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 with Jazmyn Scott, Charles E. Irwin, Jr., Jane Park 11 th Annual Provider Gathering: Increasing Patient Centered Care for Young Women Adolescent Health Working Group April 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 CDC WONDER 2010

Young Women’s Health: Leading Causes of Death Ages 10-14Ages 15-19Ages Unintentional Injury 2. Cancer2. Suicide 3. Suicide3. Homicide3. Cancer 4. Congenital Anomalies4. Cancer4. Homicide 5. Heart Disease 6. Homicide6. Congenital Anomalies6. Complicated Pregnancy 7. Benign Neoplasms7. Complicated Pregnancy7. Congenital Anomalies 8. Chronic Lower Respiratory Disease 8. Cerebrovascular8. Influenza & Pneumonia 9. Cerebrovascular9. Chronic Lower Respiratory Disease 9. Diabetes Mellitus 10.Influenza & Pneumonia10. Septicemia10. Cerebrovascular WISQARS 2010

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

Substance Use, Continued CDC WONDER 2010

Young Women’s Health: Substance Use CDC WONDER 2010

Young Women’s Health: Sexual Behaviors NSDUH 2012

Young Women’s Health: Sexual and Reproductive Health NVSS

Current Health Status: Disparities NVSS

Current Health Status: Disparities CDC 2011

Current Health Status: Disparities CDC 2011

Current Health Status: Disparities NSDUH 2012

Current Health Status: Disparities NHIS 2012

Current Health Status: Disparities NHIS 2012

Current Health Status: Disparities NHIS 2012

Current Health Status: Disparities NHIS 2012

Current Health Status: Disparities 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 Adolescents and Young Adults

All SpecialtiesPrimary CareOb/Gyn Any30.6%32.7%33.6% Injury 2.4% 3.1% 0.8% Smoking3.1% 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% Diet10.0%12.4% Adapted from “Ambulatory Care Among Young Adults in the US”, Fortuna, et al,

Preventive Services Received by Young Adults (18-25) by Gender, 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 adherence Prevention and wellness Chronic disease Patient engagement Coordinated care Pediatric health Health IT

Reported Medical Home Outcomes Millbank Report Studies on Patient Centered Medical Home (PCMH) released between August 2012 and December studies – 13 from peer-reviewed literature and 7 industry reports

Reported Medical Home Outcomes Millbank Report

Current Status: Medical Homes 54% adolescents ages 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

Let’s not throw the Baby out with the Bath water !!!!! Violet Brindis-Reich 7 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): 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): Lau JS, Adams SH, Irwin CE Jr., Ozer EM. Receipt of Preventive Services in Young Adults. J Adolesc Health. 2013:52: 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, Available at: Centered_Medical_Homes_Impact_on_Cost_and_Quality.pdf 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): Ozer EM. Scott JT, Brindis CD. Seizing the opportunity: Improving young adult preventive health care. Adolesc Med State Art Rev. 2013;24(3): 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):