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 From the Experts

A Conversation with Paula Fields, MSN, BSN, RN

paula.pngSenior Program Manager, School-Based Health Alliance

Can you briefly describe the School-Based Health Alliance?

The Alliance is the national voice in Washington for school-based health care practitioners. With their distinct expertise, knowledge, and experiences in school settings, the Alliance staff occupies a unique position at the intersection of education and health care. We provide our field – more than 3,000 school health centers across the country – with high-quality resources, training, and motivation to help them excel in their work, empowering them to redefine health for kids and teens.

What are the origins of the Alliance's focus on performance measurement?

It's long been a dream of the Alliance founders for the organization to create a repository for school-based health centers to report performance data and set benchmarks for the field. In 2014, opportunity came knocking in the form of a public funding opportunity from the Maternal and Child Health Bureau, Division of Child, Adolescent and Family Health to improve the quality of school health services and strengthen their sustainability. The Bureau's aim was ambitious: to see a minimum of 50 percent of all school health and mental health programs voluntarily contribute to a core set of performance measures across the United States by 2018. We figured, who better to drive this effort than the field's national membership organization? So, we applied and won the competition!

How did you arrive at well-child visits?

We called our new initiative "Quality Counts" and went directly to the field to ask them which measures they'd be most excited about voluntarily adopting and reporting. After an extensive consensus building process, our field narrowed the priority measures to:

  1. annual well-care visits (WCV);
  2. annual risk assessments;
  3. body mass index (BMI) assessments and nutrition and physical activity counseling;
  4. depression screenings and follow-up plan for positive screens; and
  5. Chlamydia screenings.

The measures emphasize the school health centers' strengths as hubs for prevention, well-care, and early intervention on issues that have long-term consequences if left unaddressed. We believe this work has the potential to transform school-based health care. Standardized measures will allow health centers to compare themselves statewide and nationally — in turn driving quality, improving the model's sustainability, and ultimately bettering health outcomes for kids.

As you've embarked on this campaign, what are some of the promising strategies to increase well care visits?

Our early adopter sites have taught us a lot about what it takes to improve well-care visit rates. Successful SBHCs convert acute care visits and sports physicals into comprehensive WCVs by including age-appropriate components and preventive services. If unable to do a full WCV due to the complexity of a sick visit, then they schedule it for another date. They also implement an electronic health record tickler system to identify students who are due for WCVs and to document any WCVs that happen outside of the SBHC. Lastly, the most successful SBHCs work in partnership with school staff (e.g., the school nurse or social worker) and parents to pinpoint students who need a WCV and schedule those visits at the SBHC.

How is this work and the focus on WCVs being incorporated into other Alliance Initiatives?

The Alliance recognizes the WCV as the cornerstone of care and continues to promote the WCV as the anchor for our work, even beyond our Quality Counts initiative.

A few examples:

  • Our Bureau of Primary Health Care (BPHC) work. The BPHC work focuses on WCVs in three of its initiatives: Project ECHO (Extension for Community Healthcare Outcomes), social determinants of health, and learning collaboratives around screening for children and adolescents at risk for Type II diabetes as part of every WCV.
  • The Conrad N. Hilton Foundation SBIRT (Screening, Brief Intervention, and Referral to Treatment) in SBHCs Project incorporates substance use and depression screening at every primary care visit, including all WCVs.
  • Our the school oral health work, funded by the DentaQuest Foundation, works to recognize the need to connect to the WCV status and integrate oral health with overall health.
  • The Alliance and Adolescent and the Young Adult Health National Resource Center have identified opportunities to cross-collaborate on WCV and work across CoIINs to improve WCV completions.

Our vision is to see all children and adolescents thrive, and we're in a prime position to expand well -care visits and, most importantly, improve student outcomes. We look forward to working together even more in the future!

Improving the Adolescent Well-Visit (AWV) Through Other Public Health Efforts 

kristin.jpgKristin Teipel
Director, State Adolescent Health Resource Center (SAHRC)
University of Minnesota

In times of limited budgets and staff, working to improve access and quality of the adolescent well-visit (AWV) can be complicated. One way to stay sane is to align and partner with other MCH and state public health efforts – in essence, getting your AWV strategies accomplished through others' programs.

  • Immunization programs – They are often working with health care providers, clinic systems, and professional organizations to support clinical quality improvement efforts, training providers, clinic recognition (high rates of immunizations), and outreach and promotion of youth vaccines. Since getting teens immunized is a component part of the AWV, there are opportunities to combine efforts with immunization programs. This could include slipping in promotion of the AWV into immunization outreach efforts in which the well-visit, adding a focus on AWV into provider training, and expanding clinic recognition efforts to include recognition of high rates of AWV.
  • Family home visitation programs – Many parents served by FHV programs are teens and young adults. Work with the FHV staff to build their skills in supporting young parents to not only get their children in for well-visits, but also themselves.
  • Rural health and primary care programs – These programs often focus on supporting federally qualified health centers in partnership with state primary care associations. Quality improvement is often a part of this work. Look for opportunities to help them "shift" their efforts to focus on teens and young adults.
  • Medicaid programs – State Medicaid programs often fund Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) promotion efforts with public health agencies. Talk with your Medicaid program to identify what they're doing to promote the adolescent EPSDT visit to parents. Identify ways you can help them do this outreach, promotion, and marketing more effectively for parents (and youth!).
  • Youth in foster care, juvenile justice, and/or homeless - Look for opportunities to expand or enhance health care focused efforts through these programs to bring health insurance coverage and the well visit as a critical part of health care of young people in foster care, juvenile justice settings, and homeless programs.

Are you doing anything like this to embed a focus on AWV into other public health efforts or programs? We'd love to hear what you're doing! Please send a brief description of your work to Anna Corona at acorona@amchp.org, and we'll feature your efforts in the next bi-monthly newsletter!

Leveraging Clinical Opportunities to Promote the Adolescent Well Visit

charles.jpgCharles E. Irwin, Jr., MD

Project Director, Adolescent and Young Adult
Health National Resource Center

For decades, professional health organizations have recommended the delivery of preventive services to adolescents, usually in the context of an annual well visit.1 The 4th Edition of the "Bright Future Guielines" issued in 2017 by American Academy of Pediatrics recommend the delivery of preventive services to adolescents and young adults up to age 21 years in an annual well visit.2 Research supports the effectiveness of several clinical preventive services. For example, the US Preventive Services Task Force recommends screening for tobacco use, depression, and obesity, among other areas.3 In the context of a strong evidence base and professional consensus, the Patient Protection and Affordable Care Act of 2010 required most private insurers to cover preventive services recommended by AAP/Bright Futures and the USPSTF* with no copay to patients.4

Despite the evidence base and public policy support of preventive services to adolescents, receipt of the well visit remains low. A recent analysis of 2012-14 health care utilization rates found that less than half (48%) of adolescents (ages 10-17) received a past-year well visit.5 This rate significantly drops in young adulthood as roughly one in four (28%) young adults (ages 18-25) received a past-year well visit in 2011-14.6

One strategy to increase receipt of well visits among AYAs focuses on converting other clinical visits into well visits, and leverage clinical encounters to promote the well visit. Examples of common clinical encounters with AYAs include:

  • Acute/illness visits: Adolescents are more likely to visit their provider for acute/illness care than well care. The visit rate (per 100 population) for well care in 2012 among adolescents (ages 12-17) was 29 compared to 183 for other medical visits.7 There is also a seasonality to these visits as illness-related visits occur in the Fall/Winter season. These acute visits provide a perfect opportunity for clinic staff to check if the AYA has received their annual well visit, and if not, schedule a future well visit.
  • Sports physicals: Each year, approximately 30 million athletes younger than 18 receive medical clearance to participate in sports.8 However, sports physicals are limited exams that do not follow recommended guidelines set forth by AAP/Bright Futures. As a result, some states health agencies recommend youth receive a well visit in place of a sports physical.
  • Sexual health services: Women utilize sexual health services at a higher rate than males. Roughly one in three (36%) teenage females (ages 15-19) received a family planning service (e.g., a check-up or medical test for birth control) in the past-year. In young adulthood, more than half (58%) of females (ages 20-24) received a family planning service in the past-year.9 These services may want to consider expanding the visit to include a full range of preventive care.

The AYAH CoIIN states has made tremendous progress in leveraging clinical opportunities to promote and increase well visits among AYAs. Highlights include:

  • The Vermont CoIIN team partnered with the state's largest insurance providers to increase receipt of well visits through implementation of a "reminder recall system" in participating practices by reaching out to patients due for a well visit.
  • The Iowa CoIIN team was awarded an AAP Community Access to Child Health (CATCH) grant to promote adolescent well-visits through the high school state athletic tournaments in an effort to convert sports physicals into well visits. The team also partnered with a school-based health center and the associated high school to educate clinic staff, school administrators, and students about the importance of well visits.
  • The Texas CoIIN team partnered with school nurses to identify youth that are due for a well visit and make appropriate referrals and follow-up.

References:

  1. Elster AB, Kuznets NJ. American Medical Association Guidelines for Adolescent Preventive Services: Recommendations and Rationale. Baltimore, MD: Williams & Wilkins; 1994.
  2. Hagan J, Shaw J, Duncan P, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents: Pocket Guide. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
  3. US Preventive Services Task Force. Published recommendations: http://www.uspreventiveservicestaskforce.org/BrowseRec/Index?age=Pediatric,Adolescent. Accessed December 14, 2017.
  4. English A, Park MJ. Access to Health Care for Young Adults: The Affordable Care Act of 2010 is Making a Difference. San Francisco, CA: National Adolescent and Young Adult Health Information Center; 2012.
  5. Adams SH, Park MJ, Twietmeyer L, Brindis CD, Irwin CE Jr. Association between adolescent preventive care and the role of the Affordable Care Act. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2017.3140.
  6. National Adolescent and Young Adult Health Information Center, University of San Francisco. 2011-2014 Medical Expenditures Panel Survey [private data run]. U.S. Department of Health and Human Services. Available at: https://meps.ahrq.gov/mepsweb/.
  7. Uddin SG, O'Connor KS, Ashman JJ. Physician office visits by children for well and problem-focused care: United States, 2012. NCHS data brief, no 248. Hyattsville, MD: National Center for Health Statistics. 2016.
  8. Mirabelli MH, Devine MJ, Singh J, Mendoza M. The preparticipation sports evaluation. Am Fam Physician. 2015; 92(5):371-6.
  9. Martinez GM, Chandra A, Febo-Vazquez I, Mosher WD. Use of family planning and related medical services among women aged 15-44 in the United States: National Survey of Family Growth, 2006-2010. National Health Statistics Report; n 68. Hyattsville, MD: National Center for Health Statistics, 2013.