Indiana's Section 1115 Medicaid Waiver And Interagency Coordination Improve Enrollment For Justice-Involved Adults.

Timely access to Medicaid coverage offers many potential benefits to justice-involved adults reentering the community. In 2015 Indiana's Section 1115 Medicaid waiver (the Healthy Indiana Plan [HIP]) expanded eligibility for low-income adults. To expedite coverage for justice-involved adults, Indiana subsequently improved interagency coordination in two ways. First, the Indiana Department of Correction began initiating Medicaid applications for those in custody. Second, Medicaid began temporarily suspending coverage for people while they were incarcerated instead of discontinuing it. Prison release data from the Indiana Department of Correction linked to Medicaid enrollment data indicate that before HIP was implemented, approximately 9 percent of justice-involved adults received Medicaid coverage within 120 days of release. After HIP implementation, coverage rates increased by 9 percentage points. After both interagency coordination policies were implemented, an additional 29-percentage-point increase in coverage occurred. Furthermore, coverage effective within seven days of release increased by 14 percentage points after the interagency coordination policies went into effect. These findings support the notion that policies and procedures encouraging interagency coordination are beneficial in increasing timely access to Medicaid coverage for justice-involved people.

Caregiver Comfort in Adolescents Independently Completing Screening Tablet-Based Questionnaires at Primary Care Visits.

PURPOSE: The objective of this study was to assess caregiver comfort regarding adolescent completion of computerized health screening questionnaires created for adolescents. METHODS: We conducted a mixed-method, cross-sectional survey of caregivers of adolescent patients (n = 104) aged 12-18 years who had a medical visit between June 2017 and August 2017. Topics assessed included who completed the questionnaire, caregiver comfort and concern regarding questionnaire data, and caregiver reasons for involvement in completing the questionnaire. A one-way analysis of variance was used to compare the age of the adolescent and caregiver involvement in the questionnaire. RESULTS: The majority of adolescents (64%) reported independent completion of the questionnaire. Thirteen percent of caregivers completed the questionnaire with no involvement of the adolescent and 23% reported that caregivers and adolescents completed the questionnaire in tandem. The majority of caregivers (84%) were comfortable with adolescents completing the questionnaire. A variety of reasons were identified for caregivers completing the questionnaire (time constraints, 22%; adolescent requested caregiver help, 19%; caregiver desired to answer questions, 14%; caregiver did not realize that the questionnaire was intended for the adolescent, 11%; caregiver believed that the adolescent was too young to respond alone, 11%). Caregiver comfort with adolescent completing the questionnaire increase with age. CONCLUSION: We found the reason most caregivers gave for completing the questionnaires were related to clinic processes (e.g. time constraints). Caregivers were more likely to complete the questionnaire with younger adolescents. Thus, pediatricians should consider how to best prepare families for initial questionnaires in primary care.

Suicide Screening in Primary Care: Use of an Electronic Screener to Assess Suicidality and Improve Provider Follow-Up for Adolescents.

PURPOSE: The purpose of this study was to assess the feasibility of using an existing computer decision support system to screen adolescent patients for suicidality and provide follow-up guidance to clinicians in a primary care setting. Predictors of patient endorsement of suicidality and provider documentation of follow-up were examined. METHODS: A prospective cohort study was conducted to examine the implementation of a CDSS that screened adolescent patients for suicidality and provided follow-up recommendations to providers. The intervention was implemented for patients aged 12-20 years in two primary care clinics in Indianapolis, Indiana. RESULTS: The sample included 2,134 adolescent patients (51% female; 60% black; mean age = 14.6 years [standard deviation = 2.1]). Just over 6% of patients screened positive for suicidality. A positive endorsement of suicidality was more common among patients who were female, depressed, and seen by an adolescent-medicine board-certified provider as opposed to general pediatric provider. Providers documented follow-up action for 83% of patients who screened positive for suicidality. Documentation of follow-up action was correlated with clinic site and Hispanic race. The majority of patients who endorsed suicidality (71%) were deemed not actively suicidal after assessment by their provider. CONCLUSIONS: Incorporating adolescent suicide screening and provider follow-up guidance into an existing computer decision support system in primary care is feasible and well utilized by providers. Female gender and depressive symptoms are consistently associated with suicidality among adolescents, although not all suicidal adolescents are depressed. Universal use of a multi-item suicide screener that assesses recency might more effectively identify suicidal adolescents.

Physician Intervention to Positive Depression Screens Among Adolescents in Primary Care.

PURPOSE: The objective of this study was to determine the effectiveness of computer-based screening and physician feedback to guide adolescent depression management within primary care. METHODS: We conducted a prospective cohort study within two clinics of the computer-based depression screening and physician feedback algorithm among youth aged 12-20 years between October 2014 and October 2015 in Marion County (Indianapolis), Indiana. RESULTS: Our sample included 2,038 youth (51% female; 60% black; mean age = 14.6 years [standard deviation = 2.1]). Over 20% of youth screened positive for depression on the Patient Health Questionnaire-2 and 303 youth (14.8%) screened positive on the Patient Health Questionnaire-9 (PHQ-9). The most common follow-up action by physicians was a referral to mental health services (34.2% mild, 46.8% moderate, and 72.2% severe range). Almost 11% of youth in the moderate range and 22.7% of youth in the severe range were already prescribed a selective serotonin reuptake inhibitor. When predicting mental health service referral, significant predictors in the multivariate analysis included clinic site (40.2% vs. 73.9%; p < .0001) and PHQ-9 score (severe range 77.8% vs. mild range 47.5%; p < .01). Similarly, when predicting initiation of selective serotonin reuptake inhibitors, only clinic site (28.6% vs. 6.9%; p < .01) and PHQ-9 score (severe range 46.7% vs. moderate range 10.6%; p < .001) were significant. CONCLUSIONS: When a computer-based decision support system algorithm focused on adolescent depression was implemented in two primary care clinics, a majority of physicians utilized screening results to guide clinical care.

Making the Legal and Ethical Case for Universal Screening for Postpartum Mood and Anxiety Disorders in Pediatric Primary Care.

Postpartum depression (PPD), part of a larger spectrum of perinatal mood and anxiety disorders, affects up to 15% of women following the birth of an infant. Fathers may also be affected. PPD not only affects caregivers, but also impacts infants through mechanisms such as inadequate caregiver-infant interactions and non-adherence to safety practices. The negative impact on infants may extend across the life course through adulthood. This article seeks to move the needle toward universal screening for PPD using validated tools in pediatric primary care settings for new caregivers by making the legal and ethical case for this course of action in a manner that is both compelling and accessible for clinicians. Toward this end, we summarize current literature as it applies to provider responsibilities, liabilities and perspectives; and caregiver autonomy, confidentiality, and privacy. We then assess utility by balancing the benefits and burdens of this approach to practices, providers, and caregivers; and take the analysis one step further by looking across multiple populations to assess distributive justice. We conclude that there is a strong ethical case for universal screening for PPD in pediatric primary care settings using validated tools when informed consent can be obtained and appropriate follow-up services are available and accessible. Clinical considerations, practical resources, and areas ripe for future research are also addressed.

Moral conflict and competing duties in the initiation of a biomedical HIV prevention trial with minor adolescents.

BACKGROUND: Biomedical HIV prevention research with minors is complicated by the requirement of parental consent, which may disclose sensitive information to parents. We examine the experience of principal investigators (PIs) and study personnel who faced this complex ethical issue in the first biomedical HIV prevention study that allowed minors to self-consent for enrollment. METHODS: We conducted in-depth interviews with PIs and study personnel from 13 medical trial sites in cities across the United States. Data were analyzed using a conventional content analysis. RESULTS: Participants experienced moral conflict as they struggled to fulfill conflicting duties in this trial involving minor adolescents with multiple vulnerabilities. Our participants experienced conflict between the two types of duties-protective and scientific-previously identified by Merritt. Protective duties were owed to the child, the parents, and the institution, and participants expressed tension between the actions that would protect these subgroups and the actions necessary to fulfill their scientific duties. CONCLUSIONS: Moral conflict was resolved in a variety of ways, including reflecting on the protocol's alignment with federal regulations, modifying consent language, considering each individual for enrollment carefully, and accepting institutional review board (IRB) decisions. Potential solutions for future studies are discussed, and include flexible protocol consent procedures and centralized IRB reviews.

Parent and Adolescent Views on Barriers to Adolescent Preventive Health Care Utilization.

OBJECTIVES: To determine adolescent and parent views of barriers to annual adolescent preventive care. STUDY DESIGN: A nationally recruited cross-sectional study of adolescents between ages 13 and 18 years, and parents of adolescents from different families, were recruited. The primary outcome was self-report of preventive care in the last 12 months. Demographic, family health discussions, physical/emotional health importance, and preventive care barriers were gathered from adolescents and parents. RESULTS: The majority of the sample (500 adolescents and 504 parents in different families) reported a primary care visit within 12 months (parents = 78.7%; adolescents = 66.9%). Adolescent participants identified more barriers than parents (parents = 0.69; adolescents = 1.42). Adolescent who reported having discussions with parents about health (aOR 1.57, 95% CI 1.26-1.98) and seeing a subspecialist provider (aOR 3.72, CI 1.21-11.47) were more likely to report preventive visits. Barriers for parents and adolescents include the belief that an appointment is only needed when a child is sick (parent aOR 0.21, CI 0.08-0.61; adolescent aOR 0.29, CI 0.17-0.51) and family cannot afford cost (parent aOR 0.34, CI 0.15-0.81; adolescent aOR 0.50, CI 0.26-0.97). Barriers for parents include the child sees a specialist (aOR 0.26, CI 0.08-0.88) and their child does not need a checkup (aOR 0.12, CI 0.05-0.34). Lastly, a barrier for adolescents was parents never schedule preventive visits (aOR 0.31, CI 0.17-0.58). CONCLUSIONS: The Affordable Care Act has the potential to limit preventive care barriers. The results of the current study find there are parental and adolescent issues regarding preventive services that should be addressed.

Medical legal partnership and health informatics impacting child health: Interprofessional innovations.

Dramatic differences in health are closely related to degrees of social and economic disadvantage. Poverty-induced hardships such as food insecurity, utility shut-offs, and substandard housing, all have the potential to negatively impact the health of families. In an effort to better address social determinants of health in pediatric primary health care settings using the Medical Legal Partnership (MLP) model of health care delivery, an interprofessional team of investigators came together to design an innovative process for using computerized clinical decision support to identify health-harming legal and social needs, improve the delivery of appropriate physician counseling, and streamline access to legal and social service professionals when non-medical remedies are required. This article describes the interprofessional nature of the MLP model itself, illustrates the work that was done to craft this innovative health informatics approach to implementing MLP, and demonstrates how pediatricians, social workers and attorneys may work together to improve child health outcomes.

Adolescent Self-Consent for Biomedical Human Immunodeficiency Virus Prevention Research.

PURPOSE: The Adolescent Medicine Trials Network Protocol 113 (ATN113) is an open-label, multisite demonstration project and Phase II safety study of human immunodeficiency virus (HIV) preexposure prophylaxis with 15- to 17-year-old young men who have sex with men that requires adolescent consent for participation. The purpose of this study was to examine factors related to the process by which Institutional Review Boards (IRBs) and researchers made decisions regarding whether to approve and implement ATN113 so as to inform future biomedical HIV prevention research with high-risk adolescent populations. METHODS: Participants included 17 researchers at 13 sites in 12 states considering ATN113 implementation. Qualitative descriptive methods were used. Data sources included interviews and documents generated during the initiation process. RESULTS: A common process for initiating ATN113 emerged, and informants described how they identified and addressed practical, ethical, and legal challenges that arose. Informants described the process as responding to the protocol, preparing for IRB submission, abstaining from or proceeding with submission, responding to IRB concerns, and reacting to the outcomes. A complex array of factors impacting approval and implementation were identified, and ATN113 was ultimately implemented in seven of 13 sites. Informants also reflected on lessons learned that may help inform future biomedical HIV prevention research with high-risk adolescent populations. CONCLUSIONS: The results illustrate factors for consideration in determining whether to implement such trials, demonstrate that such protocols have the potential to be approved, and highlight a need for clearer standards regarding biomedical HIV prevention research with high-risk adolescent populations.

Clinical conversations about health: the impact of confidentiality in preventive adolescent care.

PURPOSE: To better understand how confidentiality impacts the delivery of preventive adolescent health care by examining adolescent and parent beliefs and the relationship between confidentiality and the number and subject matter of health topics discussed at the last visit. METHODS: This study represents a secondary analysis of nationally representative online survey data collected from adolescents aged 13-17 years (N = 504) and parents of adolescents aged 13-17 years (N = 500). Descriptive statistics were conducted on confidentiality variables of interest. Analysis of variance and Scheffe post hoc tests were computed to determine whether the mean number of topics discussed varied by level of confidential consultation provided. Associations between confidential consultation and health topics discussed at the last visit were examined using multivariate logistic regression. RESULTS: Approximately, half of both samples reported provision of confidential consultation. Eighty-nine percent of parents believed adolescents should be able to speak with providers alone, yet 61% preferred to be in examination room for the entire visit. Nearly half of all adolescents believed parental presence impacted conversation. Mean number of topics discussed was significantly higher when a visit was partially confidential (4.11 ± 3.05; p = 0) versus when a visit was not confidential (2.76 ± 2.68; p = 0). There were significant associations between confidential consultation and discussions about 8 of 11 health topics. CONCLUSIONS: Confidential consultation significantly impacts the number and subject matter of health topics discussed. A split-visit confidentiality model for adolescent preventive care visits may result in clinical conversations that address more topics. This arrangement may also appeal to parents who have mixed feelings about confidentiality.

Proactive parents are assets to the health and well-being of teens.

OBJECTIVES: To analyze parents who self-identified themselves as being proactive parents (PPs) compared with non-PPs who were queried about their teen's health to understand common adolescent health concerns, parenting practices/behaviors around health, and whether their adolescent had received a preventive care visit in the last year STUDY DESIGN: Secondary analyses of parents (n = 504) from a nationally representative online panel were surveyed to assess health beliefs/attitudes, perceived adolescent health concerns, frequency of health discussions, topics that pediatricians should discuss, and their teen's last annual visit. Demographics, parental beliefs, frequency of health conversations, and topics that physicians should discuss were compared. Logistic regression determined the likelihood of PPs compared with non-PPs reporting a teen annual health visit within the last year. RESULTS: Greater education and having a single-child household were slightly more common among PPs. PPs expressed greater concern about their teens getting good grades, getting sick, and their teen's future (P < .001). PPs indicated a greater severity of worry (P < .02) across all health topics and rated issues of sexual health, vaccines, and stress/mental health as very important for pediatricians to discuss (P < .01). Controlling for demographics, PPs were 3.4 (95% CI 2.06-5.56) times more likely to report an annual visit of their teen in the last year. CONCLUSION: PPs are an asset to the health promotion and the well-being of their teens. PPs were more likely to have their teen receive an annual visit, report more frequent discussions about health, and place a high value on physician discussions about health.

Child exposure to parental violence and psychological distress associated with delayed milestones.

OBJECTIVE: To examine the association between parental report of intimate partner violence (IPV) and parental psychological distress (PPD) with child attainment of developmental milestones. METHODS: By using data collected from a large cohort of primary care patients, this cross-sectional study examined the relationship between parental report of IPV and/or PPD and the attainment of developmental milestones within the first 72 months of a child's life. Multivariate logistic regression analyses were used to adjust for parental report of child abuse concern and sociodemographic characteristics. RESULTS: Our study population included 16 595 subjects. Children of parents reporting both IPV and PPD (n = 88; 0.5%) were more likely to fail at least 1 milestone across the following developmental domains: language (adjusted odds ratio [aOR] 2.1; 95% confidence interval [CI] 1.3-3.3), personal-social (aOR 1.9; 95% CI 1.2-2.9), and gross motor (aOR 3.0; 95% CI 1.8-5.0). Significant associations for those reporting IPV-only (n = 331; 2.0%) were found for language (aOR 1.4; 95% CI 1.1-1.9), personal-social (aOR 1.7; 95% CI 1.4-2.2), and fine motor-adaptive (aOR 1.7; 95% CI 1.0-2.7). Significant associations for those reporting PPD-only (n = 1920; 11.6%) were found for: language (aOR 1.5; 95% CI 1.3-1.7), personal-social (aOR 1.6; 95% CI 1.5-1.8), gross motor (aOR 1.6; 95% CI 1.4-1.8), and fine-motor adaptive (aOR 1.6; 95% CI 1.3-2.0). CONCLUSIONS: Screening children for IPV and PPD helps identify those at risk for poor developmental outcomes who may benefit from early intervention.