Overview and Context of Population Domain

Adolescence is a critical period for physical, mental, and emotional development. Reducing risk exposure and adapting health-promoting behaviors at this transitional stage can have life-long impacts on health outcomes. At the same time, experiencing trauma or adapting unhealthy behaviors during adolescence may have negative impacts on long-term well-being1. While certain adolescent health indicators have improved in Louisiana, including declining teen birth rates (NOM 23) and increasing immunization rates (NOM 22.2-22.5), significant concerns remain for safety and social and behavioral supports. Adolescent suicide rates have increased steadily since 2010 (NOM 16.3). In 2018, suicide attempts among high school students in Louisiana were more than double the average for the US, and self-harm was the second leading cause of injury hospitalizations for adolescents in Louisiana2,3.

Multiple risk factors related to suicidal thoughts and behaviors are on the rise across the state. Depression rates of Louisiana adolescents age 18-24 are above the national average and increasing steadily4. Rates of bullying are increasing significantly, including electronic bullying2. Adolescents in Louisiana are more likely to carry a weapon compared to the national average, and teens in Louisiana skip school due to feeling unsafe at rates nearly double the national average, with rates increasing over time2.

Summary and Reflection of Adolescent Health Efforts

Evolution of Adolescent School Health Program (ASHP): Since the 2015 Needs Assessment, Louisiana Title V efforts to improve adolescent health centered around improving the quality, relevance, and uptake of available services at school-based health centers (SBHCs) operating under the OPH Adolescent School Health Program (ASHP). The legislatively-mandated charge of ASHP is to “facilitate and encourage the development of comprehensive health centers in Louisiana public schools.” Title V funds staff to manage ASHP and facilitates evidence-based quality improvement in Louisiana SBHCs by providing informational resources, technical assistance, strategic direction, and monitoring support. Each of the 60 SBHCs under ASHP supervision operate independently and are funded through 21 different sponsoring agencies and other state funds. In FFY 2019, ASHP-supported SBHCs served students at 97 schools located in 25 Louisiana parishes.

In the summer of 2016, ASHP was brought under BFH and became administratively united with the other major Title V programs. Since joining BFH, ASHP staff has invested significant time and energy in understanding the current status and needs of these important healthcare access points for youth around the state.

During the 2016-2017 school year, ASHP staff traveled around the state to meet with SBHC directors and observe and interview SBHC staff. These visits and discussions brought to light some key challenges and opportunities within the SBHC network that led the program to begin reevaluating ASHP’s role as a supportive, supervising entity.

The site visits and data analysis revealed that many of the SBHCs were experiencing difficulty operating at a financially sustainable level. Although SBHCs bill third-party payers to generate revenue, the reimbursement often does not cover the cost of the visit. Therefore, a priority for ASHP was to increase the number of students seen in order for the clinics to achieve financial sustainability.

Implementing new standards and accountability: An approach to increase SBHC productivity was to implement new standards and accountability into the annual contracts. In order to motivate providers to see more students, the contracts for the 2019 fiscal year included a targeted average number of visits for the medical provider, nurse (only), and behavioral health specialist. These strategies were a part of the FFY 2019 Title V State Action Plan for NPM 10: Adolescent Well Visits. ASHP also compared the number of well visits and sports physicals completed to determine opportunity gaps for services that yield higher reimbursement and better health outcomes. One resulting strategy was to encourage SBHCs to convert sports physicals to adolescent well visits when time permits.

Addressing Barriers to SBHC Access: SBHC staff continued to report barriers that prevented them from reaching the desired level of productivity, such as lack of signed consent forms, SBHC staff capacity, parent objections, and limited times when students can attend the SBHC.

During FFY 2018, ASHP conducted research with Worldways Social Marketing to learn how SBHCs can develop strategies for reducing health disparities while also developing an understanding of school administration and SBHC personnel’s perceptions about SBHC services. The research project began in early 2018 and data collection was completed in June 2018. Four key findings were revealed: 1) SBHCs play a vital role in prevention, intervention, and care. Because of the at-school location, they are a consistent support to student health; 2) students are likely or highly likely to experience social challenges; 3) 90% of school administrators call their SBHC “indispensable” or “very important” ; 4) strong mutually respectful and collaborative relationships exist between school administrators and SBHC managers and staff. This project also confirmed the belief that services offered at SBHCs have not been adequately marketed. Worldways worked with Title V ASHP and communications staff to develop a suite of marketing materials targeted to adolescents, including posters, banners, postcards, table tents and retractable banners that advertised services offered at SBHCs. The SBHCs utilized the materials during the 2019-2020 school year, and BFH staff distributed a survey to measure the effectiveness of the marketing materials.

Assessing Adolescent Friendly Practices: A strategy to increase overall SBHC visits, including adolescent well visits, was to ensure adolescent friendly practices in the health centers. Informed by the evidence-based Bright Futures guidelines, BFH developed a survey to assess student satisfaction with SBHC services and other adolescent friendly criteria. In FFY 2017, five SBHCs piloted the BFH adolescent friendly survey, and during FFY 2018, ASHP designated one week each month for the SBHCs to administer the survey to students aged 12 to 17 who accessed a SBHC. More than 3,500 survey responses were received, and each SBHC received their respective results, including comments from adolescents regarding services and their experiences at the SBHC. Overall, surveys indicated a 95% satisfaction rate with SBHCs; however, the survey was completed only by students who accessed the SBHC. During FFY 2020, ASHP planned to explore alternate methods to better understand the needs of students not engaged with the SBHCs, but due to changes in OPH and ASHP strategic direction discussed below and in the 2021 Application, this strategy and related ESM will be retired along with NPM 10.

Changes in OPH and ASHP Direction: In FFY 2019, program staff conducted a comprehensive review of SBHC operations and the overall adolescent health needs in the state. The objectives of this review were to modernize the ASHP program and meet the current needs of the adolescents in the state.

The review found that implementation of services on-the-ground has been variable in reach, quality, and relevance to community needs. Some sites have lost support from their sponsors and have closed. There is greater access to primary care in local communities now than there was when the program was established. Similarly, Louisiana’s adolescent wellness visit utilization rate is significantly higher than it was at the time of program conception.

SBHCs help provide Louisiana adolescents with services they may not have access to otherwise. With the passing of the Affordable Care Act, the state’s 2016 Medicaid expansion, and other health system reforms over the past decade, the demand for SBHCs to function as primary care providers has diminished in many areas. At the same time, demand for mental and behavioral health services has continued to increase. Some school or district student populations have increased significantly, while others have decreased. The original contract amounts that were set over a decade ago have not adjusted to these changes in demand. In FFY 2019, OPH, BFH, and ASHP leadership began to reexamine the ASHP contracting model to ensure that SBHC funding is aligned with community needs and maximizes site operational capacity. 

Addressing Adolescent Self-Harm

Mortality and Injury Surveillance: Louisiana Title V’s primary role in addressing youth suicide is to fund and support the Louisiana Child Death Review (CDR). As described in other domain narratives, the CDR consists of state and local panels that meet to review unexpected deaths of children under age 15, identify risk factors, and provide recommendations for preventive action. To bring additional attention to the issue, a specific section in the 2015-2017 CDR report focused on deaths by suicide. During 2015-2017, twenty-four children under the age of 15 years old died from suicide in Louisiana, and half of those deaths were completed using firearms.

In FFY 2019, the State CDR panel identified safe firearm storage as a priority focus area and created a committee to address and promote safe firearm storage to prevent child deaths. Title V-funded communications specialists and other Title V staff supported the committee with the development of a social norms campaign targeting Louisiana gun owners with children who live in or visit their homes and store their firearms unlocked or otherwise unsecured.

The State and local CDR panel partners work closely with the suicide prevention coordinator of the Louisiana Department of Health, Office of Behavioral Health (OBH). Through this collaboration, CDR panel partners have worked with local and regional suicide prevention taskforces to create a Suicide Prevention Plan and Crisis Intervention Quick Resource Guide and promote training opportunities on suicide prevention, shared risk and protective factors, and Adverse Childhood Experiences (ACEs).

Although CDR does not review deaths among adolescents 15 years and older, suicide fatalities for individuals of all ages are included in the CDC-funded National Violent Death Reporting System (NVDRS). BFH has participated in NVDRS since 2016 and began collecting statewide data in January 2018. Collection of NVDRS data will enable enhanced monitoring of suicide trends, as well as contributing factors for these fatalities among older adolescents. BFH also recently partnered with the OPH Infectious Disease Epidemiology program on a new CDC-funded Emergency Department Surveillance of Nonfatal Suicide-Related Outcomes (ED-SNSRO) project that will expand surveillance to include non-fatal suicide attempts. NVDRS and ED-SNSRO do not receive Title V funds, but both efforts will enhance overall Title V assessment capacity and are supported by Title V infrastructure.

ACE Educator Program: Research demonstrates a strong positive association between ACES and suicide attempts5. To address this association, Title V funds a statewide ACE Educator Program that builds community awareness around ACEs, trauma, and resilience science. The program provides trainings for small cohorts of volunteers to become ACE Educators. Once trained, these educators offer no-cost presentations to agencies, organizations, and community groups across the state of Louisiana.

Child Safety Learning Collaborative (CSLC): In FFY 2019, BFH participated in a national Child Safety Learning Collaborative (CSLC) supported by the Children’s Safety Network. The Louisiana CSLC team, which includes several Title V staff, is working on an intervention for Suicide and Self-Harm Prevention (SSHP). The SSHP project started in the Lafayette area with an assessment of screening practices in schools and a pilot project to improve screening of suicide risk for children and adolescents in hospital emergency departments and schools.