Investing in the Health and Well-Being of Young Adults (2015) / Chapter Skim
Currently Skimming:
7 The Health Care System
7 The Health Care System
Pages 275-346
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From page 275... ...
• The transition from child to adult medical and behavioral health care often is associated with poor outcomes among young adults. Challenges include discontinuities in care, differ ences between the child/adolescent and adult health systems, a lack of available adult providers, difficulties in breaking the bond with pediatric providers, lack of payment for transi tion support, a lack of training in childhood-onset conditions among adult providers, the failure of pediatric providers to prepare adolescents for an adult model of care, and a lack of communication between pediatric and adult providers and systems of care.
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From page 276... ...
Certain groups of young adults -- such as young adults exiting the foster care system, young adults involved in the justice system, and unauthorized immigrants -- have particular difficulties in obtaining health care coverage. The Patient Protection and Affordable Care Act and state-level efforts are increasing coverage for many young adults, including young adults who age out of the foster care system, but others, such as unauthorized immigrants, remain outside the system.
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From page 277... ...
Young still hard to access health adults are transitioning from pediatric care. It is so complicated to adult health care providers and from and you don't really learn in the child to the adult behavioral health school how to navigate it."*
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From page 278... ...
BOX 7-1 Barriers to Optimal Health Care for Young Adults The following are barriers faced by young adults in accessing care and/or continuing to receive care in the health care system: • Transitions − avigating the differences between pediatric and adult health care n providers, including differences in treatment culture, family involve ment, and care coordination; − iscontinuity of care caused by age-based changes in eligibility criteria d or target populations for behavioral health services and management of chronic medical conditions; and − hanges in insurance coverage. c • Content − o unified set of young adult preventive care guidelines; and n − ignificant gaps in interventions and treatments with strong evidence s of efficacy for young adults, particularly in preventive and behavioral health.
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From page 279... ...
We first briefly describe where young adults currently receive health care services and what services they use. We then explore in turn transitions from pediatric to adult medical health care systems and from child to adult behavioral health care systems, preventive care for young adults, behavioral health interventions for young adults, health care coverage, and systems issues related to young adults.
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From page 280... ...
This table shows that small percentages of young adults received care for substance use and mental health disorders, even though more than 50 percent reported having a usual source of care and having received a routine general checkup within the past 12 months, and even though early young adulthood is often when the burden of illness emerges for substance abuse and mental health conditions. Emergency rooms represent a major component of care for young adults, utilized by an estimated 15 to 20 percent of this age group (Fortuna et al., 2010; Lau et al., 2014a)
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From page 281... ...
* NOTES: Hospital outpatient visits are to general clinics that are hospital-based.
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From page 282... ...
TRANSITIONS Most young adults face the challenge of accessing a new health care system and new health care team independently of their parents or guardians. In addition to the differences between pediatric and adult health care systems and the possibility that the adult system is less well suited to their developmental stage, they may have changes in insurance coverage and face confidentiality concerns.
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From page 283... ...
While much of the published literature focuses on the transition challenges for those with chronic illness, requiring close medical care, there appears to be no systematic coordination of the transition to adult care for those without chronic medical conditions. It is important to improve the transition process for all youth moving to the adult health care system, not just those who have identified chronic medical conditions.
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From page 284... ...
Despite these challenges, it is possible to plan for a smooth transition with good outcomes. In the case of cystic fibrosis, a chronic illness for which more programs have been implemented for transition care relative to most childhood conditions, a recent study contradicts many previous studies, finding that those who transitioned to adult care had a less rapid
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From page 285... ...
Next we further explore reasons behind the poor outcomes associated with that transition. Limitations of Adult Health Care Providers' Familiarity with the Disease Process and Developmental Needs of Young Adults Because many individuals with serious congenital and childhood-onset diseases are now living into the young adult years, many are now receiving care from adult-focused health professionals who previously did not see patients with these diseases and may not have received training in these areas (e.g., Tuchman et al., 2010)
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From page 286... ...
In the case of cancer treatment, it may be that the transition to adult care should be based not on age but on disease outcome, meaning that some people may need to have pediatric subspecialty care even though they have transitioned to adult primary care and taken on adult roles in other areas of life. Like some adult providers, adult health systems are new to providing care to large numbers of young adults with serious childhood-onset diseases.
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From page 287... ...
An argument for the former approach is that adult care systems are burdened with a growing elderly population and lack the resources to care for young adults. On the other hand, one could argue that keeping young adults in pediatric centers does not facilitate their being treated as adults with appropriate preventive care and confidentiality, and that adult systems are not being encouraged to develop appropriate systems of care based on a life span approach.
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From page 288... ...
. Studies on the perspectives of patients, providers, and families underscore the general discomfort with and lack of a structured process for the transition to adult health care (Peter et al., 2009; Reiss et al., 2005)
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From page 289... ...
These ap ply to all youth and young adults, and the guidelines provide additional information for youth and young adults with special health care needs. The document also identifies the following educational and policy recommen dations for the transition from pediatric to adult health care systems: • enhanced payment for transition services; • ase finding of those in need of transition services who are not receiving c them; • insurance coverage for patients in need of transition planning; • standards of care and credentialing of providers; • raining for primary care physicians and medical subspecialists to pro t mote transitions within the medical home; and • romotion of training and clinical learning experience on transition and p transfer of youth and young adults (both with and without special needs)
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From page 290... ...
for pediatric, internal medicine, family medicine, and med-peds4 practices (The National Alliance to Advance Adolescent Health, 2014b) : • establishing a transition policy, • tracking and monitoring transition progress, • conducting transition readiness assessments, • planning for adult care, • transferring into adult care (if applicable)
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From page 291... ...
The increased emergency room utilization noted above may speak to the difficulty experienced by young adults in transitioning to the adult health care system and their unmet health needs. Behavioral Health Care Transitions Behavioral health care systems typically are separate from medical health care systems, and include both mental health and substance abuse systems.
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From page 292... ...
. In addition, the ACA now prohibits lifetime or annual dollar limits for essential health benefits, which include mental health and substance abuse care (CMS, 2014a)
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From page 293... ...
. Although discussed here in the context of behavioral health transitions, many of these same discontinuities apply more generally to health care coverage issues for young adults.
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From page 294... ...
Children with serious mental health conditions often are involved in multiple systems, including child welfare, juvenile justice, special education, and mental health. Providers in these systems typically are aware of the involvement of other systems, and often communicate and coordinate with them.
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From page 295... ...
PREVENTIVE CARE FOR YOUNG ADULTS The majority of health problems during young adulthood are preventable, and behaviors associated with negative health outcomes have high prevalence among young adults, as described in Chapter 6. These behaviors often are also responsible for the onset of many chronic health conditions
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From page 296... ...
Many of these behaviors represent an opportunity for cessation of harmful behaviors, the development of healthy alternatives, or further entrenchment of the behaviors that threaten adult health. Use of Preventive Care in Young Adults Knowledge of the use and delivery of preventive services for young adults is limited by the lack of attention to this age group in clinical delivery systems and health services research noted throughout this report.
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From page 297... ...
The clinical preventive services recommendations6 of the U.S. Preventive Services Task Force (USPSTF)
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From page 298... ...
(2012) , lists the preventive services that most private plans must cover under the ACA, which include the evidence-based screening and counseling services rated highly in either Category A or B by the USPSTF,7 the Advisory Committee on Immunization Practices' recommended immunizations, the Bright Futures recommendations, and the services specified in the Women's Preventive Services Guidelines (HHS, 2012)
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From page 299... ...
Original sources are the evidence-based screening and counseling services rated highly either in Category A or B by the USPSTF, immunizations recommended by the Advisory Committee on Immunization Practices, the Bright Futures recommendations, and the services specified in the Women's Preventive Services Guidelines. listed in Table 7-5 must be provided to women by private plans without cost sharing (Armstrong, 2012a,b; HHS, 2012; HRSA, 2014)
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From page 300... ...
At present, however, there is no consensus among health professional organizations, the USPSTF, health care plans, and state and federal agencies on guidelines that should be used as the starting point for implementation. Barriers that impede the delivery of preventive services in clinical settings include both clinician factors (e.g., lack of knowledge of guidelines; attitudes toward the efficacy of preventive services; and lack of training, skills, and confidence to deliver the services)
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From page 301... ...
. In addition, current adult health care monitoring efforts do not cover many key topics relevant to young adult screening and counseling, such as obesity-related issues, substance use, and reproductive health issues.
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From page 302... ...
SAMHSA funds the Campus Suicide Prevention Grants8 to support efforts at postsecondary institutions to prevent suicide and to improve services for students with problems that put them at risk of suicide, such as depression, substance abuse, and other behavioral health issues; however, there are currently no rigorously tested interventions to implement. A growing body of research documents brief interventions for reducing college binge drinking with some evidence of efficacy (e.g., Kulesza et al., 2013)
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From page 303... ...
The experience of psychological stress is pervasive in young adults and may contribute to the subsequent development of behavioral or physical health disorders, as described in Chapter 6. A variety of stress reduction techniques are available for which there is evidence of efficacy in adults, such as mindfulness-based approaches or cognitive therapy (Abbott et al., 2014; Querstret and Cropley, 2013)
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HEALTH CARE COVERAGE FOR YOUNG ADULTS Young adults without health insurance or with gaps in insurance coverage are less likely to access health services compared with young adults who are continuously insured (see Figure 7-1)
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From page 305... ...
We also discuss several groups of young adults "My boss took the time to who have particular difficulty access discuss general health care ing care, including unauthorized im information with me, which migrants, those exiting the foster care helped me understand my system, those involved in the justice choices better." system, and those with mental illness. The focus is primarily on financial bar riers, but we identify additional barri ers as well.
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From page 306... ...
. The Patient Protection and Affordable Care Act The ACA includes four principal pathways for increasing health insurance coverage for young adults -- one specific to this age group (coverage under their parents' employer-sponsored health plans)
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. Medicaid expansion and health insurance exchanges under the ACA are the major pathways for increasing coverage among lower-income young adults.
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From page 308... ...
. 9 Calculation performed on access health CT, the Connecticut health insurance exchange, using these parameters during the first ACA enrollment cycle for 2014 coverage.
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From page 309... ...
. Higher rates of both physical and mental health issues are found among children and youth in foster care, including birth defects, developmental delays, emotional adjustment problems, chronic medical problems such as asthma, dental caries, and substance abuse (AAP, 2012; CMHS and CSAT, 2013; Halfon et al., 1995)
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From page 310... ...
Even among those who are living in nonsecure residential placements or on probation or parole, health insurance coverage under both Medicaid and private plans is uneven (English et al., 2014)
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From page 311... ...
For example, legislation in Nevada allows the director of the Department of Corrections to apply for determination of Medicaid eligibility on a prisoner's behalf.10 Having health insurance in place before exiting the system is key so that follow-up health care appointments can proceed immediately thereafter. Among other benefits, this can help prevent recidivism, particularly for those with mental health and substance abuse issues (English et al., 2014)
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From page 312... ...
. While there are important questions about whether and how this population and the communities in which they live would benefit from health insurance coverage, research suggests a positive relationship between extending coverage to all uninsured residents (regardless of legal status)
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. However, DACA recipients are specifically excluded from the ACA's Medicaid expansion and health insurance exchanges (Brindis et al., 2014)
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For example, the Society for Adolescent Health and Medicine includes both
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. As noted above, for those in family and internal medicine who seek board certification in adolescent medicine, preparing adolescents with cystic fibrosis for the transition to adult care is mentioned in the examination content guide (ABP, 2010)
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From page 316... ...
The National Adolescent and Young Adult Health Information Center has collected clinical preventive screening guidelines for young adults aged 18-26, extracting recommendations from the USPSTF, Bright Futures, and ACOG (NAHIC, 2014)
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. The general rule of the Health Insurance Portability and Accountability Act (HIPAA)
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. This might happen if an adolescent or young adult receiving services paid the co-pay or if a service were one of the preventive services for which co-pays cannot be imposed under the ACA.
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. Thus, while integrated care holds promise for better behavioral health care delivery and early intervention with physical health conditions that contribute to early mortality, research is needed to test this promise.
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From page 320... ...
Harnessing Technology for Young Adult Health Care The emerging field of "mHealth" focuses on innovative approaches to using social media and mobile technology for public health and health care delivery (see, for example, the annual mHealth Summit [2014] , the mHealth Alliance [2014]
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From page 321... ...
First, appealing to young people, most of this research focuses on young yet there is definitely a adults with chronic health conditions, concern about privacy. and their preferences and needs may If I lose my phone and not be applicable to all young adults.
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From page 322... ...
found that the existing body of research on peer-led approaches among adults with severe mental health conditions is weak, with inconsistencies in both methods and reporting. Peer-led approaches appear to be as effective as, but no better than, usual behavioral health services provided to adults (LloydEvans et al., 2014)
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From page 323... ...
Young adults with chronic health conditions, including mental health and substance use disorders, often have lower educational attainment and less successful employment experiences and outcomes, as described in Chapter 4. Improving the Transition Process The transition from pediatric to adult health care -- including both medical and behavioral health care -- is associated with poor outcomes for young adults.
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Institute of Medicine Framework for Delivering Quality Health Care Services (IOM, 2001) • afe -- Protocols are in place to reduce medical errors and foster quality S assurance.
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1) Rather than developing a separate approach for improving the transition to adult health care, we propose drawing attention to this transition
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From page 326... ...
• Health care delivery systems and provider organizations serving young adults should develop a coordinated pediatric-to-adult transition-of-care process within their organizations. • Pediatric-to-adult transition-of-care performance metrics should be incorporated into quality measurement and reporting frameworks by the National Committee for Quality Assurance, the National Quality Forum, and other quality measurement entities for all health care delivery models serving young adults, such as medical homes, accountable care organizations, and integrated delivery systems.
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From page 327... ...
Improving Preventive Care for Young Adults As described in Chapters 2 and 6, young adults are less healthy than commonly perceived, the majority of the health problems they face are preventable, and the health habits developed during these years have lifelong implications. Knowledge about the use and delivery of preventive services for young adults is limited, but the available evidence suggests that young adults receive little preventive care.
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From page 328... ...
Recommendation 7-3: Federal, state, and local governments, com mercial insurers, employer-sponsored health plans, and medical and behavioral health systems should adopt the clinical preventive services recommended by the U.S. Preventive Services Task Force, include the delivery of those services in quality performance metrics used for pay for-performance and other health care provider assessments, and re quire public reporting of compliance.
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From page 329... ...
Developing Evidence-Based Practices for Young Adults Most prevention approaches are targeted at children and adolescents, and some are targeted at college students. With the exception of interventions for treating early psychosis, there are few behavioral health interventions developed specifically for young adults, all of which are in early stages of development, and few interventions with demonstrated efficacy specifically in this age group.
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From page 330... ...
2007. ACGME program requirements for graduate medical education in child and adolescent psychiatry.
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2013. ACGME program requirements for graduate medical education in family medicine.
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From page 332... ...
2014. A triple aim approach to transition from pe diatric adult health care for youth with special health care needs.
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From page 333... ...
2013. Sustaining enrollment in health insurance for vulnerable populations: Lessons from Massachusetts.
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From page 334... ...
2012. Young, uninsured, and in debt: Why young adults lack health insurance and how the Affordable Care Act is help ing findings from The Commonwealth Fund Health Insurance Tracking Survey of Young Adults, 2011.
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From page 335... ...
1994. Guidelines for Adolescent Preventive Services (GAPS)
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From page 336... ...
Chapel Hill, NC: Center for Adolescent Health and the Law National Adolescent and Young Adult Health Information Center. English, A., A
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From page 337... ...
2013. Patient Protection and Affordable Care Act; health insurance market rules; rate review.
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From page 338... ...
2012. Preventive services covered under the Affordable Care Act.
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2013. Establishing health insurance exchanges: An overview of state efforts.
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2014b. Improvement in preventive care of young adults after the Affordable Care Act: The Affordable Care Act is helping.
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Washington, DC: NACo. NAHIC (National Adolescent and Young Adult Health Information Center)
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2009. Use of inexpensive technology to enhance adolescent health screening and counseling.
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From page 343... ...
2004. Prevalence and correlates of successful transfer from pediatric to adult health care among a cohort of young adults with complex congenital heart defects.
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Cancer Program. http://www.seattlechildrens.org/clinics-programs/cancer/services/adolescent-young-adult program (accessed July 24, 2014)
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USPSTF (U.S. Preventive Services Task Force)
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From page 346... ...
2014. The effect of the Affordable Care Act's ex panded coverage policy on access to dental care.
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