Decision-making among adolescents prescribed antipsychotic medications: Interviews to gain perspectives of youth without psychosis or mania.

OBJECTIVES: This study aimed to understand the experiences of youth who had been prescribed antipsychotics but did not have psychosis, mania, autism spectrum disorder, or developmental disability. METHODS: Twenty-three qualitative telephone interviews were conducted with youth aged 11-18 who had been prescribed an antipsychotic medication but did not have a diagnosis of psychotic disorder, bipolar disorder, autism spectrum disorder, or developmental disability. Participants were recruited from four U.S. healthcare systems participating in the pragmatic trial Safer Use of Antipsychotics in Youth (SUAY). Interviews were recorded, transcribed and analyzed using template analysis techniques. RESULTS: Prior to initiating an antipsychotic medication, most participants experienced behavioral health crises; many felt that they had no options other than to start the medication. Other core themes included: (1) antipsychotics had both positive psychosocial outcomes, such as improvement of family life, and adverse effects, such as drowsiness or weight gain, (2) antipsychotics were only one part of a broader treatment plan, (3) efforts were made to maximize benefits and minimize side effects through careful titration, (4) feedback from friends and family was important in the decision to continue. CONCLUSIONS: The findings provide valuable insights into how to engage youth in conversations around the use of antipsychotics.

Implementing an EMR-based Health-related Social Needs Screen in a Pediatric Hospital System.

INTRODUCTION: There is growing recognition of the need for effective screening methods and delivering interventions to address health-related social needs (HRSN) in hospital systems, but few studies exist on implementing such a wide-scale undertaking. This article describes the implementation and preliminary findings of a phased roll-out of an institution-wide HRSN screening. METHODS: We describe the HRSN implementation and data tracking procedures. RESULTS: During the first 13 months of the roll-out, 62,315 patient encounters from multiple clinics were eligible for screening, and 52,331 (84.0%) completed the screening. Twelve percent of patients had at least one HRSN need, and 3.5% of those had an urgent need and thus received a social work consult. CONCLUSION: Implementation of the first phase of an institution-wide HRSN screen resulted in high screening and follow-up rates among those with urgent needs, demonstrating feasibility across different clinic settings.

Improving Teen Girls' Skills for Using Electronic Health Information.

BACKGROUND: In a world increasingly dependent on the Internet for information, it is not surprising that people use the internet to find answers to their health-related questions. Research has shown that teen girls are more likely to search for health information online than boys, but that they do not feel confident in using the information they find. OBJECTIVE: To address this disparity, teen girls were engaged in the process of developing a teen-friendly, internet-based tool that explains the best way to find, evaluate, and use online health information. METHODS: Focus groups were held with girls and their parents to inform the design of the tool. After collaborating with information technology, marketing, and video production teams, a tool was developed consisting of a webpage, videos, and an interactive game. The efficacy and acceptability of the tool were tested among our target demographic through a usability trial. KEY RESULTS: Parent and teen focus groups informed the three-step design of the tool. Teen girls reported significantly higher levels of eHealth literacy after using the tool. Dissemination of the tool through a national targeted ad campaign generated web traffic to the tool. CONCLUSIONS: An internet-based training tool has been shown to improve teen girls' eHealth literacy. Findings from this developmental study can be used to inform efforts to improve eHealth literacy in adolescent girls. [HLRP: Health Literacy Research and Practice. 2021;5(1):e26-e34.] PLAIN LANGUAGE SUMMARY: This research study used teen and parent input to help design an internet-based training tool to teach teen girls the best way to use the internet to find health information. Teen girls' ability to find, understand, and evaluate online health information significantly improved after using the tool. The tool was advertised throughout the United States on various social media platforms.

Do health literacy disparities explain racial disparities in family-centered care for youths with special health care needs?

OBJECTIVE: To explore the relationship among youth health literacy, parental health literacy, and family-centered care (FCC) for youth with special health care needs (YSHCN) and assess potential racial disparities. METHODS: HL and FCC were assessed in 486 Medicaid-enrolled YSHCN (ages 12-18) and their healthcare-responsible parent/caregiver. Analyses assessed racial differences in HL and FCC for parents and youth using logistic regression. RESULTS: Half of youth and over 80 percent of parents had adequate HL (REALM score ≥62). Adequate HL was significantly lower in African Americans (AA) for both YSHCN and parents. Only 57 % of parents and 29 % of YSHCN reported FCC. AA YSHCN reported significantly lower levels of FCC compared to White YSHCN. AA parents trended lower for FCC compared to Whites, though the disparity was not significant. AA youth and parents had significantly lower odds of reporting that doctors spent enough time with them compared to Whites. CONCLUSION: Results suggest that AA and those with less than adequate health literacy experience lower FCC, however the relationship between race and health literacy does not explain the racial disparity in FCC. PRACTICAL IMPLICATIONS: Provider time spent focused on HL may not reduce the racial disparity in FCC, but opportunities for improvement exist.

Exploring Health Literacy, Transition Readiness, and Healthcare Utilization in Medicaid Chronically Ill Youth.

PURPOSE: Youths with special healthcare needs face challenges transitioning from pediatric to adult health care. Understanding possible mechanisms contributing to poor healthcare transition could improve care. This study explores associations between health literacy (HL), transition readiness, and healthcare utilization. METHODS: Youths with special healthcare needs aged 12-18 years were recruited from a Medicaid accountable care organization (2012-2017). Outcome measures included transition readiness (Transition Readiness Assessment Questionnaire), and healthcare utilization (any well-check, hospitalization, emergency department [ED] visit, or ambulatory sensitive condition ED visit). Multivariate regression analyses examined whether HL (adequate vs. inadequate) predicted outcomes, after adjusting for covariates. Models were then created to examine whether the effect of HL on healthcare utilization was mediated by transition readiness. RESULTS: Among 417 youths with special healthcare needs, 67.1% reported adequate HL. Relative to inadequate HL, teens with adequate HL had significantly higher average Transition Readiness Assessment Questionnaire-20 scores (ß = .34, p < .001). Controlling for covariates, HL was a significant predictor of having an ambulatory sensitive condition ED visit and having any ED visits neared significance. There was a positive transition readiness mediation effect on having an ED visit, with higher transition readiness being associated with higher odds of having any ED visit in the mediation analysis. CONCLUSIONS: HL is independently associated with higher transition readiness and lower ambulatory sensitive condition ED use, but pathways of action require further study.

An Integrative Review of Social Determinants of Health Screenings used in Primary Care Settings.

BACKGROUND: There is limited evidence on how to implement social determinants of health (SDH) screenings. OBJECTIVE: To synthesize recent evidence investigating the implementation of SDH screening in primary care settings. DESIGN: Electronic strategies were used to find articles published between September 2008 and 2018. Articles in the review (N = 15) varied in study design and methodologic rigor, complicating the analysis. RESULTS: Many articles lacked specification on who administered the screening, where the screening was administered, and resource referral rates. The majority of the screenings were administered during the clinic visit by a medical provider. The four primary SDH domains assessed were income, housing stability, education, and employment status. CONCLUSION: More specific implementation research is needed on the best way for providers to screen for SDH in addition to how screening practices influence resource referrals, resource utilization, and health improvements.

A Community Development Program and Reduction in High-Cost Health Care Use.

Adverse housing and neighborhood conditions influence child health. The Healthy Neighborhoods Healthy Families community development initiative was established in 2008 to address housing, education, employment, and other neighborhood-level, child health-influencing factors on the south side of Columbus, Ohio, with the goal of improving child health and well-being. In this article, we discuss the path from advocacy to outcomes analysis in this initiative and assess changes in high-cost health care use by children in the target area over the first decade of implementation. Change in health care use was measured by using a difference-in-differences approach comparing emergency department visits, inpatient stays, and inpatient length of stay in the intervention neighborhood and a propensity score-matched, pooled comparator neighborhood in the same city. The baseline and follow-up periods were August 2008 to July 2010 and August 2015 to July 2017, respectively. Findings from this analysis reveal that compared to 2 pooled comparison neighborhoods, the intervention neighborhood trended, nonsignificantly, toward greater decreases in inpatient stays and emergency department visits and smaller increases in length of stays. These results suggest that our community development activities may be influencing health care use outcomes, but in the early years of the intervention relative changes are modest and are variable based on the definition of the intervention and comparator neighborhoods. Lessons learned in expanding from advocacy to analysis include the importance of building multidisciplinary teams that can apply novel approaches to analysis, moderating expectations, and retaining focus on the broader social context.

Sustainably Implementing Social Determinants of Health Interventions in the Pediatric Emergency Department.

This Viewpoint discusses 5 principal challenges and opportunities for the sustainable implementation of social determinants of health interventions in emergency department settings.

Quality Improvement Initiative to Improve Human Papillomavirus Vaccine Initiation at 9 Years of Age.

OBJECTIVE: Adolescent human papillomavirus (HPV) vaccine rates remain low. Early vaccination may improve the efficacy of the vaccine and immunization rates; however, clinicians have not routinely made a strong recommendation for younger adolescents. This study assessed the feasibility of routine vaccination at 9 years of age. METHODS: Three sequential quality improvement (QI) interventions were implemented to shift the initiation of the HPV vaccine to 9 years of age in a primary care network in low-income neighborhoods in Columbus, Ohio. The first intervention changed the electronic medical record alert for the HPV vaccine from 11 to 9 years of age and focused on cancer prevention when discussing the vaccine with families. The second intervention was formation of an HPV QI team. The third intervention was a clinic incentive for HPV captured opportunity rates. Immunization rates were monitored using statistical process control charts to compare the HPV immunization rate in a sample of 9- and 10-year-old children with a sample of 11- and 12-year-old children. RESULTS: The percentage of patients receiving an HPV vaccine before 11 years increased from 4.6% to 35.7% during the 6 months after the QI initiative began and to 60.8% 18 months after the project began. In comparison, the HPV vaccination rate in the sample of 11- and 12-year-olds increased from 78.7% to 82.8% 18 months later. CONCLUSIONS: This QI project used multiple interventions to increase HPV vaccination at 9 years of age in a large primary care network serving a diverse low-income population.

Benefits of Medical Home Care Reaching Beyond Chronically Ill Teens: Exploring Parent Health-Related Quality of Life.

BACKGROUND: Caring for teens with special health care needs places physical and mental health burdens on parents, which can be exacerbated by the stresses of transitions to independence. Medical homes can improve teen transitions to greater self-management and reduce health care-related time and financial burdens for families. We examined the association between parent-reported teen medical home status and caregiver health-related quality of life (HRQOL). METHODS: The study sample included parents or caregivers of teens with special health care needs aged 15 to 18 recruited from a pediatric Medicaid accountable care organization who participated in a survey (response rate, 40.5%). The primary outcome was parent HRQOL scores (0-100 points) measured using the Pediatric Quality of Life Inventory Family Impact Module. Medical home status was based on parent report of teen's health care meeting medical home criteria. Linear regression models were used to estimate HRQOL scores, adjusted for demographic characteristics, health literacy, and teen functional limitation. RESULTS: Among 488 parents, 27% reported their teen received care consistent with a medical home. Adjusted parent HRQOL scores were significantly higher among those whose teens had a medical home (74.40; 95% confidence interval, 71.31-77.48), relative to those whose teens did not (65.78; 95% confidence interval, 63.92-67.65). Medical home subscale analyses showed HRQOL scores had significant positive associations with family-centered care and coordinated care, but not other subscales. CONCLUSIONS: Teen medical home status was positively associated with caregiver HRQOL, suggesting that the medical home may benefit overall caregiver well-being. In particular, receiving care that was family centered and coordinated appeared to be the most beneficial.