Adolescent Health Services Missing Opportunities (2009) / Chapter Skim
Currently Skimming:
3 Current Adolescent Health Services, Settings, and Providers
3 Current Adolescent Health Services, Settings, and Providers
Pages 135-193
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From page 135... ...
– ffective at fostering health promotion or addressing risky be e haviors that are prevalent among adolescents, such as sub stance use and unsafe sexual activity.
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From page 136... ...
– mportant mechanisms for resolving the disparities and inequi i ties that exist within private office-based primary care. Specialty Care Services • Evidence shows that specialty care services for the adolescent population are not accessible to most adolescents.
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The chapter then reviews the current array of mainstream and safety-net primary care services, as well as specialty services, that respond to the adolescent health needs identified in Chapter 2; a brief discussion of inpatient hospital services for adolescents is also presented. This review is followed by a discussion of what is known about adolescents' use of health services.
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From page 138... ...
identified ways to foster patient–provider relationships that can lead to better health for adolescents. This research from various sources and the experiences of adolescents and health care providers, health organizations, and research centers have directed attention to the importance of designing primary care services that can attract and engage adolescents, create opportunities to discuss sensitive health and behavioral issues, and offer high-quality health services as well as guidance on both disease prevention and health promotion.
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Table 3-1 summarizes this comparison and illustrates that while there is considerable overlap between the two frameworks, there are important differences that merit consideration. The IOM framework reflects concerns about how to improve quality and reduce inefficiencies in services received by patients who have access to health care providers, especially those who need specialty care for chronic conditions
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From page 140... ...
Since all adolescents need to interact with primary care providers and fewer need specialty services, the WHO framework offers a more appropriate conceptual design for an analysis of the adolescent health system. With the WHO framework in mind, the committee reviewed components of the current adolescent health system -- adolescent health services, the settings where these services are delivered, how services are delivered in these settings, and by whom.
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TABLE 3-1 Comparison of Criteria of the Institute of Medicine and World Health Organization Frameworks for Delivering Health Services IOM Framework Efficient Timely Patient-Centered Equitable Effective Safe WHO Framework Accessible X Acceptable X Appropriate X Effective X X Equitable X NOTES: IOM = Institute of Medicine; WHO = World Health Organization. SOURCES: Institute of Medicine (2001)
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Examples include the primary care services offered by Planned Parenthood clinics (which specialize in reproductive health care) , as well as mental health services that are offered within certain types of community health or hospital-affiliated primary care clinics.
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Private office-based primary care services frequently cover the following: health maintenance or well-care visits (the scope of which is often guided by local school board policies) , basic diagnostic tests (such as height, weight, and blood pressure)
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For example, insurance reimbursements are often inadequate to compensate for the time it takes to offer adequate health promotion or disease prevention services for adolescents (McManus, Shejavali, and Fox, 2003; O'Connor, Johnson, and Brown, 2000)
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But access to adolescent specialists is severely limited, since these practitioners are commonly available only in academic health centers. According to one recent estimate, just 466 certificates in adolescent medicine were issued from 1996 to 2005 (for a population of about 40 million people aged 10–19)
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Furthermore, few centers are specifically focused on the primary care needs of special subpopulations of adolescents, such as those who are in the foster care system, in families that have recently immigrated, or LGBT. The lack of quality private office-based primary care services for these groups creates service gaps that constitute basic disparities and inequities in the health care system.
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. As noted in earlier IOM studies, the safety net consists of public hospital systems; academic health centers; community health centers or clinics funded by federal, state, and local public health agencies; and local health departments.
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Survey of adolescent users of school-based health centers statewide Guo et al.
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CURRENT ADOLESCENT HEALTH SERVICES 149 Populations Findings Middle and high school students Increased receipt of needed health care among users of school center Middle and high school students Increased enrollment and continued high utilization among users of school center Middle and high school students Improved health knowledge and reported health behavior among users of school center Elementary and middle school students with Lower risk of asthma-related hospitalization asthma and emergency department utilization among users of school center General population aged 10–15 Decrease in emergency department utilization among users of school center High school students Increased access to health services and improved health knowledge among users of school center Children and adolescents aged 5–18 Comparable improvement on Children's Global Assessment Scale and Global Assessment of Function Middle school students, mostly Hispanic, Baseline cost of implementation for 2 years, low-income societal perspective Students in grades 7–12 Increased utilization of mental health counseling services in school-based program Primarily pregnant African American Lower risk of low-birthweight infants in adolescents school-based program Children and adolescents, low-income Lower emergency department utilization and hospitalization, less follow-up for asthma among users of school center Elementary, middle, high school students Increased receipt of needed health care in schools with centers; provided a baseline for further evaluation Elementary, middle, high school students Mixed results; set baseline goals for improvement Elementary, middle, high school students Qualitative associations to provide a baseline for further evaluation Continued
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From page 150... ...
While many community-based health centers have the capacity to offer reproductive health or behavioral health services, few have the resources to provide routine or specialized oral health services for adolescents. These free-standing centers are frequently housed in locations that provide easy access to and opportunities for unscheduled encounters with adolescents in need.
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From page 151... ...
in center Children and adolescents with asthma Higher visit rates for asthma compared with both; lower emergency department utilization compared with hospital; higher hospitalization rates compared with solo/ group physicians Adolescents, high proportion receiving Lower rates of anemia and pre-eclampsia in Medicaid pregnant adolescents Such centers often encourage interdisciplinary teams and integrated case management among their staff; in some situations, they assist adolescents in resolving housing, school, employment, legal, and family problems that contribute to their health conditions. Community-based adolescent health centers frequently are vulnerable to the same limitations that characterize many other community-based programs: they serve a limited population of adolescents; they have a low-volume patient base; they are often poorly reimbursed for services associated with counseling, team interaction, and case management; they frequently rely on part-time health care providers and have difficulty attracting and retaining skilled personnel (because of limited funding, time demands, and difficulty securing malpractice insurance)
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From page 152... ...
Most adolescents in school already have access to and utilize mainstream primary care services. Yet many high-risk adolescents -- a significant and growing segment of the population according to the 1997 IOM study -- may be better served by providers in schoolbased health centers if they lack access to other community health personnel or do not find their local providers to be sensitive to their needs.
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From page 153... ...
One study found that hospitals were the leading organizers of school-based health centers, sponsoring 32 percent of the total number. Health departments and federally funded community health centers each sponsored 17 percent, school districts 15 percent, and community-based nonprofit organizations 12 percent (Juszczak et al., 2003)
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Many centers are unable to provide a full range of reproductive health care services on site. Many are not able to employ full-time providers.
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Overall, little coordination successfully coordinated services with managed care with managed care organizations occurs. organizations.
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Hospital-, community-, and school-based health centers provide valuable services for adolescents who have difficulty gaining access to mainstream primary care services or who require additional support in engaging with health care providers. While an extensive literature on the quality of schoolbased health services for adolescents is available, few studies have examined the quality of hospital- or community-based primary care services for adolescents.
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SPECIALITY CARE SERVICES The preceding section reviewed knowledge of and experience with an array of programs and centers that offer primary care services for adolescents. This section focuses on specialty services in the areas of mental health, sexual and reproductive health, oral health, and substance use treatment and prevention.
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. Sexual and Reproductive Health The American Medical Association and the American College of Obstetricians and Gynecologists, among others, recommend that adolescents receive guidance and counseling on responsible sexual behavior, including abstinence, methods of birth control, and prevention of STIs and HIV infection (American Medical Association, 1997; Committee on Adolescent Health and American College of Obstetricians and Gynecologists, 2006)
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. Reproductive health services include family planning services and/or related medical services.
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. Studies evaluating the effectiveness of clinic services tailored specifically to adolescents have found that clinic interventions can increase adolescents' use of contraception, reduce rates of adolescent pregnancy, and increase adolescents' knowledge about sexual and other reproductive health issues (Burlew and Philliber, 2007)
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From page 161... ...
This frequent contact gives dentists both opportunities and responsibilities to engage their adolescent patients in promoting salutary health behaviors, to detect eating disorders and risky behaviors, and to identify health conditions that require referral. Despite the frequency with which adolescents visit dentists, however, the dental profession and its pediatric specialty have until recently focused relatively little on adolescence beyond orthodontic issues.
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. Unmet need for preventive dental care among children and adolescents who have not seen a dentist in the past year increases steadily by age to one in five adolescents aged 12–17 (Maternal and Child Health Bureau, 2005)
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From page 163... ...
The criminal justice system is the major source of referrals for adolescent substance use treatment. In 2004, for example, the criminal justice system accounted for 52 percent of referrals for admission to treatment among adolescents aged 12–17, and the same percentage was reported for older adolescents aged 18–21 (Substance Abuse and Mental Health Services Administration, 2006a)
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In the National Survey on Drug Use and Health (2003–2004) , among those who were classified as needing treatment but had received no specialty treatment in the past year, only 2.2 percent perceived a need for treatment for alcohol use problems and only 3.5 percent for drug use problems (Substance Abuse and Mental Health Services Administration, 2006b)
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, studies of the relative effectiveness of a limited number of adolescent substance use treatment programs have been unable to demonstrate that one particular program or approach consistently works better than others (Godley et al., 2004; Morral et al., 2006; White, White, and Dennis, 2004)
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Findings: • vidence shows that specialty care services for the adolescent popu E lation are not accessible to most adolescents. Existing specialty services in the areas of mental health, sexual and reproductive health, oral health, and substance use treatment and prevention are generally insufficient to meet the needs of many adolescents.
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. Adolescents aged 13–17 account for 11 percent of all hospital stays by those aged 0–17.
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data that are based on adolescents aged 18 and over reporting for themselves and parents reporting for those under age 18. This is the standard methodology for most national household surveys.
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. A very small proportion of adolescents report nontraditional sites, such as school-based health centers, hospital emergency departments, or family planning centers, as their usual source of
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Age FIGURE 3-2 Usual source of care for adolescents (%) , by age and setting, 2005 National Health Interview Survey.
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The usual source of care for these adolescents may not embody all aspects of a medical home; for example, a recent analysis from the Child and Adolescent Health Measurement Initiative 2005–2006 found that fewer than half of adolescents with special health needs experienced all facets of a medical home (Maternal and Child Health Bureau, 2008)
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MISSED opportunities FOR PREVENTION AND HEALTH PROMOTION AMONG ADOLESCENTS As reviewed in Chapter 2, more than 70 percent of all deaths among adolescents aged 10–19 can be attributed to three causes: unintentional injuries (including motor vehicle crashes) , homicides, and suicide (National Center for Injury Prevention and Control, 2007)
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report that only 18 percent of adolescents aged 14–18 said they had received counseling on risky behavior (such as smoking, use of alcohol or street drugs, sexual/physical abuse, and violence) ; 23 percent had received preventive screening and counseling on emotional health and relationship issues; and 36 percent had received preventive screening and counseling on sexual activity and STIs.
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In the case of substance use, physicians may be unaware of positive treatment outcomes or lack information on treatment resources for adolescents (Kulig and Committee on Substance Abuse, 2005; Van Hook et al., 2007)
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Understanding the demographics of the primary care panel is critical to any screening process. Summary Health maintenance visits and health supervision are important components of primary care services for adolescents.
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Compared with white children and adolescents aged 4–18, Hispanic and Asian children and adolescents had higher odds (1.30 [1.14–1.48]
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minority youths receive more reproductive health services than white adolescents; and (4) socioeconomic status has a modest impact on health service delivery but does not completely account for the disparities seen.
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in which substantial numbers of adolescents in Massachusetts cited deep concern regarding confidentiality that affected how and when they sought care. Further, studies have examined the impact of limiting confidentiality on adolescents' use of specific health services, such as those addressing sexual and reproductive health, mental health, and substance use.
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From page 179... ...
Of interest, parental notification in one area appears to affect how adolescents view a wider range of reproductive health services: many adolescents said they would alter their use of other health services -- STI and HIV testing and treatment or pregnancy testing -- even if parental notification were required only for birth control. A commentary on this work underscores the dangers to adolescent health indicated by these findings and cites smaller-scale studies that reinforce this concern (Ford and English, 2002)
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180 ADOLESCENT HEALTH SERVICES Accessibility In addition to the importance of confidentiality to adolescents' willingness to seek health services and disclose information to health care providers, it is necessary to ensure access to these confidential services. Consent The protection of confidentiality cannot be considered outside of the legal framework for consent, as it is in the law governing consent to care that difficulty arises in protecting the secrets of adolescents.
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From page 181... ...
The major federal funding programs at issue are Medicaid and the Title X clinics funded under the Public Health Service Act, both of which provide for minors' receipt of confidential family planning services ("without regard to age" in the case of Title X, 42 Code of Federal Regulations § 59.5)
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From page 182... ...
. Proposed legislative changes are often aimed at requiring parental consent and/or notification for such services as abortion, contraception, treatment for substance use, or even diagnosis and treatment for STIs, but sometimes they are aimed at requiring notification of sexual activity by minors in general (Rudoren, 2006)
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• xisting state and federal policies generally protect the confiden E tiality of adolescents' health information when they are legally allowed to consent to their own care. SUMMARY This chapter has presented a review of current health services for adolescents and the settings where those services are typically received, with a focus on both the array of mainstream and safety-net primary care services and specialty services.
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. School based health centers: Accessibility and accountability.
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. Connecticut Association of School Based Health Centers.
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. School-based health centers.
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. Impact of school-based health centers on children with asthma.
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. Do school-based health centers improve adolescents' access to health care, health status, and risk-taking behavior?
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W., and Committee on Substance Abuse.
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. The Rel ative Effectiveness of 10 Adolescent Substance Abuse Treatment Programs in the United States (RAND Technical Report No.
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. Process of care for Medicaid-enrolled children with asthma: Served by community health centers and other providers.
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. Youth-friendly primary-care services: How are we doing and what more needs to be done?
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. A comprehen sive and comparative review of adolescent substance abuse treatment outcome.
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