Transcript New Adolescent Health Package: What it means for school

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
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Update: Proposed Adolescent Health
Package
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Consensus document prepared by DPH/C&Y in collaboration with
the Primary Care Community (NCPS, NCAFP, SHCs, CHCs; HDs;
and others).
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Clinical Policy for an Adolescent Health Check Screening
Assessment developed by DMA based on the consensus document.
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DMA’s Physician Advisory Group reviewed / approved the policy.
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Policy was made available for public comment on May 28, 2009 with
a July 13th deadline for submitting comments.
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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 The policy is still a “proposed, unpublished policy.”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].
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
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DMA should:
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Implement DMA Adolescent Health Check Screening Assessment Policy
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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.
Consensus Document for Adolescent
Health Package
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Based on “best practice” guidelines (and where
possible “evidence-based” practice).
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Involved content experts in development of policy.
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Cites and links to sources of guidance throughout
including AAP/2008 Bright Futures; CDC; USPSTF;
ACIP; etc.
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Provides links to resources available to support the
implementation of these guidelines.
2009 Health Check Billing Guide
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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]
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Proposed Adolescent Package of Services
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Adolescent Health Check Screening Assessment:
Clinical service package appropriate for and applicable to
adolescents receiving routine preventive health screening.
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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.
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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).
Adolescent Health Screening Assessment
- Components at a Glance
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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]
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:
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Enhanced Anticipatory Guidance
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Cervical Dysplasia Screening [as clinically indicated for immune compromised]
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Pelvic/Bi-Manual Examination [as appropriate]
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.
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[Sources: AAP/2008 Bright Futures]
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.
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[Sources: cms/hhs; 2008 Bright Futures]
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
Laboratory Tests:
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Urinalysis: Not recommended as routine screening test.
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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]
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Adolescent Health Screening Assessment
Components / Best Practice Guidelines
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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:
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Suspected of having TB disease based on clinical symptoms
Present for care with one of the following risk factors:
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Foreign-born and from high-prevalence area: Asia, Africa, Caribbean,
Latin America, Mexico, South America, Pacific Islands, Middle East,
Eastern Europe.
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Migrants, seasonal farm workers, homeless, or previously incarcerated
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HIV infected
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Inject illicit drugs or use crack cocaine
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Traveled outside USA & stayed with resident in high-prevalence area for
greater than 1 month cumulatively
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Exposed to high risk adult (homeless, incarcerated, HIV positive, past
or present illicit drug use)
[Source of Policy: NC TB Control Branch]
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
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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:
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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:
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Overweight or obese
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Daily cigarette smoking
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Hypertension
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Type 2 diabetes mellitus
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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]
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
Sexually Transmitted Diseases:
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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.
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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:
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Annual screen for all sexually active women <24. [Source: USPSTF]
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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]
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
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Sexually Transmitted Diseases (Continued):
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HIV:
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CDC recommends universal voluntary HIV screen for all sexually active
youth beginning at age13.
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Minimally, HIV testing of youth at risk should be repeated annually. Risk
factors include:
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[Source: CDC]
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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
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
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Sexually Transmitted Diseases (Continued):
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Syphilis:
[Source: USPSTF]
Recommended for all sexually active youth at risk, including:
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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.
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[Content Expert Source for All STD/HIV Screening Policies: DPH / HIV/STD Prevention and Care Unit]
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
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Cervical Dysplasia Screening (Pap Smear)
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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). *
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Earlier screening with history of sexual abuse or immune compromise. *
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ACOG & ACS recommend annual screening with traditional Pap smear & every 2
years if liquid-based system used.*
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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]
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Adolescent Health Screening Assessment
Components / Best Practice Guidelines
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Pregnancy Testing
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As sexually active adolescents are at risk of becoming
pregnant, review the personal medical history and perform a
pregnancy test if indicated.
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Assess for missed periods, unexplained vaginal bleeding;
unprotected sex; abdominal pain, or concern by the youth
that she might be pregnant.
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
Nutrition Assessment: Includes a combination of physical, laboratory, health risk
assessment, and dietary determinations.
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Non-dietary components include:
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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
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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.
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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.
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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].
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
Developmental, Psychosocial/Behavioral & Alcohol/Drug Use Screening
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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.
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Physical Growth and Development
Academic Competence
Social Relationships
Emotional Well-Being
Risk Reduction
Violence and Injury Prevention
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
Developmental, Psychosocial/Behavioral & Alcohol/Drug Use Screening (Con’t):
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Further screening for developmental, behavioral or mental health issues using
evidence-based tools is recommended. Examples of evidence-based tools include:
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Primary Broad-Based Validated Screening Tools
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Pediatric Symptom Checklist (PSC)
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Strengths & Difficulties Questionnaire (SDQ)
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Vanderbilt Assessment Scales
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Secondary (Specific) Validated Screening Tools for Depression
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Patient Health Questionnaire – Adolescent (PHQ-A) . Available from Teen Screen
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Beck’s Depression Inventory-Fast Screen for Medical Patients
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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]
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”]
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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.
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Physical Growth and Development: Physical and oral health; body image; healthy vs. disordered eating;
increased physical activity; decreased screen time; multivitamin with folic acid.
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Social and Academic Competence: Relationships with family, peers, community; limit
setting/consequences; rules/responsibilities; school performance; plans for future educ/career.
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Emotional Well-Being: Coping; independent decision-making; problem-solving skills; mood regulation/mental
health; sexuality.
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Risk Reduction: Substance use; pregnancy; STDs; making plans for resisting peer pressure.
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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.
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[Source: 2008 Bright Futures]
Additional Anticipatory Guidance for Initial
Visit of Extended Adolescent Health Screening
Assessment (with Family Planning)
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General information that includes the health benefits of abstinence &
risks/benefits for all contraceptive options.
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Specific information re: adolescent’s contraceptive choice including
effective use, benefits/efficacy; possible side effects/complications.
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Benefits of dual-method use (condoms/STD prevention & 2nd
method/contraception.
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If discontinue method selected, info on back-up methods and
emergency contraception.
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24-hour emergency number.
[Sources: DPH/Women’s Health Branch; Title X Guidance; Primary Care Consensus Group for Development of
Adolescent Health Package Policies]
Adolescent Health Screening Assessment
Components / Best Practice Guidelines
Follow-Up and Referral
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Adolescents with suspected or identified problems that are not treated inhouse must be referred / receive consultation from an appropriate source.
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If referring for family planning after a Adolescent Health Risk Screening
Assessment, send results of assessment, including lab results, with
appropriate consent.
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If communicable disease diagnosed, submit “Confidential Communicable
Disease Report”.
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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.
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Discuss timing of next appointment & schedule if appropriate.
[Source: Primary Care Consensus Group for Development of Adolescent Health Package Policies].
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:
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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.
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.
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Session 1: Adolescent Health History & Comprehensive Physical Assessment
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Session 2: Adolescent Health Risk Appraisal & Anticipatory Guidance
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Session 3: Evidence-Based Behavioral-Mental Health Screening of Adolescents
Including Alcohol / Drug Use Assessment
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Session 4: Nutritional Assessment of Adolescents
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Session 5: Adolescent Immunizations
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Session 6: Family Planning Services for Adolescents
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Session 7: Transition from Pediatric to Adult Health Care Provision
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Session 8: DMA Adolescent Package of Services & Coding / Billing
Plans to Support Practice Changes When
Adolescent Health Package is Published
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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]
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Example Algorithm:
STD/HIV Risk Assessment &
Screening in Adolescents
*High risk adolescents can be screened
Sexually active &
no symptoms
Screen for
GC/Chlamydia
*Annually for GC
and Chlamydia
in all females
*Annually for Chlamydia
in males with yes
answer to risk question,
and not for GC
Chlamydia Risk
Questions:
Prevalence in this age
population is 2-4% or
higher?
Attending an STD clinic?
Attending Job Corp?
Entering Jail?
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outside of the well visit as indicated
based on risk. If an adolescent has any
STD, consider test for syphilis and HIV.
Screen for HIV
*Annually
if answers yes to
a risk question
OR
Offer voluntarily
for all older than
13 yrs of age
& no other risks
(CDC recommends)
Screen for
Syphilis
*Annually screen
if answers yes to
a risk question
HIV Risk Questions:
Syphilis 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?
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?
There are multiple codes for GC, chlamydia, HIV and syphilis testing.
Significance of These Changes for School
Health Center Practice & Sustainability
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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 behavioralmental health services.
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The adolescent focus, based on best practice guidelines, provides
fiscal support for the provision of high quality well visits for adolescents
through age 20.
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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.
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The package also allows for the reimbursement of services currently
performed in high volume in SHCs, but until recently not reimbursed.
Questions? Discussion…
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