serves approximately 2,200 adolescent patients per year, along with more than 500 babies and young children of patients. More than three-quarters of its clients are aged 18–21, and approximately 70 percent are Hispanic. The center has developed a nationally recognized group model of prenatal care—the Centering Pregnancy Program—that includes physician examinations, consultation with a nurse midwife, group discussion sessions, self-assessment instruments, and community support within the group. Assessments of program effectiveness are based on patient satisfaction surveys, as well as data on the center’s reproductive health ser- vices. Those data show that 93 percent of the center’s adolescent patients used birth control over the past 12 months without becoming pregnant, and that 86 percent of clients with STIs had been reached and treated by the center within 14 days of testing, a rate that exceeds the state goal of 73 percent (Sandmaier et al., 2007). SUMMARY Developing an improved health system for adolescents will require at- tention to several fundamental goals: • Placing a greater emphasis on and enhancing the capacity of pri- mary care providers to offer high-quality screening, assessment, health management, referral, and care management of specialty services for this population, especially for behaviorally based health problems. • Coordinating behavioral, reproductive, mental health, and dental services in practice and community settings. • Incorporating health promotion, disease prevention, and youth development throughout the health system, in coordination with such services in the community. • Ensuring consent and confidentiality for adolescents seeking care. Strengthening these features of the settings in which health services for adolescents are provided will require explicit attention to the ways in which service environments are structured and the training and clinical experiences of health care providers. It will also require comprehensive integration of electronic health records and electronic tools for commu- nicating with adolescents, and the development of sustained partnerships with sectors such as education, the media, and the entertainment industry that are important parts of the adolescent culture. It will be necessary to introduce new incentives and assessment efforts, derived from population

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22 ADOLESCENT HEALTH SERVICES health research, aimed at realigning the health environment, provider ser- vices, and information resources, probably in regional centers with varying levels of expertise, to achieve a more explicit focus on accomplishing the national health objectives for adolescents outlined in Healthy People 2010 (as described in detail in Chapter 2). At the very least, primary care provid- ers who care for large numbers of adolescents will need to organize sup- port for comprehensive screening and monitoring initiatives that are likely to require electronic databases and trained staff. These initiatives should build upon the strengths of the existing diversity of health service settings while also attempting to move those settings toward greater coordination and a set of common objectives and screening and assessment methods that can enrich the quality of adolescent health services and ultimately lead to better health outcomes. These initiatives should also focus on the context of health services by building upon lessons learned from the delivery of services to marginalized and special subpopulations of adolescents with respect to those operational features and processes that foster adolescents’ engagement with providers. Emphasis should be placed on improving the skills and capacity of all health personnel in primary care settings—not solely physicians—to serve the needs of all adolescents. This chapter has proposed several approaches to improving health sys- tems for adolescents to make services accessible, acceptable, appropriate, effective, and equitable. Such improvements are particularly important to support healthy development for those adolescents who are more vulner- able to poor health or unhealthful habits and risky behavior because of their demographic characteristics or other circumstances. Limited evidence is available on health outcomes associated with alternative service strate- gies. Therefore, the committee has attempted to highlight areas in which research could yield knowledge that would support quality improvements in the organization and delivery of health services for adolescents. For ex- ample, the evidentiary base currently does not support the formulation of performance standards and operational criteria that would make it possible to compare the strengths and limitations of different service delivery models in meeting the needs of all adolescents, as well as specific subpopulations. In particular, few evaluations provide insight into the validity and reliability of screening tools and counseling techniques for the most vulnerable groups of adolescents. Efforts to improve the knowledge base on the provision of services to these adolescents should therefore be a major priority in efforts to improve health services and the quality of care for adolescents.

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