1. ADOLESCENT HEALTH SERVICES: Missing Opportunities Advancing Adolescent and Young Adult Health May 14, 2009 Workforce Preparation to Improve Adolescent Health Linda H. Bearinger, PhD, MS, FAAN

2. ADOLESCENT HEALTH SERVICES: Missing Opportunities Workforce charge to the IOM Committee: What kinds of training programs for health care providers are necessary to improve the quality of health care for adolescents? Linda H. Bearinger, PhD, MS, FAAN Thomas G. Dewitt, University of Cincinnati Julia Graham Lear, George Washington University

3. Movement toward assuring adolescent-focused practice 1957 J. Roswell Gallagher first articulates the need for specialists in pediatrics – adolescent medicine 1977 First federal call for interdisciplinary adolescent health training proposals – MCHB/HRSA/DHHS 1978 AAP task force recommends pediatrics as the lead specialty for improving adolescent health services 1986 American Academy of Pediatric Dentistry adopts adolescent- specific guidelines for practice 1986 Health Futures of Youth articulates core curricular components for adolescent health training across all health disciplines 1994 First certification exam in adolescent medicine in pediatrics, followed by first accreditation of fellowship programs in medicine 2000 American Nurses Association approves first position statement on adolescent health

4. Other providers involved in health care for adolescents?  Chiropractors  Counselors  Dental hygienists  EMTs  Health educators  Laboratory technicians  Occupational therapists  Optometrists  Pharmacists  Physician assistants  Physical therapists  Receptionists  Social service assistants  Speech therapists

5. Three levels of providers 1)Generalists: those serving populations that include adolescents 2)Specialists: those specializing in health services for adolescents 3)Educators and/or scholars: those with recognized expertise who have capacity to educate the workforce and conduct research contributing to the science of adolescent health and health services

6. What matters: Cross-cutting competencies to guide curricula  Health within context  Unique health needs  Developmental changes  Families as partners  Participation of adolescents in care, confidentially  Linked with community health and social services  Interplay between financing systems and policy

7. Assessing workforce competence: Finding the gaps  Self-reported competencies  Chart reviews  Exit interviews with adolescent patients  Observations of patient encounters

8. Indicators of inadequacies Surveys of providers, by discipline or by health concern show similar gaps: “self-perceptions of being ill-equipped to address even some of the most common health problems of adolescence” Example:  25% of nurses who work with adolescents indicated low levels of knowledge/skills in 14 of 28 common health concerns: - including depression, eating disorders, and violence  The more vulnerable the group – foster care, homeless, GLBTQ – the poorer the self-reported skills

9. Conclusions: Adequacy of the workforce 1.Health care providers lack necessary skills.

10. Conclusions: Adequacy of the workforce 1.Health care providers lack necessary skills. 2.Existing adolescent health care training across disciplines often fails to address key health needs of young people.

11. Regulatory bodies assuring adolescent health competencies Individual level:  Licensing, board certification Institutional level:  Accreditation of entry-level, professional, graduate, and residency/internship programs

12. Regulatory bodies assuring adolescent health competencies Individual level:  Licensing, board certification Institutional level:  Accreditation of entry-level, professional, graduate, and residency/internship programs Finding: Beyond medicine and psychology, regulatory bodies lack requirements for adolescent-health focused curricular content, knowledge, and skills.

13. Conclusions: Adequacy of the workforce 1.Health care providers lack necessary skills. 2.Existing adolescent health care training across disciplines fails to address many of the health needs. 3.Inconsistency or lack of an adolescent focus in the criteria of regulatory bodies

14. Conclusions: Adequacy of the workforce 1.Health care providers lack necessary skills. 2.Existing adolescent health care training across disciplines fails to address many of the health needs. 3.Regulatory bodies are inconsistent or lack criteria for content and knowledge/skills in adolescent health. 4. Insufficient number of adolescent health training programs translates into inadequate workforce.

15. Current training modalities  Discipline-specific programs and certification for specialists and educators/scholars  Single-disciplinary outnumber interdisciplinary  Master’s and doctoral programs (nursing, nutrition, social work, psychology)  Post-residency fellowships in medicine  Continuing education programs – maintenance of licensure or certification –may or may not be adolescent-focused –may be single-discipline or interdisciplinary

16. Current training modalities  Interdisciplinary adolescent health programs  MCHB-funded Leadership Education in Adolescent Health (LEAH)  Focus on leadership for clinical care, public health practice, research, and advocacy  Preparing specialists and educators/scholars  5 disciplines – medicine, nursing, nutrition, psychology, social work  7 LEAHs in the US; $2.6 million; nearly level funding for 30 years  The only federal funding mechanism targeted for interdisciplinary adolescent health training

17. Current training modalities  Novel approaches for training  Intensive interdisciplinary learning institutes  On-line continuing education and academic credit courses  Train-the-trainer curricula with on-line access (EuTEACH)  National Adolescent Health Information Center (NAHIC at UCSF)  Partners in Program Planning for Adolescent Health (PIPPAH) Together, have improved accessibility of training options, articulated curricular content,and expanded access to resources for trainers/educators

18. Insufficient numbers of training programs to assure adequate workforce To note: only medicine requires board certification for those specializing in adolescent health  1 adolescent medicine physician per 105,000 adolescents in the US  AAP’s recommendation: 1/6,000  7 states without any certified adolescent medicine physician

19. Recommendations for Improving Workforce Capacity To insure that an adequate number of providers are equipped to work with adolescents:  Regulatory bodies should incorporate a minimal set of adolescent health competencies for licensure, certification, and accreditation requirements.  Public and private funders should provide targeted financial support to expand and sustain interdisciplinary training programs in adolescent health – with priority on preparing specialists and educators/scholars.