Overview

The Adolescent Health unit provides programs which promote the health and well-being of adolescents and young adults (AYA) where they live, learn, work, and play. We use a health equity lens to address social determinants of health, disparities, and other barriers to optimum health for AYA, specifically priority populations. Goals include improving access to, and quality of, holistic and inclusive services for AYA, and planning and developing policies to promote new knowledge and competence in adolescent health. We strive to be human-centered, collaborative, inclusive, data-driven and innovative.

 

Priority:

Promote mental wellness and resilience through increased access to behavioral health and other support services.

 

Objective:

By September 30, 2025, increase the number of school-based health centers with licensed mental health services by 5 percent.

 

General Status on this Objective to Date:

Respondents to this year’s maternal and child health needs assessment noted that young people have difficulty finding providers, and the health care system needs to be easier to navigate – including enhanced coordination, linkages, and referrals. Respondents also consistently identified concerns related to suicide and youth mental health, including the need for providers to screen for risk when seeing adolescent patients and clients. The MCH needs assessment highlights systems-level improvements are necessary for adolescents to access and experience user-centered medical and mental health care.

 

DOH has continued work with school based health centers (SBHCs) to increase behavioral health services. Many adolescents, especially high-risk youth in vulnerable populations, may have a harder time accessing the medical care system due to many issues (lack of transportation, social isolation, complex life situations) and might find accessing health care more convenient at school or other settings in which they are more comfortable. Increasing the number of places where individuals can access care, not just to family planning/STI services, but also behavioral and more general physical health, benefits all. In fact, there is strong evidence that access to an SBHC and regular well-adolescent visits reduce absenteeism, dropout rates, chronic illness, substance use, STI and pregnancy rates, and increase graduation rates, better management of diabetes, asthma, and mental illness. An increase in the numbers/percent of clinics trained in providing mental health care will make such a system of care more available.

 

Strategy:

Improve the knowledge and ability of health care professionals to deliver comprehensive evidence-based/informed services including integrated mental health and chemical dependency screening and interventions for adolescents and young adults.

 

School-based health centers face numerous barriers to receiving adequate reimbursement for services provided. Because no student is denied services because of inability to pay, this has a detrimental effect on the funding sources and sustainability of these centers. We plan to continue work with the Health Care Authority (HCA) to help SBHCs bill effectively for behavioral services rendered. We also will deliver technical assistance to health care providers around behavioral health services to ensure they are AYA friendly.

 

Strategy:

Take action to reduce stigma surrounding adolescents’ and young adults’ behavioral health conditions, treatment and related challenges.

 

According to the US Department of Health and Human Services, National Institute of Mental Health, 32 percent of 13- to 18-year-olds experience anxiety disorders. Depression occurs in approximately 13 percent of 12- to 17-year-olds; attention deficit-hyperactivity disorder (ADHD) occurs in approximately 9 percent of 13- to 18-year-olds. However, as the need for mental health care among AYA rises, mental illness stigma can impede access to that care and make it less likely youth will seek services.

 

During the next project period, we will plan and create a communication campaign, including social media, for youth and the broader community to address issues of stigma for seeking care for behavioral health conditions. We also plan to deliver trainings on stigma reduction for providers of behavioral health care.

 

Strategy:

Implement trauma informed services into community services, health care systems, and public sector specific to adolescents and young adults.

 

According to a study by Darnell, Flaster, Hendricks, Kerbrat, & Comtois (2019), among adolescents between the ages of 13-17, 62 percent have been exposed to at least one or more traumatic event throughout their lifetime. These numbers make it critical for those serving AYA to incorporate trauma-informed approaches in their programs.

 

Working with community organizations and other state agencies, the goal of DOH and HCA is to move Washington towards a statewide culture of trauma-informed approach. We plan to create an education and training campaign for health providers and youth-serving organizations around trauma-informed services for AYA, working with experts throughout our agency.

 

Strategy:

Support interventions to address suicide ideation among youth, especially among vulnerable populations.

 

Suicide is the second leading cause of death for Washington youth between the ages of 15 to 19. On average, in 2017, each week in Washington, nearly four youths killed themselves and two youths ages 10-24 were hospitalized because of intentional self-injuries, which includes suicide attempts. Responses to the 2018 Washington Healthy Youth Survey showed that 23 percent of tenth graders considered attempting suicide in the past year. Ten percent of tenth-graders reported making a suicide attempt in the 12 months prior to the survey.

 

Responses by eighth-graders on the 2018 Washington Healthy Youth Survey showed that 20 percent had considered killing themselves and that 10 percent had attempted suicide in the past year.

 

We plan to partner with our Injury and Violence Prevention program to use their resources and expertise to collaborate on shared goals of reducing and preventing suicide among youth. We will seek ways to expand existing interventions that are proven effective.

 

Strategy:

Promote standardized depression, anxiety and substance use screening for adolescents and young adults.

 

We will promote the use of a youth-friendly standardized risk behavior screening tool. Screening and counseling adolescents on risk behaviors is universally recommended by the Society for Adolescent Health and Medicine, American Medical Association, American Academy of Pediatrics, American Academy of Family Physicians, and American College of Preventive Medicine, but not universally followed, and rates of use range from only 15-50 percent.

 

The Adolescent Health Initiative (AHI) at the University of Michigan has toolkits and resources for providers and clinics that can be adapted to the local setting to encourage risk screening of adolescents. The effectiveness of risk screening is also dependent on ensuring confidentiality. Research shows that adolescents are more likely to share risk behaviors and answer screenings honestly if they believe their care is confidential. The Washington Youth Sexual Health survey demonstrated that teens in Washington have significant concerns about their privacy and confidentiality when accessing services and more work is needed in Washington to implement best practices using innovative interventions to incorporate these tools into clinical workflows.

 

Strategy:

Support efforts to address and mitigate individual and community effects of substance use among adolescents and young adults.

 

While the rates of tobacco use and exposure have significantly declined in our state, we are particularly concerned with the youth vaping epidemic because tobacco use is a risk factor for teen pregnancy. Additionally, the high smoking prevalence among pregnant women in our state presents serious health risks for both expectant mothers and their babies.

 

Over the next five years, the DOH Adolescent Health program will collaborate with the Tobacco and Vapor Product Prevention and Control Program (TVPPCP) on the following efforts to help address these issues:

 

• Connecting with adolescent health providers, understanding that school-based health centers may better serve youth than the traditional framework of primary care providers or behavioral health providers.
• Partnering on prevention and cessation outreach to American Indian/Alaska Native tribes and communities.
• Promoting the Washington State Tobacco Quitline and tobacco cessation smartphone app, with emphasis on each program’s tailored pregnancy programs.

 

As mentioned above, we will also encourage the use of AYA-friendly screenings for risk behaviors, including substance use, during primary care visits.

 

Strategy:

Build on efforts to identify scope of impacts of substance use, including inequities among adolescents and young adults from priority populations.

 

Health disparities continue to be evident in substance use. Among tenth-graders in 2016 Healthy Youth Survey data, the percentage reporting binge drinking in the past two weeks was highest among American Indian or Alaska Native (16 percent), Black or African American (15 percent), and Native Hawaiian or other Pacific Islander (15 percent) students.

 

We will assess data around impacts of substance use on priority populations to identify gaps in services and underlying socioeconomic factors playing into substance use. We also will examine structural issues through a lens that acknowledges systemic racism, sexism, and homophobia and their effects on health inequities.

 

We will form a cross-agency workgroup to explore partnerships to promote effective strategies, ,best use programmatic expertise, and avoid duplication of services. Potential partners include Injury and Violence Prevention, TVPPCP, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Immunizations, Heart Disease, Stroke, and Diabetes Prevention unit, and Healthy Eating and Active Living (HEAL).

 

Priority:

Identify and reduce barriers to accessible, quality health care.

 

Objective:

By September 30, 2025, develop and provide technical assistance for school-based health centers and adolescent health providers so they report the ability to appropriately bill insurance for 50 percent of services delivered.

 

General Status on this Objective to Date:

As mentioned in the report, collaboration with HCA has continued to address billing issues and cost sharing. Many SBHCs have an “in-person assister” to help with Medicaid enrollment for youth who are eligible but not yet enrolled. Additional training will expand this service, and training development is currently under way.

 

Strategy:

Conduct needs assessment to identify top barriers for adolescents and young adults in seeking health care services.

 

2019 Washington Youth Sexual Health Survey findings highlight issues for AYA with access to and experience with health care visits. Seventy-five percent of respondents reported they have a health care provider that they have seen more than once, yet only 18 percent reported having had a sexual health wellness exam. Respondents also reported barriers associated with going to see a health care provider, such as the hours of the clinic don’t work with their schedule (37 percent), not understanding how insurance works (38 percent), feeling judged (39 percent), and being afraid that their parent or caregiver will find out (48 percent).

 

Our MCHBG epidemiologist is currently working on a project, in collaboration with the Adolescent Health Program Manager, on well-adolescent visits. One of our goals is to identify major barriers to seeking care for AYA. We will utilize the results of this project, and a follow up survey to a 2017 survey on AYA well visits to identify and address gaps in health care services.

 

Strategy:

Through partnerships, understand and mitigate issues related to financial eligibility for health care and other support services for adolescents and young adults.

 

A significant number of adolescents eligible for Medicaid coverage are yet to be enrolled. We will continue to work with Washington Apple Health (Medicaid), to discuss strategies to ensure that adolescents have appropriate health insurance and better understand issues around billing for care. We will also work with the Family Planning program to ensure that clinics provide appropriate preventive services with no cost sharing.

 

Strategy:

Ensure all adolescents and young adults, regardless of race, ethnicity, sexual orientation, and gender identity, have a full range of education, access, and ability to utilize health services that meet their individual needs.

 

We will continue to partner with tribal organizations to identify and help address specific needs of American Indian/Alaska Native youth. We will also work with community partners to evaluate the unique needs of other priority populations, including LGBTQ youth, Latinx youth, Asian American, Black/African American, and homeless youth. Youth can also inform this information gathering so we can be best informed of their individual needs in health services.

 

According to the Health Resources and Services Administration (HRSA), low health literacy can cause individuals difficulty in locating providers and services, sharing their medical history with providers, seeking preventive health care, managing chronic health conditions and understanding directions on medicine. Evidence demonstrates that addressing health literacy at an early age can help develop one’s ability to understand health information and improve interactions with the health care system that will lead to positive health outcomes later in life. We will continue to promote health literacy among AYA by partnering with the Office of Superintendent of Public Instruction (OSPI) to ensure curricula include health literacy education, and with entities like HCA and managed care organizations to make sure that health statements and documents utilized are user-friendly and available in multiple languages to increase accessibility.

 

Priority:

Improve the safety, health, and supportiveness of communities.

 

Objective:

By September 30, 2025, reduce the percentage of tenth graders receiving our interventions who reported that someone they were dating limited their activities, threatened them, or made them feel unsafe by 10 percent (from 9.5 to 8.5 percent).

 

General Status on this Objective to Date:

Through four successful cycles of the Pregnancy Assistance Fund (PAF) project through the federal Office of Population Affairs, we have expanded and coordinated a diverse network of partners. The group of intervention partners through the PAF grant included: State agencies (OSPI and Office of the Attorney General); the NPAIHB and tribal health centers; LHJs; a non-profit domestic violence coalition; a federally-qualified health center and other community-based organizations. We plan to continue relationships with these partners to increase access to community resources for AYA throughout the state.

 

Strategy:

Support violence prevention efforts and promote healthy relationships among adolescents and young adults.

 

We plan to:

 

• Partner with Injury and Violence Prevention on healthy relationships and violence prevention to create a youth workgroup and develop a social media campaign directed at youth around healthy relationships.
• Partner with OSPI to review and support materials in the education sphere that promote and teach healthy relationships.
• Provide or support trainings to health care providers (including emergency medical technicians) to recognize signs of dating abuse, partner violence, and trafficking.
• Continue to collaborate with tribal partners and other community entities such as the Washington State Coalition Against Domestic Violence (WSCADV) working with priority populations to address community-specific issues around intimate partner violence and other related concerns.

 

Our Personal Responsibility Education Program (PREP) programs will continue to provide education on adult preparation topics such as healthy relationships, including positive self-esteem, relationship dynamics, friendships, dating, romantic involvement, marriage, and family interactions; parent-child communication; and healthy life skills, such as goal-setting, decision making, negotiation, communication and interpersonal skills and stress management.

 

Strategy:

Implement and promote fatherhood inclusion opportunities and support resources.

 

Through our PAF project, we have worked with stakeholders and partners around the state on numerous programs specifically focused on teen fathers, including specific strategies to implement fatherhood programs for teens, conduct outreach focused towards teen fathers, increase father engagement and linkage to resources, and address fathers’ unemployment rates. We plan to continue and expand these partnerships.

 

Priority:

Optimize the health and well-being of children and adolescents, using holistic approaches.

 

Objective:

By September 30, 2021, form youth advisory council and hold at least one initial meeting.

 

General Status on this Objective to Date:

The Health and Human Services Office of Adolescent Health defines “youth-friendly health care services” as “those that attract young people, respond to their needs, and retain young clients for continuing care.” These services are based on a comprehensive understanding of what young people want and need (rather than being based only on what providers believe youth need). Adolescents are often reluctant to seek health care services and it is important to find ways to offer care in a manner that adolescents perceive as welcoming, comfortable and responsive.

 

Access to appropriate health care services is a continuing issue for adolescents in Washington. This is particularly true in rural areas where providers’ knowledgeable about AYA-specific health concerns can be scarce. The Family Planning program will continue to provide teen-friendly services in communities across the state. They will also continue to partner with state and local programs on community-based intervention and education programs to prevent teen pregnancy, such as the PREP program.

 

Adolescent Health staff continue to participate on OSPI’s Exemplary Sexual Health Education steering committee to ensure that Healthy Youth Act criteria are met for all adolescent health programs. Staff will continue to provide technical assistance for the review of sexual health education curricula. Additionally, as described in the report, the Adolescent Health Program Manager served as the DOH representative on the Sexual Health Education Workgroup convened by OSPI, which provided two reports to the State Board of Education and the education committees of the Legislature: Sexual Health Education Workgroup Recommendations and Comprehensive Sexual Health Education Data Survey.

 

According to the OSPI Needs Assessment Profile, depression and suicidal ideation have increased in Washington youth aged 10 to 24, with suicide being the second-leading cause of death. The 2018 Healthy Youth Survey indicates feelings of distress among youth in Washington have been rising. As stated in the Washington State Hospital Association’s community health needs assessment, it is critical to address adolescent health in a way that maximizes care coordination and emphasizes provider awareness of common mental health occurrences for children and adolescents.

 

We continue to disseminate health information and education through PREP; Graduation, Reality and Dual-role Skills (GRADS); and Teen Pregnancy Prevention (TPP) programs. Through TPP, DOH worked with community partners in eastern Washington to adapt and test the All Stars curriculum, a character education program that emphasizes decision-making and goal setting (ideals) among high school students. The aim is to improve adolescent health, address sexual youth risk, and ultimately, reduce teen pregnancy rates in our state.

 

Strategy:

Promote use of the Bright Futures guidelines for adolescents among providers.

 

We continue to encourage adoption of the Bright Futures Guidelines for clinical services and will include evidence-based practices for providing a culturally appropriate environment of care.

 

Bright Futures was officially recognized in the Patient Protection and Affordable Care Act (ACA) as the blueprint for all visits to the health care provider for health supervision (often referred to as well-child visits). Bright Futures Guidelines for provider visits include priority issues that should be addressed. These issues for adolescents include:

 

• Physical growth and development (physical and oral health, body image, healthy eating, physical activity).
• Social and academic competence (connectedness with family, peers and community; interpersonal relationships; school performance).
• Emotional well-being (coping, mood regulation and mental health, sexuality).
• Risk reduction (tobacco, alcohol, or other drugs; pregnancy; sexually transmitted infections).
• Violence and injury prevention (safety belt and helmet use, substance use disorder and riding in a vehicle, guns, interpersonal violence [fights], bullying).

 

In addition to continuing to promote the use of Bright Futures Guidelines, we will conduct qualitative evaluation activities to discover barriers that providers face in using the guidelines and try to find ways to address them.

 

Strategy:

Support and enhance efforts to increase health literacy among adolescents and young adults.

 

We plan to:

 

• Identify and promote programs that already increase health literacy, such as GRADS.
• Support OSPI to ensure that sexual/reproductive health curricula are culturally relevant.
• Create a campaign to AYA about the importance of health literacy and how to be their own best advocates.

 

Strategy:

Increase the proportion of Washington adolescents who receive age-appropriate, evidence-based clinical preventive services.

 

The Adolescent Health program conducted a survey of youth in 2017 on AYA friendly care, and developed a list of best practices for clinicians based on the results. Our MCHBG epidemiologist is currently working on a project, in collaboration with the Adolescent Health Program Manager, on well-adolescent visits. One of our goals is to identify why youth may not be seeking care. We will utilize the results of this project, and a follow up survey to the 2017 questionnaire to identify the gaps in AYA friendly preventive services. We will use this needs assessment data to work with providers to develop technical assistance and training. Our program staff will also develop ways to help youth navigate health care system and advocate for themselves as end users and consumers of services, including promoting health literacy.

 

One promising intervention we will explore is the use of Spark Trainings for health centers and other organizations serving youth. The Spark training model was developed by AHI to meet the needs of busy clinical staff. The mini-trainings, called “Sparks,” are made to be delivered in about 15 minutes so that this meaningful professional development can occur within the context of a regular staff meeting. The Spark training can last longer depending on the depth of the conversation that is “sparked” and it can be enhanced by ongoing “sparklers” and other complementary activities. The ease of facilitating a short training in a clinic setting and its adaptability make it well-suited to diffuse information about adolescent-friendly practices to a diverse network of partners.

 

Strategy:

Promote preventive care screening and wellness visits for adolescents and young adults.

 

We will support improved communications strategies to youth and parents about the importance of well visits. We also will continue our partnership with the Immunization program to promote and improve access to human papillomavirus (HPV) vaccine. One avenue we will explore is how best to provide information and training to providers about ways to discuss the HPV vaccine with youth and parents.

 

Strategy:

Foster measurable quality improvements in preventive care across the health system to increase adolescent and young adult-friendly care.

 

We will conduct needs assessment activities such as surveys and key informant interviews to assess what quality improvement (QI) practices are already in place, and then develop measures for QI based on our findings to ensure optimal AYA-friendly care.

 

One method of doing this will be creating an AYA-friendly provider certification program similar to Breastfeeding Friendly Washington. Our goal will be to encourage organizations to promote and support AYA-friendly care through changes in their policies and procedures. We will develop a checklist of AYA-friendly services based on research and evidence, including criteria for making appointments, the waiting area, patient communications, provider visits, and follow-up procedures. There will be an application process in which the program will evaluate an organization and provide feedback if the organization is not yet considered ready for certification. Successful applicants will receive a certificate and promotion by DOH on our website and on social media.

 

Strategy:

Promote school-based health strategies to serve adolescent populations where they are.

 

Through previous and current initiatives, we have developed strong partnerships with many SBHCs throughout the state. In 2017, we convened a workgroup, led by Title V staff, for the Adolescent and Young Adult Health (AYAH) Collaborative Improvement & Innovation Network (CoIIN) Cohort #2 through the Association of Maternal and Child Health Programs (AMCHP). This SBHC workgroup included representatives from DOH, HCA, Medicaid managed care organizations (MCOs), OSPI, the Leadership Education in Adolescent Health (LEAH) project at the University of Washington, and the Washington School-Based Health Alliance. The project examined ways to increase youth engagement in SBHCs and increase well-visits at SBHCs.

 

Additionally, we have been participating on the Healthy Students, Promising Futures (HSPF) Learning Collaborative. This national collaborative is co-convened by the Healthy Schools Campaign and Trust for America’s Health. The purpose of this collaborative is to increase access to school health services through Medicaid reimbursement. The HSPF focuses on federal and state polices that impact school-based health services for children in Medicaid, models for delivering school-based health services and cross-state collaboration.

 

We will continue to assist SBHCs to bill for services rendered to promote sustainability of centers, support efforts to increase youth engagement with SBHCs to improve/enhance services and promote legislative work around expanding SBHCs, including statewide committees in which DOH staff already participate.

 

Strategy:

Identify and develop methods to monitor systems and data gaps and improvements needed in adolescent health.

 

Our first activity will be to assess data already being collected by the PREP and GRADS programs, which serve adolescents and young adults through existing projects in the Adolescent Health unit. For example, PREP program surveys evaluate adult preparation subjects, including healthy relationships, parent-child communication and healthy life skills. We will also work with our evaluation partners to identify communities that are disproportionately impacted, and find possible solutions to data gaps.

 

Another useful source of data is the Washington Youth Sexual Health survey from OSPI, of which we will continue to support the development, distribution and evaluation. In 2019, OSPI conducted a statewide youth survey to update the Washington Youth Sexual Health Plan. This effort was done collaboratively with stakeholders, including those from our Adolescent Health program, and was inclusive of youth in Washington State. The process honored the voices of youth, and their input was received through the survey as well as through engagement on the written goals in the Washington Youth Sexual Health plan.

 

Strategy:

Include adolescents in this work through strategies such as building and supporting a youth advisory council and identify other meaningful ways to engage the population to be served.

 

We recognize the importance of getting input from a variety of youth voices on our programs and programmatic needs. One of the ways we will obtain this perspective is to convene a youth advisory council. Having a youth advisory council will enable us to better represent the individuals we serve, and to expand our reach to more of the community. By forming a stronger connection to AYA, we can gain insight into their needs and as a result, our programs can have more of an impact. We will work with our partners at OSPI, who currently have a youth advisory council, to identify best practices for recruitment and retention, communication about how youth recommendations are being used and evaluation. Our goal is to have four quarterly meetings by the end of this five-year cycle.