What’s New in Clinical Preventive Services? Challenges & Opportunities

1. What’s New in Clinical Preventive Services? Challenges & Opportunities Adolescent and Young Adult Health National Resource Center SAHM Annual Meeting Seattle, WA March 16, 2018

2. Charles E. Irwin, Jr., MD1 Claire D. Brindis, DrPH1, 2 Elizabeth Ozer, PhD1 Judy Shaw, EdD, MPH, RN, FAAP3 Judy Klein4 Erin Hemlin, MA5 1Division of Adolescent and Young Adult Medicine, UCSF Benioff Children’s Hospital, University of California, San Francisco 2 Philip R. Lee Institute for Health Policy Studies, UCSF 3Vermont Child Health Improvement Program, University of Vermont College of Medicine 4UNITY Consortium 5Young Invincibles, Washington, DC

3. The Adolescent and Young Adult Health National Resource Center (“The AYAH Center”) Purpose: To improve adolescent and young adult health and address their health issues by strengthening the capacity of State Title V MCH Programs and their public health and clinical partners to better serve these populations (ages 10-25) Four-year cooperative agreement supported by MCHB (2014 - 2018)

4. Acknowledgements • Funder: Maternal and Child Health Bureau, Health Services and Resources Administration, USDHHS (cooperative agreement U45MC27709) • Project Officer: Trina M. Anglin, MD, PhD

5. University of CaliforniaSan Francisco University of Minnesota University of Vermont

6. Conflict of Interest Statement The speakers have no commercial relationships to disclose. The speakers will not be discussing any unapproved uses of pharmaceuticals or devices.

7. Session Goals Participants will be able to: • Describe updates to CPS guidelines and recommendations • Aware of the implications of policy developments for CPS delivery • Understand youths and their families’ perspectives on preventive services and well care

8. Session Goals Participants will be able to: • Describe updates to CPS guidelines and recommendations • Aware of the implications of policy developments for CPS delivery • Understand youths and their families’ perspectives on preventive services and well care

9. What is Prevention? Community Preventive Services Clinical Preventive Services AYA Health

10. What Are Clinical Preventive Services? • Services delivered by a provider in a clinical setting • Services designed to avert/delaythe onset of various health and mental health disorders or to identify problems (or assets) early in order to minimize (maximize) their impact

11. Why Provide Clinical Preventive Services?

12. Why Provide Clinical Preventive Services? • Majority of morbidity/mortality during adolescence/young adulthood is preventable • Behaviors responsible for leading causes of morbidity/mortality during adulthood are often identified in the second decade of life (e.g., mental health, smoking, substance use, physical inactivity, sexual behavior, driving, etc.) • Co-occurrence of risk behaviors is common

13. Global burden of disease in young people aged 10-24 years: A systematic analysis Source: Gore et al., 2011

14. Global burden of disease in young people aged 10-24 years: A systematic analysis Prevention Source: Gore et al., 2011

15. Why Provide Clinical Preventive Services? • Adolescents/parents view clinician as credible resources for information • Families expect that clinicians will provide guidance about health behaviors • Three quarters of adolescents in the U.S. see a primary care clinician at least once per year • Underutilized time in clinical practice

16. Effectiveness Preventive Interventions • Primary care clinicians have been successful in reducing alcohol and tobacco use and increasing seat belt use with office-based ADULTinterventions • Depression Screening in ADOLESCENTS • Some evidence, though mixed, that office-based interventions improve adolescent behavior

17. Summary of Clinical Guidelines

18. NCQA Guidelines (HEDIS) • Nine Adolescent-specific measures • Weight assessment and counseling for nutrition and physical activity • Annual well visit to provider • Initiation and engagement of alcohol & other drug dependence treatment • Immunization status • HPV for female adolescents • Screening sexually active females for Chlamydia trachomatis (over 15 years old) • Access to primary care practitioners • Use of first-line psychosocial care for those on antipsychotics • Metabolic monitoring for those on antipsychotics National Committee for Quality Assurance. HEDIS Measures. Available at: www.ncqa.org. Accessed May 22, 2017.

19. NCQA Guidelines (HEDIS) • Six Young Adult-specific measures • BMI assessment • Cervical cancer screening • Flu vaccination • Medical assistance with smoking & tobacco cessation • Chlamydia screening in women • Well-care visits (up through age 21) National Committee for Quality Assurance. HEDIS Measures. Available at: www.ncqa.org. Accessed May 22, 2017.

20. U.S. Preventive Services Task Force – Recommendations Adolescents Young Adults Recommendation ✝ For those at increased risk * Update in progress U.S. Preventive Services Task Force. Published Recommendations. Accessed May 22, 2017.

21. Clinical Guidelines • Bright Futures: Consensus document, Age Specificity, Ages 0-21 – since 1990s. 4th Edition, February 2017 • GAPS: Consensus document, Age Specificity, Ages 11-21 – early 1990s • USPSTF: Rigorous Evidence Rules, Age Specificity, Ages 11-24 • ACIP: Immunizations for AYAs and adults

22. Primary care providers screenbehaviors, as well as remind adolescents & families about strengths And that adolescent has some time alone with clinician during preventive visit. Adolescent Clinical Guidelines Annual Visit

23. Implementation of Guidelines:Are AYAs Receiving Preventive Services?

24. Receipt of a Well Visit by Age, Ages 10-25, MEPS (2007-09 & 2015) 2007-2009 2015 Young Adults *All rates significantly increased Source: Medical Expenditure Panel Survey

25. The well visit matters:Adolescents AND Young Adults who have a past-year well visit report higher rates of preventive services

26. Receipt of physical parameters among ADOLESCENTS, with a preventive visit vs. non-preventive visit, Ages 10-17, MEPS 2013-15 *All rates significantly higher among those with preventive visit. Source: Medical Expenditure Panel Survey

27. Receipt of anticipatory guidance among ADOLESCENTS, with a preventive visit vs. non-preventive visit, Ages 10-17, MEPS 2013-15 *All rates significantly higher among those with preventive visit. Source: Medical Expenditure Panel Survey

28. Receipt of anticipatory guidance (all 6) and time alone among ADOLESCENTSwith a preventive visit vs. non-preventive visit, Ages 10-17, MEPS 2013-15 *All rates significantly higher among those with preventive visit. Source: Medical Expenditure Panel Survey

29. Receipt of preventive services among YOUNG ADULTS, with a preventive visit vs. non-preventive visit, Ages 18-25, MEPS 2013-15 *All rates significantly higher among those with preventive visit. Source: Medical Expenditure Panel Survey

30. Questions? Thoughts?

31. Overview & Accomplishmentsof the AYAH-National Resource CenterClaire D. Brindis, DrPHCo-Director, Adolescent & Young Adult Health National Resource Center (The AYAH Center)

32. The AYAH Center Primary focus is improving receipt and quality of the well-visit among adolescents and young adults Under the Revised Title V/State Maternal and Child Health Program Block Grants, states had to choose at least one performance measure focused on adolescents. 39 states chose National Performance Measure #10: the percent of adolescents aged 12-17 with a well-visit in the past year.

33. 39 states & territories that selected NPM #10

34. The AYAH Center Major Activities: The Collaborative Improvement and Innovation Network (CoIIN): intensive focus on improving receipt and quality of well visit in 12states Technical assistance to other states that selected MCHB’s National Performance Measure #10 (increase % of adolescents receiving a well visit) http://nahic.ucsf.edu/resource-center/

35. 12 AYAH CoIIN States

36. The AYAH Center:National Strategies • To the door: Improving access to services and engaging youth, their families and clinics to increase uptake of an annual well visit. • In the door: Improving delivery of youth-centered family engaged care • Across the state: Improving state- and systems-level policies and practices

37. The AYAH Center:National Strategies • To the door: Improving access to services and engaging youth, their families and clinics to increase uptake of an annual well visit. • In the door: Improving delivery of youth-centered family engaged care • Across the state: Improving state- and systems-level policies and practices

38. Improving Access to the Well Visit:AYAH CoIIN States • Strategies of NST #1 include: • Engaging AYAs and parents to promote the value of the well visit and improve health literacy • Using clinic outreach systems for AYAs overdue for a well visit • Leveraging “seasonality” of acute care visits

39. Improving Access to the Well Visit:AYAH CoIIN States • Accomplishments of NST #1 include: • Vermont, Iowa, and TexasCoIIN teams engaged AYAs and parents to create marketing messages and materials to promote the well visit • Vermont and IowaCoIIN teams implemented a “reminder recall system” where letters were sent to AYAs due for a well visit

40. Improving Access to the Well Visit:AYAH CoIIN States • Accomplishments of NST #1 include: • The Mississippi CoIIN team partnered with a SBHC and the associated high school to educate students, teachers, coaches and clinic staff about the importance of the well visit

41. The AYAH Center:National Strategies • To the door: Improving access to services and engaging youth, their families and clinics to increase uptake of an annual well visit. • In the door: Improving delivery of youth-centered family engaged care • Across the state: Improving state- and systems-level policies and practices

42. Improving the Quality of the Visit:AYAH CoIIN States • Strategies of NST #2include: • Promote evidence base & guidelines for preventive services • Conduct Clinician Training • Address Confidentiality • Support Quality Improvement

43. Improving the Quality of the Visit:AYAH CoIIN States • Accomplishments of NST #2 include: • The Mississippi CoIIN team developed a confidentialityguidebook and hosted a 1-day training with Abigail English, attended bywith by clinicians and clinic staff • Texas CoIIN team developed online training modules to improve the quality of the visit

44. The AYAH Center:National Strategies • To the door: Improving access to services and engaging youth, their families and clinics to increase uptake of an annual well visit. • In the door: Improving delivery of youth-centered family engaged care • Across the state: Improving state- and systems-level policies and practices

45. Improving Policy & Practices:AYAH CoIIN States • Strategies of NST #3 include: • Promote the annual WV in state Medicaid programs • Outreach and enrollment protocols • Confidentiality • Workforce capacity & training • Care coordination & management

46. Improving Policy & Practices:AYAH CoIIN States • Accomplishments of NST #3 include: • The Iowa CoIIN team successfully changed their state Medicaid program’s periodicity schedule for the well visit from biannual to annual, consistent with Bright Futures. • The Minnesota CoIIN team, with the their state Medicaid program, adopted Bright Futures recommendations (e.g., annual well visit, depression screening, HIV screening) as Medicaid policy