Reforms Needed in Health Care Services for Adolescents, Including Greater Coordination of Care and Better Training for Providers

WASHINGTON - Current health services for adolescents are fragmented and poorly designed to meet the health needs of all of the nation’s adolescents, says a new report from the National Research Council and Institute of Medicine. Although most U.S. adolescents are healthy, many engage in risky behavior, develop unhealthy habits, and have physical and mental conditions that can jeopardize their immediate and future health. Health care providers need better training in how to meet the specific health needs of those aged 10 to 19, said the committee that wrote the report.

“Adolescents have unique health care needs, and our health system should not approach their care the same way it does children or adults,” said committee chair Robert S. Lawrence, professor of environmental health sciences and health policy at the Johns Hopkins Bloomberg School of Public Health. “As policymakers discuss how to restructure the way health care is delivered in the U.S., the distinct problems faced by adolescents - such as risky behavior - deserve particular attention. And because adolescence is a critical period for developing habits that build a strong foundation for health throughout one’s entire life, services need to focus on promoting healthy behaviors, preventing disease, and managing health conditions.”

Some young people, particularly those who are uninsured or underinsured, have little or no access to mainstream primary care services; they rely largely on “safety-net” settings, such as hospitals, community centers, and school-based health centers for their care, the report says. In fact, adolescents are in the age group most likely to rely on emergency departments for routine health care.

The various services and providers that are needed and used by adolescents are often fragmented, resulting in gaps in care, the report says. For example, specialty services in mental health, sexual health, oral health, and substance abuse treatment are not accessible to most adolescents.

Federal and state agencies, private foundations, and insurers should work together to develop a coordinated health care system that improves services for all adolescents, the report says. This system should foster coordination between primary and specialty care; it should also include opportunities for primary care services to reach adolescents through safety-net settings, such as hospitals and community health centers and programs. Also, a stronger focus is needed on meeting the needs of adolescents who may be especially vulnerable to risky behavior or poor health - for example, those who are poor, recent immigrants, or in foster care.

Federal and state policymakers also should develop strategies to ensure that all adolescents have comprehensive, continuous health insurance coverage, the report says. Large numbers of adolescents – more than 5 million Americans ages 10 to 18 – are uninsured, and these young people use care less often and are less likely to have a regular source of primary care than young people who are insured. And uninsured adolescents who are eligible for public coverage often are not enrolled. Rates of uninsurance are higher among the poor and near poor, racial and ethnic minorities, and noncitizens, the report notes.

Health professionals frequently lack the skills to interact effectively with this age group, a problem that should be remedied, the report says. At all levels of professional education, providers from relevant disciplines that serve adolescents should receive detailed education about this age group’s health problems and effective ways to treat disease and promote healthy behaviors. Regulatory bodies should incorporate competencies in adolescent care in their licensing, certification, and accreditation requirements. And public and private funders should provide financial support to expand and sustain interdisciplinary training programs in adolescent health.

The report recommends that as an overarching principle, adolescents should give their own consent before their health information is shared with others, even their parents. A balance is needed between maintaining confidentiality about care for which minors are allowed to give their consent, and encouraging the involvement of parents and families whenever possible, respecting their importance in adolescents’ lives and health care. Federal and state policymakers should maintain current laws and policies that enable adolescents to give their own consent for health services, and to receive services - such as contraception, mental health care, and substance abuse treatment - on a confidential basis when necessary to protect their health.

The report was sponsored by the Atlantic Philanthropies, an international foundation. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. They are private, nonprofit institutions that provide science, technology, and health policy advice under a congressional charter. The Research Council is the principal operating agency of the National Academy of Sciences and the National Academy of Engineering. A committee roster follows.

NATIONAL RESEARCH COUNCIL

Division of Behavioral and Social Sciences and Education

and

INSTITUTE OF MEDICINE

Board on Children, Youth, and Families

Committee on Adolescent Health Care Services and Models of Care

for Treatment, Prevention, and Healthy Development

Robert S. Lawrence, M.D. (chair)
Professor of Environmental Health Sciences and Health Policy and Management
Bloomberg School of Public Health
Johns Hopkins University
Baltimore

Linda H. Bearinger, Ph.D., R.N., FAAN
Professor and Director
Center for Adolescent Nursing
School of Nursing
University of Minnesota
Minneapolis

Shay C. Bilchik, J.D.
Research Professor and Director
Center for Juvenile Justice Reform and Systems Integration
Georgetown Public Policy Institute
Georgetown University
Washington, D.C.

Sarah S. Brown, M.P.H.
Chief Executive Officer
National Campaign to Prevent Teen and Unplanned Pregnancy
Washington, D.C.

Laurie Chassin, Ph.D.
Professor of Psychology
Prevention Research Center
Arizona State University
Tempe

Nancy Neveloff Dubler, LL.B.
Professor and Director
Division of Bioethics
Department of Epidemiology and Social Medicine
Montefiore Medical Center
Albert Einstein College of Medicine
Bronx, N.Y.

Burton L. Edelstein, D.D.S., M.P.H.
Professor of Clinical Dentistry and Clinical Health Policy and Management
School of Dental and Oral Surgery
Mailman School of Public Health
Columbia University
New York City

Harriette B. Fox, M.S.S.
Chief Executive Officer
The National Alliance to Advance Adolescent Health
Washington, D.C.

Charles E. Irwin Jr., M.D.
President and Vice Chairman of Pediatrics, and
Director
Division of Adolescent Medicine
School of Medicine
University of California
San Francisco

Kelly Kelleher, M.D., M.P.H.
Professor
Division of Behavioral and Developmental Pediatrics
College of Medicine and Public Health
Ohio State University, and
Director
Office of Clinical Sciences
Columbus Children’s Research Institute
Columbus

Genevieve Kenney, Ph.D.
Principal Research Associate
Health Care Policy Center
The Urban Institute
Washington, D.C.

Julia Graham Lear, Ph.D.
Research Professor and Director
Center for Health and Health Care in Schools
Department of Prevention and Community Health
George Washington University
Washington, D.C.

Eduardo Ochoa Jr., M.D.
Assistant Professor of Pediatrics
Department of Pediatrics
College of Medicine
University of Arkansas for Medical Sciences
Little Rock

Frederick P. Rivara, M.D.
Children’s Hospital Guild Association Endowed Chair in Pediatrics
School of Medicine
University of Washington
Seattle

Vinod K. Sahney, Ph.D.
Senior Vice President and Chief Strategy Officer
Corporate Strategy, Planning, and Business Development
Blue Cross and Blue Shield of Massachusetts
Boston

Mark A. Schuster, M.D., Ph.D.
Chief of the Division of General Pediatrics
Vice Chair for Health Policy Research
Department of Medicine
Children’s Hospital
Boston

Lonnie R. Sherrod, Ph.D.
Executive Director
Society for Research in Child Development
Ann Arbor, Mich.

Matthew W. Stagner, Ph.D.
Executive Director
Chaplin Hall Center for Children
University of Chicago
Chicago

Leslie R. Walker, M.D., FAAP
Associate Professor
Department of Pediatrics
School of Medicine
University of Washington, and
Chief
Adolescent Medicine Division
Children’s Hospital and Regional Medical Center
Seattle