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

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New Approaches to Care for Underserved
AdolescentsThe Enhanced Medical Home

• Seth Ammerman, M.D.
• Clinical Associate Professor
• Division of Adolescent Medicine
• Department of Pediatrics
• Stanford University
• Lucile Packard Childrens Hospital

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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
  Childrens Hospital as a Model That Works

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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.

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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

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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

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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

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The Latest Homeless Youth Numbers USA

• gt 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

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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

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What is A Medical Home?

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

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What is Access?

• Access is getting provider and patient
  together
• in the same place
• at the same time
• in a straightforward and easy manner

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What is Health Care?

• Health care broadly defined is
• Comprehensive
• Continuous
• Youth-centered
• Affordable

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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

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A Medical Home is not

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

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A Medical Home is not (cont.)

• Clinics focusing on a specific problem, e.g.,
• STD clinics
• Family Planning Clinics
• Mammography Vans

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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

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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

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What is an Enhanced Medical Home?

• An enhanced medical home adds to the medical home
  model
• Mental health services
• Nutrition services
• Oral Health Services
• Others acupuncture, massage therapy, yoga, etc.

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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

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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

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Barriers to Care, cont.

• Lack of transportation is major barrier
• Most youth dont 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.

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Barriers to Care Youth-Related

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

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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

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Barriers to Care System Related

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

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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

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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)

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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

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The Enhanced Medical HomeNew Approaches

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

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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

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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

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Community Clinics

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

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Community Clinics

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

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Mobile Clinic

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

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Mobile Clinic

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

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Adolescent Outreach ProgramPackard Childrens
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

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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.

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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

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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

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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

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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)

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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)

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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

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Patient Numbers

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

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Comprehensive Continuous Health Services Offered

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

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Comprehensive Continuous Health Services, cont.

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

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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

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Components of Providing Successful Health Care

• Listen to the adolescent
• Spend time with the adolescent
• Meet the adolescents agenda
• Remember, you cant do it all at once
• Continuity a must
• Follow-up a must
• Consistency a must

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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

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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

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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.

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Components of Providing Successful Health Care

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

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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)

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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

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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

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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 youths strengths and always try to
  comment on successes, however small
• Have ongoing youth outreach
• Have fun!

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References

• Brito A, Grant R, Overholt S, Aysola J, Pino I,
  Spalding SH, Prinz T, Redlener I. The enhanced
  medical home the pediatric standard of care for
  medically underserved children. Adv Pediatr.
  2008559-28.
• Busen NH, Engebretson JC. Facilitating risk
  reduction among homeless and street-involved
  youth. J Am Acad Nurse Pract. 2008
  Nov20(11)567-75.
• Strunk JA. The effect of school-based health
  clinics on teenage pregnancy and parenting
  outcomes an integrated literature review. J Sch
  Nurs. 2008 Feb24(1)13-20.
• Fletcher CW, Slusher IL, Hauser-Whitaker M.
  Meeting the health care needs of medically
  underserved, uninsured, underinsured
  Appalachians. Ky Nurse. 2006 Oct-Dec54(4)8-9.
• Redlener I, Grant R, Krol DM. Beyond primary
  care Ensuring access to subspecialists, special
  services, and health care systems for medically
  underserved children. Adv Pediatr. 2005529-22.
• Forrest CB, Whelan EM. Primary care safety-net
  delivery sites in the United States A comparison
  of community health centers, hospital outpatient
  departments, and physicians' offices. JAMA. 2000
  Oct 25284(16)2077-83.

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Web Resources

• The Childrens 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 Childrens
  Health www.lpfch.org