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

1. 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

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

11. What is A “Medical Home?” For optimal health care, a medical home provides • Access • Health Care, broadly defined

12. What is “Access?” • “Access” is getting provider and patient together: • in the same place • at the same time • in a straightforward and easy manner

13. What is “Health Care?” “Health care” broadly defined is: • Comprehensive • Continuous • Youth-centered • Affordable

14. 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

15. A Medical Home is not: • Emergency room visits • Episodic sick care clinic visits • Urgent care clinic visits • Clinics not ensuring medication provision

16. A Medical Home is not (cont.): • Clinics focusing on a specific problem, e.g., • STD clinics • Family Planning Clinics • Mammography Vans

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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.

23. Barriers to Care: Youth-Related • Health care is not a priority • Denial • Shame • Fear • Distrust

24. 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”

25. Barriers to Care: System Related • Address requirements and lengthy bureaucratic processing • Crowded waiting rooms • Long waits • Not youth focused

26. 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

27. 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)

28. 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

29. 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

30. 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

31. 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

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

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

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

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

36. Adolescent Outreach ProgramPackard 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

37. 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.

38. 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

39. 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

40. 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

41. 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)

42. 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)

43. 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

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

45. Comprehensive & Continuous Health Services Offered • Acute illness and injury care • Complete history and physical exams • Family planning • Health education and anticipatory guidance

46. Comprehensive & Continuous Health Services, cont. • HIV counseling and testing • Immunizations • Mental health counseling and referrals • Nutrition counseling • Pregnancy testing and counseling

47. 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

48. 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

49. 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

50. 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