Iowa HHS is currently in the process of creating a funding opportunity to create peer to peer projects to advance adolescent health in Iowa. The funding opportunity will have two focuses: 1) Increase the quality and availability of adolescent well visits in the medical home 2) Increase the ability of Primary Care Providers to manage adolescent mental health in the primary care setting. The funding opportunity is being planned from the beginning with youth, family members and primary care providers as part of the team to ensure the needs of each affected population are included.

Historically, Iowa HHS has contracted with local Title V agencies to work on all the Iowa selected NPMs and SPMs across the state. With the 2015 & 2020 MCAH needs assessments demonstrating a need for additional focus contractors have spent decades partnering with WIC and early care and education programs as the primary ways to find and serve pregnant clients, infants, and young children. After years of trying to make this model successful, and gathering the feedback of contractors, stakeholders, and families, Iowa HHS removed the adolescent well visit and adolescent mental health performance measures from the CAH RFP in FFY2023, with the exception of well visit reminders for adolescents enrolled in Title V and Fee-For-Service Medicaid, and outreach during the Informing service. Local Title V contractors will still have the option to provide direct health care services and screenings as a gap-filling service, with demonstrated need through their Screening Center Provider Status with Medicaid.

Moving adolescent health to its own funding opportunity will move it to contractors with expertise in adolescent health. The intent is to focus on building the capacity of medical homes to serve adolescents expertly through well visits and management of frequent mental health needs in the primary care setting. Primary Care Provider to Primary Care Provider and/or Mental Health Clinician to Primary Care Provider consultation, education and peer support is an evidence-based practice and a method primary care provider are comfortable using.

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

The 2019 National Survey of Children's Health (NSCH) reported 88.5% of parents responding that their adolescent had a well visit in the previous year. This increase in awareness of the importance of well visits is encouraging, however this data precedes the COVID-19 pandemic. For 2020, 83.2% reported having a well visit in the past year. Medicaid’s CMS 416 data shows a significant discrepancy between the number of children with a health care provider coded well visit and the NHSC survey parent report of a well visit.

The CMS 416 data of Medicaid enrolled adolescents receiving a well visit in 2019 showed 52% for 10-14 year olds, 45% for 15-18 year olds, and 19% for 19-20 year olds. The COVID-19 pandemic adversely impacted the number of adolescents accessing well visits in 2020 and 2021. These percentages decrease to 46% for 10-14 year olds, 40% for 15-18 year olds and 18% for 19-20 year olds in 2020. The numbers rebounded a little in 2021 with 50% for 10-14 year olds and 43% for 15-18 year olds, but declined to 17% for 19-20 year olds. The numbers continue to slowly increase for younger adolescents in 2022 with 48% for 10-14 year olds, and 41% for 15-18 year olds. Unfortunately, well visits continue to decline further for 10-20 year olds with only 16% accessing a well visit in 2022.

Public health professionals are all watching closely to see if families will return to preventive care at the same rate as pre-pandemic or if the pandemic will have a lasting effect on preventive care. The 19-20 year olds will need to be closely followed as the well visit proportion is so small already, and continues to decline.

Children and Adolescents who identify as LGBTQI+ were designated a priority population for Iowa’s Title V program. The University of Michigan developed an Adolescent Friendly Clinic Assessment, education and resources for providers. Iowa participated in piloting the tool several years ago. Utilizing youth to work with primary care providers not only builds the health literacy of the adolescents but provides valuable feedback and collaboration between youth and providers in expanding capacity to address the health needs of adolescents including individuals identifying as LGBTQI+.

Local Title V contractors are required to provide culturally and linguistically appropriate annual well visit reminders for adolescents enrolled as Title V or Medicaid Fee for Service; Managed Care Organizations are responsible for the well visit reminders for adolescents enrolled in managed care. Local Title V contractors are also required to have a family engagement group and to recruit at least one member to participate in a group at the state level so the Title V program can gather input and recommendations for increasing adolescent well visits from family members with adolescents eligible for Title V services. Our Health Equity Advisory Committee will also be utilized to gather input for increasing well visits, as well as new approaches and partnerships.

Contractors of Iowa Medicaid working on EPSDT gather quarterly to work on initiatives to improve EPSDT services and implementation in Iowa, including the University of Iowa, Iowa Medicaid, Bureau of Family Health/Title V and the Managed Care Organizations.

SPM 4:  Percent of adolescents who report that during the past 12 months they have felt so sad or hopeless almost every day for 2 weeks or more in a row that they stopped doing some usual activities

From 2018, there has been a significant increase in the percentage of adolescents that report that during the past 12 months they were feeling so sad or hopeless almost every day for 2 weeks or more in a row that they stopped doing usual activities. The increase in the percentages is alarming. In the IYS special topics report released in March 2022 the percentage of 6th graders reporting on this measure increased from 19% to 27%. The percentage of 8th graders increased from 24% to 29% and the 11th grade percentage went from 33% to 36%. A reasonable deduction for the increase in percentages can be attributed to the COVID-19 pandemic. It is likely the closure of schools and halt of extracurricular activities may have exacerbated teens feeling lonely and isolated. The COVID-19 pandemic also brought other struggles for families. With the closure of schools and other activities halted, more families were home together. This brings an increase in emotional and physical abuse of children and adolescents as well as other stressors such as job losses and financial stress. Our goal is to reduce the overall percentage across the three grades by .5% each year starting in 2024.

Title V local contractors have provided a few depression screens, substance abuse screening with brief intervention and referral, and intimate partner violence screens over the past decade, however there are additional mental health services that are included as part of the Screening Center Provider package. These services include mental health assessment, mental health therapy, psychosocial screenings, and nutrition counseling. With the growing need for mental health support, Title V can expand the capacity and services that Screening Centers are able to provide to address some of these gaps. State Title V staff are working with Iowa Medicaid to build out these codes through, selecting screening tools and resources, providing training and support for implementation.