Why Aren’t AYAs Going to Well-Care? Challenges and Opportunities in Improving Receipt of Preventive Care Adolescent and Young Adult Health National Resource Center SAHM Annual Meeting New Orleans, LA March 8, 2017

University of California San Francisco University of Minnesota University of Vermont

The Adolescent and Young Adult Health National Resource Center Purpose: To improve adolescent and young adult health and address their health issues by strengthening the capacity of State Title V MCH Programs and their public health and clinical partners to better serve these populations (ages 10-25) Four-year cooperative agreement supported by MCHB (2014 - 2018)

Acknowledgements Funder: Maternal and Child Health Bureau, Health Services and Resources Administration, USDHHS (cooperative agreement U45MC27709) Project Officer: Trina M. Anglin, MD, PhD

Christina Postolowski2 Charles E. Irwin, Jr., MD1 Elizabeth Ozer, PhD1 Christina Postolowski2 Charlene Wong, MD, MSHP3 1Division of Adolescent and Young Adult Medicine, UCSF Benioff Children’s Hospital, University of California, San Francisco 2Young Invincibles, Denver, CO 3Department of Pediatrics & Margolis Center for Health Policy, Duke University

Conflict of Interest Statement The speakers have no commercial relationships to disclose. The speakers will not be discussing any unapproved uses of pharmaceuticals or devices.

Session Goals Participants can describe: Research and trends relevant to increasing receipt of well visits and preventive services for AYAs ACA provisions relevant to insurance, preventive services and well visits Participants will identify clinical, public health and policy strategies to improve receipt of preventive care

Session Goals Where we’ve been: Background & Trend Data What we know and need to know: Research on factors related to the well visit & preventive services What we can do: Tools, resources and initiatives to increase receipt of the well visit & preventive services

Session Outline Where we’ve been: Background & Trend Data Importance of prevention Overview of ACA CPS Provisions What changed before and after ACA implementation What we know and need to know: Research on factors related to the well visit & preventive services What we can do: Tools, resources and initiatives to increase receipt of the well visit & preventive services

Prevention is Critical for Adolescents and Young Adults (AYAs)

Global burden of disease in young people aged 10-24 years: A systematic analysis Depressive disorder 2 Lower RTI Schizophrenia RTA 3 Violence 4 Asthma Bipolar disorder HIV/AIDS 5 Refractive errors Alcohol use 6 Iron deficiency anaemia 7 Falls Self-inflicted injuries Tuberculosis 8 Migraine Panic disorder Self-inflicted injury 9 Drownings 10 Diarrhoeal diseases Abortion Source: Gore et al., 2011

Mortality by Cause, Sex and Age, Ages 10-24, 2015 Rate per 100,000 16.9 Ages 10-14 Ages 15-19 Ages 20-24 Source: CDC Wonder

Past-Month Substance Use, by Age, Ages 12-25, 2015 Source: National Survey of Drug Use and Health, SAMSHA

Chlamydia—Rates by Sex and Age, United States, 2015 Source: Centers for Disease Control and Prevention

The well visit matters: Adolescents AND Young Adults who have a past-year well visit report higher rates of preventive services

Receipt of preventive services, comparing those with and without a past-year well visit, among ADOLESCENTS, Ages 10-17, MEPS (2007-09 & 2011-14) *All rates significantly higher among those with a past-year well visit. Source: Medical Expenditure Panel Survey

Receipt of anticipatory guidance, comparing those with and those without a past-year well visit among ADOLESCENTS, Ages 10-17, MEPS (2007-09 & 2011-14) * All rates significantly higher among those with a past-year well visit. Source: Medical Expenditure Panel Survey

Receipt of anticipatory guidance (all areas) and time alone, comparing those with and those without a past-year well visit among ADOLESCENTS, Ages 10-17, MEPS (2007-09 & 2011-14) SA may update * All rates significantly higher among those with a past-year well visit. Source: Medical Expenditure Panel Survey

Receipt of preventive services comparing those with and those without a past-year well visit among YOUNG ADULTS, Ages 18-25, MEPS (2007-09 & 2011-14) *All rates significantly higher among those with a past-year well visit Source: Medical Expenditure Panel Survey

ACA Preventive Service Provisions Access to Preventive Services Provided by plans without cost-sharing to members Requirements established by: US preventive Services Task Force “A” and “B” recommendations Bright Futures Guidelines for Children and Adolescents CDC- ACIP Immunization Recommendations HRSA-supported IOM recommendations for women’s health

Insurance, visits & preventive services: Comparing pre- & post-ACA measures Adolescents and Young Adults differ Insurance increased for both groups Any past-year visit increased for adolescents only Past-year well visits increased for adolescents only UPDATE

Insurance Coverage by Age, Ages 10-25, NHIS (2010 & 2015) Young Adults* *Significantly increased Source: National Health Interview Survey

Receipt of ANY health care visit by Age, Ages 10-25, MEPS (2007-09 & 2011-14) 2007-09 2011-14 Adolescents* *Significantly increased Source: Medical Expenditure Panel Survey

Receipt of a Well Visit by Age, Ages 10-25, MEPS (2007-09 & 2011-14) 2007-2009 2011-2014 Young Adults *Significantly increased Source: Medical Expenditure Panel Survey

Have a Usual Source of Health Care, by Sex and Age, Ages 10-25, NHIS 2015 NHIS, Have a Usual Source of Care: Definition: Usual place When Sick: place one usually goes to when he/she is sick or when parent needs advice about his/her health (no time frame) Measure: Is there a place that you USUALLY go to when you are sick or need advice about your health? Source: National Health Interview Survey

Location of Usual Source of Care (of those with a USC), by Age, Ages 10-25, NHIS 2015 * Includes ER, hospital outpatient department, some other place, and don’t go to one Place most of the time Source: National Health Interview Survey

Session Outline Where we’ve been: Background What we know and need to know: Research on factors related to the well visit & preventive services What we can do: Strategies to improve receipt of care

Research on Factors Related to Preventive Service Delivery for AYAs Elizabeth M. Ozer, PhD Professor of Pediatrics Division of Adolescent and Young Adult Medicine University of California, San Francisco

System-level Community-clinic linkages Substantial evidence base links school-based clinics to increase receipt of preventive services Retail clinics are a growing source of care for youth AYAs are more likely than children to utilize retail clinics for primary care Coordinated networks shown to be successful in engaging hard-to-reach populations in care (e.g., foster youth, juvenile justice) Add source data Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Optimizing the Clinical Encounter Clinician-Targeted Strategies Barriers to preventive service delivery: Knowledge/confusion around guidelines Time Self-efficacy Motivation to change practice Outcome expectancy Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Optimizing the Clinical Encounter cont. Clinician-Targeted Strategies Of particular promise to address these barriers include: Brief screening tools with appropriate clinician training Integrating screening and clinician decision support – including integrating tools into innovative interactive technology & electronic medical record systems Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Optimizing the Clinical Encounter cont. Parent Engagement Parents play an important role in the health care of AYAs Research shows that adolescents are less likely to receive preventive care if parents perceive it as unnecessary Tools and models to engage parents as partners in their child’s health care, while providing care that is confidential Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Extend Clinicians’ Preventive Reach Using Technology Augment provider interactions with self- guided online-based prevention and treatment modules Social gaming platforms (e.g., physical activity, STD prevention) Social media/Apps Wearable devices Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Needed Research to Increase Delivery of Preventive Services Implement & evaluate larger, practice- based multi-site research trials of promising clinician-focused interventions Incorporating screening and training tools Clinical decision support Electronic medical record systems Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Needed Research to Increase Delivery of Preventive Services Demonstrate delivering CPS makes a difference for AYAs Some evidence that CPS can make a difference for adolescents in helmet & seatbelt use, sexual behavior, diet, exercise, drug use, drinking & driving Need to prioritize further rigorous, outcomes focused research on behavior change/ health outcomes Deepen understanding of effective components and timing for behavior change Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Needed Research to Increase Delivery of Preventive Services Demonstrate delivering CPS makes a difference for AYAs Identify effective, brief, practical generalized interventions within developmental windows of opportunities Need greater focus on young adults Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Needed Research to Increase Delivery of Preventive Services Implement & evaluate effectiveness of CPS interventions across settings and on broader scale Implement developmentally and culturally appropriate strategies to engage parents in the clinical encounter of AYAs & evaluate effects on receipt of CPS and health outcomes Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Needed Research to Increase Delivery of Preventive Services How to best leverage new technological tools to enhance/improve AYA health services How to better align the delivery of preventive services to the needs of AYAs Source: Harris SK, Aalsma MC, Weitzman ER, et al., 2017.

Additional Resources NEW! Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go? (JAH, 2017) http://www.sciencedirect.com/science/article/pii/S1054139X1630 4013 Set of QI measures to assess and track progress in pediatric and family practices (NIPN, 2016) http://www.uvm.edu/medicine/nipn/?Page=measures_form.html

Additional Resources Summary of Recommended Guidelines for Clinical Preventive Services with 1-page clinical tool & supplement (NAHIC) Adolescents: http://nahic.ucsf.edu/adolescent-guidelines/ Young Adults: www.nahic.ucsf.edu/yaguidelines/ Evidence-based clinical preventive services fact sheet for AYAs (NAHIC) http://nahic.ucsf.edu/cpsfactsheet/

For more information and resources please visit www.nahic.ucsf.edu

Session Outline Where we’ve been: Background & Trend Data What we know and need to know: Research on factors related to the well visit & preventive services What we can do: Tools, resources and initiatives to increase receipt of the well visit & preventive services

Christina Postowloski Rocky Mountain Regional Director Young Invincibles

Charlene Wong, MD, MSHP Department of Pediatrics & Margolis Center for Health Policy, Duke University

Questions? Thoughts?