1. Overview of Adolescent Healthcare Patterns and the Need to Look Beyond the Medical Home Peter G. Szilagyi MD MPH Department of Pediatrics University of Rochester School of Medicine and Dentistry

2. What do these two people know about adolescent healthcare utilization?

3. The Top Ten List! …about adolescent healthcare utilization patterns and implications for vaccinations

4. Definition of Adolescent

5. Parent’s Perspective

6. Definition of Adolescent School’s Perspective

7. Definition of Adolescent Public Health Perspective – Adolescent Vaccinations 11-21 years of age 40 million adolescents across the US 14% of the US population

8. #10 Most Adolescents do have a usual source of care.

9. Percent of Adolescents with a Usual Source of Care Summary from several studies

10. Percent of Children with a Usual Source of Healthcare (US, 2002) Analysis of 2002 MEPS Percent Age (years)

11. In One Decade: Coverage Trends in Health Insurance for Adolescents Source: National Adolescent Health Information Center (NAHIC) 2008 Fact Sheet on Health Care Access and Utilization: Adolescents and Young Adults. http://nahic.ucsf.edu/index.php/data/article/briefs_fact_sheets/ http://nahic.ucsf.edu/index.php/data/article/briefs_fact_sheets/ Private Public Uninsured

12. #9 Just because you have it doesn’t mean you use it. Many adolescents do not go to their medical homes (or any other place) for care.

13. Receipt of Ambulatory Care* and Primary Care ** Within 1 Year * Ambulatory care- Any visit to a physician, nurse/nurse practitioner, physician assistant or midwife Christina Albertin et al. PAS Meetings, 2006

14. Receipt of Ambulatory Care and Primary Care Within 1 Year by Age Year and Gender Christina Albertin et al. PAS Meetings, 2006 * Ambulatory care- Any visit to a physician, nurse/nurse practitioner, physician assistant or midwife

15. Who is Most Likely to Lack Visits? Poor Minority Uninsured Older adolescents

16. #8 An ounce of prevention is …. often lacking Many adolescents lack preventive visits

17. Proportion of Adolescents with A Preventive Visit in Past Year Study Year Scope & Method Data Source Ages or Grades % with Preventive Visit 1999USA- schoolTeensGr. 9-1260% 1999USA- phoneParentsAges 11-1770% 1997USA-schoolTeensGr. 5-1285% 1995USA-schoolTeensGr. 7-1268% 2002State-HEDISClaimsAges 12-2134% Source: Broder et al, Pediatrics Supplement. 2008

18. #7 Home Sweet Home (usually) The medical home is burdened with new vaccinations

19. HPV Vaccine

20. HPV Vaccine Percent of 11-12yr old Girls Needing 0,1,2, or 3 Additional Visits for HPV Vaccination (in 12m) # additional visits needed First vaccine at PREVENTIVE visit % Cynthia Rand et al, Pediatrics. 2007

21. HPV Vaccine Percent of 11-12yr old Girls Needing 0,1,2, or 3 Additional Visits for HPV Vaccination (in 12m) # additional visits needed % First vaccine at PREVENTIVE visit First vaccine at ANY visit % Cynthia Rand et al, Pediatrics. 2007

22. Universal Influenza Vaccination

23. Percent of Children 9-18 Years Old Needing More Visits for Flu Vaccinations Percent 5-Month Window

24. Additional primary care visits needed for influenza vaccination of 11-18yr olds In My Urban Clinic # Teens # Visits in 12 months Additional Visits for flu Vaccination* % More Visits 11-18 Year olds 4,8006,0001,44024% *Assumes: ● 5-month window ● All visits used for vaccinations

25. #6 Other healthcare settings used by adolescents: several

26. No Ambulatory Care Within 1-Year Females Christina Albertin et al. PAS Meetings, 2006

27. Visit to ED Only Christina Albertin et al. PAS Meetings, 2006

28. Visits to Specialty Only Christina Albertin et al. PAS Meetings, 2006

29. Visit to School-based Clinic Only Christina Albertin et al. PAS Meetings, 2006

30. Visits to Ob/gyn Only Christina Albertin et al. PAS Meetings, 2006

31. Visits to Ob/gyn and Any Other Site (except 1° care) Christina Albertin et al. PAS Meetings, 2006

32. Any Primary Care Visit Christina Albertin et al. PAS Meetings, 2006

33. Overall Healthcare Utilization by Females within a 1-Year Period Christina Albertin et al. PAS Meetings, 2006

34. Overall Healthcare Utilization by Males within a 1-Year Period Christina Albertin et al. PAS Meetings, 2006

35. #5 Currently few adolescents receive healthcare at schools

36. Number of SBHCs in US http://www.healthinschools.org/static/sbhcs/survey02.aspxhttp://www.healthinschools.org/static/sbhcs/survey02.aspxSBHC=School-based health centers

37. Number of Teens at Schools with SBHCs Assume 3,000 SBHCs across the US in 2008* 54% are in middle or high school* Thus 1,600 SBHCs in schools with adolescents *From Center for Health and Healthcare in Schools

38. Number of Teens at Schools with SBHCs Assume 3,000 SBHCs across the US in 2008* 54% are in middle or high school* Thus 1,600 SBHCs in schools with adolescents Assume each school has 1,000 teens Then 1.6 million teens exposed to SBHCs = Only 5% of all 11-18yr olds across the US *From Center for Health and Healthcare in Schools

39. SBHCs Across the US Summary Increasing Still very few Available to only a small percent of teens More likely in schools with poor teens

40. #4 Although most adolescents are in school, many drop out

41. Graduation Rates Across the US 50-59% Orange 60-69% Blue 70-79% Green 80-89% Yellow >90% White Manhattan Institute, 2001

42. High School Completion Rates Manhattan Institute, 2001 %

43. #3 Prototype examples exist for school-based vaccinations Challenges: Dissemination Sustainability

44. #2 Being ≠ Being able to in school receive vaccines Challenges: Dissemination, Sustainability

45. NVAC Quality Standards to Insure Quality of Vaccination Delivery Information and education for vaccine recipients Vaccine storage and handling Pre-vaccination screening Contraindications Record keeping Vaccine administration Adverse events

46. NVAC Quality Standards to Insure Quality of Vaccination Delivery Information and education for vaccine recipients Vaccine storage and handling Pre-vaccination screening Contraindications Record keeping Vaccine administration Adverse events Are schools ready?

47. #1 Do no harm Do good Measure and evaluate what you do Because: Children (adolescents) are our future

48. Summary: Top 10 Lessons 10. Most adolescents have a usual source of care 9. Many do not use their medical home 8.Many teens lack preventive care 7.The medical home is critical, but gives lots of vaccines. 6.Other sites: ED, Specialty, OB/GYN, few school 5.Few adolescents use school-based clinics 4.Although most teens are in school, many drop out 3. Some prototype school vaccination programs exist 2.Being in school ≠ being able to receive vaccinations 1. Follow key principles: Do no harm. Do good. Evaluate. Children (adolescents) are our future

49. Implications The medical home is key but burdened –Many adolescents not seen in a year Two possible school-based models –School-based health centers (SBHCs) –Using schools as sites for vaccinations All models have advantages and challenges We need studies to evaluate new models Importance of information transfer

50. Implications The medical home is key but burdened –Many adolescents not seen in a year Two possible school-based models –School-based health centers (SBHCs) –Using schools as sites for vaccinations All models have advantages and challenges We need studies to evaluate new models Importance of information transfer

51. Thank You