Efforts by the American Academy of Pediatrics to Promote the New Adolescent Preventive Care Guidelines from the Bright Futures, 4th Edition
|Wendy Davis, MD, FAAP|
Vermont Child Health Improvement Program
Larner College of Medicine at the University of Vermont
Judy Shaw, EdD, MPH, RN, FAAP
Professor, Department of Pediatrics and Nursing
Executive Director, Vermont Children's Health Improvement Program
Director, National Improvement Partnership Network
|Rachel Wallace-Brodeur, MS, Med|
Quality Improvement Coach
Vermont Child Health Improvement Program
The Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents (4th edition) was released in March 2017 and includes updated background and recommendations for health promotion activities and health supervision visits from infancy through adolescence. The new and revised content reflects efforts to support health care professionals in improving the efficiency and effectiveness of these visits; strengthening their partnerships with children and families; and increasing their knowledge of changes in family, communities, and society that affect a child's health.
Along with the inclusion of three new health promotion themes (Promoting Lifelong Health for Families and Communities, Promoting the Healthy and Safe Use of Social Media, Promoting Health for Children and Youth With Special Health Care Needs), the Guidelines include new clinical content about the latest age-specific recommendations for adolescents. As summarized in the Bright Futures/American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care (Periodicity Schedule), many of the updated screenings and assessments recommended at each well-child visit focus on adolescent topics, such as depression screening; hearing screening; and tobacco, alcohol, and drug use screening. In addition, the 4th Edition addresses social determinants of health, identifying both risks (e.g., interpersonal violence, food security, and living situation), as well as the strengths and protective factors (e.g., connectedness with family and peers, school performance, and coping with stress and decision making).
In order to assure broad dissemination and understanding of both the Bright Futures Guidelines and Periodicity Schedule, the AAP has been promoting these materials through many channels, such as regional and national health care conferences, state public health departments, and other partners. The Bright Futures National Center hosted introductory webinars for health care and public health professionals, during which the editors discussed updates to several adolescent visit screening recommendations, addressing how to efficiently and effectively integrate these new components into practice settings. The webinar slide sets and archived recordings are posted on the Bright Futures website. The AAP is also happy to provide slide sets related to all of these topics for people interested in using and/or adapting for local audiences.
In addition, the AAP's Section on Adolescent Health has developed an Adolescent Sexual Health website that provides information and resources highlighting key areas related to providing comprehensive care to adolescent and young adult patients. Content is aligned with the Bright Futures Guidelines and includes setting up an adolescent friendly practice, confidentiality and consent, and billing for services.
The AAP's HPV Champion Toolkit may also be of interest to all who care for adolescent and young adult patients. The toolkit is comprised of resources aimed at increasing the number of young people receiving the HPV vaccine, such as teaching sessions, CME activities, video clips, resources, articles, and success stories, with an emphasis on strategies for successful communication with parents and patients about HPV vaccination.
The AAP's Bright Futures web site also includes examples of how individual states are implementing the use of Bright Futures materials and resources across the country. Be sure to visit the webpage for comprehensive information regarding the development and implementation of this unique resource to support the provision of high quality care for adolescents and young adults!
Finding Partners to Train Health Care Providers
Rachel Wallace-Brodeur, MS, Med
Quality Improvement Coach
Vermont Child Health Improvement Program
To improve health outcomes, we need to modify the behavior of health care providers and change clinical systems. Some of the most commonly used techniques used to train providers have proven to be the least effective.1 Didactic conferences where content is presented in lecture form, distribution of printed educational materials, and other training models where health care providers are passive recipients of information are a common but ineffective way to change the behavior of health care professionals and thus have little impact on improving the quality of health care. Active, multifaceted interventions have been proven to be more effective at changing provider behavior and are more likely to result in changes in behavior. These interventions include academic detailing, outreach programs, and audit and feedback. However, providing this type of training is complex and time-consuming, and few organizations have this expertise or capacity.
Organizations that lack internal capacity to train health care providers can develop partnerships with other entities to support those efforts. Quality improvement (QI) experts have the tools and experience to train health care professionals. While it may take some creativity, you can find these QI experts in most communities. Public health or other related state agencies may have internal QI expertise (e.g. performance managers), medical centers often have internal quality improvement expertise, and many states have quality organizations, such as Improvement Partnerships (IPs).2
Once you have identified a partner, you can start working on developing the training. Components to consider when training health care professionals include:
- Content, materials, tools
- Model for QI or active training methods
- Recruitment of clinical sites and/or health care professionals
- Incentives for training, e.g. maintenance of certification, CME
- Data collection, analysis, and feedback to measure improvement
- Coaching and support to effect system change
- Policy changes to support or incentivize improvement
As part of your collaboration, identify what each partner can do that makes the best use of their expertise or resources. For example, QI consultants from medical centers may have relationships with clinical sites and can help recruit them so your organization can provide training. Or perhaps the QI expert will provide training to health care professionals on the desired topic and you will address policy topics to support the content. However the roles are divided, creating an infrastructure to support systems change and provider behavior through QI activities and projects is the key to sustained improvement.
Training health care providers to improve quality of care and health outcomes is a resource-intensive task. When you make this kind of investment, direct those resources towards more active, multi-faceted interventions where you are far more likely to see the desired outcome. Partnering with organizations or individuals with quality improvement expertise to provide this training is an effective investment of resources. When looking for a partner, consider developing a long-term relationship that sets you up to improvement not only on the topic at hand, but for future collaborations.
1. F Mostofian, C Ruban, N Simunovic, M Bhandari. Changing Physician Behavior: What Works? AJMC 2015;21:75-84.
2. IPs are organizations that use measurement-based efforts and a systems approach to improve child health outcomes and the quality of their health care.
Partnering with Young People to Train Healthcare Providers: You Can Do It!
Kristin Teipel, Director
State Adolescent Health Resource Center (SAHRC)
University of Minnesota
Caring for adolescent and young adult patients is a challenging premise for many health care providers. Many report lacking skills to effectively provide care to and often are uncomfortable caring for young people (Adolescent Health Services: Missing Opportunities). Therefore, training healthcare providers is a critical strategy to improve access and quality of care that meets the developmental needs of youth.
One of the best ways to train healthcare providers to really understand young people and feel comfortable working with them is to partner with youth. Youth-led trainings can have a significant impact. An informal assessment of a University of Minnesota youth-led training model with medical residents found that is improved clinicians' confidence in conducting clinical interviews with adolescents. Confidence in taking an accurate health history (pre and post training) rose from 20% to 90%; this was also seen in interviewing about sexual risk (< 30% to 80 %), substance use (35% to 80%), and protective factors (20% to 85%) (unpublished report).
Partnering with youth makes sense but it may seem an overwhelming and daunting task. Where do you find the young people to be trainers? What do they teach? What is an efficient/effective way to find and train healthcare providers? Who will manage this and where do you find funding? The answer is to build on what you already have at hand.
Start by assessing if anyone is already partnering with young people as trainers in healthcare. The best place is to look at universities with Medical (Dept of Pediatrics - Adolescent Medicine or Family Medicine programs) and Nursing schools (Nurse Practitioner programs). Many work with adults and young people as simulated patients to train students and residents; some will have specialized adolescent trainers. For example, colleagues at the Boston Children's Hospital – Adolescent & Young Adult Health Division and Leadership Education in Adolescent Health (LEAH) program partner with peer leaders from their Youth Advisory Group to train residents, medical students, nursing students and more within the university. They've also partnered with the Massachusetts Dept. of Public Health – Office of Sexual Health & Youth Development to train providers (Reversing the Script: Strength-based approaches to the adolescent interview). Didactic lectures and simulation exercises (providers practicing interviewing skills with youth trainers) are used to increase skill and comfort in communicating with adolescents and developing a therapeutic alliance.
If you're not able to find an existing university-based training program, bring an outside curriculum to your University colleagues to refine for trainings in your state. For example, the New Mexico Dept of Health – Office of Adolescent & School Health adopted a university-based training program (YouthCHAT) and partnered with a local high school (Public Academy of Performing Arts Charter School) and the NM State University to train primary care and behavioral health providers. The well-trained teen actors/teachers role play clinical scenarios with providers and then provide constructive feedback on ways to provide a comfortable and emotionally safe space that opens doors for young people and providers to address health needs. For help finding university-based trainings, take a look at YouthCHAT Guide – overview of a training model based on a U of MN program, or contact Kristin Teipel at the Adolescent & Young Adult Health National Resource Center (email@example.com).
Another approach is to use a pre-packaged training program such as PATCH (Providers and Teens Communicating for Health). The Wisconsin Dept of Health Services is currently using PATCH in communities through their Title V MCH program. The Minnesota Dept of Health – Adolescent Health program recently used the University of Michigan's Sparks training materials in their Adolescent & Young Adult Healthcare CoIIN. Young adult advisors used the materials to train healthcare providers in clinics involved in a clinical QI effort.
Finding young people to partner with can also be challenging. Again, build on what's already available in your state. For example:
- School of the Arts high schools (often have vibrant drama programs)
- Existing youth advisory groups
- 4-H programs (this could be an excellent partnership with your state's 4-H program in its outreach to local 4-H clubs)
- HOSA programs (Health Occupations Students of America – contact your state's Association to explore possibilities) \
- SBHC youth advisors (they could train providers within the clinic system that sponsors SBHC, or other clinics in their community)
Finding places to teach is another interesting conundrum. Instead of creating new trainings, bring an adolescent-led training to existing training efforts. Look within your health department – for example partner with your Rural Health program to train FQHC providers or bring a youth-led training into telehealth programs; or partner with your Immunization program to expand their HPV training for providers. Check with professional association state chapters to see if they have any training opportunities to build on (pediatrics, family physicians, pediatric or family nurse practitioners, community health centers). Scope out large clinic health care systems to see if any are interested in training providers in efforts to reach adolescent health care objectives. For example, the Colorado Dept of Public Health and Environment Title V MCH program partnered with Kaiser Permanente to adopt and adapt a university-based youth-led program to train healthcare providers in the Kaiser system.
Finally, finding funding. Again, building on existing opportunities can be a great way to reduce or share the costs. For example, use existing Title V funding to contract with a University program to train healthcare providers outside university walls or support a new effort within a 4-H or HOSA program. Or build on partnerships with healthcare clinic systems or health plans to help them adopt and pay for youth-led trainings within their system. For example, the University of Minnesota Adolescent Health program partnered with Blue Cross Blue Shield to train BCBS providers with the YouthCHAT adolescent trainers.
Start small and see what's possible!
What Does Research Say About Improving Clinician's Delivery of Preventive Services to Adolescents?
M. Jane Park, MPH
Coordinator, Adolescent and Young Adult Health Research Network and Adolescent and Young Adult Health National Resource Center, Division of Adolescent and Young Adult Medicine, Department of Pediatrics UCSF Benioff Children's Hospital, UCSF
Sion K. Harris, PhD
Associate Professor of Pediatrics, Harvard University;
Director, Center for Substance Abuse Research, Division of Adolescent and Young Adult Medicine, Boston Children's Hospital
Elizabeth M. Ozer, PhD
Director, Adolescent & Young Adult Health Research Network
Professor, Division of Adolescent & Young Adult Medicine, Department of Pediatrics UCSF Benioff Children's Hospital, Director of Research & Faculty Equity Advisors, UCSF Office of Diversity & Outreach, University of California, San Francisco
This summary is based on a longer article reviewing research on clinical preventive services for adolescents and young adults, written by researchers from the Adolescent and Young Adult Health Research Network. The article, published in the Journal of Adolescent Health (March 2017), is available to the public.
What does research say about clinician barriers to delivering preventive services to adolescents?
Clinicians report several factors that hinder delivery of preventive services to adolescents. Given the large number of recommended services and health advice directives, many find it difficult to find time to deliver some types of services, such as those related to more sensitive health topics like mental health and substance use, in a busy clinical practice. Clinicians also are not aware of or do not fully understand clinical guidelines and related tools to help delivery. Some clinicians feel they have insufficient training to deliver some recommended services ("low self-efficacy") or do not believe the services will be effective ("low outcome expectancy"). Clinicians also say they are not motivated to change practice.
What does research say about addressing clinician barriers?
The most promising approaches combine clinician training in serving adolescents with tools to facilitate provision of preventive services after training is completed. Interventions using brief screening tools in conjunction with appropriate clinician training have improved clinician screening rates across multiple areas of adolescent health (e.g., sexual health, safety, substance use, violence).
In addition to screening questions, promising interventions include prompts for clinician responses, depending on adolescents' answers (e.g., supporting positive choices and addressing areas of concern). Of particular promise are computerized "pre-visit" screening questionnaires that are completed (or "self-administered") by adolescents. These tools generate a "report" to the clinician, including results of the questionnaire and guidance for clinicians that is tailored to the results for each adolescent patient. In one study, a computer self-administered pre-visit health screener significantly increased clinician mental health-related counseling and adolescent's disclosure of mental health issues. Research suggests that use of pre-visit screening with a validated standardized tool is more effective ("sensitive") in identifying problems than clinician impression, while using less time.
Some research also suggests that electronic medical record (EMR) systems hold promise for helping increase delivery of preventive services. EMR systems can harness data to enhance clinician decision-making support (CDS) tools, which help clinicians assess a patient's risks and guide clinician delivery of the most appropriate preventive services. Among adults, studies show CDS tools can increase delivery of screening and preventive services while decreasing emergency department visits and hospitalizations. While few studies have addressed CDS and adolescent care, this remains a promising area of work. However, as use of EMR systems increases, it is critical to develop mechanisms to protect confidentiality of care received by adolescents. Professional groups such as the American Academy of Pediatrics and the Society for Adolescent Health and Medicine have issued recommendations to protect confidentiality in EMR systems.
What areas need further research?
Many areas! The review article on which this is based concludes with numerous recommendations across many areas of clinical preventive services for adolescents and young adults, including clinician-focused research. First, little is known about how best to train clinicians to increase delivery of preventive services to young adults. Other areas needing further research include effective, developmentally appropriate models of engaging parents in AYA preventive services and the benefits and challenges of using technology to advance delivery of preventive services.