Embracing Adolescent and Young Adult Health Holistically: How the Maternal and Child Health Bureau and Our Partners Have Made the Well-Being of Youth A Priority
Iliana S. White, MPH
Sr. Program Manager, Adolescent Health
With the start of 2020, we reflect on a period of life that many may choose to forget: adolescence! Although MCH is the universal acronym for maternal and child health, the field has made many strides to remind us that "A" is for Adolescents and should never be overlooked. Set out below are a few ways in which this developmental stage has gained more attention among the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau (MCHB) and Title V investments, projects, and partnerships.
The launch (and continuation) of the Adolescent and Young Adult Health National Resource Center (AYAH-NRC)
Created in September 2014 through funding support from MCHB, the AYAH-NRC supports MCH investments into the health of adolescents and young adults. Led by the University of California, San Francisco, in collaboration with AMCHP, University of Minnesota/State Adolescent Health Resource Center, and the University of Vermont College of Medicine/National Improvement Partnership Network, the NRC builds on MCHB's long history of funding programs focused on these critical populations. Each of the NRC's organizational partners collaborate to meet priority goals and build the capacity of state MCH professionals. The NRC offers a range of training and technical assistance through remote consultation, learning communities and webinars on selected topics, conference workshops, and support for quality improvement projects to improve preventive services.
The Collaborative Improvement and Innovation Network (CoIIN) framework becomes part of our everyday dialogue on improvement
Although learning collaboratives have been utilized to address systemic and capacity challenges, the MCHB's emphasis on quality improvement models brought more rigor to how state Title V programs operationalize their MCH priorities, which include adolescent health. Collaborative Improvement and Innovation Networks, known affectionately as CoIINs, became a widespread model in MCH programs and activities following the uptake and participation for the infant mortality collaborative. Opportunities for CoIINs began to surface, and the well-visit was considered an important initiative for the AYAH CoIIN back in 2015. Led by the newly launched AYAH National Resource Center, the AYAH CoIIN aimed to build Title V's capacity and support to address the new National Performance Measure #10: Percentage of adolescents, ages 12 through 17, who received a preventive medical visit in the past year. The effort to build support didn't stop there—states also placed a new emphasis on young adulthood. Led by Title V, state partnerships formed and collaborated to advance access to, and improve the quality of, preventive health services for adolescents and young adults. Using collaborative learning and quality improvement methods, this CoIIN drove a series of national strategies to address preventive health care for young people. Twelve states and two cohorts later, the CoIIN generated "change packages" for other state Title V programs and partnerships to utilize, and provided many lessons learned within the collaborative experience.
Multiple ways of encouraging adolescents and young adults to make well-visit appointments and feel positive about future appointments
It became essential to find creative ways that resonate with the youth's perspective to promote and educate young people and their caregivers on the importance of the well-visit. The CoIIN brought awareness to how quality is demonstrated in clinical encounters. One aspect of quality relates to the time alone that is devoted between the adolescent patient and the provider. Another aspect is respecting and adhering to confidentiality rights of the patient, which we learned anecdotally had a major influence on whether a young person sought—or avoided—preventive services. Providers serving adolescents and young adults sought to maintain and improve their capacity to offer youth-friendly services, thereby ensuring that young people have positive interactions with the health care system. Meaningful youth engagement was formally operationalized in many of these quality improvement efforts. Key instruments to measure the quality of service delivery included youth-led clinical assessments and patient satisfaction surveys.
Preventive health care visits provide an opportunity for adolescents and young adults to establish healthy habits that will carry into adulthood; they are the place to identify potential problems and provide interventions, particularly those related to teens engaging in risky behaviors and teens' mental health concerns. From this exciting work, we discovered that to successfully address preventive health care for AYA, we needed to have new and creative ideas, collaborations between leaders working in diverse sectors, leadership from young people themselves, and opportunities to test and replicate on strategies. The experience of the AYAH adolescent well-visit CoIIN paved the way for a new multi-state opportunity for Title V and partners to address the mental health of AYAs. In 2018, with support from MCHB, the AYA Behavioral Health CoIIN officially commenced; its primary objective was to increase and improve depression screening and follow up for young people. The collaborative plays a key role in responding to the adolescent health priority. This is needed because rates of depression are increasing among young people, but screening rates and referrals to treatment continue to remain low.
Other key MCHB-supported adolescent initiatives
Other key MCHB-supported initiatives for adolescents that began over the past decade also deserve attention:
MCHB supported a multi-state collaborative to address the five leading causes of child and adolescent injuries: child passenger injuries, falls, motor-vehicle-related injuries to teens, interpersonal violence, and suicide. Launched in 2015 and led by the Children's Safety Network, the child's safety CoIIN sought to test, implement, and disseminate strategies designed to reduce these injuries. Several states focused on strategies pertinent to adolescents, including teen driver safety, interpersonal violence prevention, and youth suicide.
Another CoIIN that emerged and expanded with MCHB's support is the School-Based Health Services CoIIN. This collaborative tasked school-based health centers (SBHCs), sponsoring organizations, and community- and state-level organizations to expand the number of SBHC programs and comprehensive school mental health programs. The objective was also to improve the quality of the health services they provide and strengthen their sustainability by crafting a set of national standardized performance measures. Several of the performance measures related to adolescents include age-appropriate annual risk assessments, body mass index screening, depression screening, and chlamydia testing.
Insights from Title V partners and MCHP programs
Title V partners and MCH programs offer the following commentary on the variety of ways our focus has shifted during the last decade on adolescent health and the positive impact of this shift:
"With the addition of [a required NPM for] the Adolescent Health Domain, an emphasis on this important period of growth in a young person's life is increasing. MCH partners continue to learn about the important role that young people play in the health of the nation, and the role that adults need to play in [adolescents'] lives. I feel that as a whole [our team], we've become more involved and leadership has shown more interest in making Adolescent Health a priority." —Andra Jungmeyer, Adolescent Health Coordinator for Missouri Department of Health and Senior Services
"Over the past decade, MCHB has expanded its leadership in adolescent and young adult health. The MCH Block Grant Transformation acknowledged that adolescents are a critical segment of the MCH population, by requiring—for the first time—that states adopt at least one national performance measure focused on adolescents. The range of measures go beyond "deficit" indicators, including two measures that track receipt of age-appropriate health care that fosters healthy development. [These measures are] receipt of an annual well visit and receipt of services to transition to adult care (NPM 10 & NPM 12). * MCHB has also advanced young adult health in the past 10 years. It supported the work of an Institute of Medicine committee focused on young adult health, which issued a comprehensive report** [that brought] national attention to a neglected age group. MCHB increasingly requires a focus on young adult health in new funding opportunities that have traditionally focused on adolescents, such as the Leadership Education in Adolescent Health (LEAH) Program. In addition, MCHB supports the Bright Futures Guidelines, *** which covers the early young adult years, with specific health supervision guidelines for ages 18 through 21. Two additional efforts that focus on adolescents and young adults include the AYAH-NRC and the Adolescent and Young Adult Health Research Network." —Dr. Charles Irwin, Director, Adolescent & Young Adult Health National Resource Center, Distinguished Professor of Pediatrics, University of California, San Francisco
"By turning attention to life course theory in the last decade, MCHB has helped to elevate the importance of and strengthen understanding of adolescence and young adulthood as key points in the life course. Through initiatives such as the CoIIN and the AYAH National Resource Center, MCHB has provided essential technical assistance and support to states to improve the quality of services and programs for young people by better understanding how they interact with their world and how they want and need to be engaged in health programs and policies that serve them." —Rena Large, Training & Technical Assistance Consultant, State Adolescent Health Resource Center
"Improving population health outcomes requires collaboration between health care and public health professionals. The Title V Block Grant transformation and NPM revision process has resulted in a set of measures that are meaningful to both groups and invite this type of collaboration. Measures such as NPM #10, the percentage of adolescents ages 12 through 17 with a preventive medical visit in the past year, unite these sectors [in the sense that] each [has] a defined but collaborative role to play. While public health professionals focus on the systems and policies needed to deliver high quality preventive care to adolescents and young adults, health care professionals can apply quality improvement tools and methods to improve both access to and the quality of these visits. The Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents (4th ed.) serves as a common platform for the delivery of evidence-based and evidence-informed services. [It contains] the very latest resources on a wide variety of AYA health-related topics readily accessible through the AYAH-NRC. This evolution has been invaluable for work conducted across the National Improvement Partnership Network, a group of state-based entities through which public and private partners use measurement-based efforts and a systems approach to improve the quality of child, adolescent, and young adult health care." ‒ Dr. Wendy Davis, Associate Director, National Improvement Partnership Network
Kogan, Dykton, Hirai, et al. (2015). A new performance measurement system for maternal and child health in the United States. MCH Journal, 19, 945–957.
** (the IOM was renamed the National Academy of Medicine in 2015) See: http://www.nationalacademies.org/hmd/Activities/Children/ImprovingYoungAdultHealth.aspx
*** Hagan, J., Shaw, J., & Duncan, P. eds. (2017). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics: