Embed Size (px)
DESCRIPTION
Adolescent and Young Adult Health in San Francisco: Opportunities for Change. Claire D. Brindis , DrPH Division of Adolescent and Young Adult Medicine UCSF Benioff Children’s Hospital Philip R. Lee Institute for Health Policy Studies University of California, San Francisco - PowerPoint PPT Presentation
Citation preview
Adolescent and Young Adult Health in San Francisco: Opportunities for Change
Claire D. Brindis, DrPHDivision of Adolescent and Young Adult Medicine
UCSF Benioff Children’s HospitalPhilip R. Lee Institute for Health Policy Studies
University of California, San Franciscowith Jazmyn Scott, Charles E. Irwin, Jr., Jane Park
11th Annual Provider Gathering: Increasing Patient Centered Care for Young Women
Adolescent Health Working GroupApril 11, 2014
Overview• Young Women’s Health: A Summary• Medical Homes for Adolescents• Preventive Health Services• Tying It All Together
YOUNG WOMEN’S HEALTH
Why Young Women?• Critical period for health.• The major health problems of early adulthood
are largely preventable.• Many problems are linked to behaviors and
conditions with related outcomes in adult health, including diabetes, cancer, heart disease.
Why Young Women?• Few young adults have serious impairment that
interferes with daily functioning, BUT• Those with chronic conditions, including mental
health disorders, must learn to manage these conditions with increasing interdependence.
• Mental and reproductive health issues major concern for adolescent and young adult women.
Critical Health Issues of Adolescence & Young Adulthood Within a Developmental
Context
Increasing independence in habits related to:
* diet, physical activity, and sleep,
* how they spend their time and form relationships (e.g., more opportunities to become engaged in romantic and sexual relationships),
* use alcohol and drugs, and
* work, community volunteer service, trouble with the law.
*Adapted from the Healthy People 2020 Core Indicators for Adolescent and Young Adult Health
Critical Health Issues of Adolescence & Young Adulthood Within a Developmental
Context
• Critical period to prevent chronic conditions of adulthood, in areas such as:• Diseases related to tobacco use,• Obesity,• Dental caries,• Hearing loss,• Other.
Importance of transitions to young adulthood
*Adapted from the Healthy People 2020 Core Indicators for Adolescent and Young Adult Health
The Current Status of Young Women’s Health
• Mortality • Leading causes of death• Mental health• Substance abuse• Sexual/reproductive health
Young Women’s Health: Mortality
10-14 years 15-19 years 20-24 years05
101520253035404550
14.1
35.7
47.1
9.7
21.7 21.7
Female Mortality Rate per 100,000, by Age, 2000-2010
National San Francisco County
CDC WONDER 2010
Young Women’s Health: Leading Causes of Death
Ages 10-14 Ages 15-19 Ages 20-24
1. Unintentional Injury 1. Unintentional Injury 1. Unintentional Injury
2. Cancer 2. Suicide 2. Suicide
3. Suicide 3. Homicide 3. Cancer
4. Congenital Anomalies 4. Cancer 4. Homicide
5. Heart Disease 5. Heart Disease 5. Heart Disease
6. Homicide 6. Congenital Anomalies 6. Complicated Pregnancy
7. Benign Neoplasms 7. Complicated Pregnancy 7. Congenital Anomalies
8. Chronic Lower Respiratory Disease
8. Cerebrovascular 8. Influenza & Pneumonia
9. Cerebrovascular 9. Chronic Lower Respiratory Disease
9. Diabetes Mellitus
10.Influenza & Pneumonia 10. Septicemia 10. Cerebrovascular
WISQARS 2010
Young Women’s Health: Injury Behaviors
Sometime, Nearly Always, or Always Wore Seatbelts*
Drove under influence of alcohol (only) in the past 12 months
(2012)
Rode with a driver who had been drinking alcohol (2011)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%94%
6%
25%
97%
20%
Injury Behaviors by Age, 2010-2012
AdolescentsYoung Adults
*Year for adolescents: 2011, year for young adults: 2010
YRBSS, BRFSS, NSDUH
Substance Use, Continued
Smoked cigarettes (past month)
Had at least one drink (past month)
Used marijuana one or more times (past month)
Ever used any form of cocaine0%
10%20%30%40%50%60%70%80%90%
100%
16%
38%
20%
6%8%
22%28%
5%
Substance Use Behaviors among Female High School Students, 2011
National San Francisco County
CDC WONDER 2010
Young Women’s Health: Substance Use
0%20%40%60%80%
100%
2% 3% 7%20% 22%
2% 3% 10% 10%24%
Substance Use Behaviors among Female High School Students, 2011
National San Francisco County
CDC WONDER 2010
Young Women’s Health: Sexual Behaviors
0%20%40%60%80%
100%
46%
18%
46%
16% 15%26%
15%
53%
16% 17%
Sexual Risk Behaviors among Female High School Students, 2011
National San Francisco County
NSDUH 2012
Young Women’s Health: Sexual and Reproductive Health
2000 2005 2007 2008 2009 2010 2011 20120.0
20.0
40.0
60.0
80.0
100.0
120.0
47.7
39.7 41.5 40.2 37.934.2 31.3 29.4
109.7
101.8105.4
101.896.2
90.085.3 83.1
Birth Rates by Age, 2000-2011
AdolescentsYoung Adults
Year
Rate
per
1,0
00
22.8%
77.2%
Adolescents, 2006-2010
Intended Unintended
49.9%50.1%
Young Adults, 2006-2010
Intended Unintended
NVSS
Current Health Status: Disparities
All White NH Black NH American Indian or Alaska Native
Asian/Pacific Islander Hispanic0.0
20.0
40.0
60.0
80.0
100.0
120.0
29.4
20.5
43.9
34.9
9.7
46.5
83.1
70.2
109.0
81.7
41.4
111.4
Birth Rates by Race/Ethnicity, 2012
15-19
20-24
Race/Ethnicity
Rate
per
1,0
00
NVSS
Current Health Status: DisparitiesAm
eric
an In
dian
or A
lask
a N
ative
Asia
n or
Pac
ific
Isla
nder
Blac
k or
Afr
ican
Am
eric
an
His
pani
c
Whi
te
Fem
ale-
tota
l
Amer
ican
Indi
an o
r Ala
ska
Nati
ve
Asia
n or
Pac
ific
Isla
nder
Blac
k or
Afr
ican
Am
eric
an
His
pani
c
Whi
te
Fem
ale-
tota
l
Chlamydia Gonorrhea
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
3624
594
7507
2115
1301
3416
42458
1930
188 121557
4688
857
7680
2675
1595
3722
669
61
2050
237 169584
STD Rates by Age and Race/Ethnicity, 2011
15-19 20-24
Rate
per
100
,000
CDC 2011
Current Health Status: Disparities
Total Native American/Alaska Native NH
Asian NH Black NH Hispanic White NH0
20
40
60
80
100
120
140
160
10.45.8 2.9
46.3
8.12.5
36.4
19.9
10.7
146.9
33.3
12.3
HIV Diagnoses, by Age and Race/Ethnicity, 201115-1920-24
CDC 2011
Current Health Status: Disparities
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
14% 15%13%
11%
4%
15%
12% 13%
9%
14%
10%12%
Past Year Major Depressive Episode by Race/Ethnicity and Age, 2012
12-17 18-25
NSDUH 2012
Current Health Status: Disparities
NHIS 2012
Full Year Insured Full Year Uninsured Partial Year Uninsured0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
88%
6% 6%
72%
14% 15%
Insurance Status by Age, Females, 2011
Ages 10-17 Ages 18-25
Current Health Status: Disparities
Total group FPL lowest FPL middle FPL highest0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
89%85% 82%
93%
5%8% 9%
3%6% 7% 9%
4%
Insurance Status by Poverty Level, Ages 10-17, 2012
Full Year Insured Full Year Uninsured Partial Year Uninsured
NHIS 2012
Current Health Status: Disparities
Total group FPL lowest FPL middle FPL highest0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
69%63%
55%
81%
18%22%
26%
11%13% 15%20%
9%
Insurance Status by Poverty Level, Ages 18-25, 2012
Full Year Insured Full Year Uninsured Partial Year Uninsured
NHIS 2012
Current Health Status: Disparities
Delay in Care, past year Unmet Need for Dental Care, past year
Unmet Need for Prescriptions, past year
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
9%
5%2%
5%
24%
9%
13%
24%
8%
Delay in Care and Unmet Needs by Insurance Status, Ages 10-17, 2012
Full Year Insured Full Year Uninsured Partial Year Insured
NHIS 2012
Current Health Status: Disparities
Delay in Care, past year Unmet Need for Dental Care, past year
Unmet Need for Prescriptions, past year
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
10%7%
3%
9%
30%
17%16%
29%
14%
Delay in Care and Unmet Needs by Insurance Status, Ages 18-25, 2012
Full Year Insured Full Year Uninsured Partial Year Insured
NHIS 2012
THE ACA AND YOUNG WOMEN’S HEALTH
Key Elements of ACA for Youth
Medicaid expansion Health insurance exchanges Subsidies and cost sharing Dependent coverage Essential health benefits
Preventive services
The ACA and Preventive Services
• Provided by plans without cost sharing• From US Preventive Services Task Force,
Institute of Medicine, Bright Future, and CDC Immunizations Recommendations (children and adolescents)
• Services must be administered by a provider within the healthcare network
Screening Services for Women• Anemia• Breast Cancer• Cervical Cancer• Chlamydia• Contraception• Domestic Violence • STI • Well-woman visits
Guidelines for Young Adults
Preventive Services
for Adolescent
s and Young Adults
33
Percentage of Visits During Which Preventive Counseling was Provided to
Young Adults, 1996 to 2006All Specialties Primary Care Ob/Gyn
Any 30.6% 32.7% 33.6%
Injury 2.4% 3.1% 0.8%
Smoking 3.1% 4.2% 3.1%
Exercise 8.2% 9.4% 8.2%
Weight reduction 3.0% 3.8% 3.4%
Mental health 4.1% 4.2% 1.3%
STD/HIV 2.7% 2.6% 7.1%
Diet 10.0% 12.4% 12.4%
Adapted from “Ambulatory Care Among Young Adults in the US”, Fortuna, et al, 2009
34
Preventive Services Received by Young Adults (18-25) by Gender,
2011
% BP Check % Fasting Blood Sugar
Talked about Diet
Talked about smoking if
smoker
Flu Shot0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
60%
11% 12%
31%
13%
81%
23% 22%
51%
25%
MaleFemale
National Health Interview Survey, 2011
MEDICAL HOMES FOR ADOLESCENTS AND YOUNG ADULTS
The ACA and Medical Homes• Optional Medicaid State Plan benefit for states
to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions.
• Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the “whole person.”
Who is eligible for a Medical Home?
Health Homes are for people with Medicaid who:
• Have 2 or more chronic conditions• Have one chronic condition and are at risk for a second• Have one serious and persistent mental health condition• States can target health home services geographically• States can not exclude people with both Medicaid and
Medicare from health home services
Who is eligible for a Medical Home?
Chronic conditions listed in the statute include:* mental health, * substance abuse, * asthma, * diabetes, * heart disease, and * being overweight.
Additional chronic conditions, such as HIV/AIDS, may be considered by CMS for approval.
A medical home should be…• Person-centered• Comprehensive• Accessible• Coordinated• Committed to
quality and safety through a systems approach
Key Components of Medical Homes
Care Partnership Support
Payment and Finance
Clinical Care Organization
Practice Performance
Measurement
Resources and
Linkages
Care Delivery Management
Key Patient Outcomes for Medical Homes
Medication adherencePrevention and wellnessChronic diseasePatient engagementCoordinated carePediatric healthHealth IT
Reported Medical Home Outcomes
Millbank Report
• Studies on Patient Centered Medical Home (PCMH) released between August 2012 and December 2013
• 20 studies – 13 from peer-reviewed literature and 7 industry reports
Reported Medical HomeOutcomes
Millbank Report
Current Status: Medical Homes• 54% adolescents ages 10-17• Medical home rates for Black (42%)
and Hispanic (33%) adolescents lower than White adolescents (64%), as well as adolescents from non-English-speaking households (22%) vs. English-Speaking households (58%)
• Medical home rates higher for insured (57%) adolescents than uninsured (28%)
Adams et al 2013
Current Status: Medical Homes• Medical home attainment
lower for those with only a mental health condition (46%) & those with both mental and physical conditions (35%), when compared with those who had a physical condition only (56%)
Adams et al 2013
Medical Home Examples: Military Health System Patient-Centered Medical Home Initiative
• National Initiative • 4% fewer inpatient admissions • 18% more inpatient days• 7% fewer ED visits• 13% reduction in pharmacy costs• 16% reduction in ancillary health costs
Millbank Report
Medical Home Examples: University of Pittsburgh Medical Center Health Plan
Medical Home Pilot• 5% fewer ED visits • 6% increase in inpatient admissions• 13% fewer readmissions• 160% return on investment for Primary Care Medical
Homes
Millbank Report
MEDICAL HOMES AND YOUTH
Key Aspects of Age-Appropriate Care
• No wrong door • SB 138: Confidentiality • Recommended Preventive Screening,
incorporating Clinical Evidence-Based Guidelines
No Wrong Door• Electronic Health Care Records• Coordination of Care• Co-location of Services• Eligibility Screening
California SB 138* Loopholes in Explanation of Benefits (EOBs) letters allow for breaches in patient confidentiality according to existing federal regulations* Senate Bill 138 – Effect January, 2015• Requires health plans to honor confidential communications
requests; • Health plans will be able to communicate directly with the
patient about having provided sensitive services; • Sensitive services include: birth control, STI tests, mental
health care, or any other service if disclosure of information to policy holder could lead to harm.
Screening• Guidelines for Adolescents and Young Adults– United States Preventive Services Task Force– Bright Futures– American Congress of Obstetricians and
Gynecologists (ACOG)– CDC (Immunizations)
Guidelines for Young Adults
ASSURING MEDICAL HOME EFFECTIVENESS
Managed Care Checklist
Managed Care Checklist
Let’s not throw the Baby out with the Bath water !!!!!
Violet Brindis-Reich7 Months
References• Adams SH, Newacheck P, Park MJ, Brindis CD, Irwin CEI Jr. Medical Home for Adolescents: Low Attainment
Rates for those with mental Health Problems and Other Vulnerable Groups. Academic Pediatrics. 2012; 13(2): 113-121.
• Christensen EW, Dorrance KA, Ramchandani S, Lynch S, Whitmore CC, Borsky AE, Kimsey LG, Pikulin LM, Bickett Ta. Impact of a patient-centered medical home on access, quality, and cost. Mil Med. 2013;178(2): 135-141.
• Lau JS, Adams SH, Irwin CE Jr., Ozer EM. Receipt of Preventive Services in Young Adults. J Adolesc Health. 2013:52:42-49.
• Nelsin M, Olayiwola JN, Grundy P, Grumbach K. The Patient-Centered Medical Home’s Impact on Cost and Quality: An Annual Update of the Evidence, 2012-2013. Available at: http://www.milbank.org/uploads/documents/reports/Patient-Centered_Medical_Homes_Impact_on_Cost_and_Quality.pdf
• Ozer EM, Urquhart JT, Brindis CD, Park MJ, Irwin CE, Jr. Young adult preventive health care guidelines: there but can't be found. Arch Pediatr Adolesc Med. Mar 2012;166(3):240-247.
• Ozer EM. Scott JT, Brindis CD. Seizing the opportunity: Improving young adult preventive health care. Adolesc Med State Art Rev. 2013;24(3):507-525.
• Rosenberg CN, Peele P, Keyser D, McAnallen S, Holder D. Results from a Patient-Centered Medical Home Pilot at UPMC Health Plan Hold Lessons for Broader Adoption of the Model. Health Affairs. 2012;31(11): 2423-2431.
