Transcript Homeless Adolescents: Practical Aspects of Providing

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 1221.
• 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,” “HighRisk,” “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:
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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 atrisk 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
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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
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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
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New patients : 31%
Return patients: 69%
Male patients: 41%
Female patients: 59%
Comprehensive & Continuous
Health Services Offered
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Acute illness and injury care
Complete history and physical exams
Family planning
Health education and anticipatory guidance
Comprehensive & Continuous
Health Services, cont.
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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
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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 nonhealth 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 (“1stop 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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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. 2008;55:9-28.
Busen NH, Engebretson JC. Facilitating risk reduction among homeless and streetinvolved youth. J Am Acad Nurse Pract. 2008 Nov;20(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
Feb;24(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-Dec;54(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. 2005;52:9-22.
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 25;284(16):2077-83.
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