Adolescent Health Overview
The needs of adolescents are addressed at the state and local level in Michigan through a diffuse network of governmental and non-governmental organizations. Within MDHHS, the Division of Child and Adolescent Health (DCAH) plays a central role in meeting the health needs of Michigan’s adolescents. DCAH includes programs designed to build healthy relationship skills among adolescents, prevent unintended pregnancy, and address bullying. It houses programs designed to meet adolescents’ health needs in school settings thru Child and Adolescent Health Centers and school nursing. The Division of Immunization includes sections focused on adolescent outreach and education, as well as assessment and local support. The Children’s Special Health Care Services (CSHCS) Division administers programs that impact adolescents and young adults with special health care needs, especially as they relate to transition. Title V funds support a variety of programs and services for adolescents through state and local organizations—including HPV immunization, pregnancy prevention and bullying—as well as services for adolescents who have special health care needs. Other federal MCH funds that impact adolescents include the State Abstinence Education Program (ACF funding), the State Personal Responsibility Education Program (ACF funding), the Pregnancy Assistance Fund to reduce unintended repeat teen pregnancy and an Epilepsy grant (HRSA funding). In addition, critical partnerships in the state that impact adolescent health include those with school-based health centers, the Michigan Department of Education, the Youth Risk Behavior Survey and its state-based counterpoint (the Michigan Profile for Healthy Youth), the Michigan Organization on Adolescent Sexual Health, and the School-Community Health Alliance of Michigan.
At the local level, LHDs expended Title V funds in three performance measures in this domain in FY 2020. Four LHDs worked on NPM 10 (adolescent well-visit) with gap-filling activities such as well-visit physical exams, family planning services, HIV and STI counseling and testing, health education and links to community services. Twelve LHDs completed activities related to SPM 3 on adolescent immunization measure which included media campaigns, initiatives to determine barriers to HPV vaccine, provision of gap-filling adolescent vaccinations, waiver education, recalls and reminders. Four LHDs selected former SPM 3 (depression across the life course) and activities included suicide prevention, gap-filling adolescent depression screening, and provision of mental health education to middle/high school youth. All activities were impacted by the pandemic and occurred in reduced capacity.
Michigan’s approach to adolescent health emphasizes reducing mortality, especially through suicide prevention, and protecting adolescents from adverse health outcomes due to a variety of factors, such as HPV or unplanned pregnancies. While the past decade has seen positive change in several dimensions of adolescent health, adolescents continue to face risks at the intersection of behavioral and physical health. The adolescent mortality rate of 32.8 per 100,000 has improved since 2009 but remains slightly above the national average (NVSS, 2018) and is highest among non-Hispanic Black adolescents (51.4 per 100,000, NVSS, 2016_2018). However, the motor vehicle mortality rate (11.66 per 100,000, NVSS, 2014_1016) among adolescents has dropped over the past six years to below the national average. Following alarming national trends, the suicide mortality rate (11.0 per 100,000, NVSS, 2014_2018) for adolescents has increased steadily over the past several years and currently exceeds the national average. The HPV vaccination rate has steadily increased, with the percent of female adolescents who have received at least one dose of the HPV vaccine increasing from 39.0% in 2009 to 72.5% in 2018 (NIS), and higher rates of vaccination among Hispanic (81.4%) and non-Hispanic Black (76.9%) adolescents as compared with non-Hispanic white (61.9%) adolescents. The teen birth rate has also steadily declined from 31.9 per 1,000 females in 2009 to 15.1 in 2019 (MDHHS). However, the teen birth rate was 30.5 and 23.1 in 2019 per 1,000 non-Hispanic Black adolescent females and Hispanic adolescent females, respectively. This disparity suggests a need to explore the appropriateness and responsiveness of teen pregnancy programs and services. In 2018, parents reported that 20.0% of Michigan adolescents bullied others (NSCH), compared with 15.3% nationally. In 2019, 27.7% Michigan adolescents (12-17) reported being bullied, a non-significant decrease since 2011 (29.7%, YRBS). Students who identify as lesbian, gay, bisexual or transgender were significantly more likely to report being bullied (43.2%) than those who identified as cis-gender heterosexual (27.1%, YRBS, 2019). Similarly, female students (31.6%) and non-Hispanic White students (29.7%) all reported higher risk of being bullied than the state average. These data suggest a need to take gender and sexual orientation into account when addressing bullying in Michigan’s schools.
Adolescent Well-Visit (FY 2020 Annual Report)
In FY 2020, planned activities were focused on implementing a Motivational Interviewing (MI) web course and follow-up training to public and private providers, as well as implementation of a behavioral health quality measure among state-funded school-based and school-linked health centers, known as Child and Adolescent Health Centers (CAHCs) in Michigan.
The in-person Motivational Interviewing training was impacted by the COVID-19 pandemic in FY 2020, which prohibited in-person training for the majority of the year. The Evidence-based Strategy Measure (ESM) target for FY 2020 (98% of health care providers who completed the Motivational Interviewing web course and subsequently attended the Motivational Interviewing professional development in-person training reported improved skills and confidence in effectively counseling youth on changing risky behaviors using MI strategies) was not specifically evaluated, as in-person trainings were prohibited by the State of Michigan beginning in March. An adaptation was made to provide the training virtually, with one training held in July. Among health care providers who completed the web course and subsequently participated in the virtual training, 91% reported improved skills and confidence in effectively counseling youth on changing risky behaviors using MI strategies, which fell just short of the goal.
Each state-funded CAHC is required to report on a standardized set of quality measures with an ultimate goal of improvement in care for CAHC clients. In FY 2020, a behavioral health quality measure to assess appropriate follow-up care (treatment) for youth age 12 years and up who have a diagnosis of depression was implemented after a one-year pilot of the measure. This measure was likely negatively impacted by the pandemic as some providers were not able to see clients in person for several weeks; and some were initially not able to successfully engage a large number of clients in telehealth visits either due to client reluctance using a virtual visit platform, lack of technology and/or lack of internet access to participate in virtual visits. Additionally, some providers were temporarily deployed elsewhere within their medical sponsoring organizations to assist with pandemic response, which limited access to usual services for several months. In response, state CAHC staff and CAHC partners across Michigan worked together to develop a series of guidance documents which outline best practice strategies for outreach and communication with clients, parents, schools and communities; as well as planning for modified service provision during the pandemic so that clients could continue to seek and receive care to the extent possible.
Meaningful family and consumer engagement of parents and youth is a longstanding priority of the CAHC Program and is accomplished through various strategies. Per boilerplate requirements, each CAHC must operate a community advisory committee that is comprised of at least one-third parents of school-aged children and youth. Parents are recruited through a variety of means, including but not limited to social media postings, mailings in conjunction with schools, recruitment at in-person events, direct invitation, or word of mouth (e.g., when parents attend visits with youth, by invitation from other parents, teachers, etc.). Other organizations may also be involved in recruitment. These organizations are typically member organizations of the CAHC (such as community-based organizations, youth-serving organizations, and faith-based organizations) but may also include outreach from other parent organizations such as a Parent/Teacher/Student/Organization, Booster Club, etc.
The community advisory committees are tasked with giving input and approving core health center policies, including confidentiality, abuse and neglect and parental consent. Each group has a range of other responsibilities that are unique to each center. When funding for the CAHC program was eliminated in 2003, these advisory groups rallied other parents to provide a critical advocacy voice that was instrumental in reinstating the funding. Parents are a powerful ally in this work.
Youth input is also a longstanding requirement of the program and occurs through various strategies. Centers are required to have youth input through either their existing Community Advisory Council (CAC) or through a stand-alone youth advisory committee. As part of their work on these committees, youth routinely provide feedback on center services and programs, the center’s environment, and reading material. Youth are strong advocates for CAHC utilization among their peers. Some CAHCs also conduct focus groups with youth to identify ways to increase health center utilization and improve services and outreach. As part of ongoing CQI activities, CAHCs must implement a client satisfaction survey at least annually. Results of these surveys are compiled, and centers must demonstrate how this critical feedback was used to improve services to clients. Again, the guidance documents created by state and local CAHC partners outline best practice strategies for outreach and communication with community advisory council and youth advisory members; as well as strategies to modify and implement client satisfaction surveys in an electronic format so that family and youth engagement and feedback could continue, despite limitations imposed by the pandemic.
Objective A: Increase the percent of adolescents, ages 12 through 17, enrolled in Medicaid, with a preventive medical visit in the past year.
This objective was not addressed in FY 2020 as resources were shifted to address the pandemic.
Objective B: Of the health care providers who completed the Motivational Interviewing web course and the Motivational interviewing professional development training, 98% will report skills in effectively counseling youth on changing risky behaviors.
In 2014 and 2015, MDHHS Child, Adolescent and School Health (CASH) Section staff partnered with the Michigan Public Health Institute to design two web-based Adolescent Health Courses, grounded in research and best practice, to improve provider competencies in Motivational Interviewing (MI) and Positive Youth Development/Resiliency. Two additional courses were developed and released in 2017 including Adolescent Brain Development & Decision Making, and Encouraging Healthy Teen Relationships (interpersonal violence prevention). These courses have been promoted and offered at no charge to public and private providers throughout Michigan and the United States. The objective is to reach 250 providers over five years with these foundational adolescent health courses.
Health behaviors are increasingly recognized as multidimensional and embedded in healthy lifestyles. Social determinants of health (SDOH) are influenced by the interrelationship of social factors, health services, individual behavior, and biology. It is the interrelationships among these factors that determine individual and population health. Therefore, interventions that target multiple determinants of health are most likely to be effective. The motivational interviewing course focuses on identifying risk and preventing harmful effects on adolescent population health. Assessment of SDOH combined with evidence-based motivational interviewing counseling and referrals results in improved adolescent health and well-being.
As noted above, the ESM for this measure is the percent of health care providers who complete the MI web course and subsequently attend the MI professional development training who report improved skills and confidence in effectively counseling youth on changing risky behaviors using MI strategies. Through the Title V program in 2020, MDHHS offered one virtual MI training reaching 22 providers, for a total of 168 providers who have attended the training over the past four years. Participants have included physicians, nurse practitioners, physician assistants, nurses, social workers and health educators. The trainings were promoted through provider organizations such as the Michigan Regional Chapter of the Society for Adolescent Health and Medicine, American Academy of Pediatrics, American Family Physicians, National Association of Pediatric Nurse Practitioners and the CAHC Medical Directors listserv. As a result of the MI training, 91% of evaluation respondents (n=22) reported improved skills and confidence in effectively counseling youth on changing risky behaviors using MI strategies. Therefore, in 2020 Michigan fell just short of the ESM target (98%).
Objective C: Increase percentage of CAHC clients age 12+ with a positive depression screen who have documented follow-up.
As a first strategy to meet this objective, the CAHC program established a required behavioral health quality measure to assess appropriate follow-up care (treatment) among clients age 12 years and older who have a diagnosis of depression. A threshold of 90% has been established for this objective (e.g., 90% of clients age 12 years and older who have a diagnosis of depression will have documented, appropriate follow-up care).
Appropriate follow-up care has been defined as having ALL of the following elements of an appropriate follow-up plan: a) psycho-social assessment completed by third visit (includes suicide risk assessment/safety plan); AND b) treatment plan developed by third visit; AND for those on the caseload for at least 90 days, c) treatment plan reviewed after 90 days; AND d) screener re-administered at appropriate interval to determine change in score. The goals of appropriate follow-up care are early intervention for behavioral health concerns, resolution of or a decrease in symptom severity, better overall mental health, reducing stigma surrounding mental health care, and lowered risk of negative outcomes associated with depression including, but not limited to, suicide ideation and/or attempt.
A total of 1,728 clients age 12+ were reported as having a diagnosis of depression. (A total of 69 CAHCs reported having at least one client age 12+ with a diagnosis of depression in FY 2020). Of these 1,728 clients, 75% (median percentage) were reported as having appropriate follow-up care in FY 2020.
A full year of pilot data collection in 2019 for this new behavioral health measure revealed questions and concerns from the field that have been, and continue to be, addressed by the state CAHC program staff. The two most frequent concerns were 1) assurance that CAHCs have a proper understanding of the measure and subsequently the data to be collected and reported and 2) provider fear and/or reluctance of diagnosing depression among youth. Both concerns continue to be the subject of numerous site-specific and program-wide technical assistance calls and correspondence and have been incorporated into webinars, meetings and training.
Immunizations – Adolescents (FY 2020 Annual Report)
This section discusses the Immunization SPM focused on adolescent health: Percent of adolescents 13 to 18 years of age who have received a completed series of Human Papillomavirus (HPV) vaccine. The COVID-19 pandemic has presented many challenges to both healthcare and public health and has impacted much HPV-related activity that would have otherwise taken place in FY 2020. The MDHHS Division of Immunization has been closely monitoring the impact of the COVID-19 pandemic on vaccine administration and reporting patterns to the Michigan Care Improvement Registry (MCIR).
The HPV immunization coverage estimates for adolescents saw a decline in FY 2020. Given the decrease in vaccine confidence and an increase in refusal and delaying of vaccines in Michigan, as well as the global pandemic, the decrease of HPV coverage levels is consistent with the decline of other vaccination coverage levels. The HPV series completion rates over the last year for 13 to 18-year-old adolescents decreased by approximately 8.3% to 44.1%. Michigan HPV vaccine coverage continues to be significantly less than the Healthy People 2020 goal of 80% HPV vaccine coverage.
Objective A: Increase the percentage of adolescents who have completed the HPV series.
In the FY 2020 reporting year, 44.1% of adolescents 13 to 18 years of age completed the HPV series (based on MCIR data) which represents an 8.3% decrease from FY 2019. The Michigan Immunization Program, in FY 2020, needed to pause workgroups and collaborations with other state programs due to activities and priorities of the COVID-19 pandemic. The Michigan Immunization Program had minimal capacity during FY 2020 to collaborate with the state Cancer Program, the Michigan Cancer Consortium, the American Cancer Society or with Michigan Medicine as part of the Michigan HPV Cancer Prevention Alliance which is focused on implementing strategies and other activities to improve timely administration of HPV vaccine and result in increased HPV immunization rates in Michigan.
Objective B: Increase outreach to adolescent immunization providers with low immunization rates.
In FY 2020, the Michigan Immunization Program was not able to dedicate staff to work on this objective due to COVID-19 response activities and priorities. Outreach to Michigan adolescent immunization providers did not occur. The third annual Michigan HPV Cancer Summit was also cancelled, due to the pandemic.
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