Priority Need: Strengthen the health system to better meet the mental and physical health needs of adolescents.

Minnesota’s five-year needs assessment found that our current health systems that serve adolescents are not providing the supports our young people need to ensure healthy outcomes. The first priority need identified in the needs assessment for the Adolescent Health domain was to strengthen the health system to better meet the mental and physical needs of adolescents. National Performance Measure (NPM) 10 was the most applicable to this priority need.

NPM 10: Percent of adolescents, ages 12-17, with a preventive medical visit in the past year

According to the 2016-2017 National Survey of Children’s Health, 76.5% of Minnesota adolescents had a past year preventive medical visit. This means our target of 78.9% for FFY2018 was not met.

Objective(s): By 2020, Increase percentage of adolescent well visits by 5%.

Minnesota’s collaborative efforts to increase preventive medical visits for 12-17 year-old adolescents during this reporting period were ongoing. Our focus centered on training pediatric providers, school nurses and counselors, and other youth service providers; identifying best practices and methods to improve service delivery and access; expanding capacity to provide outreach and service delivery; and collaborating with state partners and external stakeholders to promote adolescent health services. Strategies implemented during FFY2018 in these four areas are discussed below.

A. Training providers, tribal health outreach coordinators, and school nurses and counselors

Recognizing the significance of C&TC visits, one of Minnesota’s strategies was to create outreach strategies for parents and youth for use by local public health agencies on the importance of C&TC visits. During this reporting period, the Adolescent and Young Adult Health (AYAH) Collaborative Improvement and Innovation Network (CoIIN) created a statewide marketing campaign, which included print and electronic ads on bus and train stations, buses and trains, billboards, and online social media. The campaign also:

• Engaged diverse youth from across the state in virtual focus groups to identify key values, messaging, and methods for marketing the AYA well visit.
• Advertised on Facebook, Instagram and AdTheorent Mobile platforms gathering 14,219,606 impressions and 109,754 individual clicks.
• Reached an additional 22,684,172 impressions during the course of the campaign from the transit postings and billboards

• Created emoji equations to inform people of the services available in a well visit, and links driving them to a webpage for resources, and information on the well visit and how to contact local C&TC coordinators to schedule appointments.

Activities around Minnesota’s strategy to provide targeted outreach, consultation, training, and technical assistance to clinics providing adolescent visits to increase Early Periodic Screening, Diagnosis, and Treatment (EPSDT) rates were:

• The pediatric and family medicine clinics participating in the AYAH CoIIN project received the above interventions to increase EPSDT rates.
• The AYA representatives on the project conducted clinic walk-through assessments using the Adolescent Health Initiative’s (AHI) Youth- Led Health Center Assessment Tool.
  • The results of the clinic assessments led the AYA representatives to create resource tools and SPARK trainings to clinic staff and residents on adolescent centered topics and care. SPARKs are free, ready-to-use presentations, which includes a script, and follow-up materials. SPARKs trainings are designed for providers or staff to deliver in 15-30 minutes at staff meetings or professional development opportunities. SPARKS can be facilitated by providers or staff in any role, and are specifically designed to “spark” discussion and reflection among a multidisciplinary audience. The AYA representatives presented AHI SPARK training to project clinics on Nonverbal Communication Bias, Being Youth Friendly, Being an Askable Adult, and Strengths Based Approached to Adolescent Sexual Health. 
• Because of the AYAH CoIIN and the input from AYA representatives, MCH staff are revamping trainings to focus on youth-centered care vs. “check-box care”. FFY 2018 was spent learning more from youth via the YA representatives and pilot clinic AYA satisfaction surveys; this information will inform FFY 2019 and 2020 trainings, webinars, conferences and other ways of disseminating this approach and related tools.
• Staff provided ongoing technical assistance to school nurses throughout the state regarding best practices in age appropriate care and intervention.
• The Minnesota Expectant and Parenting Student Program (MEPSP), a federal grant program administered by MDH, hosted a professional development workshop called “The Role of Lifestyle in Adolescent Mental Health: Practical Strategies that Work”. Public health nurses and social workers attended this professional development training in March 2018. Nimi Singh, MD, MPH, Division of Adolescent Health and Medicine, Department of Pediatrics, University of Minnesota was the keynote speaker.

B. Identifying best practices to improve adolescent health service delivery and access

• Explore University of Michigan Adolescent Champion Model and Better Together Hennepin My Clinic model for possible replication and expansion in Minnesota to strengthen health systems to better meet the health needs of young people.
  • We explored both models and were able to adapt pieces of each model in addition to work happening in adolescent sexual health with our partners at HealthPartners, and implementing feedback and direction from our AYA representatives to create our own interventions and models that worked with our partners.
• Another Minnesota strategy was to connect with states with higher rates of adolescent Early Periodic Screening, Diagnostic, and Treatment (EPSDT) visits (per CMS-146 report) for strategies on increasing the number of EPSDT visits. Through the AYAH CoIIN, Minnesota teleconferenced with other states regarding meeting with Medicaid to change the EPSDT periodicity schedule to promote yearly visits instead of every-2-year visits.

C. Expanding capacity to provide outreach and service delivery

Activities supporting Minnesota’s strategy to partner with school-based health centers to promote adolescent health services implemented in FFY2018 are discussed below.

• Through monthly Minnesota School Based Health Alliance (Alliance) meetings, staff consistently look for ways to support the work of the school-based health centers in Minnesota through training, technical assistance, and advocacy. This reporting period the Alliance hosted an all staff summit focusing on adolescent social media and mental health.
• Other staff activities around our strategy to promote adolescent health services in collaboration with school-based health centers include:
  • Maintained the school health services website and list serve to build community amongst the 584 school districts in Minnesota
  • Collaborated with the Minnesota Department of Education and Minnesota’s State School Nurse Organization (SNOM) to provide annual school nurse orientation for nurses new to the profession to ensure their understanding of the needs specific to the specialty of school nursing, serving 104 nurses
  • Provided training to 432 school nurses and, in partnership with SNOM, will offer ongoing annual conferences to school nurses
  • Attended 88 regional school nurse meetings to obtain feedback regarding statewide needs provide continuing education opportunities for school-based nursing services
  • Served on the Every Student Succeeds Act (ESSA) Advisory Group for Minnesota as a health in all policies partner. All schools should consider health in all policies to ensure students have access to learning and health needs
  • Received ACE Interface training and provided 14 train-the-trainer sessions to school professionals, families, community members and future education professionals
  • Provided ongoing ACE interface training as needed per request

• Explore promoting changes to minor consent law to include access to mental health services.
  • Staff did not promote any changes to the Minnesota minor consent law, but through work on the AYAH CoIIN and in partnership with the center for Adolescent Health & the Law, created “Adolescent & Young Adult Health Care in Minnesota: A Guide to Understanding Consent & Confidentiality Laws”.

D. Collaborating with state agency partners and others to promote adolescent well visits and health services

School health services is an incredibly valuable tool to marry health and education to build healthy successful futures for Minnesota’s kids and families. MDH strives to create a health in all policies approach of working and serving Minnesota students statewide. Staff led the interagency services group, an ongoing MDH partnership with the Departments of Human Services and Education, to expand school-based health services, improve communication between schools and other health care services, and build more equitable and sustainable school health services in Minnesota through billing for the high quality services being provided by school nurses. The interagency services group developed a policy for schools to bill Medicaid for school health nursing services. In FFY2018, the group began pilot testing the policy with a K-12 metro school. An example of how the billing policy will work: A school nurse teaches a student with asthma how to use an inhaler. If this same student returns to school nurse again for treatment, or if the students uses the inhaler and it does not work, the student is encouraged to return to school nurse, and receives treatment, then the billing for the school nurse services would include initial training, treatment, and follow-up. Currently, these services are provided at no cost to the student.

Other accomplishments of note include partnerships formed by staff in FFY2018, to expand understanding of and to support school health services, are described below.

• PACER Medical Advisory Board provided consultation and support to families to meet health needs.
• Minnesota’s Asthma team, comprised of the Association of Asthma Educators, Minnesota school health and MCH School Nurse Consultant, supported advanced school-based asthma management. Staff provided asthma training to 200 nurses throughout the state during this reporting period.
• Minnesota Oral Health program advanced school-based sealant and services program, educated dental providers on the Whole School, Whole Child, Whole Community (WSCC) Model, and supported preparatory efforts for the Building Supportive Schools (BSS).

ESM 10.2: Number of youth engagement activities to improve adolescent and young adult (AYAH) preventive care utilization and quality

Minnesota’s FFY 2018 objective was to involve youth in 2-4 activities. During this reporting period, five youth engagement activities were completed. This means we surpassed our target of 2-4 activities. The five activities, which proved very successful are described below along with their impact:

1. Young Adult representative (YA rep) retreats and general guidance for the AYAH CoIIN project. The in-person retreat at the beginning of the project set the course for the team. The YA reps identified key issues that should be prioritized for the AYAH CoIIN project related to well visits:
   • One-to-one (1:1) time between the clinician and the young person at every well visit
   • Training for providers on youth-centered care, including the need for a strengths-based approach, cultural humility (not making assumptions about the individual based on appearance, race, dress, sex, name, language)
   • A “youth-approved” designation for clinics: this resulted in our later approach of engaging young people in assessing participating clinics for youth-friendliness.
2. YA rep development of the “Talk to Me” guidelines for pediatric health care providers, regarding what questions to ask to engage young people in well visits. YA reps had identified the need for “real conversations” with their providers. The clinicians participating in the AYAH CoIIN project asked the young people for specific guidance regarding what to ask about at the visit, and how to approach those questions. This resulted in the development of the “Talk to Me” guidelines by the YA reps, in collaboration with Minnesota staff. These serve as a conversational tool for clinicians providing AYA well visits.
3. YA reps SPARKS trainings in clinic pilot sites. Engaging young people in actually providing the SPARKS training (a resource of the University of Michigan Adolescent Health Initiative) resulted in several things:
   • Having youth as trainers increased our access to clinics to provide trainings. Clinics were enthusiastic about providing dates and time, knowing that young people rather than clinic staff would be providing clinic training on youth-friendly health care.
   • The YA reps brought diverse perspectives to their clinic trainings and, as young people, were able to speak as legitimate experts on young people.
4. YA reps clinic walk-throughs, piloting the University of Michigan AHI Youth-Led Clinic Assessment tool. Again, participating clinics were eager to have young people enter and provide an assessment of their clinic sites. Clinic staff indicated having input from young people helped leverage change with clinic administrators. Specific areas for change included: making confidentiality practices more clear; having visual cues of LGBTQ-friendly care; and providing youth-focused waiting room and exam room informational materials. The YA reps helped develop a “flip chart” of youth-specific resources that clinics are now using in exam rooms.
5. Youth focus groups for input on top value foci for the AYA well visit marketing campaign, along with choosing a “look” and messaging for the campaign. Diverse adolescents from across the states met in virtual focus groups with the marketing campaign. The young people identified top priority values for the campaign (mental health and sexual health), helped develop messaging that resonates with young people, and helped chose the design and “look” of the marketing campaign. To see an example of the campaign materials, refer to https://getctc.com/.

Priority Need: Build community capacity to engage and support young people to be connected to community, school and caring adults.

The second priority area identified in the five-year needs assessment is to increase opportunities for adolescents to become connected to their community, school, and caring adults. After-school programming also supports working families and keeps young people safe. Minnesota created a state performance measure (SPM) as a proxy measure to address this priority need.

SPM 3: Percent of adolescents participating in out-of-school activities

The data source for reporting this state performance measure (SPM 3, percent of adolescents participating in out-of-school activities) is the Minnesota Student Survey (MSS). For FFY2018, 2016 is the most recent data available and it shows that 64.8% of adolescent participated in out-of-school activities (see Figure 3 below). The MSS is conducted every three years, 2016 was the last year the survey was conducted. Therefore, we are unable to report on this target.

Objective: By 2020, increase participation of young people participating in out-of-school activities

Supporting high quality, accessible out-of-school-time programming is an essential part of a broader model of wrap-around supports for young people. These supports help to address outcomes related to graduation rates, teen pregnancy, health literacy, and provide greater success in the lives of participating young people. Participation in high-quality out-of-school-time programs helps to improve student work-study habits, homework completion rates, and grades. Participation in quality programs also helps to increase student engagement and school connectedness, self-esteem, as well as improve relationships with peers and adults, and decrease negative, risk-taking behavior. Increased student engagement and performance in school can help to improve overall educational attainment. Minnesota created SPM 3 to increase the percentage of adolescent participating in out-of-school activities.

Minnesota’s efforts to increase the number of adolescents participating in after-school activities focused on the following two areas in FFY2018:  1) evaluating, developing and disseminating best practices and toolkits for community engagement/support for youth and 2) collaborating and supporting partners in promoting positive youth development. The strategies implemented in these areas are discussed below.

A. Evaluating, developing and disseminating best practices and toolkits for community engagement/support for youth and collaborating

One of Minnesota’s strategies during this reporting period was to complete an evaluation of Making Authentic Connections (MAC), a Ramsey County-based community training tool, to determine if it has replicable value for sharing as a promising practice in other Minnesota communities. The evaluation methods were conducted through participant surveys, follow-up and Ripple Effect Mapping. MAC surveys showed that participants were not only highly satisfied with the programming, but they also credit the program for changing their lives. Some comments from participants were “They increased their level of comfort and connecting with adolescents”. “…increased confidence in connecting with adolescents.” and “They increased their motivation to connect with adolescents.”

Individuals who participated in Ripple Effect Mapping clearly delineated the following outcomes: MAC equips participants with a set of simple, effective guidelines for building authentic relationships across a variety of contexts and domains. MAC empowers individuals to engage in respectful, thoughtful interactions with others from backgrounds different from their own. MAC has the potential to influence the culture of organizations whose staff are educated in and embrace its principles. This strategy was completed in September 2018. This grant also ended in September 2018.

B. Collaborating and supporting partners in promoting positive youth development

Another one of Minnesota’s strategies was to provide technical assistance and train communities through their youth serving organizations to incorporate youth development strategies, such as positive youth development, adolescent brain development, Making Authentic Connections, and It's That Easy into their youth outreach work.

Other Minnesota strategies related to this area and implemented in FFY2018 include:

• Provided numerous training and technical assistance to partners, grantees and work groups. Topics covered this year include: Adolescent development and sleep, youth friendly clinic services, American Indian Youth Live It! Training, Making Authentic Connections (MAC) Sessions, Writing to Change the World Training, Sex Positive Abstinence Education Training, Teen Outreach Program Partner’s Training, Minnesota Reproductive Health Update, Adolescent Health Summit, Adolescent Health Summer Institute, MDH Let’s Talk Data and Resource Symposium and Curriculum Implementation Foundations training.
• Continued to work collaboratively with Ignite Afterschool, the statewide network of afterschool funders, program providers, researchers and supporters for out-of-school-time programming for young people. In turn, each collaborative colleague within this activity participated on each other’s leadership/advisory committees. Providing technical assistance in positive youth development, adolescent brain development, and quality out of school programming is ongoing.

• Supported, trained, and provided technical assistance to community partners by offering high quality, medically accurate, evidence-based quality sex education to Minnesota youth.
  • Curriculums include: Teen Outreach Program (TOP), Making Proud Choices!, Be Proud! Be Responsible! Be Protective, Cuidate! (Take Care of Yourself), Sexual Health and Adolescent Risk Prevention (SHARP), Safer Sex Initiative (SSI), All 4 You and Live it!
  • Total number served from January 1, 2018 to September 30 of 2019 was 411 youth. Hours of programming was 406.
• Strengthened the capacity to implement positive youth development interventions in youth serving organizations/school districts through the CDC Division of Adolescent and School Health (DASH) grant collaboration that focuses to improve school climate and increase student access to youth friendly health services in 10 Minnesota communities. This strategy was completed in July 2018. The DASH grant ended in July 2018.
• Launched the Minnesota Partnership for Adolescent Health strategic plan highlighting promising practices and strategies for community outreach to youth.
  • The Minnesota Partnership for Adolescent Health (MNPAH) has partnered and aligned its work with the national Office of Adolescent Health (OAH) Think, Act, Grow (TAG) Initiative. Parts of the plan highlighting different priorities have been presented and discussed with the University of Minnesota LEND Fellows, Participants of the AMCHP conference, the State Agency School Health and Education Collaborative Meeting, Minnesota School-Based Health Alliance, MCH staff, American Public Health Association Conference attendees, Evergreen Conference attendees, and recorded on a webinar with OAH. Each presentation highlights a priority from the plan and discusses action steps to implement and support the priority.
• Partnered with Ignite Afterschool Network and their Regional Igniters to offer youth development trainings to:
  • Support programs such as the Teen Outreach Program (TOP) that delivers programming aimed to help youth develop positive self-image and effective life management skills. For the Abstinence Education Grant Program, St. Paul-Ramsey County provided six TOP clubs in the metro and suburban St. Paul-Ramsey County area.
  • Participate on the CDC 1801 Grant Advisory Board to support statewide development of chronic condition management systems for out of school time, making more programs more accessible to students with ongoing health needs. The CDC 1801 Grant is a Healthy Schools grant awarded to states to support the implementation and evaluation of evidenced-based strategies and activities in schools.