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7 Overall Conclusions and Recommendations According to the World Health Organization (1995, p. 3), “One of the most important commitments a country can make for future economic, social, and political progress and stability is to address the health and devel- opment needs of its adolescents.” Adolescence is a time of major transition between childhood and adulthood. It is a period when significant physical, psychological, and behavioral changes occur and when young people de- velop many of the habits, behaviors, and relationships they will carry into their adult lives. The health system has a crucial role to play in promoting healthful behavior and preventing disease during adolescence. The National Academies’ Board on Children, Youth, and Families formed the Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention, and Healthy Development, with funding from The Atlantic Philanthropies, in May 2006 to study adolescent health and the adolescent health system. This committee was asked to explore the following issues: • Features of Quality Adolescent Health Services. What does the evi- dence base suggest constitutes high-quality health care and health promotion services for adolescent populations? What do parents, community leaders, and adolescents themselves perceive to be es- sential features of such services? • Approaches to the Provision of Adolescent Health Services. What are the strengths and limitations of different service models in addressing adolescent health care needs? What lessons have been learned in efforts to promote linkages and integration among ado- 2

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2 ADOLESCENT HEALTH SERVICES lescent health care, health promotion, and adolescent development services? What service approaches show significant promise in offering primary care as well as prevention, treatment, and health promotion services for adolescents with special health care needs and for selected adolescent populations? • Organizational Settings and Strategies. What organizational set- tings, finance strategies, and communication technologies promote engagement with, access to, and use of health services by adoles- cents? Are there important differences in the use and outcomes of different service models among selected adolescent populations on the basis of such characteristics as social class, urbanicity, ethnicity, gender, sexual orientation, age, special health care needs, and risk status? • Adolescent Health System Supports. What policies, mechanisms, and contexts promote high-quality health services for adolescents? What innovative strategies have been developed to address such concerns as decision making, privacy, confidentiality, consent, and parental notification in adolescent health care settings? What strat- egies help adolescents engage with and navigate the health care system, especially those at significant risk for health disorders in such areas as sexual and reproductive health, substance use, mental health, violence, and diet? What barriers impede the optimal provi- sion of adolescent health services? • Adolescent Health Care Providers. What kinds of training pro- grams for health care providers are necessary to improve the qual- ity of health care for adolescent populations? CHALLENGES, LIMITATIONS, AND SUCCESSES The committee was challenged in addressing the above issues because (1) the relevant data and scientific literature are limited in a number of key areas; (2) a broad diversity of profiles characterizes adolescents aged 10–19 in the United States; (3) the health status of adolescents is defined by multiple measures, including not only traditional measures of mortality and morbidity, but also behavioral characteristics; (4) health services for adolescents comprise a series of individual services delivered in myriad settings and through varied institutional structures, with limited common goals and no coherent, organizing system; (5) evaluation of health ser- vices for adolescents has been limited, and there is no agreed-upon set of standards within the field of adolescent health with which to evaluate the success of individual programs or compare services and service models; and (6) information on issues related to the adolescent health workforce,

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25 OVERALL CONCLUSIONS AND RECOMMENDATIONS such as competency requirements for health professionals who work with adolescents, is difficult to obtain. To carry out this study in the face of these challenges, the committee: • Conducted a comprehensive review of the existing evidence on the health status of adolescents. • Examined the current health system as it relates to the care of adolescents—health services available to adolescents, the settings where they receive these services, how the services are delivered and by whom. To this end, the committee: – reviewed the existing literature. – visited programs that provide a range of adolescent health services. – commissioned papers on a number of the issues the committee was asked to address. – conducted public workshops with invited expert speakers to solicit additional information on these issues. – interviewed both adolescents and health care providers. The committee then applied its collective expertise and experience to consolidate and deliberate upon this wide range of information. In its deliberations, the committee identified important areas of emphasis for adolescent health services, as well as behavioral and contextual charac- teristics that require attention in the design of these services; agreed upon standards of service quality; and made an assessment of the gaps between these standards and the current range of services available to adolescents. The committee also reviewed the training needs and current requirements for providers of adolescent health services and identified deficits in these areas. In addition, it examined health insurance alternatives for adolescents and assessed the extent to which public and private financing options meet adolescents’ health service needs. As a result of these efforts, the committee formulated many findings that are highlighted throughout this report. In this final chapter, these findings are summarized and consolidated into seven overall conclusions. These conclusions serve in turn as the basis for the committee’s eleven recommendations, directed to both public and private entities, for invest- ing in, strengthening, and improving the system of health services for adolescents.

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2 ADOLESCENT HEALTH SERVICES SUMMARY FINDINGS AND OVERALL CONCLUSIONS Adolescent Health Status Adolescents aged 10–19 make up a significant portion of the total U.S. population—14 percent (42 million) in 2006. The health of adolescents can be defined by traditional measures (mortality rates, incidence of disease, and prevalence of chronic conditions). A more complex and complete pic- ture of adolescent health status, however, also encompasses the prevalence of various leading adolescent behaviors and health outcomes, as well as health indicators that may adversely affect health status in adulthood. An analysis of the 21 Critical Health Objectives for ages 10–24, a sub- set of the Centers for Disease Control and Prevention’s (CDC’s) Healthy People 2010, highlights how little progress has been made in the overall health status of adolescents since the year 2000. Of the 21 objectives— which encompass a broad range of concerns, from reducing deaths, reduc- ing suicides, and increasing mental health treatment to increasing seat belt use, reducing binge drinking, and reducing weapon carrying—the only ones that have shown improvement for adolescents since 2000 are behaviors leading to unintentional injury, pregnancy, and tobacco use. Negative trends include increased mortality due to motor vehicle crashes related to alcohol, increased obesity/overweight, and decreased physical activity. Certain groups of adolescents have particularly high rates of comorbid- ity, defined as the simultaneous occurrence of two or more diseases, health conditions, or risky behaviors. These adolescents are particularly vulnerable to poor health. Moreover, specific groups of adolescents—such as those who are poor; in the foster care system; homeless; in families that have recently immigrated to the United States; lesbian, gay, bisexual, or trans- gender; or in the juvenile justice system—may have higher rates of chronic health problems and may engage in more risky behavior as compared with the overall adolescent population. These adolescents may have especially complex health issues that often are not addressed by the health services and settings they use. Furthermore, members of racial and ethnic minorities are becoming a larger portion of the overall U.S. adolescent population. And because minority racial or ethnic status is closely linked to poverty and a lack of access to quality health services, the number of adolescents experiencing significant disparities in access to quality health services can be expected to increase as well. Overall Conclusion 1: Most adolescents are thriving, but many engage in risky behavior, develop unhealthful habits, and experience physi- cal and mental health conditions that can jeopardize their immediate health and contribute to poor health in adulthood.

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27 OVERALL CONCLUSIONS AND RECOMMENDATIONS Features of Quality Adolescent Health Services The committee was asked to consider what features constitute high- quality adolescent health services. The provision of such services is de- pendent on successful interactions between adolescents and health service settings and systems, and achieving this requires a multifaceted approach. The committee was guided by two basic frameworks in its data collection, review of the evidence, and deliberations on various dimensions of adoles- cent health status and health services. The first of these frameworks focuses on behavioral and contextual characteristics that influence how adolescents interact with the health system, and the second on the objectives of adoles- cent health services. Neither framework alone is sufficient to explain signifi- cant variations in adolescent health outcomes; rather, they complement each other and, in tandem, provide a more complete picture of the features of the health system that should be improved in order to provide adolescents high-quality care and thus help to improve their health status. Framework 1: Behavioral and Contextual Characteristics Certain sets of behavioral and contextual characteristics, listed below, matter for adolescents in the ways they approach and interact with health care services, providers, and settings. When these characteristics are ad- dressed in the design of health services for adolescents, those services can offer high-quality care that is particularly attuned to the needs of this age group. These characteristics helped frame the chapters of this report and, where relevant and supported by the evidence, are reflected in the commit- tee’s recommendations. • Development matters. Adolescence is a period of significant and dramatic change spanning the physical, biological, social, and psy- chological transitions from childhood to young adulthood. This dynamic state influences both the health of young people and the health services they require. • Timing matters. Adolescence is a critical time for health promo- tion. Many health problems and much of the risky behavior that underlies later health problems begin during adolescence. Preven- tion, early intervention, and timely treatment improve health sta- tus for adolescents and prepare them for healthy adulthood; such services also decrease the incidence of many chronic diseases in adulthood. • Context matters. Social context and such factors as income, ge- ography, and cultural norms and values can profoundly affect the health of adolescents and the health services they receive.

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2 ADOLESCENT HEALTH SERVICES • Need matters. Some segments of the adolescent population, defined by both biology and behavior, have health needs that require par- ticular attention in health systems. • Participation matters. Effective health services for young people invite adolescents and their families to engage with clinicians. • Family matters. At the same time that adolescents are growing in their autonomy, families continue to affect adolescents’ 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 therefore often require additional support in health service settings. • Community matters. Good health services for adolescents encom- pass population-focused as well as individual and family services since the environment in which adolescents live, as well as the sup- ports they receive in the community, are important. • Skill matters. Young people are best served by providers who un- derstand the key developmental features, health issues, and overall social environment of adolescents. • Money matters. The availability, nature, and content of health ser- vices for adolescents are affected by such financial factors as pub- lic and private health insurance, the amount of funding invested in special programs for adolescents, and the support available for adequate training programs for providers of adolescent health services. • Policy matters. Policies, both public and private, can have a pro- found effect on adolescent health services. Carefully crafted policies are a foundation for strong systems of care that meet a wide variety of individual and community needs. Framework 2: Objectives of Health Services for Adolescents Research from various sources and the experiences of adolescents and health care providers, health organizations, and research centers suggest the importance of designing health services that can attract and engage adolescents, create opportunities to discuss sensitive health and behavioral issues, and offer high-quality care as well as guidance for health promotion and disease prevention. Consistent with these findings and views, a variety of national and international organizations have defined critical elements of health systems that would improve adolescents’ access to appropriate services, highlighted design elements that would improve the quality of those services, and identified ways to foster patient–provider relationships that can lead to better health for adolescents.

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2 OVERALL CONCLUSIONS AND RECOMMENDATIONS The World Health Organization has identified five characteristics that constitute objectives for 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 five objectives provided the committee with a valuable framework for assessing the use, adequacy, and quality of adolescent health services; comparing the extent to which different services, settings, and providers meet the health needs of young people in the United States; identifying the gaps that keep services from achieving these objectives; and recommending ways to close these gaps. Approaches to the Provision of Adolescent Health Services and Organizational Settings and Strategies The committee was asked to explore the range of approaches to the pro- vision of adolescent health services and elucidate their respective strengths and limitations. In doing so, the committee was to highlight efforts aimed at promoting linkages and integration among adolescent health care, health promotion, and adolescent development services, and at offering primary care, prevention, treatment, and health promotion services for adolescents with special health care needs and for selected subpopulations. This study was also focused on settings and strategies that influence the use and out- comes of different services by the diverse adolescent population. Adolescents receive both primary care and specialty care services. They receive these services in various settings, including private physician and dentist offices, community outpatient departments, school-based health centers, emergency departments, and even mobile vans, and from various providers, including doctors, nurse practitioners, dentists, psychologists, and social workers. 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 always accessible, acceptable, ap- propriate, or effective for some adolescents, particularly those who are uninsured or underinsured. Such young people often have difficulty gaining

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00 ADOLESCENT HEALTH SERVICES access to mainstream primary care services; require additional support in order to connect with health care providers; and may rely extensively on such safety-net settings as hospital-, community-, and school-based health centers for their primary care. For example, adolescents are the age group most likely to depend on emergency departments for routine health care. Indeed, evidence shows that for some adolescents, safety-net settings may be more accessible, acceptable, appropriate, effective, and equitable than mainstream services. This may be especially so for more vulnerable popu- lations of uninsured or underinsured adolescents. Although an extensive literature on the quality of school-based health services for adolescents is available, few studies have examined the quality of other safety-net primary care services, such as those that are hospital- or community-based, on which so many adolescents depend. Evidence also shows that existing specialty services in the areas of mental health, sexual and reproductive health, oral health, and substance abuse treatment are not accessible to most adolescents, nor do they always meet the needs of many adolescents who receive care in safety-net settings. Even when such services are accessible, many adolescents may not find them acceptable because of concerns that confidentiality is not fully en- sured, especially in such sensitive domains as substance use or sexual and reproductive health. In general, the committee found that some existing models of primary and specialty care services for adolescents reflect one or more of the five objectives of accessibility, acceptability, appropriateness, effectiveness, and equity. However, none of these models have been demonstrated to possess all five of these characteristics. Overall Conclusion 2: Many current models of health services for adolescents exist. There is insufficient evidence to indicate that any one particular approach to health services for adolescents achieves significantly better results than others. Furthermore, the committee found that the various settings, services, and providers used by adolescents often are not coordinated with each other, and the result is barriers to and gaps in care. In some areas, such as the organization of mental health services for adolescents, the system of services is in substantial disarray because of financing barriers, eligibil- ity gaps, and both confidentiality and privacy concerns—all of which can hamper transitions across care settings. Overall Conclusion 3: Health services for adolescents currently consist of separate programs and services that are often highly fragmented,

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0 OVERALL CONCLUSIONS AND RECOMMENDATIONS poorly coordinated, and delivered in multiple public and private settings. The committee also found that many adolescent health services and settings take a limited, problem-oriented approach and focus on care for certain health conditions or specific issues, thus failing to meet the broader needs and behavioral challenges that characterize adolescence. Because of this narrow focus, many providers of health services are poorly equipped to foster disease prevention and health promotion for adolescents. This is es- pecially true in the areas of mental health, oral health, and substance abuse, as well as services that address sexual behavior and reproductive health. Overall Conclusion 4: Health services for adolescents are poorly equipped to meet the disease prevention, health promotion, and behav- ioral health needs of all adolescents. Instead, adolescent health services are focused mainly on the delivery of care for acute conditions, such as infections and injuries, or special care addressing specific issues, such as contraception or substance abuse. Adolescent Health System Supports The committee was asked to explore the policies and mechanisms of support that promote high-quality health services for adolescents, as well as the barriers that impede optimal service provision. In doing so, the com- mittee considered issues related to privacy and confidentiality, as well as health insurance. Privacy and Confidentiality Concerns about privacy and confidentiality may be a significant aspect of many adolescents’ interactions with health services. During screening and assessment, for example, sensitivity to stigma and bias may affect the adolescent patient’s willingness to trust and communicate with health professionals or return for follow-up care. As well, while professional guidelines for the practice of adolescent medicine stress the importance of privacy and confidentiality in interactions with adolescent patients, parents frequently receive information about their children’s health services. Many medical professionals recognize the importance of parents’ involvement in their adolescent children’s health care decisions. At the same time, however, privacy concerns influence adolescents’ willingness to seek services at all, their choice of provider, their candor in giving a health history, their will- ingness to accept specific services, and other important aspects of access to care. The committee found evidence showing that confidentiality increases

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02 ADOLESCENT HEALTH SERVICES 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. The committee concluded that existing state and federal policies generally protect the confidentiality of adolescents’ health information when they are legally allowed to consent to their own care, and that it is critical that any efforts to improve health systems for adolescents ensure continued consent and confidentiality for adolescents seeking care. Health Insurance The committee found that financial support for health services is fun- damental to promoting adolescents’ engagement with, access to, and use of these services. More than 5 million adolescents aged 10–18 are uninsured. Uninsured rates are higher among the poor and near poor, racial and ethnic minorities, and noncitizens. As is true for all Americans, uninsured adolescents are less likely to have a regular source of primary care and use medical and dental care less often than those who have insurance. Having health insurance, however, does not ensure adolescents’ access to afford- able, high-quality services given current shortages of health care providers and problems associated with high out-of-pocket cost-sharing requirements, limitations in benefit packages, and low provider reimbursement levels, especially in areas that involve counseling or case management of multiple health conditions. For example, the current system of health insurance cov- erage is often limited or nonexistent for treatment and prevention in areas that are particularly problematic for adolescents, such as obesity, inten- tional and unintentional injury, mental health, dental care, and substance abuse. Furthermore, uninsured adolescents aged 10–18 who are eligible for public coverage often are not enrolled either because their parents do not know they are eligible or because complexities of the enrollment processes deter participation. Overall Conclusion 5: Large numbers of adolescents are uninsured or have inadequate health insurance, which can lead to a lack of access to regular primary care, as well as limited behavioral, medical, and dental care. One result of such barriers and deficits is poorer health. Adolescent Health Care Providers The committee was asked to consider the elements of health provider training necessary to improving the quality of health services for adoles- cent populations. The committee found that whether providers report on their own perceptions of their competencies or adolescents describe the care they have received, data reveal significant gaps in the achievement of

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0 OVERALL CONCLUSIONS AND RECOMMENDATIONS a well-equipped and appropriately trained workforce ready to meet the health needs of adolescents. At all levels of professional education, health care providers in every discipline serving adolescents should receive spe- cific and detailed education in the nature of adolescents’ health problems and have in their clinical repertoire a range of effective ways to treat and prevent disease in this age group, as well as to promote healthy behavior and lifestyles within a developmental framework. Evidence suggests this currently is not the case. Overall Conclusion 6: Health care providers working with adolescents frequently lack the necessary skills to interact appropriately and effec- tively with this age group. Research Needs Developing a clear definition of adolescent health status is a critical step in delivering health services and forming health systems that can respond appropriately to the specific needs of adolescents. Moreover, the ability to understand and characterize health status within this definition is dependent on available data, particularly that related to adolescent behavior. Those concerned with the health of adolescents—health practitioners, policy mak- ers, and families—would benefit from ready access to high-quality and more precise data that would aid in better understanding the consequences of health-influencing behaviors for the health status of adolescents. Overall Conclusion 7: The characterization of adolescents and their health status by such traditional measures as injury and illness does not adequately capture the developmental and behavioral health of adolescents of different ages and in diverse circumstances. This report proposes several approaches to improving health systems for adolescents to make services more 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. As noted above, however, limited evidence is available on health outcomes associated with alternative service approaches. Therefore, the committee attempted to iden- tify areas in which research could yield knowledge that would support quality improvements in the organization and delivery of health services for adolescents. For example, the evidentiary base currently does not sup- port the formulation of performance standards and operational criteria that would make it possible to compare the strengths and limitations of different

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0 ADOLESCENT HEALTH SERVICES 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 knowl- edge base on the provision of services to these groups should therefore be a major priority in efforts to improve health services and the quality of care for adolescents. LOOKING AHEAD: RECOMMENDATIONS The committee’s ultimate goal in this report is to synthesize contempo- rary issues in adolescent health and to examine strengths and deficiencies in the health system that responds to these issues. The report also provides a framework for identifying key objectives of a high-quality system of health services for all adolescents in the United States, with particular attention to those who engage more heavily in risky behavior or who face major barriers in gaining access to health services. Based on the overall conclusions presented above and reflecting the need for a multifaceted approach to fostering successful interactions be- tween adolescents and health service settings and systems, the committee makes eleven recommendations, directed to both public and private entities, for investing in, strengthening, and improving health services for adoles- cents. These recommendations embody many of the behavioral and con- textual characteristics—development, timing, context, need, participation, family, community, skill, money, and policy—that the committee explored in its evidence review. If acted upon in a coordinated and comprehensive manner, the following recommendations should improve the accessibility, acceptability, appropriateness, effectiveness, and equity of health services delivered to adolescents. Primary Health Care Recommendation 1: Federal and state agencies, private foundations, and private insurers should support and promote the development and use of a coordinated primary health care system that strives to improve health services for all adolescents. Carrying out this recommendation would involve federal and state agencies, private foundations, and private insurers working with local pri- mary care providers to coordinate services between primary and specialty care services. It would also entail providing opportunities for primary care services to interact with health programs for adolescents in multiple safety- net settings, such as schools, hospitals, and community health centers.

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05 OVERALL CONCLUSIONS AND RECOMMENDATIONS Recommendation 2: As part of an enhanced primary care system for adolescents, health care providers and health organizations should fo- cus attention on the particular needs of specific groups of adolescents who may be especially vulnerable to risky behavior or poor health because of selected population characteristics or other circumstances. Implementing this recommendation would involve focusing explicit attention on issues of access, acceptability, appropriateness, effectiveness, and equity of health services for an increasingly racially and ethnically diverse population of adolescents and for selected adolescent groups, such as those who are poor; in the foster care system; homeless; in families that have recently immigrated to the United States; lesbian, gay, bisexual, or transgender; or in the juvenile justice system. Recommendation 3: Providers of adolescent primary care services and the payment systems that support them should make disease prevention, health promotion, and behavioral health—including early identification, management, and monitoring of current or emerging health conditions and risky behavior—a major component of routine health services. For this recommendation to be realized, providers of adolescent pri- mary care services would need to give attention to the coordination and management of the specialty services young people often need. They would coordinate screening, assessment, health management, and referrals to spe- cialty services. They would also monitor behavior that increases risk in such areas as injury, mental health, oral health, substance use, violence, eating disorders, sexual activity, and exercise. Performance measures for these services would need to be incorporated into criteria used for credentialing, pay-for-performance incentives, and quality measurement. And perhaps most important, payment systems would need to finance such services and activities. Public Health System Recommendation 4: Within communities—and with the help of public agencies—health care providers, health organizations, and community agencies should develop coordinated, linked, and interdisciplinary ado- lescent health services. To effect this recommendation, health care providers across communi- ties would need to work together to encourage rapid and coordinated ser- vices through collocation or participation in regional planning and action groups organized by managed care plans, large group networks, health

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0 ADOLESCENT HEALTH SERVICES professional associations, or public health agencies. Beyond direct patient services, primary care providers and providers of mental health/substance abuse, reproductive, nutritional, and oral health services would have to establish public and private programs in a region for managing referrals; coordinating electronic patient information; and staffing adolescent call centers and regional services to communicate directly with adolescents, their families, and various providers. In addition, the particular health needs of adolescents, especially the most vulnerable populations, would need to be addressed in the development of electronic health records. Such records offer a significant opportunity to ensure coordinated care, as well as to provide adolescent-focused patient portals, messaging and reminder services, and electronic personalized health education services to improve interventions. An overarching principle in the implementation of this recommendation is that adolescents should be asked to give explicit consent for the sharing of information about them, a point addressed in the committee’s next recommendation. Privacy and Confidentiality Recommendation 5: Federal and state policy makers should maintain current laws, policies, and ethical guidelines that enable adolescents who are minors to give their own consent for health services and to receive those services on a confidential basis when necessary to protect their health. To implement this recommendation, federal and state policy makers would need to examine the variations among states in the age of consent for care for adolescents and consider the impact of such variations on ado- lescents’ access to and use of services that are essential to protecting their health (e.g., services for contraception, sexually transmitted infections/HIV, mental health, and substance use). A balance is needed between maintain- ing the confidentiality of information and records regarding care for which adolescent minors are allowed to give their consent, and encouraging the involvement of parents and families in the health services received by ado- lescents whenever possible, both supporting and respecting their role and importance in adolescents’ lives and health care. Adolescent Health Care Providers Recommendation 6: Regulatory bodies for health professions in which an appreciable number of providers offer care to adolescents should incorporate a minimal set of competencies in adolescent health care and development into their licensing, certification, and accreditation requirements.

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07 OVERALL CONCLUSIONS AND RECOMMENDATIONS To implement this recommendation, regulatory bodies would need to use national meetings of specialists and educators/scholars within relevant disciplines to define competencies in adolescent health. They would also have to require professionals who serve adolescents in health care settings to complete a minimum amount of education in basic areas of adolescent development, health issues unique to this life stage, and a life course frame- work that encourages providers to focus on helping their adolescent pa- tients develop healthful habits that can be carried forward into their adult lives. Finally, agencies that fund training programs would have to adhere to the requirements of the regulatory bodies (i.e., with regard to accreditation, licensure, and certification, and to maintenance of licensure or certification where appropriate), and content on adolescent health would have to be mandatory in all relevant training programs. Recommendation 7: Public and private funders should provide targeted financial support to expand and sustain interdisciplinary training pro- grams in adolescent health. Such programs should strive to prepare specialists, scholars, and educators in all relevant health disciplines to work with both the general adolescent population and selected groups that require special and/or more intense services. To effect this recommendation, public and private funders would need to ensure that professionals who serve adolescents in health care settings are trained in how to relate to adolescents and gain their trust and coop- eration; how to develop strong provider–patient relationships; and how to identify early signs of risky and unhealthful behavior that may require further assessment, intervention, or referral. Also essential to the train- ing of these professionals is knowing how to work with more vulnerable adolescents, such as those who are in the foster care system; homeless; in families that have recently immigrated to the United States; lesbian, gay, bisexual, or transgender; or in the juvenile justice system. Important as well is to increase the number of Leadership Education in Adolescent Health programs that train health professionals in adolescent medicine, psychol- ogy, nursing, social work, and nutrition, and to enhance the program by adding dentistry. Health Insurance Recommendation 8: Federal and state policy makers should develop strategies to ensure that all adolescents have comprehensive, continu- ous health insurance coverage.

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0 ADOLESCENT HEALTH SERVICES Federal and state legislatures and governments should consider the following options for implementing this recommendation: require states to provide Medicaid or other forms of health insurance coverage for especially vulnerable or underserved groups of adolescents, particularly those who are in the juvenile justice and foster care systems, and support states in meet- ing this requirement; design and implement Medicaid and State Children’s Health Insurance Program policies to increase enrollment and retention of eligible but uninsured adolescents; and improve incentives for private health insurers to provide such coverage (e.g., by requiring school-based coverage and allowing nongroup policies tailored to adolescents). Note that while these options would increase insurance coverage among adolescents, broader health care reform efforts would be required to ensure univer- sal coverage. A consequence of allowing more segmentation in nongroup health insurance policies across age groups could be increased costs for older adults if younger, healthier adults are removed from the risk pool. In addition, expanding access to and election of coverage among poor adoles- cents would be necessary to increase the rates of insured adolescents. Recommendation 9: Federal and state policy makers should ensure that health insurance coverage for adolescents is sufficient in amount, dura- tion, and scope to cover the health services they require. Such coverage should be accessible, acceptable, appropriate, effective, and equitable. Public and private health plans, including self-insured plans, should consider several options for carrying out this recommendation. First, they could see that benefit packages cover at a minimum the following key services for adolescents: preventive screening and counseling, at least on an annual basis; case management; reproductive health care that includes screening, education, counseling, and treatment; assessment and treatment of mental health conditions, such as anxiety disorders and eating disorders, and of substance abuse disorders, including those comorbid with mental health conditions; and dental services that include prevention, restoration, and treatment. Second, they could ensure coverage for mental health and substance abuse services at primary or specialty care sites that provide integrated physical and mental health care, and require Medicaid to cover mental health rehabilitation services. Third, they could make certain that providers are reimbursed at reasonable, market-based rates for the ado- lescent health services they provide. Finally, they could ensure that out-of- pocket cost sharing (including mental health and other health services) is set at levels that do not discourage receipt of all needed services.

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0 OVERALL CONCLUSIONS AND RECOMMENDATIONS Research Agenda Recommendation 10: Federal health agencies and private foundations should prepare a research agenda for improving adolescent health ser- vices that includes assessing existing service models, as well as develop- ing new systems for providing services that are accessible, acceptable, appropriate, effective, and equitable. Federal health agencies should consider a number of options for carry- ing out this recommendation. First, they could identify performance stan- dards and operational criteria that could be used to compare the strengths and limitations of different models of health service delivery in meeting the needs of all young people, as well as specific groups. In developing such standards and criteria, an effort should be made to translate the features of accessibility, acceptability, appropriateness, effectiveness, and equity into clear standards and ways to measure their achievement. Second, they could determine the effectiveness (not just the efficacy) of selected mental health, behavioral, and developmental interventions for adolescents. This research should be aimed at identifying individual, environmental, and other con- textual factors that significantly affect the likelihood of establishing, oper- ating, and sustaining effective interventions in a variety of service settings. Third, they could assess and compare the health status (defined by selected population characteristics and other circumstances) and health outcomes of young people who receive care through different service models and in different health settings, as well as of those who are difficult to reach and serve. Fourth, they could identify effective ways to reach more underserved and vulnerable adolescents with appropriate and accessible health services. Such research might also consider how to integrate the features of acces- sibility, acceptability, appropriateness, effectiveness, and equity into the primary care environment for all adolescents, as well as into the training of providers who interact with adolescents. Finally, they could evaluate the validity and reliability of various screening tools and counseling techniques for selected groups of adolescents. Monitoring Progress Recommendation 11: The Federal Interagency Forum on Child and Family Statistics should work with federal agencies and, when pos- sible, states to organize and disseminate data on the health and health services, including developmental and behavioral health, of adolescents. These data should encompass adolescents generally, with subreports by age, selected population characteristics, and other circumstances.

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0 ADOLESCENT HEALTH SERVICES To implement this recommendation, federal agencies would need to adopt consistent age brackets that cluster data by ages 10–14 and 15–19 and consistent identifiers of socioeconomic status, geographic location, gen- der, and race and ethnicity. Also needed are consistent identifiers of specific vulnerable adolescent populations, including those in the foster care sys- tem; those who are homeless; those who are in families that have recently immigrated to the United States; those who are lesbian, gay, bisexual, or transgender; and those in the juvenile justice system. Important as well is to track emerging disparities in access to and utilization of health services, with attention to specific components of health care, such as screening, assessment, and referral, as well as an emphasis on racial and ethnic dif- ferences. Finally, longitudinal studies are needed on the effects of both health-promoting and health-compromising behaviors that often emerge in the second decade of life and continue into adulthood. CLOSING THOUGHTS While the gaps and problems in the health services used by young people discussed in this report are not unique to this age group, a com- pelling case can be made for improving health services and systems both to support the healthy development of adolescents and to enhance their transitions from childhood to adolescence and from adolescence to adult- hood. Current interest in restructuring the way health care is delivered and financed in the United States—and defining the content of care itself more broadly—is based on a growing awareness that existing health ser- vices and systems for virtually all Americans have important and costly shortcomings. In the midst of these discussions, the distinct deficits faced by adolescents within the health system deserve particular attention. Their developmental complexities and risky behavior, together with the need to extend their care beyond the usual disease- and injury-focused services, are key considerations in any attempt to reform the nation’s chaotic health care system—especially if adolescents are to benefit. Even if the larger systemic issues of access to the health system were resolved, more would likely need to be done to achieve better health for adolescents during both the adoles- cent years and the transition to adulthood. REFERENCE World Health Organization, United Nations Population Fund, and United Nations Children’s Fund. (1995). Action for Adolescent Health: Towards a Common Agenda: Recommenda- tions from a Joint Study Group. Available: http://www.who.int/child_adolescent_health/ documents/frh_adh_97_9/en/index.html [May 28, 2008].