New Approaches to Care for Underserved Adolescents: The Enhanced Medical Home

Seth Ammerman, M.D.

Clinical Associate Professor Division of Adolescent Medicine Department of Pediatrics Stanford University Lucile Packard Children’s Hospital

Goals

• • • • • Definitions and current stats for underserved youth in USA Key concepts of the Medical Home and the Enhanced Medical Home Common barriers to care Pros and Cons of typical school-based, community, and mobile clinic programs Adolescent Outreach Program Lucile Packard Children’s Hospital as a Model That Works

Definitions of Adolescents

• • American Academy of Pediatrics: ages 12 21.

Society for Adolescent Medicine and the World Health Organization: ages 10-25 – Developmentally (bio-psycho-social-cognitive) this age range makes a lot of sense.

Definitions of Underserved Adolescents

• • • Common Descriptive Terms: “At-Risk,” “High Risk,” “Vulnerable,” “Underserved,” “Marginalized” Homeless youth (terms also include: street youth, couch surfers, street-connected, runaway, throwaway, curb-siders,) are the most disadvantaged of these youth Homelessness means an unstable housing situation, and ranges from living with relatives to living on the streets

Uninsured Youth USA

• Approximately 12% (5 million) adolescents do not have health insurance • Medicaid and S-CHIP (State Child Health Insurance Programs) main programs for the poor • Numbers of uninsured increasing

Definitions of Homelessness

• • U.S. Government: Homelessness means an unstable housing situation • Homelessness ranges from living with relatives to living on the streets Poverty is a common denominator for being homeless

The Latest Homeless Youth Numbers: USA

• • • > 1,000,000 adolescents experience homelessness in the United States each year Numbers increasing Demographics vary by region, city, and neighborhood – Minority youth over-represented – LGBTQ –I – Two Spirit youth over-represented

The Latest Homeless Youth Numbers: Local

• • • In San Francisco: ~2,000-3,000 homeless adolescents In San Mateo, ~500 homeless adolescents In San Jose, ~1,500 homeless adolescents

What is A “Medical Home?”

• •

For optimal health care, a medical home provides Access Health Care, broadly defined

What is “Access?”

•

“Access” is getting provider and patient together:

– –

in the same place at the same time

–

in a straightforward and easy manner

What is “Health Care?”

• • • •

“Health care” broadly defined is: Comprehensive Continuous Youth-centered Affordable

What is “Health Care?” cont.

• Care

provided or coordinated by a qualified primary care practitioner

•

Care includes health screening, preventive care, and management of acute and chronic conditions

–

including organizing and f/u of sub-specialty needs

A Medical Home is not:

• • • •

Emergency room visits Episodic sick care clinic visits Urgent care clinic visits Clinics not ensuring medication provision

A Medical Home is not (cont.):

•

Clinics focusing on a specific problem, e.g.,

–

STD clinics

–

Family Planning Clinics

–

Mammography Vans

A Medical Home means:

• • •

Increased opportunities for health screening

•

Preventive health interventions, including immunizations Timely follow-up of acute illness Increased opportunities for health education and anticipatory guidance

A Medical Home means, cont.

• • • •

Improved management of chronic conditions like asthma or diabetes Increased access to critically needed specialists Improved functionality and decreased cost of the health care system Improved health and well-being of underserved youth

What is an “Enhanced Medical Home?”

•

An enhanced medical home adds to the medical home model:

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Mental health services

–

Nutrition services

–

Oral Health Services

–

Others: acupuncture, massage therapy, yoga, etc.

The “Enhanced Medical Home”

• • • •

Ensures the most comprehensive care for at-risk youth Ensures the most continuous care for at risk youth Is the most focused on prevention and early intervention Is the most cost-effective model of health care

Barriers to Care

• Lack of health insurance is major barrier, as are insurance-related issues if one has insurance – Co-Pays for visits and for medications – No coverage for “pre-existing conditions” – Carve-outs of mental health, nutrition, dental, and other services

Barriers to Care, cont.

• Lack of transportation is major barrier – Most youth don’t have cars or easy access to cars – Public transportation often not simple or quick – Rural areas often without local clinics – Have to get to clinic, then to lab, then to pharmacy, etc.

Barriers to Care: Youth-Related

• • • • • Health care is not a priority Denial Shame Fear Distrust

Barriers to Care: Youth Related, cont.

• • • Communication problems: illiteracy or language barriers • Limited access to telephones, showers, and laundry facilities Limited or unfamiliarity with available services Lack of skills to manage “red tape”

Barriers to Care: System Related

• • • • Address requirements and lengthy bureaucratic processing Crowded waiting rooms Long waits Not youth focused

Barriers to Care: Provider Related

• • • • Difficulty dealing with issues around confidentiality Usually not “youth friendly” practice Lack of comfort working with adolescents Lack of experience with the range of adolescents health care needs: medical, psychosocial, mental health, nutrition, and developmental

Legal Issues: California Law for Health Care for Minors

• Minors in California (under age 18) may consent to treatment for 3 categories of services on their own without parental consent (and for free): – Reproductive health care (birth control, STI testing and treatment, abortions) – Substance abuse (tobacco, alcohol, and other drugs) – Mental Health (need parental consent for meds)

California Law for Health Care for Minors, cont.

• Minors in California (under age 18) may consent to treatment for all other services on their own without parental consent if they are: – Emancipated (formal court process) – “Self-sufficient”: not living at home and not being financially supported by their parents

The Enhanced Medical Home: New Approaches

• • • Three major types of health care models for underserved youth School-based clinics Community fixed-site clinics Mobile clinics

School-Based Clinics

• • Pros: Setting is where youth spend many hours a day Teachers, counselors, administrators, and peer leaders can: – – identify youth in need enhance health education and health promotion – Help with follow up and case management

School-Based Clinics

• • • • Cons: Youth needs to be attending school “Continuation Schools” often have limited resources for neediest youth Often limited services – not medical home model Often politically charged issue in the United States

Community Clinics

• • • Pros: In neighborhoods where underserved populations live Typically integrated into the community Often hooked up with other community resources

Community Clinics

• • • Cons: Variable services offered, not usually medical home model Typically not youth-focused Rarely separate adolescent services

Mobile Clinic

• • • Pros: Goes to where the target patients are Sites can change if neighborhoods or circumstances change Friendly, non-intimidating environment

Mobile Clinic

• • • Cons: Variable services offered, not usually medical home model Often a specific focus (Family planning; HIV counseling; mammography) Typically not youth-focused

Adolescent Outreach Program Packard Children’s Hospital

• • • Enhanced medical home model Program begun September 1996 Mobile Clinic (36 feet long, 2 exam rooms, and mini-pharmacy) Specifically targets homeless and uninsured adolescents ages 10-25: unique model

Program Components

• • • Clinical care to the underserved Teaching medical students, residents, fellows, etc.

– Core component of adolescent and community medicine rotations; outstanding evaluations by trainees Research – Projects include juvenile delinquency and homelessness; sexual attitudes and behaviors; nutrition knowledge, behaviors, and body image; media influence and disordered eating; emergency contraception knowledge, attitudes, and beliefs.

Personnel: Multidisciplinary

• • • • • • Pediatrician/adolescent medicine specialists Pediatric Nurse Practitioner (female) Medical Assistant Social Worker Registered Dietician Psychiatrist (with trainees) 1x/month to Van, and refers to his office as needed

Personnel, cont.

– Van driver (registration of pts. by MA and Van driver) – Business Manager – Administrative assistant (also performs data collection and entry) – IT services – Most providers bilingual Spanish; some bicultural

Finances

• • Funding provided by generous philanthropic individuals, foundations, corporations, and state/local programs • Yearly budget ~$500,000 for 2 days/week Van services, plus SW and RD outreach.

Cost-savings (conservative estimate) of $10- for every $1 spent for this program

Service Sites

• • Services provided in Santa Clara, San Mateo, and San Francisco Counties: clinic hours correspond to site hours Tenderloin Recreation Center (SF) - partners include Indochinese Development Housing Corporation and the Boys and Girls Club Peninsula Continuation High School (San Bruno)

Service Sites, cont.

• East Palo Alto Continuation High School (Menlo Park) • • Los Altos High School (Los Altos) Alta Vista Continuation High School (Mountain View) • Emergency Housing Consortium Youth Shelter “Our House” (San Jose)

Outcomes, Teen Health Van

– Outcomes may be of 3 types, depending upon type of program • Short-term: e.g., #s of new and return patients • Medium-term: e.g., immunization rates • Long-Term: e.g., behavior change – Outcomes may overlap

Patient Numbers

• Current statistics (through December 2008) > 9,000 patient visits – New patients : 31% – Return patients: 69% – Male patients: 41% – Female patients: 59%

Comprehensive & Continuous Health Services Offered

• • • • Acute illness and injury care Complete history and physical exams Family planning Health education and anticipatory guidance

Comprehensive & Continuous Health Services, cont.

• • • • • HIV counseling and testing Immunizations Mental health counseling and referrals Nutrition counseling Pregnancy testing and counseling

Comprehensive & Continuous Health Services, cont.

• • • Referrals to collaborating agencies Risk reduction counseling Sexually transmitted infection testing and counseling • • Substance abuse counseling and referrals Urine, blood testing options on site for basic tests; rest to hospital lab or DPH

Components of Providing Successful Health Care

• • • • Listen to the adolescent Spend time with the adolescent Meet the adolescent’s agenda Remember, you can’t do it all at once: – Continuity a must – Follow-up a must – Consistency a must

Components of Providing Successful Health Care

• • Meet immediate needs first Then help address other aspects of their lives • Start with clean socks, and a snack: staff and patients share the same food • Provide clothing

Components of Providing Successful Health Care

• • • Provide hygiene kits Provide dental hygiene items The Human Connection: Building Trust over time is a key factor to success – We typically spend an hour with each patient – Patients typically have multiple diagnoses and unmet health care needs: are “complex” patients

Components of Providing Successful Health Care

• Collaborate with community and neighborhood agencies that provide non health care services

and importantly

that perform youth outreach and will help promote the program • Have a formal evaluation process on a regular basis, with a designated point person: we do it Q 6 months.

Components of Providing Successful Health Care

• • • Collaborate with local agencies that provide health care, e.g., Juvenile Hall, Children’s Shelter Have all patients sign a “release of information” to ensure sharing of information with these agencies “Seamless” referrals; provide transportation if needed.

Components of Providing Successful Health Care

• • • Utilize a screening questionnaire: we have both a “Teen Questionnaire” and a “Family Planning” questionnaire.

Explain limits of confidentiality up-front Let patients know you work as a team and may share information with the team as needed (with patient ok)

Components of Providing Successful Health Care

• • • • Utilize both male and female providers Personnel must be respectful, caring, nonjudgmental, and enjoy adolescents Provide comprehensive health services (“1 stop shopping”) (pts may focus initially on only 1 service, but access others later) Provide medications for free at the time of the visit: significantly increases compliance

Components of Providing Successful Health Care

• • • Invite partners to “see you in action” – make the abstract concrete Steward donors Involve the media: newspapers, radio, and television

Components of Providing Successful Health Care

• • • • • • Provide incentives: movie tickets, gift cards Maintain privacy and confidentiality Use peer outreach and counseling – adolescents respond particularly well to this Focus on the youth’s strengths and always try to comment on successes, however small Have ongoing youth outreach Have fun!

References

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Web Resources

• • • • • The Children’s Health Fund: www.chf.org

The National Health Care for the Homeless Council: www.nhchc.org

End Homelessness: www.endhomelessness.org

www.adolescenthealth.org

Lucile Packard Foundation for Children’s Health: www.lpfch.org