Adolescent Health Services Missing Opportunities (2009) / Chapter Skim
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4 Improving Systems of Adolescent Health Services
4 Improving Systems of Adolescent Health Services
Pages 194-239
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From page 194... ...
• Incorporate health promotion, disease prevention, and youth devel opment throughout the health system and within the community. • Focus attention on the health and health service needs of those adolescents who are most vulnerable to risky behavior and poor health.
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From page 195... ...
These systems must encompass (1) evidence-based and standardized screening tools and management and referral processes in adolescent-friendly primary care settings, including primary care provider
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From page 196... ...
, specialty care (including mental health, sexual and reproductive health, oral health, and substance abuse treatment and prevention services) , organizational arrangements, workforce development, and financial systems so that adolescent health services can place greater emphasis on health promotion, disease prevention, and youth development.
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From page 197... ...
Systematic efforts to identify and respond appropriately to these behaviors can delay their onset or reduce their severity and duration, as well as prevent the initiation of other, co-occurring behaviors, such as use of alcohol, drugs, and tobacco products; unprotected sex; violence; and hazardous driving. Designing interventions to address unhealthful habits and risky behaviors requires attention to several key components of primary care: screening, assessment, health management, referral, and care management of specialty services.
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From page 198... ...
; and positive benefits from the early initiation of intervention. Despite their infrequent use, a number of routine screening instruments for unhealthful habits and risky behaviors are available for use in primary care settings.
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From page 199... ...
Less clear, however, is whether adolescents who screen positive for these behaviors will have the insurance benefits, transportation access, or cultural predisposition to take advantage of such treatment. It is clear that most criteria for the implementation of screening for unhealthful habits and risky behaviors as part of adolescent primary care, especially those related to depression, substance use, and violence, are not met in most settings that treat large numbers of adolescents, but should See www.ahrq.gov/clinic/prevenix.htm.
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From page 200... ...
• ne recommendation pertains to the use of immunizations for the primary O prevention of selected infectious diseases. The 14 topics or health conditions addressed by GAPS are divided into those aimed at health promotion and those aimed at disease prevention: Promotion • Parents' ability to respond to the health needs of their adolescents • Adjustment to puberty and adolescence • Safety and injury prevention • Physical fitness • Healthy dietary habits and prevention of eating disorders and obesity • ealthy psychosexual adjustment and prevention of the negative health H consequences of sexual behaviors Prevention • Hypertension • Hyperlipidemia • The use of tobacco products • The use and abuse of alcohol and other drugs • Severe or recurrent depression and suicide • Physical, sexual, and emotional abuse • Learning problems • Infectious diseases SOURCE: American Medical Association (1997)
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From page 201... ...
Specifically, the increased willingness of payors to reimburse primary care clinicians for screening and assessment activity and the rapid expansion of pay-for-performance contracting that rewards early detection, as well as the greater availability of automated screening tools and brief paper tools, are all likely to encourage clinicians to consider universal screening during adolescent visits. Assessment Research has identified a developmental sequence in the emergence of unhealthful habits and risky behaviors such as substance use.
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From page 202... ...
Health Management Health management of unhealthful habits and risky behaviors in primary care settings has a limited research base except for some studies of specific domains or risks. For example, there has been considerable research on the prescription of psychotropic drugs for the management of depression and attention-deficit hyperactivity disorder (ADHD)
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From page 203... ...
. While primary care management of mental health disorders such as ADHD and depression is fairly well documented, much less evidence exists on the primary care management of high-risk sexual activity, substance use disorders, adolescent obesity, or other nutritional problems.
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From page 204... ...
When care is less continuous and youths are seen only once every few years, the potential benefits are much more difficult. In addition to the establishment of close ties with adolescents, primary care management will increasingly require monitoring strategies.
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From page 205... ...
In many areas of the country, managed care "carve outs" -- separate insurance plans for the delivery of specialty oral health, mental health, and substance abuse benefits -- provide their insured customers with a limited panel of professionals who may or may not have expertise in working with adolescents and may or may not provide evidence-based interventions. Furthermore, the primary care clinician may have no access to the list of See http://www.nrepp.samhsa.gov/.
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From page 206... ...
health system is the absence of resources devoted to managing specialty care services and easing transitions across multiple settings for the treatment of chronic, complex, or comorbid health conditions. While these challenges exist for all populations, they are especially problematic for adolescents and their families who lack experience in navigating transitions between primary and specialized care settings.
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From page 207... ...
Summary Health settings can play a critical role in the early identification, management, and monitoring of adolescents who are experimenting with unhealthful habits and risky behaviors. Fulfilling this role, however, requires an intentional and systematic process of screening, assessment, health management, referral, and care management of specialty services.
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From page 208... ...
The dental care delivery system functions separately from the medical care system; lacks a discrete adolescent focus; is rarely collocated with medical services for adolescents; and is overwhelmingly private, with only a small safety-net component that is readily accessible to the socially and medically disadvantaged. Physicians typically do not screen for dental caries and periodontal disease, the two most common oral health problems in adolescence.
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From page 209... ...
Collocation of specialty, dental, and primary care services is beneficial in some settings, especially for adolescents with transportation and confidentiality concerns. The shortages and inequitable distribution of mental health, oral health, sexual and reproductive health, nutritional, and other specialty services necessary for adolescents are long-standing problems.
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From page 210... ...
Various health settings or programs may provide opportunities to strengthen health promotion and disease prevention. As well, the area of youth development offers another approach to promoting health among adolescents.
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From page 211... ...
Through their national organizations and state chapters, providers should endeavor to present messages consistent with those of other groups and to encourage healthy behaviors through available educational materials. Disease Prevention As noted earlier in this chapter, unhealthful habits and risky behaviors directly related to leading causes of premature death and disease in adulthood are usually initiated in adolescence, but have consequences that extend into adulthood.
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From page 212... ...
These protective factors operate within multiple domains -- the individual, the family, the school, the peer group, the neighborhood, and the larger community. Intervention with the family is an important component of most successful disease prevention programs.
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Unfortunately, as discussed in Chapter 3, the proportion of adolescents making any sort of a visit to a health care provider decreases as adolescents mature, as does the proportion making a health maintenance visit in particular (Schuchter and Fairbrother, 2008)
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From page 214... ...
to administer vaccines. • The continued and increased education of health care providers, parents, and adolescents regarding the disease prevention benefits of immunization.
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From page 215... ...
IMPROVING SYSTEMS OF ADOLESCENT HEALTH SERVICES 215 BOX 4-2 Personal and Social Assets That Facilitate Positive Youth Development Physical Development • Good health habits • Good health risk management skills Intellectual Development • Knowledge of essential life skills • Knowledge of essential vocational skills • School success • Rational habits of mind -- critical thinking and reasoning skills • In-depth knowledge of more than one culture • Good decision-making skills • Knowledge of skills needed to navigate through multiple cultural contexts Psychological and Emotional Development • Good mental health, including positive self-regard • Good emotional self-regulation skills • Good coping skills • Good conflict resolution skills • Mastery motivation and positive achievement motivation • Confidence in one's personal efficacy • "Planfulness" -- planning for the future and future life events • Sense of personal autonomy/responsibility for self • Optimism coupled with realism • Coherent and positive personal and social identity • Prosocial and culturally sensitive values • Spirituality or a sense of a "larger" purpose in life • Strong moral character • A commitment to good use of time Social Development • onnectedness -- perceived good relationships and trust with parents, C peers, and some other adults • ense of social place/integration -- being connected and valued by larger S social networks • ttachment to prosocial/conventional institutions, such as school, church, A and nonschool youth programs • Ability to navigate in multiple cultural contexts • Commitment to civic engagement SOURCE: Reproduced from National Research Council and Institute of Medicine (2002)
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From page 216... ...
Positive social norms Rules of behavior, expectations, Normlessness, anomie, laissez-faire practices, injunctions, ways of doing things, values antisocial and amoral norms, norms that and morals, obligations for service. encourage violence, reckless behavior, consumerism, poor health practices, conformity.
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From page 217... ...
Support for efficacy and mattering Youth-based empowerment practices Unchallenging, overcontrolling, that support autonomy, making a real disempowering, disabling. Practices that difference in one's community, and undermine motivation and desire to learn, being taken seriously.
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From page 218... ...
These efforts are seen as a complement to, and sometimes a substitute for, problem-based disease prevention and treatment programs, especially in such areas as substance abuse, juvenile delinquency, and risky sexual activity. The Center for Youth Development and Policy Research within the Academy of Educational Development, for example, offers an extensive array of research publications and other resources that support the undertaking of such efforts in different communities.
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From page 219... ...
ENsuring Access to confidential services As reviewed in Chapter 3, health care services that are confidential increase the acceptability of services and the willingness of adolescents to seek care, especially for sensitive issues such as sexual behavior, reproductive health, mental health, and substance use. Not only may the confidentiality of health services for patients increase utilization of health care, but it also may be morally appropriate.
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From page 220... ...
Physicians and other health practitioners who care for adolescents understand that, as in medicine generally, the assurance of confidentiality in adolescent medicine is not an absolute. Given that the stakes are high for adolescents and their health and that the persons to whom confidences would be revealed are most often parents, health care professionals treating adolescents must constantly walk a fine line in determining how best to secure the trust of their adolescent patients and in deciding what to disclose and when.
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From page 221... ...
The data cited earlier make this clear: even for intimate forms of care such as reproductive health services and even at public clinics, the great majority of parents are involved (Jones et al., 2005) , and most organizations of health care professionals encourage communication between parents and adolescents about important health concerns and health services (Morreale, Stinnett, and Dowling, 2005)
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From page 222... ...
privacy concerns influence adolescents' willingness to seek services at all, their choice of provider, their candor in giving a health history, their willingness to accept specific services, and other important aspects of access to care; (3) few adolescents plan to stop risky behaviors if confidential care is unavailable; (4)
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From page 223... ...
INNOVATIONS IN ADOLESCENT HEALTH SERVICES A greater focus on community resources, linkages to specialty care, and increased standardization of adolescent health services will not happen in a vacuum. Advances in health information technology for adolescents hold promise for facilitating the integration and coordination of adolescent health services across geographic areas.
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From page 224... ...
Their comfort level with electronic communications and activity far exceeds that of their parents and other older family members, and for many, e-mail, the Internet, social networking sites, mobile phones, and text messaging are an integral form of communication. Health institutions, however, have not kept pace with their young patients in this regard, especially in considering how such technologies can improve health service delivery and reduce unhealthful habits and risky behaviors.
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From page 225... ...
These efforts demonstrate both the potential and the drawbacks of highly focused adolescent specialty sites. Almost all of them provide the types of services needed by adolescents -- from reproductive services to counseling and mental health -- in a more comprehensive way than do traditional primary care settings.
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From page 226... ...
Denver Health manages all policies, procedures, protocols, registration, billing, quality assurance, staff development, strategic planning, grant management, utilization review, and outcome monitoring internally. The system also works with other community partners, including the local mental health authority, a substance abuse organization, two other local hospitals, Denver public schools, and other community services (Special Supplemental Nutrition Program for Women, Infants, and Children; immunization; early periodic screening, diagnosis, and treatment; and services for children with special health needs)
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From page 227... ...
The most common services provided to adolescents in the school-based and community health centers are immunizations; health maintenance visits; asthma treatment; gynecological and reproductive health services (family planning, pregnancy testing) ; STI screening and treatment; behavioral services (e.g., for ADHD)
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From page 228... ...
It is the only center in the region that provides health services focused on adolescents. The following services are offered by a multidisciplinary team: medical and wellness services, gynecology, sports medicine, athletic training, sports physical therapy, mental health services, nutrition counseling, diabetes treatment, substance abuse services, and treatment for eating disorders.
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From page 229... ...
All policies, procedures, protocols, billing, quality assurance, staff development, strategic planning, grant management, and utilization review and outcome monitoring are managed through the Office of Youth Development in partnership with LSU. The Jetson Center for Youth provides health services to 150 to 200 males aged 12–21, 80 percent of whom are African American and most of whom come from low-income rural communities.
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From page 230... ...
The center's diverse and multiethnic staff operates as a collaborative team focusing on coordinated, comprehensive, and highly individualized care. It includes 6 adolescent medicine specialists; 20 clinical social workers; 3 health educators; specialists in obstetrics/gynecology, mental and behavioral health, and nutrition; and nurse practitioners, physician assistants, and ambulatory care technicians (Sandmaier et al., 2007)
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From page 231... ...
• Coordinating behavioral, reproductive, mental health, and dental services in practice and community settings. • Incorporating health promotion, disease prevention, and youth development throughout the health system, in coordination with such services in the community.
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From page 232... ...
Such improvements are particularly important to support healthy development for those adolescents who are more vulnerable to poor health or unhealthful habits and risky behavior because of their demographic characteristics or other circumstances. Limited evidence is available on health outcomes associated with alternative service strategies.
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From page 233... ...
. A Guide to Positive Youth Development.
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Journal of Substance Abuse Treatment, June 27, epub. Dunst, C
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. Youth development -- A perspective from Los Angeles.
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. A new brief screen for adolescent substance abuse.
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. Community Programs to Pro mote Youth Development.
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. Telepsychiatry improves paediatric behavioral health care in rural communities.
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From page 239... ...
. Co-location of mental health professionals in primary care settings: Three North Carolina models.
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