Download - What are Clinical Preventive Services?
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What are Clinical Preventive Services?
Services that are delivered by a health care provider in a clinical setting:
•Private office
•Community Health Center
•Department of Health clinic
•Hospital-based clinic
•Family Planning clinic
•School-based clinic
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1. Rationale?
2. How broadly provided?
3. Are recommendations followed?
4. Barriers to CPS?
5. Strategies that improve implementation?
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How Improve CPS?1. Technology, e.g. Computer-assisted self-
assessments
2. Provider training
3. Increase use of ancillary staff
4. Forms (e.g. checklists), guidelines, manuals
5. Improved health education materials
6. Improved referral sources
7. Health insurance expansion
8. Enforce guidelines
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Computer-assisted visits
•Based on GAPS
•Computer, review print-out with counselor/nurse
•Effective? Feasible? Acceptable?
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What is GAPS?
A comprehensive set of recommendations developed to
provide a framework for the organization and content of
clinical preventive health services
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4 Types of Services(GAPS)
• Health care (3)
• Health guidance (7)
• Screening (13)
• Immunizations (1)
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13 Topics/Health Conditions
• Parents ability to cope• Adolescent adjustment• Safety & injury prevention• Physical fitness• Diet• Psychosexual development• Hypertension• High cholesterol • Tobacco• Alcohol & other drugs• Depression & suicide• Abuse• Learning problems• Infectious diseases
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Comprehensive School-Based Health Centers
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Brief History
• School-based Health Centers established in 1970
• 200 in 1990
• 1,380 in 2000
• all regions of U.S.; all types of schools
• only Idaho, Nevada, North & South Dakota, and Wyoming report no SBHC
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Location of SBHC’s by Region158 SBHC’s in NYS; 98 in NYC
Pacific10%
Midwest15%
Southwest & Rocky
Mountains20%
Mid-Atlantic & New England
37%
Southeast & South Central
18%
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Location of SBHC’s by Region
Rural26%
Suburban11%
Urban63%
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Types of schools housing SBHC’s
High Schools37%
Elementary Schools
34%
K-12 Schools6%
Other Schools7%
Middle Schools16%
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Center for Population and Family HealthJoseph L. Mailman School of Public Health of Columbia University
Comprehensive Services
• To ensure comprehensive health services, SBHCs led by a community health-care institution
• Three-quarters of SBHCs administered by community health center, health department, or hospital
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CHEP School-Based Health Centers
• I.S. 164 (1986)
• I.S. 52 (1986)
• I.S. 143 (1989)
• I.S. 136 (1990), now TMA/B&R
• George Washington High School (1995)
• High School for Pregnant Teens (1998)
• Family Academy (2002)
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Staffing
•Nurse practitioner or physician assistant
•Social worker (MSW) or psychologist
•Health educator
•Health advocate
•MD
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SBHC Services
• Medical
• Mental Health
• Health Education
• Social Work/Support
Heilbrunn Center for Population and Family HealthJoseph L. Mailman School of Public Health of Columbia University
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In Your Face (Tiezzi)• Group and individual counseling in the
SBHC
• Classroom education
• Intensive case management and case finding
• Referrals to YMC and YAC
• STD prevention services
• HIV pre & post-test counseling and testing
Heilbrunn Center for Population and Family HealthJoseph L. Mailman School of Public Health of Columbia University
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Evaluation
• Pregnancy rates among teens younger than 15 decreased by 34% over four years
• In the fourth year of the program, the pregnancy rate in one school that was unable to continue IYF had three times the rate of pregnancy as three program schools (16.5 per 1,000 female students versus 5.8 per 1,000)
Heilbrunn Center for Population and Family HealthJoseph L. Mailman School of Public Health of Columbia University
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CHEP SBHC Funding
28.1 28
6.2 6
39.4
27 26.2
39
0
5
10
15
20
25
30
35
40
Per
cen
t
State City Medicaid Other
1997-1998
1998-1999
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School Enrollment & Clinic Consents
7712
6428
3158 3270
0
1000
2000
3000
4000
5000
6000
7000
8000
SchoolEnrollment
ClinicConsents
ConsentsMale
ConsentsFemale
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Screening Survey:
administered school-wide risk screening survey to identify students
who might otherwise not utilize health services
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Results
• Fall 1997, over 2,200 7th and 8th graders surveyed:– 3% cigarettes every day– 2% alcohol every day– 13% sex– 2% tried suicide– 15% easy to buy gun
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– 6% adult in home use substances– 13% > 1 fight in past 3 months – 12% “Hooky Party” in past year– 38% something happen makes them feel
terrible when think about it– 16% to a Botanica
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Depression & Suicide Risk Screening @ George Washington H.S.: the Klingenstein Project
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Leading Causes of Mortality, Ages 15-19, 2000
Other19%
Malignant Neoplasms6%
Homicide14%
Suicide12%
Other Unintentional Injuries11%
Motor Vehicle Accidents38%
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24.00%
14.00%
18.00%
12.00%11.00%
6.00%3.00%2.00%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
SeriouslyConsidered
AttemptedSuicide
Suicidal Ideation and Non-Lethal Behavior by Gender, High School Students, 2001
Females
Males
PlanNeed MD attention
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Depression & Suicide
•Major depressive disorder
•Dysthymic disorder
•Bipolar disorder
•Reactive depression
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Major Depressive Disorder
•5% of 9-17 year olds
•Episodes 7-9 months
•Symptoms:
•Sad
•Lose interest
•Critical of self & others
•Hopeless
•Irritable….aggressive
•Trouble concentrating
•Lack energy & motivation
•Appearance; sleep patterns
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Dysthymic Disorder
•Fewer symptoms
•More chronic
•Depressed most of day, most days, several years (average 4 years)
•Begin to tolerate depressed mood as “normal”
•Prevalence 3%
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Bipolar Disorder
•Manic episodes fluctuate with depressive
•Usually depressive first; manic maybe not for years
•Often begins in adolescence
•Manic: energetic, confident, special, trouble sleeping but not tired, talk a lot & rapidly, racing thoughts, disorganized, inflated sense of self, reckless behavior
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Reactive Depression
•AKA “adjustment disorder with depressed mood”
•Brief
•In response to rejection, loss, disappointment
•Most common mood disorder
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Case Study
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“Male Adolescent Use of Health Care Services: Where Are the Boys?”
Arik Marcell, etal. Jnl of Adolescent Health, 2002: 30
• Secondary analysis of NAMCS, NHAMCS, CAHSS
• 13-19 males make fewer visits to adolescent health programs (schools, hospitals, community health centers)
• Of all adolescent health clinic venues, SBCs see highest proportion of males (40% vs. 60%)
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DHHS Office of Family Planning
R & D funding from Title X for SBC program for male adolescents in 1999:
• one SBC
• full-time health educator
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Engaging male students in health services at the SBC
Heilbrunn Department of Population and Family HealthMailman School of Public Health of Columbia University
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Faculty Meetings
Classroom presentations
“Life Space” Meetings(cafeteria, hallways, etc.)
After-school 3-on-3
Basketball
Male Involvement Health Educator
Heilbrunn Department of Population and Family HealthMailman School of Public Health of Columbia University
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After-schoolTournament• 18 males
• 3 prior visit to SBC
• 15 newly recruited
• All examined and screened
• identified risk taking behaviors
• 7 of 15 new males currently in SBC groups
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Brief classroom presentations to motivate young men to take health
action
Heilbrunn Department of Population and Family HealthMailman School of Public Health of Columbia University
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Why do differences
between racial/ethnic groups exist?
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Health Disparities:
•Infant mortality
•Cancer
•Cardiovascular disease
•Diabetes
•Immunizations
•HIV/AIDS
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There are many reasons…
• Risky behaviors• Unhealthy environments
• Not enough health services• Other ideas?
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Clinic-based Activities
• Comprehensive intake assessment
• Small groups
• Case management of high risk
• Referrals
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Percentage of enrolled male students making individual health ed visit to SBC
21%10%
72%
0%10%20%30%40%50%60%70%80%
1998-1999 1999-2000 2001-2002
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Condom Distribution Programs in Schools
•In >400 U.S. high schools (1997)
•22 randomly selected schools in NYC & Chicago
•Modest, significant increase on condom use
•Does not increase rates of sexual activity
•“school may not be the best place to reach adolescents at highest risk of HIV infection”???????