Proposed Adolescent Health Package: What It Means for School Health Centers”

1. Proposed Adolescent Health Package:What It Means for School Health Centers” Carolyn Sexton, RN, MPH, Consultant, DPH/Children and Youth Branch Carol A. Ford, MD, Adolescent Medicine, UNC School of Medicine & UNC Gillings School of Global Public Health

2. Update: Proposed Adolescent Health Package • Consensus document prepared by DPH/C&Y in collaboration with the Primary Care Community (NCPS, NCAFP, SHCs, CHCs; HDs; and others). • Clinical Policy for an Adolescent Health Check Screening Assessment developed by DMA based on the consensus document. • DMA’s Physician Advisory Group reviewed / approved the policy. • Policy was made available for public comment on May 28, 2009 with a July 13th deadline for submitting comments. • DHHS is considering the fiscal impact and timing for publication of this policy. The policy is still a “proposed, unpublished policy.” [The policy has strong support from DMA & the provider community].

3. NC Institute of Medicine Adolescent Health Task Force Recommendation Recommendation 4.1: Cover and Improve Annual High-Quality Well Visits for Adolescents Up to Age 20 • DMA should: • Implement DMA Adolescent Health Check Screening Assessment Policy • Review and Update the DMA Adolescent Health Check Screening Assessment Policy at Least Once Every Five Years • Other public and private insurers, including the State Health Plan, should cover annual well child visits for adolescents that meet the quality of care guidelines of the US Preventive Services Task Force, Centers for Disease Control and Prevention, American Academy of Pediatrics/Bright Futures and the Advisory Committee on Immunization Practices.

4. Consensus Document for Adolescent Health Package • Based on “best practice” guidelines (and where possible “evidence-based” practice). • Involved content experts in development of policy. • Cites and links to sources of guidance throughout including AAP/2008 Bright Futures; CDC; USPSTF; ACIP; etc. • Provides links to resources available to support the implementation of these guidelines.

5. 2009 Health Check Billing Guide • Effective with the July 1 implementation of the “2009 Health Check Billing Guide”, annual visits are recommended for children ages 2 through 20. [Source of guidance: AAP/2008 Bright Futures Guidelines]

6. Proposed Adolescent Package of Services • Adolescent Health Check Screening Assessment: Clinical service package appropriate for and applicable to adolescents receiving routine preventive health screening. • Extended Adolescent Health Check Screening Assessment: Clinical service package appropriate for and applicable only to female adolescents receiving preventive health screening that includes a family planning component. • Interperiodic Adolescent Health Check Screening Assessment: Appropriate when a comprehensive Adolescent Health Check Screening Assessment is required outside of the routine periodicity schedule (i.e. more often than the routine annual screening assessment for adolescents).

7. Adolescent Health Screening Assessment - Components at a Glance • Comprehensive Health History • Measurements [BP; Height; Weight; BMI plotted on gender-specific chart] • Visual Risk Assessment & Screening • Hearing Risk Assessment & Screening • Dental Screening • Laboratory Tests [as clinically indicated based on risk assessment] • Nutrition Assessment • Developmental, Psychosocial/Behavioral and Alcohol/Drug Use Assessments • Comprehensive Physical Assessment • Immunizations [as clinically indicated, according to ACIP guidelines] • Anticipatory Guidance and Health Education • Follow-Up and Referral [as indicated]

8. Added Components for an “Extended” Adolescent Health Screening Assessment (with a Family Planning Component) In addition to the components of the Adolescent Health Screening Assessment: • Enhanced Anticipatory Guidance • Cervical Dysplasia Screening [as clinically indicated for immune compromised] • Pelvic/Bi-Manual Examination [as appropriate]

9. Adolescent Health Screening Assessment Components / Best Practice Guidelines Comprehensive Health History Includes medical history, family medical history, review of systems. Measurements Includes blood pressure, height, weight, BMI, and BMI-for-Age Percentile plotted on a gender-specific growth chart. BP Percentile may be assessed using gender-specific “BP Levels by Age & Height Percentile” Tables. [Various tools and resources linked]. [Sources: 2008 Bright Futures; CDC; NIH] Vision Risk Assessment and Screening Must be screened every three years. Selectively screen vision at other ages based on the provider’s assessment of risk, including any academic difficulties. [Sources: AAP/2008 Bright Futures]

10. Adolescent Health Screening Assessment Components / Best Practice Guidelines Hearing Risk Assessment and Screening Selectively screen hearing in adolescents using an audiometer based on the provider’s assessment of risk. Screening should occur if the adolescent is exposed to potentially damaging noise levels, head trauma with loss of consciousness, recurring ear infections, or ototoxic medications or if s/he reports problems, including academic difficulties. [Sources: AAP/2008 Bright Futures] Dental Screening Oral screening to be performed at every Adolescent Health Screening Assessment as a part of a comprehensive physical assessment. Refer for routine dental care (every 6 month visit) as well as for identified dental problems. [Sources: cms/hhs; 2008 Bright Futures]

11. Adolescent Health Screening Assessment Components / Best Practice Guidelines Laboratory Tests: • Urinalysis:Not recommended as routine screening test. • Hgb/Hct:Annual hgb/hct for adolescent females if any of the following risk factor(s) are present: extensive menstrual or other blood loss, low iron intake, or a previous diagnosis of iron deficiency anemia. Otherwise not recommended as routine screening test. [Sources: 2008 Bright Futures; CDC]

12. Adolescent Health Screening Assessment Components / Best Practice Guidelines • TB Test (PPD):Not recommended as routine screening test. Criteria for baseline TB screening of children/adolescents according to NC TB Control Branch are as follows: • Suspected of having TB disease based on clinical symptoms • Present for care with one of the following risk factors: • Foreign-born and from high-prevalence area: Asia, Africa, Caribbean, Latin America, Mexico, South America, Pacific Islands, Middle East, Eastern Europe. • Migrants, seasonal farm workers, homeless, or previously incarcerated • HIV infected • Inject illicit drugs or use crack cocaine • Traveled outside USA & stayed with resident in high-prevalence area for greater than 1 month cumulatively • Exposed to high risk adult (homeless, incarcerated, HIV positive, past or present illicit drug use) [Source of Policy: NC TB Control Branch]

13. Adolescent Health Screening Assessment Components / Best Practice Guidelines • Dyslipidemia Risk Assessment & Screening:Professional organizations vary in recommendations for dyslipidemia screening. Consider a fasting or non-fasting lipid profile (total cholesterol, triglycerides, HDL, LDL) based on an assessment of risk: • Family history of dyslipidemia • Family history of premature cardiovascular disease (CVD; heart disease or stroke) occurring in men < 55 or women < 65. • Youth with a personal history of other CVD risk factors: • Overweight or obese • Daily cigarette smoking • Hypertension • Type 2 diabetes mellitus • Youth for whom no family medical history is available • If within reference range, may retest every 5 years. For abnormal values, develop an appropriate plan for repeating labs, follow-up and referrals. [Additional resources referenced in policy]. [Sources: AAP; USPSTF; Eat Smart Move More NC 2008 Pediatric Obesity Prevention/Treatment Algorithm/NC Design Team]

14. Adolescent Health Screening Assessment Components / Best Practice Guidelines • Sexually Transmitted Diseases: • For school-based health centers that cannot address reproductive health issues in a school setting, referral and follow-up must be offered to encourage receipt of STD screening tests. • Sexually active adolescents are at high risk for STDs due to higher rate of partner change, greater likelihood of unprotected sex, may select partners at higher risk, & are biologically more susceptable. Screening tests should be offered according to the following protocols: • Chlamydia: • Annual screen for all sexually active women <24. [Source: USPSTF] • Annual screen for males <26 if at risk (Consider if population prevalence 2-4% or higher in sexually active young men; all young men attending STD clinics or Job Corps or <30 & entering jail). All men with diagnosed chlamydia infection should be rescreened in approximately 3 months. [Source: CDC] • Gonorrhea:Annual screen-sexually active adolescent females. [Source: USPSTF]

15. Adolescent Health Screening Assessment Components / Best Practice Guidelines • Sexually Transmitted Diseases (Continued): • HIV: [Source: CDC] • CDC recommends universal voluntary HIV screen for all sexually active youth beginning at age13. • Minimally, HIV testing of youth at risk should be repeated annually. Risk factors include: • Inject drugs or steroids with used injection equipment • More than one sex partner since the last HIV test • Had sex with an HIV-infected person • Male and have had sex with another male • Had sex for money or drugs • Diagnosed with or treated for a STD, hepatitis, or tuberculosis • Have a partner with any of the above risk factors

16. Adolescent Health Screening Assessment Components / Best Practice Guidelines • Sexually Transmitted Diseases (Continued): • Syphilis:[Source: USPSTF] Recommended for all sexually active youth at risk, including: • Males who had sex with males & engage in high-risk sexual behavior. • Commercial sex workers. • People who exchange sex for drugs • Inmates in correctional institutions Clinicians may use clinical judgment to individualize screening for syphilis based on local prevalence. [Content Expert Source for All STD/HIV Screening Policies: DPH / HIV/STD Prevention and Care Unit]

17. Adolescent Health Screening Assessment Components / Best Practice Guidelines • Cervical Dysplasia Screening (Pap Smear) • Sexually active females should have a Pap smear as part of a pelvic assessment approximately 3 years after onset of sexual activity or age 21 (whichever comes first). * • Earlier screening with history of sexual abuse or immune compromise. * • ACOG & ACS recommend annual screening with traditional Pap smear & every 2 years if liquid-based system used.* • Note: New ACOG Guidelines released 11/20/09 recommend that women have their first cervical cancer screening at age 21 and every two years from ages 21-30 using standard Pap or liquid-based cytology. [Discussion of earlier Pap screening for immunosuppressed]. [Sources: 2008 Bright Futures; Journal of Pediatric Adolescent Gynecology; ACOG; ACS]

18. Adolescent Health Screening Assessment Components / Best Practice Guidelines • Pregnancy Testing • As sexually active adolescents are at risk of becoming pregnant, review the personal medical history and perform a pregnancy test if indicated. • Assess for missed periods, unexplained vaginal bleeding; unprotected sex; abdominal pain, or concern by the youth that she might be pregnant.

19. Adolescent Health Screening Assessment Components / Best Practice Guidelines Nutrition Assessment: Includes a combination of physical, laboratory, health risk assessment, and dietary determinations. • Non-dietary components include: • Height, Weight, BMI, BMI-for-Age Percentile plotted on gender-specific chart • Dyslipidemia screening results, as clinically indicated • Blood pressure • Hgb/Hct on adolescent females at risk • Counsel adolescents on the importance of healthy eating and physical activity habits. The Eat Smart Move More “Prescription for Health-5-3-2-1-Almost None” guide is a helpful tool. • Further assessment or an appropriate management plan with referral and follow-up when dietary practices suggest risk factors for co-morbidities, dietary inadequacy, obesity, disordered eating practices (pica, eating disorders, or excessive supplementation) or other nutritional problems. • It is recommended that all females of childbearing age take a multivitamin with folic acid. [Sources: CDC; NIH; Eat Smart Move More NC; AMA; USDA Dietary Guidelines for Americans and My Pyramid recommendations. Numerous tools and resources are linked].

20. Adolescent Health Screening Assessment Components / Best Practice Guidelines Developmental, Psychosocial/Behavioral & Alcohol/Drug Use Screening • Must perform an Adolescent Health Risk Screen (such as HEADSSS, GAPS, or Modified GAPS, Bright Futures Tool) that gathers information in the following priority areas, focusing on assets (strengths) as well as areas of concern for the youth or his or her parents. • Physical Growth and Development • Academic Competence • Social Relationships • Emotional Well-Being • Risk Reduction • Violence and Injury Prevention

21. Adolescent Health Screening Assessment Components / Best Practice Guidelines Developmental, Psychosocial/Behavioral & Alcohol/Drug Use Screening (Con’t): • Further screening for developmental, behavioral or mental health issues using evidence-based tools is recommended. Examples of evidence-based tools include: • Primary Broad-Based Validated Screening Tools • Pediatric Symptom Checklist (PSC) • Strengths & Difficulties Questionnaire (SDQ) • Vanderbilt Assessment Scales • Secondary (Specific) Validated Screening Tools for Depression • Patient Health Questionnaire – Adolescent (PHQ-A) . Available from Teen Screen • Beck’s Depression Inventory-Fast Screen for Medical Patients • 3/09 - USPSTF recommends adolescent screening (ages 12-18) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy, and follow-up. Grade: B • Alcohol/Drug Use Assessment: CRAFFT Screening Tool for Adolescents [Sources: 2008 Bright Futures; Various Sites that Offer Best Practice or Evidence-Based Tools in the Public Domain]

22. Adolescent Health Screening Assessment Components / Best Practice Guidelines Complete Physical Assessment The Extended Adolescent Health Screening Assessment (with Family Planning) may include a pelvic and bi-manual assessment for females, as clinically indicated. Immunization Status Assessed at each clinical service visit, with immunizations provided as clinically indicated according to ACIP guidelines. [Source: CDC’s “Recommended Immunization Schedule for Persons Aged 7-18 Years – United States 2009”]

23. Adolescent Health Screening Assessment Components / Best Practice Guidelines Anticipatory Guidance and Health Education Should be tailored to the questions issues, or concerns for that particular adolescent and family. The five areas of focus below, from 2008 Bright Futures, represent anticipatory guidance priorities for discussion over the series of annual visits that occur during early, middle, and late adolescence. • Physical Growth and Development:Physical and oral health; body image; healthy vs. disordered eating; increased physical activity; decreased screen time; multivitamin with folic acid. • Social and Academic Competence:Relationships with family, peers, community; limit setting/consequences; rules/responsibilities; school performance; plans for future educ/career. • Emotional Well-Being:Coping; independent decision-making; problem-solving skills; mood regulation/mental health; sexuality. • Risk Reduction:Substance use; pregnancy; STDs; making plans for resisting peer pressure. • Violence and Injury Prevention:Safety belt and helmet use; substance abuse & riding in a vehicle; guns; interpersonal violence; bullying; resisting coercive attempts to engage in sex. [Source: 2008 Bright Futures]

24. Additional Anticipatory Guidance for Initial Visit of Extended Adolescent Health Screening Assessment (with Family Planning) • General information that includes the health benefits of abstinence & risks/benefits for all contraceptive options. • Specific information re: adolescent’s contraceptive choice including effective use, benefits/efficacy; possible side effects/complications. • Benefits of dual-method use (condoms/STD prevention & 2nd method/contraception. • If discontinue method selected, info on back-up methods and emergency contraception. • 24-hour emergency number. [Sources: DPH/Women’s Health Branch; Title X Guidance; Primary Care Consensus Group for Development of Adolescent Health Package Policies]

25. Adolescent Health Screening Assessment Components / Best Practice Guidelines Follow-Up and Referral • Adolescents with suspected or identified problems that are not treated in-house must be referred / receive consultation from an appropriate source. • If referring for family planning after a Adolescent Health Risk Screening Assessment, send results of assessment, including lab results, with appropriate consent. • If communicable disease diagnosed, submit “Confidential Communicable Disease Report”. • Plan for youth’s transition from pediatric to adult health care by encouraging his/her involvement in healthcare decision making & encouraging parents’ role in developing these skills. • Discuss timing of next appointment & schedule if appropriate. [Source: Primary Care Consensus Group for Development of Adolescent Health Package Policies].

26. Plans to Support Practice Changes When Adolescent Health Package is Published NC Institute of Medicine Adolescent Health Task Force Recommendation 4.1: Cover and Improve Annual High-Quality Well Visits for Adolescents Up to Age 20 CCNC, AHEC and DPH should pilot tools and strategies to help primary care providers deliver high quality adolescent health checks. Strategies could include: • Trainings and other educational opportunities around the components of the Adolescent Health Check… • The development and implementation of a quality improvement model for improving adolescent health care. NC’s foundations should provide $500,000 over three years to support this effort.

27. Plans to Support Practice Changes When Adolescent Health Package is Published Webinar series is planned to provide clinical training on the Adolescent Package of Services. Initially will be presented “live” and recorded for future viewing. Each session will be one hour & presented by a content expert. CE credit will be offered. • Session 1: Adolescent Health History & Comprehensive Physical Assessment • Session 2: Adolescent Health Risk Appraisal & Anticipatory Guidance • Session 3: Evidence-Based Behavioral-Mental Health Screening of Adolescents Including Alcohol / Drug Use Assessment • Session 4: Nutritional Assessment of Adolescents • Session 5: Adolescent Immunizations • Session 6: Family Planning Services for Adolescents • Session 7: Transition from Pediatric to Adult Health Care Provision • Session 8: DMA Adolescent Package of Services & Coding / Billing

28. Plans to Support Practice Changes When Adolescent Health Package is Published • Algorithm Tools Have Been Developed for the Adolescent Health Check Screening Assessment to Assist with Risk Assessments and Next Steps. [Gerri Mattson, MD, Peds: 2009 NC Medical Society Leadership College Project]

29. Example Algorithm: STD/HIV Risk Assessment & Screening in Adolescents Sexually active & no symptoms *High risk adolescents can be screened outside of the well visit as indicated based on risk. If an adolescent has any STD, consider test for syphilis and HIV. Screen for GC/Chlamydia Screen for Syphilis Screen for HIV *Annually for GC and Chlamydia in all females *Annually if answers yes to a risk question Offer voluntarily for all older than 13 yrs of age & no other risks (CDC recommends) *Annually screen if answers yes to a risk question OR *Annually for Chlamydia in males with yes answer to risk question, and not for GC HIV Risk Questions: Injects drugs or steroids with used injection equipment? Has had more than one sex partner since last test? Has had sex with an HIV infected person? Is male and has had sex with another male? Has had sex for money or drugs? Has been diagnosed with or treated for STD, Hepatitis, or TB? Has a partner with any of the above risk factors? Syphilis Risk Questions: Is in an area with high prevalence? Is a male who has sex with males and engages in high risk sexual behavior? Is a commercial sex worker? Exchanges sex for drugs? Is in a correctional institution? Chlamydia Risk Questions: Prevalence in this age population is 2-4% or higher? Attending an STD clinic? Attending Job Corp? Entering Jail? There are multiple codes for GC, chlamydia, HIV and syphilis testing.

30. Significance of These Changes for School Health Center Practice & Sustainability • The proposed DMA Adolescent Health Package is complementary to the comprehensive, integrated practice model of School Health Centers that offer preventive/primary care, nutrition, and behavioral-mental health services. • The adolescent focus, based on best practice guidelines, provides fiscal support for the provision of high quality well visits for adolescents through age 20. • Reimbursement for Annual PEs provide an opportunity to perform timely risk assessments and offer anticipatory guidance that promote healthy lifestyle choices related to nutrition, exercise, sexuality, behavioral/mental health issues, substance use and other risk factors that impact health throughout life. • The package also allows for the reimbursement of services currently performed in high volume in SHCs, but until recently not reimbursed.

31. Questions? Discussion…