Adolescent Well-visit (FY 2020 Application)

Through the ongoing needs assessment process, in 2018 the state priority need to “Promote social and emotional well-being through the provision of behavioral health services” was linked to the percent of adolescents, ages 12-17, with a preventive medical visit in the past year. According to the National Survey of Children’s Health, 84.7% of Michigan’s children aged 0-17 received a preventive medical care visit in the year preceding the survey. While this may seem high, it is important to note the disparity among adolescent well-care rates. According to the Michigan Medicaid 2017 HEDIS Results, an average of 55.69% of Michigan’s Medicaid-covered adolescents aged 12-21 were current with at least one comprehensive well-care visit, with a range of performance among Michigan’s Medicaid Health Plans (MHPs) from 24.07% to 64.42%. This disparity in well-care exams will be examined and addressed through the adolescent well-visit NPM work.  The importance of addressing bullying is also recognized by MDHHS. The Michigan Department of Education coordinates efforts with multiple stakeholders (including MDHHS) to address this issue and has launched multiple initiatives to reduce bullying among all school-aged youth.

A key objective to improving the adolescent well-visit measure was increasing the delivery of well child care to adolescents receiving services through the Child and Adolescent Health Centers (CAHCs) which is Michigan’s school-based health center program. CAHCs are placed in medically underserved areas of the state where an established threshold of need is met. They are often in documented provider shortage areas. CAHCs are located in schools with a high proportion of Medicaid or Medicaid-eligible youth; ranging anywhere from 50%-98% of their student population. Of CAHC clients that reported their race in FY2018, 51% were White, 38% were Black/African-American and 8% were more than one race. At least 9% of clients were Hispanic/Latino of any race.

Each state-funded CAHC is required to report on a standardized set of quality measures and to participate in a Continuous Quality Improvement (CQI) project. This requirement has dramatically improved quality measures, including an increase in clients who are up-to-date with a documented comprehensive physical exam. In FY 2018, half of the state’s CAHCs reported 71% or more of their clients were up-to-date with annual well-care exams; whereas only 39% reported the same in FY 2012. This objective focusing on CAHC CQI efforts was discontinued in FY 2019, due in part to marked improvements in this measure among CAHCs as well as MDHHS plans to engage Medicaid Health Plans in future adolescent well-care promotion activities.

MDHHS has shifted focus to development of a required quality measure regarding appropriate treatment for clients diagnosed with depression among state-funded CAHCs. This quality measure (i.e., percentage of clients age 12+ with a positive depression screen who have documented, appropriate follow-up) has been incorporated into NPM 10 as an objective. The past success seen with other quality measure initiatives (e.g., increasing adolescent well-visits) suggests that CAHCs will also see improvement in this measure over time. Additionally, this measure and its ensuing strategies will more directly address adolescent mental health needs as identified through the ongoing needs assessment process.

The rationale for incorporating this measure under NPM 10 is that CAHCs provide comprehensive well-care visits that include risk assessment screening. Risk assessment screening includes initial depression screening (flagging) for youth ages 10 to 21 years. These initial positive screens lead to a more thorough depression screen (diagnosis/assessment, which includes suicide risk assessment) that should ultimately result in appropriate follow-up care. 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.

The Rapid Assessment for Adolescent Preventive Services (RAAPS) is the most widely-used risk assessment across Michigan’s CAHCs. Among 20,275 unduplicated CAHC clients screened with this tool during the 2017-2018 school year, 28% flagged positive for depression risk. Among these clients, notable disparities exist among gender, race and health insurance coverage. Females were twice as likely as males to flag positive for risk for depression (35% of females versus 18% of males). Nationally, data show that risk for depression is higher among transgender and gender queer populations. While CAHC program data support this increased risk (over 60% of transgender youth were flagged at risk), too few clients self-identified in these gender categories to make the data reliable at this time. American Indian/Alaskan Native, Black/African-American, Hispanic and clients of more than one race all had significantly higher risk of depression (nearly one-third of the population in each of these groups flagged positive for risk) compared to Asian/Pacific Islanders and those of Middle-Eastern or Arab descent, who had the lowest risk among all racial/ethnic groups (15% and 17%, respectively).

Medicaid beneficiaries and those with county, tribal, or whose health insurance coverage status was unknown were at significantly higher risk when compared to those with commercial insurance; and also reported higher risk than those who reported no insurance coverage. Thirty percent of those with Medicaid, county or tribal insurance, or who whose coverage status was unknown, were flagged at risk compared to 22% of commercially-insured and 24% of uninsured youth. Data such as these inform CAHCs in the development and implementation of outreach, health education, support programs and clinical intervention strategies that more effectively address risk disparities among their clients.

Meaningful family and consumer engagement of parents and youth is a longstanding priority of the CAHC program and is accomplished through various strategies. Per legislative 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. As discussed in the annual report, these advisory groups are tasked with giving input and approving core health center policies. They also have a range of other responsibilities that are unique to each center.

Youth input is also a 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, décor and reading material. They 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. Survey results are compiled, and centers must demonstrate how this critical feedback was used to improve services and supports to clients. Diverse client and parent representation promotes the implementation of culturally appropriate strategies that reach populations most impacted by health disparities in diversified communities across the state.

It should be noted that the objectives and activities reflected in this FY 2020 plan align with the Department’s Mother Infant Health & Equity Improvement Plan (MIHEIP) that was released for public comment in February 2019. Promoting the physical and mental health of adolescents is an upstream approach to positioning the next generation of mothers to be in the best possible health during critical preconception care and throughout pregnancy. CAHCs also improve health literacy and confidence with navigating the health care system among their adolescent clients. This work will better equip young adults to manage their physical and mental health care in a proactive manner.

Objective A: Increase the percent of adolescents, ages 12 through 17, enrolled in Medicaid, with a preventive medical visit in the past year.

The first strategy in FY 2020 is to develop a state plan to improve adolescent well-care, focusing on Medicaid-eligible youth. To be developed in year five of the current block grant cycle, this plan will include specific strategies involving local health departments (LHDs) in leading local efforts to promote and improve adolescent well-child exams in their jurisdictions. LHDs will be expected to report on progress in contributing to an improvement in adolescent well-care rates. It is expected that level of participation and progress will vary among LHDs based not only on varying need, but also on varying levels of local funding and staff capacity.

The second strategy is to convene a workgroup or leverage an existing group to promote comprehensive adolescent well-care. While initiatives are underway to improve adolescent well-care in Michigan, these efforts are largely uncoordinated among key stakeholders. As a strategy to improve well-care rates, MDHHS will convene a state-level workgroup comprised of health plans, provider groups (e.g., Michigan Chapter of the American Academy of Pediatrics and the Society for Adolescent Medicine), Michigan Quality Improvement Consortium (MQIC), LHDs, health systems and Federally Qualified Health Centers (FQHCs) to examine gaps in existing efforts and to identify opportunities for coordinating efforts to promote comprehensive adolescent well-care.

The third strategy is to expand strategies to incentivize well-child exams by working with health plans. Expanding on the work of this subgroup, MDHHS will work with the state Medicaid office to convene a sub-group of MHPs to share and expand strategies to incentivize well-child exams among their provider networks. Ideally, this will include initiatives already underway, such as linking payments to achievement of well-child exam goals and adolescent-friendly performance requirements including care satisfaction, privacy and confidentiality.

MDHHS will capitalize on current relationships and successes with established stakeholders to facilitate achievement of the proposed strategies. For example, health plan Quality Managers and several other state-level stakeholders are engaged in an HPV Immunization Improvement Initiative facilitated by the MDDHS Division of Immunization. This initiative brings stakeholders together to share best practice, data collection and reporting, and evaluation strategies to improve HPV immunization rates among adolescents. Participants have voiced the importance of increasing annual well-child exams to improve immunization rates, providing an opportunity to work toward achieving this mutual objective.

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.

The first strategy is to increase the number of providers trained on culturally-competent adolescent-friendly care. According to SAMHSA, cultural competence means being “respectful and responsive to the health beliefs and practices—and cultural and linguistic needs—of diverse population groups.” A key component of quality adolescent care is the extent to which services are delivered in a developmentally-appropriate, adolescent-friendly and confidential manner. Positively impacting adolescent care requires significant system changes aimed at addressing known barriers to quality care: lack of training among health professionals; lack of effective communication skills; and low self-efficacy in providing adolescent preventive services. In real-world practice, the quality and delivery of preventive health care for adolescents varies widely and is highly dependent on the experience of the individual healthcare provider or professional; his or her knowledge of clinical guidelines; communication skills and training; subconscious biases; and personal comfort level.

In 2014 and 2015, the 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 and Decision Making and Encouraging Healthy Teen Relationships (interpersonal violence prevention). These courses will continue to be promoted and offered at no charge to public and private providers throughout Michigan and the United States. The objective is to reach 50 providers in FY 2020 with these foundational adolescent health courses.

To supplement the MI course, an in-person training (Improving Adolescent Health by Motivating Change for Primary Care Providers) will be offered to providers who have completed the web-based course. Continuing medical education credits will be offered for those who complete both courses. Additional professional development and training opportunities focused on culturally-competent, adolescent-friendly preventive care will be offered, with a goal of reaching 75 providers in FY 2020.

The combined impact of completion of both the MI web course and professional development training will lead to higher quality care for adolescents. Increased skills in not only counseling adolescents on behavior change, but in communicating with adolescents overall, promotes a better provider-patient relationship and increases the likelihood that adolescents will access care (including preventive services) with that provider. Therefore, this objective also serves as the Evidence-based or -informed Strategy Measure (ESM) for NPM 10: Percent of health care providers who complete the Motivational Interviewing web course and subsequently complete the Motivational Interviewing professional development in-person training who report skills in effectively counseling youth on changing risky behaviors.

Objective C: Increase percentage of CAHC clients age 12+ with a positive depression screen who have documented follow-up.

The first strategy is to establish Behavioral Health Quality Measures among CAHCs. In FY 2019, a required quality measure regarding appropriate treatment for clients diagnosed with depression among state-funded CAHCs was initiated. A SMART objective with a defined target will be developed after baseline data has been established at the end of FY 2019. The past success experienced with other quality measure initiatives (e.g., increasing adolescent well-visits) suggests that CAHCs will also see improvement in this measure over time.

CAHCs provide comprehensive well-care visits that include risk assessment screening. Risk assessment screening includes initial depression screening (flagging) for youth ages 10 to 21 years. These initial positive screens lead to a more thorough depression screen (diagnosis/assessment) that should ultimately result in 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 c) treatment plan reviewed after 90 days (for those on caseload for at least 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.

The second strategy is to implement a CAHC CQI Initiative. MDDHS will engage up to five CAHCs each year in CQI initiatives to increase the percentage of CAHC clients age 12+ with a positive depression screen who have documented follow-up. State-level CAHC staff will coordinate the months-long, tailored initiatives using the Plan-Do-Study-Act cycle of change, partnered with regular coaching calls, meetings and/or site visits with all staff at participating CAHCs. To initiate each project, the state-level CAHC staff will conduct conference calls or meetings with each CAHC to review the following: current available data; data needed to set goals; current processes for consent and risk assessment/depression screening and assessment; challenges and facilitating factors for implementing the initiative; and next steps. A second conference call or meeting and a series of email, telephone and/or in-person communications will follow to review data; develop goals and action steps; and determine resources and support needed for success. The state-level CAHC team will provide ongoing support tailored to each health center which will include guidance and support for policy, procedure, and process review as well as revision and development. Access to current and relevant journal articles, tip sheets, training and educational materials will also be provided as relevant.

The final strategy is to provide support to CAHC mental health providers to assure proper data collection and reporting for behavioral health quality measures, including appropriate follow-up, to clients with positive depression screens. Establishment of the quality measure will allow for targeted interventions for low performers which may include more intensive CQI initiatives, webinars, in-person training, learning collaboratives, toolkit development, or other strategies. FY 2019 will be the first year of data collection for this quality measure. After review of the first year of data, MDHHS will determine specific strategies for implementation in FY 2020. These strategies will include linkages to existing adolescent mental health initiatives and will be designed to complement and strengthen the current and growing body of work around adolescent mental health. This work includes multiple efforts in specific topic areas—such as bullying prevention, depression, trauma and suicide prevention—which are implemented by MDHHS, MDE and other adolescent health partners.

Immunizations – Adolescents (FY 2020 Application)

To address the priority area of “Invest in prevention and early intervention strategies,” Michigan developed an SPM focusing on immunizations. As previously discussed, the original two-part SPM was split into two separate SPMs in 2018, one focusing on children and one focusing on adolescents. For the Adolescent Health population domain, the SPM measures the percent of adolescents 13 to 18 years of age who have received a completed series Human Papilloma Virus (HPV) vaccine.

The HPV vaccine has the potential to save thousands of lives from HPV-related cancers. However, parental vaccine hesitancy has increased and Michigan continues to have some of the highest vaccine exemption rates for children in the country. Michigan has made progress increasing the uptake of HPV vaccinations for adolescents, but more work needs to be done. Since 2014, Michigan has increased the coverage rate 20%; however, only 48.7% of adolescents between the ages of 13 and 18 years of age currently have completed the HPV series. The Healthy People 2020 goal is at least an 80% HPV vaccine coverage rate for adolescents in this age range. Data from the Michigan Care Improvement Registry (MCIR) show that the completion rate of females in the same age group is 51.2% while the rate for males is 46.3%. One goal of the MDHHS Immunization Program is to encourage the HPV vaccination at 11-12 years of age when it is routinely recommended. Data from the MCIR show that only 13.7% of adolescents 11-12 years of age have completed the HPV series.

As discussed in the Child Health section, the Division of Immunization operates the MCIR. MCIR can forecast needed doses of vaccine for all children in the system. Data from the MCIR show that 77.0% of adolescents 13-18 years of age who reside in Michigan have received the routinely recommend 132321 series. The 132321 series represents 1 dose of Tdap vaccine, 3 polio doses vaccine, 2 doses of MMR vaccine, 3 doses of hepatitis B vaccine, 2 doses of varicella vaccine, and 1 doses of meningococcal vaccine. When a complete series of HPV vaccine is added to the same series, the rate drops to 41.5%.

Objective A: By 2023, increase the percentage of adolescents who have completed the HPV series to 50%.

In 2014, the Immunization Program received grant funding to increase HPV immunization rates for adolescents in Michigan. At the beginning of the grant period, the HPV coverage rate was 18% for all adolescents (male and female) 13 to 18 years of age. The Division of Immunization used grant funding to send notifications to parents of adolescents 11 to 18 years of age who were overdue for one or more doses of HPV vaccine. Given the impact of this strategy, in FY 2020 the Immunization Program will continue to seek funding for and use this strategy to increase adolescent HPV immunization rates.

In Michigan, 57.4% of adolescents 11-18 years of age have initiated the HPV series but only 39.9% have completed the series. In FY 2020, the Immunization Program plans to send notices to each adolescent who has initiated the HPV series to encourage them to complete the vaccination series. It is anticipated that approximately 40,000 notices will be sent to parents of these adolescents.

The Immunization Program is also partnering with the American Cancer Society to form a stakeholder group. This stakeholder group is comprised of representatives from several organizations including the Michigan Pharmacist Association, Karmanos Cancer Center, Michigan Cancer Consortium, and representatives from some health systems. The group is tasked with creating a plan to increase awareness of the HPV vaccine and its ability to reduce cancers by increasing vaccination rates. The group will meet on a quarterly basis with the intent to expand the group to include a broader set of partners.

MDHHS has partnered with several large health systems to increase awareness and vaccination levels for the HPV vaccine. An HPV summit is planned in 2019 to bring together large immunization practices that have low immunization rates along with the partnering health systems. MDHHS plans to continue working with the health systems throughout 2019-2020 to solidify plans that health systems can put in place to increase HPV vaccination rates.

An additional strategy in FY 2020 is for the Immunization Program to continue partnering with the MDHHS cancer programs working toward a common goal of increasing HPV coverage rates and decreasing the incidence of cancers caused by HPV. The Division of Immunization has partnered with these programs to promote the message about cancer prevention using social media and public advertising.

Objective B: Increase outreach to adolescent immunization providers with low immunization rates.

In FY 2020, the Division of Immunization epidemiologist will generate a monthly list of all immunization providers that vaccinate adolescents and submit data to MCIR. The list will show how many adolescents are being seen by the practice and how many adolescents are receiving all needed vaccines. MDHHS staff will review this list and identify the largest providers with the lowest immunization rates and reach out to those providers. Follow-up will include providing a comprehensive AFIX report and working with the practice to develop a plan to increase immunization rates. Through direct outreach to the provider, MDHHS will have the opportunity to customize a practical quality improvement plan to help improve immunization rates as well as the quality of care. Data will also be used to identify providers with high HPV immunization rates. The Division of Immunization will recognize those practices achieving high immunization rates by providing Certificates of Excellence. The Immunization Program will also educate providers on the importance of HPV vaccination and the HEDIS measures that are set for 2020. These measures will assess the number of adolescents who have completed the HPV series by 13 years of age and the number of adolescents who have completed the vaccine series according to the schedule (which is to vaccinate at 11-12 years of age).

The Division of Immunization is changing its focus for how it evaluates completion of HPV vaccinations when educating provider offices. Rather than focusing on the completion rates for 13-18 years of age, more focus will be on those adolescents who are complete at 13 years of age. This focus is to bring awareness in the provider office on timely vaccinations since all children should have completed the HPV vaccination series by 13 years of age.

Past assessment indicates that clinic staff within provider practices tend to overestimate the immunization rates for the practice. Feedback to provider practices based on MCIR data is insightful because it identifies actual immunization rates and enables the practice to consider ways to improve how vaccines are promoted and administered. At times it is as simple as making sure vaccines are assessed and offered at every encounter. The Immunization Program has made it routine to provide feedback to local health departments on their immunization levels using county report cards. Report cards are posted on the MDHHS website and provide immunization rates by county along with rankings. In FY 2020, the Immunization Program will extend this concept to Federally Qualified Health Centers (FQHCs) to create report cards for each FQHC in Michigan. This feedback will allow the FQHCs to see immunization rates for their practice as well as areas for improvement. These report cards show the immunization rates for the HPV vaccine as well as all other routinely recommended vaccines.