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 populations 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 ensured, 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, eligibility 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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