Adolescent and Young Adult Health in San Francisco: Opportunities for Change

1. Adolescent and Young Adult Health in San Francisco: Opportunities for Change Claire D. Brindis, DrPH Division of Adolescent and Young Adult Medicine UCSF BenioffChildren’s Hospital Philip R. Lee Institute for Health Policy Studies University of California, San Francisco with Jazmyn Scott, Charles E. Irwin, Jr., Jane Park 11th Annual Provider Gathering: Increasing Patient Centered Care for Young Women Adolescent Health Working Group April 11, 2014

4. Overview • Young Women’s Health: A Summary • Medical Homes for Adolescents • Preventive Health Services • Tying It All Together

5. Young Women’s Health

6. 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.

7. 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.

8. 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

9. 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

10. The Current Status of Young Women’s Health • Mortality • Leading causes of death • Mental health • Substance abuse • Sexual/reproductive health

11. Young Women’s Health: Mortality CDC WONDER 2010

12. Young Women’s Health: Leading Causes of Death WISQARS 2010

13. Young Women’s Health: Injury Behaviors YRBSS, BRFSS, NSDUH *Year for adolescents: 2011, year for young adults: 2010

14. Substance Use, Continued CDC WONDER 2010

15. Young Women’s Health: Substance Use CDC WONDER 2010

16. Young Women’s Health: Sexual Behaviors NSDUH 2012

17. Young Women’s Health: Sexualand Reproductive Health NVSS

18. Current Health Status: Disparities NVSS

19. Current Health Status:Disparities CDC 2011

20. Current Health Status:Disparities CDC 2011

21. Current Health Status:Disparities NSDUH 2012

22. Current Health Status:Disparities NHIS 2012

23. Current Health Status:Disparities NHIS 2012

24. Current Health Status:Disparities NHIS 2012

25. Current Health Status:Disparities NHIS 2012

26. Current Health Status:Disparities NHIS 2012

27. The ACA and young women’s health

28. Key Elements of ACA for Youth • Medicaid expansion • Health insurance exchanges • Subsidies and cost sharing • Dependent coverage • Essential health benefits • Preventive services

29. 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

30. Screening Services for Women • Anemia • Breast Cancer • Cervical Cancer • Chlamydia • Contraception • Domestic Violence • STI • Well-woman visits

31. Guidelines for Young Adults

32. Preventive Services for Adolescents and Young Adults

33. Percentage of Visits During Which Preventive Counseling was Provided to Young Adults, 1996 to 2006 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 National Health Interview Survey, 2011

35. Medical homes for Adolescents and Young Adults

36. 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.”

37. 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

38. 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.

39. A medical home should be… • Person-centered • Comprehensive • Accessible • Coordinated • Committed to quality and safety through a systems approach

40. Key Components of Medical Homes Care Delivery Management Clinical Care Organization Resources and Linkages Payment and Finance Practice Performance Measurement Care Partnership Support

41. Key Patient Outcomes for Medical Homes • Medication adherence • Prevention and wellness • Chronic disease • Patient engagement • Coordinated care • Pediatric health • Health IT

42. Reported Medical Home Outcomes • 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 Millbank Report

43. Reported Medical HomeOutcomes Millbank Report

44. 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

45. 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

46. 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

47. 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

48. Medical homes and youth

49. Key Aspects of Age-Appropriate Care • No wrong door • SB 138: Confidentiality • Recommended Preventive Screening, incorporating Clinical Evidence-Based Guidelines

50. No Wrong Door • Electronic Health Care Records • Coordination of Care • Co-location of Services • Eligibility Screening