Adolescent Health Services Missing Opportunities (2009) / Chapter Skim
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The health system -- health services, the settings where these services are delivered, how the services are delivered and by whom -- has an important role to play in promoting healthful behavior, managing health conditions, and preventing disease during adolescence. Yet health services and settings in the United States today are not designed to help young people at this critical time in their lives, and providers often are not adequately trained in adolescent issues. As is the case in many other parts of the nation's health system, adolescents face gaps in care, fragmented services, and missed opportunities for health promotion and disease prevention.
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Definitions The concept of adolescence, which emerged only at the beginning of the twentieth century, is variable and evolving. Based on its review of various definitions of adolescence and of the literature on child and adolescent behavior and development, the committee focused this report -- including the data, conclusions, and recommendations presented -- on those aged 10–19. The report includes consideration of a number of specific groups of adolescents defined by selected population characteristics and other circumstances -- such as those who are poor; members of a racial or ethnic minority; in the foster care system; homeless; in families that have recently The committee recognized that there is disagreement among health care providers, researchers, and policy makers on the age bracket that demarcates the period of adolescence, but decided that on balance, focusing on ages 10–19 provides the best framework for the data analysis and evidence review in this report.
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Health services were defined to include routine checkups; health maintenance or well care visits; school and sports physicals; psychiatric and substance abuse counseling; reproductive health services; dental care; and medical care for injury or illness, including chronic conditions. The committee also considered risky behavior and its implications for adolescent health and health services.
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The availability, nature, and content of health ser vices for adolescents are affected by such financial factors as public 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 ser vices (Chapter 6)
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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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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 transgender; or in the juvenile justice system -- may have higher rates of chronic health problems and may engage in more risky behavior when compared with the overall adolescent population.
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This is especially 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.
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This is especially true in areas that involve counseling or case management of multiple health conditions, and in areas that are particularly problematic for adolescents, such as obesity, intentional 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.
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Carrying out this recommendation would involve federal and state agencies, private foundations, and private insurers working with local primary 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 many safety-net settings, such as schools, hospitals, and community health centers.
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To effect this recommendation, health care providers across communities would need to work together to encourage rapid and coordinated services through collocation or participation in regional planning and action groups organized by managed care plans, large group networks, health 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.
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. A balance is needed between maintaining 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 adolescents whenever possible, both supporting and respecting their role and importance in adolescents' lives and health care.
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Health Insurance Recommendation 8: Federal and state policy makers should develop strategies to ensure that all adolescents have comprehensive, continu ous health insurance coverage. 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 meeting this requirement; design and implement Medicaid and State Children's
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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.
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Also needed are consistent identifiers of specific vulnerable adolescent populations, including those in the foster care system; 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,
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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.
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