Improving Adolescent Health: Addressing Depression and Substance Abuse in a Primary Care Setting

For Primary Care ProvidersCaring for Adolescents in Oregon

A Project of:The Oregon Pediatric Society

The Oregon Chapter of the American Academy of Pediatrics

Funded by:

Oregon Health Authority Addictions and Mental Health

Public Health/Adolescent Health

In Collaboration with:Oregon Health Authority

Addictions & Mental Health

Public Health Division

School-Based Health Centers

Maternal Child Health

Oregon Psychiatric AccessLine for Kids (OPAL-K)

Mind Matters

Morrison Child & Family Services

OHSU Pediatrics

OHSU Child Psychology

OHSU Family Practice

OHSU Division of Child & Adolescent Psychiatry

Oregon Pediatric Improvement Partnership (OPIP)

Children’s Developmental Health Institute

Oregon Primary Care Association

Oregon SBIRT

Health Share of Oregon

FamilyCare

Trillium Family Services

Disclaimer

The Oregon Pediatric Society (OPS), a Chapter of the American Academy of Pediatrics, has no conflict of interest, and is not affiliated with any other organization, vendor or company.

Reasonable attempts have been made to provide accurate and complete information.

The practitioner or provider is responsible for use of this educational material, and any information provided should not be a substitution for the professional judgment of the practitioner or provider.

Disclaimer

OBJECTIVES

• EXPLAIN importance of adolescent well visit and policy landscape.

• IDENTIFY unique considerations for working with youth, including consent and confidentiality.

• OUTLINE clinical strategies to implement high-quality adolescent well visits.

The Adolescent Well Visit

Adolescent well care visit

56% of 8th & 59% of11th graders reported having a well visit in 2013.

29.3% of youth 12-21 on OHP received a well visit in the past year

• AMA, AAP, Bright Futures, & OHA recommend comprehensive annual preventive health care visits for adolescents.

• Adolescent preventive health care is a CCO incentive measure.

What is the value of an adolescent well visit?

The Triple Aims

Better Health Better Care

Lower Cost

Better Health

Leading causes of death among 10-24 year olds are

preventable.

41% Unintentional

injury

15% Suicide

15%Homicide

• 27% were depressed in the past year

• 15% seriously considered suicide in the past year

• 45% have had sex (36% didn’t use a condom at last intercourse)

• 31% drank in the past month• 21% used marijuana in the

past month

Support adolescents as they transition into adulthood.

Among 11th graders in Oregon:

Better Care

Half of all lifetime cases of mental health diagnoses first begin by age 14

Youth who begin drinking at 14 are 4-5x more likely to develop substance abuse than 19 year olds

In 2010, teen childbearing cost Oregon taxpayers at least $88 million dollars.

Overweight and obesity in adolescence tends to persist into adulthood.

Providing care to adolescentsUNIQUE ISSUES

• Period of rapid psychosocial and cognitive development

• Need to build trust, respect independence

• Youth care about their health

• Consent and confidentiality

• Sensitive topics such as relationships, substance use, mental health and sexuality

Providing care to adolescentsUNIQUE ISSUES

• Period of rapid psychosocial and cognitive development

• Need to build trust, respect independence

• Youth care about their health

• Consent and confidentiality

• Sensitive topics such as relationships, substance use, mental health and sexuality

Consent and Confidentiality

Definitions

• Minor: children and adolescents younger than 18 years of age

• Confidentiality: information will not be shared without explicit permission of the patient

• Consent: individual decides voluntarily

Consent

• 15 and over: Medical and dental services (ORS 109.640)

• 14 and over: Mental health and chemical dependency (ORS 109.675)

• Any age: family planning/sexual and reproductive health care (ORS 109.610, ORS 109.640)

Confidentiality

• Federal law– HIPAA– ERISA– Title X

• State law and regulations• Agency/corporate policy• Professional ethical obligations• Best practice recommendations

Confidentiality

• No “right” to confidentiality or “right” to disclosure. Provider best judgment (ORS 109.650)– EXCEPT:

• 42 CFR Part 2: if minor is able to self consent for drug or alcohol treatment, treatment records cannot be released without minor’s written consent.

• Reproductive health services conducted in a Title X family planning clinic

ConfidentialityWhy is it important?• Expectation underlying health care.• Youth are more likely disclose sensitive information if it

can be kept confidential.• Delay seeking care, or face emotional or physical

repercussions.

When is it a challenge?• Across the patient experience of care:

– Clinic workflow (appointment setting)– Client communication (after visit summary, patient portal)– Electronic health records (EHR) and Health Information

Exchange (HIE)– Insurance billing communication

Adolescents should be informed of exceptions to confidentiality:

Consent and confidentialityLIMITS

• RISK OF HARM TO SELF OR OTHERS

• ABUSE

Questions?

?

Strategies for implementing adolescent well care visits

Adolescent well care visitsSTRATEGIES• Schedule a longer visit

• Be flexible to respond to unexpected acute issues; may need to postpone ‘well care’ topics

• Adapt to adolescent’s developmental stage

• Clearly define confidentiality

• Address both adolescent’s and parent’s concerns

• Talk about sensitive topics with parent out of room

ConfidentialityPRACTICAL POINTS

1. Parent and patient

together at beginning of

visit 2. Parent and patient separated during sensitive questions and physical exam

3. Parent and patient

together to review

assessment

Key pointsWHEN DISCUSSING SENSITIVE TOPICSBefore asking any questions:

• Discuss confidentiality• Interview alone• Allow adequate time• Have an adolescent-friendly

environment

Interviewing adolescents pt. 1• Move from non-threatening questions

to more sensitive topics

• Explain why you’re asking the questions

• Treat comments seriously

• Explore the adolescent’s issues

• Keep the tone nonjudgmental - avoid “Why?” and lecturing

• Avoid medical jargon; speak simply

• Ask sensitive questions in the third person (particularly for younger adolescents)

• Use open-ended questions whenever possible

• Be aware of nonverbal communication

• Don’t chart during the interview

Interviewing adolescents pt. 2

• Consider the adolescent’s developmental stage, culture, ethnicity

• Reassure when the adolescent seems uncomfortable

• Encourage regular and open communication with parents

Interviewing adolescents pt. 3

American Academy of Pediatrics

…Ultimately, the health risks to the adolescent are so impelling that legal barriers and deference to parental involvement should not stand in the way of needed health care.

AAP Policy Statement “Confidentiality in Adolescent Health Care. April 1989, reaffirmed May 2004. Also endorsed by the AAFP, ACOG.

“There are some things I talk about with everyone your age. I keep this information private from your parents if you don’t want to share it with them. If I hear something that sounds dangerous to you or someone else, I may need to tell your parents about that. I encourage everyone your age to talk to their parents about important things, but if you don’t feel ready, you can talk about those things here.”

Confidentiality sample script

Case 1: Jake

• Jake is a 16 year old who has been in multiple foster homes. He has just been released from detention for a battery charge. He has been smoking “weed” daily, and has tried “ecstasy” a few times. He is living with his aunt, and he is sure she will kick him out of the house if she finds out about his drug use.

Case 1: Jake

• Jake is willing to make a pact to not use ecstasy. He agrees to decrease the frequency of marijuana use to “only on weekends.” He will return in one week. You have known Jake for a long time, and he has rarely missed an appointment.

Case 2: Lori

• Lori is a 14 year old girl accompanied by her parents. They are concerned about her poor grades and withdrawn behavior. Some of her friends have received tickets for underage drinking. Her parents are concerned that Lori is using drugs.

Case 2: Lori

• When questioned privately, Lori tells you she has been getting drunk on weekends, to the point of blacking out. She has tried multiple drugs, including marijuana, Ritalin, and “shrooms.” She doesn’t think she has a problem, and says that her parents “just need to get a life.” She doesn’t want you to tell her parents about her drug use.

Summary

• Interview the adolescent patient alone.• Explain to patients what you can and

cannot do confidentially.• Explain limits of confidentiality.• Implement policies to protect

confidentiality and inform staff.• Involvement of the family is optimal.