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7 Health System
Pages 209-256

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From page 209...
... . Additionally, many of the health issues adolescents confront are rooted in the social determinants of health and driven by underlying social and economic inequalities (Brindis et al., 2005; Philbin et al., 2014; Richardson et al., 2017; Tebb et al., 2018)
From page 210...
... The chapter concludes with a blueprint for achieving adolescent-friendly services and system-level policies to improve adolescent health. THE VISION: SEAMLESS ACCESS TO ADOLESCENT FRIENDLY HEALTH SERVICES Adolescents are distinct from both children and adults when it comes to health care.
From page 211...
... As adolescent health -- and adolescence itself -- has been reconceptualized over the past decades, and as new research in neurobiological development emerges, the necessity of integrating physical and mental health services has become increasingly apparent and important. Integration between physical and behavioral health providers becomes more pressing as the number of adolescents with mental or behavioral health issues grows (see "Behavioral Health Care" below)
From page 212...
... Adolescent-friendly health service models seek to provide services that are comprehensive, accessible, confidential, developmentally appropriate, 1 Coordinated care has four elements: (1) patients have ready access to a range of health care services and providers, (2)
From page 213...
... They have been adopted in a ­ number of health care settings; see Box 7-2. Several studies and frameworks have been developed to conceptualize youth-friendly health care services (Ambresin et al., 2013; Huppert and Adams Hillard, 2003; Mazur et al., 2018; Mount Sinai Adolescent Health Center, 2017; World Health Organization, 2012)
From page 214...
... The MSAHC Blueprint for Adoles cent and Young Adult Healthcare (Mount Sinai Adolescent Health Center, 2017) , the National Adolescent and Young Adult Health Information Center, Advocates for Youth, the Office of Adolescent Health in the Department of Health and Human Services, and the World Health Organization describe best practices and provide resources to improve access to preventive services, train staff and workflows at lescents, addressing both public and private insurance.2 It allowed states to expand Medicaid up to 133 percent of the federal poverty level and to create a health insurance exchange (or "Marketplace")
From page 215...
... Developed and maintained by a multi­ isciplinary group of d adolescent health professionals at the University of Michigan, the ­ CE-AP includes A a comprehensive self-assessment followed by a facilitated improvement process that addresses 12 key areas, including access to care, adolescent appropriate envi­ onment, confidentiality, best practices and standards of care, reproductive and r sexual health, behavioral health, nutritional health, cultural responsiveness, staff attitudes and respectful treatment, adolescent engagement and empowerment, parent engagement, and outreach and marketing. The Adolescent Champion Model is a quality improvement program ­ esigned d to help primary care sites become more adolescent-centered, also devel­ ped at o the University of Michigan.
From page 216...
... . While health insurance coverage matters, with fullyear publicly insured adolescents receiving wellness visits at higher rates, insurance in itself is not sufficient, as less than half of insured adolescents received wellness care.
From page 217...
... That is followed by a discussion of the role the health system can play in reducing these risks. Unintended Pregnancy A major focus of adolescent health policy for the past decades has been, and remains, lowering the rates of unintended pregnancies and teenage births.
From page 218...
... . In 2015 teen birth rates reached a historic low -- 22.3 births per 1,000 adolescents ages 15 through 19 (Martin et al., 2018; Romero et al., 2017)
From page 219...
... . These rates likely reflect differences in adolescent health care delivery, the emphasis of immunization programs on adolescent vaccination activities, and the prevalence of factors associated with lower vaccination coverage, such as contact with the medical system and provider failure to document risky health behaviors (Walker et al., 2017)
From page 220...
... . Adolescents may face multiple barriers to accessing quality sexual and reproductive health care services, and confidentiality is chief among them (see "Confidentiality and Parental Consent Requirements," below, for a discussion of the importance of privacy in adolescent health care)
From page 221...
... . Adolescents use health care services for a range of needs -- sickness, sports physicals, immunizations, and emergency care -- all of which provide opportunities to offer sexual and reproductive health care (Santa Maria et al., 2017)
From page 222...
... . Reports of suicide risk, based on the Youth Risk Behavior Survey, state that 18 percent of high school students seriously contemplated attempting suicide in the past year and 30 percent report feeling "sad or hopeless almost every day for 2 or more weeks in a row so that they stopped doing some usual activities" during the past 12 months (Office of Adolescent Health, 2017)
From page 223...
... . For example, Familias Unidas is an evidence-based preventive intervention that focuses on parent-adolescent relationships and has been very effective in reducing Latinx adolescents' internalizing and externalizing disorders,9 substance use, and risky sexual practices (Pantin et al., 2009; Perrino et al., 2014; Prado et al., 2013; Prado and Pantin, 2011)
From page 224...
... . These findings suggest that improving DLPFC function in social contexts may be a valuable neural target for prevention efforts or interventions geared toward breaking the cycle of social difficulties and depressive symptoms in adolescents.
From page 225...
... Non-Latinx Black adolescents have higher rates of anxiety disorders compared to their non-Latinx White counterparts. Additionally, the prevalence rates of anxiety disorders were higher for adolescents from households with divorced or separated parents, indicating a possible association between family composition and anxiety (Beesdo et al., 2009)
From page 226...
... The effect size of universal anxiety prevention programs was 0.17, whereas the effect sizes for universal depression, eating disorder, and substance use prevention disorders were 0.12, 0.08, and 0.5, respectively (Fisak et al., 2011)
From page 227...
... Of the pediatric residents whom completed the survey, 82 percent reported that they provided care to patients who misused opioids and another 82 percent reported caring for patients who they assessed as at risk for opioid overdose but only 42 percent had ever counseled patients on ways to prevent overdose and only 10 percent had ever ­ prescribed the opioid reversal drug naloxone to eligible patients (Wilson et al., 2018)
From page 228...
... . Body Dissatisfaction and Eating Disorders For youth, body image is related to identity development and mental health, as well as family, peer, and romantic relationships.
From page 229...
... found that among these five eating disorders, the median age of onset ranged from 12.3 to 12.6 years. Bulimia nervosa, binge eating disorder, and subthreshold anorexia nervosa were significantly more prevalent among girls than boys, though no significant differences emerged by gender for anorexia nervosa and subthreshold binge eating disorder.
From page 230...
... . Behavioral Health Care Services Despite a documented need for behavioral health care services, adolescents and young adults remain an underserved population.
From page 231...
... Likewise, counseling on sensitive issues is particularly important for adolescent health care, as adolescence is a time when risky behaviors, mental disorders, and sexual behaviors emerge. Adolescents ages 15 to 17 express the most concerns about confidentiality, but those ages 18 to 25 also have concerns, particularly since many of these young adults remain on their parents' health insurance plans (Sedlander et al., 2015)
From page 232...
... . Mental health services must become equitably accessible to reduce health disparities among adolescents.
From page 233...
... Despite the documented need for behavioral health care services, youth experiencing homelessness have trouble accessing behavioral and other health care services (Davies and Allen, 2017; Hudson et al., 2009, 2010; Kushel et al., 2007)
From page 234...
... . Despite its importance in adolescent health care, confidential care is not guaranteed for youth (Tylee et al., 2007)
From page 235...
... For instance, an adolescent covered by her parent's health insurance can have a confidential visit with a health care provider, and later have this confidentiality breached when a bill, known as an explanation of benefits, is sent to their parents detailing the charges for the confidential services. Some jurisdictions, such as Erie County, New York, and Massachusetts, require that sensitive services such as contraceptive and STI care be suppressed from the explanation of benefits (Tebb et al., 2014)
From page 236...
... Among these providers, the level of comfort in providing adolescent health care services may vary. According to surveys of pediatric residents and residency directors, most pediatric training programs do not adequately cover sensitive adolescent health topics, such as mental and behavioral health, interpersonal violence, reproductive health, chronic illness, and community adolescent health (Davis et al., 2018; Fox et al., 2010a; Kershnar et al., 2009)
From page 237...
... Klein and Wilson (2002) , analyzing data from a nationally representative sample of 6,278 adolescents, reported that while 71 percent reported at least one of eight potential health risks, 63 percent had not spoken to their doctor about any of these risks. They further reported that the highest-risk adolescents had the lowest rates of being asked about risky health behaviors.
From page 238...
... This includes expansion of school-based health services, in which school psychologists, social workers, and other allied health professionals are involved in primary prevention activities, as well as screening and treatment at the school or after-school site, if services are available. However, policy makers and health systems must ensure that measures to increase screening of behavioral health problems among adolescents are accompanied by knowledge of places to refer for treatment, a warm handoff to treatment providers, and, most importantly, adequate resources for treatment.
From page 239...
... . Constraints on most SBHCs -- especially regarding sexual and reproductive health care and access to contraception and HIV testing -- greatly limit their ability to provide teens with the most needed services.
From page 240...
... They recommend increased and early collaboration with adolescents and young adults to include their perspectives along with those of health experts when developing content; with technology experts to develop applications; and with research teams to measure effectiveness with data collection tools built into social media platforms. In response to adolescents' reliance on technology, recent behavioral health interventions have sought to engage adolescents through the internet
From page 241...
... Although more research and development is still needed, digital media strategies can assist in reaching adolescents -- perhaps assist providers in being more comfortable, too. They can supplement in-person behavioral health interventions, providing adolescents with health education that is reliable and accurate, helping them find and access services, preparing them
From page 242...
... For example, prolonged exposure to neighborhood poverty greatly increases the risk for teenage pregnancy (Wodtke, 2013) , perhaps due to lack of economic or job training opportunities and viable alternatives to early childbearing, but few sexual and reproductive health education interventions address these factors (Brindis and Moore, 2014)
From page 243...
... B.  ith help from federal agencies and designated funding, health care W providers, public and private health organizations, and community agen cies should work to develop or enhance coordinated, linked, and inter disciplinary adolescent health services. This includes funding community outreach efforts to attract and retain adolescents and their families in the health care system.
From page 244...
... A.  Regulatory bodies for health professions in which an appreciable number of providers offer care to adolescents -- such as the American College of Obstetrics and Gynecology, American Academy of Family Medicine, American Academy of Pediatrics, American Academy of Physician A ­ ssistants, and state boards of nursing and social work -- should include RECOMMENDATION 7-1: Strengthen financing of health care services for adolescents, including insurance coverage for uninsured or underinsured populations. The importance of health insurance coverage has been well documented, and strengthening health insurance coverage for adolescents is a cornerstone for advancing adolescent health.
From page 245...
... State and local health agencies should work with community-level adolescent service providers to identify opportunities for improvement in their programs. C.  Federal health agencies and private foundations should prepare a re search agenda for improving adolescent health services that includes assessing existing service models, developing new models for providing adolescent-friendly health services, piloting projects to develop and test innovative approaches for incorporating neurodevelopmental and socio behavioral sciences in the delivery of health care to adolescents, and evaluating the effectiveness of collaborations.
From page 246...
... In addition to this blending and braiding of services, collaborative efforts are needed to help maximize existing funding, and additional, sustainable, and integrated funding needs to be developed to meet major gaps in the field of adolescent health. RECOMMENDATION 7-2: Improve access to comprehensive, integrated, coordinated health services for adolescents.
From page 247...
... Policies that support the coordination and continuity of care, such as improving services to transition adolescents to adult care, need to be implemented universally. With help from federal agencies and designated funding, health care providers, public and private health organizations, and community agencies should work to develop or enhance coordinated, linked, and interdisciplinary adolescent health services.
From page 248...
... , it is important 17 HIPAA was passed by Congress in 1996. HIPAA does the following: provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs; reduces health care fraud and abuse; mandates industrywide standards for health care information on electronic billing and other processes; and requires the protection and confidential handling of protected health information. 18 See English et al.
From page 249...
... Federal agencies and behavioral health education institutions should work together to grow the behavioral health workforce available to adolescents, particularly those in underserved areas. They can do this, for example, by expanding HRSA's Behavioral Health Workforce Education and Training Program, which partners with universities and nonprofit organi­ ations to train behavioral health professionals and para­ rofessionals z p with an emphasis on medically underserved populations and integrative care (Kepley and Streeter, 2018)
From page 250...
... . RECOMMENDATION 7-4: Improve the training and distribution and increase the number of adolescent health care providers.
From page 251...
... Both public- and private-sector funding supporting improved interdisciplinary training and capacity-building among those delivering adolescent health care services will also be needed. In addition to strengthening the competency of the health care workforce, efforts should be made to increase the number of board-certified adolescent medicine specialists nationwide.
From page 252...
... • Congress should appropriate funds to HRSA to assess the number, type, and distribution of adolescent health care providers needed to support optimal adolescent health across the country and ex pand accordingly its Leadership Education in Adolescent Health Program, which prepares health professionals to become leaders in adolescent and young adult health. • Existing adolescent medicine training sites should offer 1-year clini cal training programs in adolescent medicine for those wishing to enhance their expertise in adolescent medicine without becoming board certified.
From page 253...
... First, efforts should be made to improve federal and state data collection on adolescent health and well-being. The current system for collecting data on adolescents' health has three gaps: 1.
From page 254...
... The spirit of this quality improvement process should be constructive and collaborative, not punitive. Federal health agencies and private foundations should prepare a research agenda for improving adolescent health services.
From page 255...
... HEALTH SYSTEM 255 support, training, and technical assistance needed to successfully implement an adolescent-friendly health services model. In addition, private foundations could support the improvement of adolescent health services by funding the development and dissemination of information to policy makers on the cost-effectiveness of prevention programs.


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