Contents
Introduction
- About Total Teen
- Key Components and Organizational Commitments
- Purpose of Total Teen
- Program Needs and Significance
- Importance of Health Screenings
- Importance of Confidentiality
- Importance of Adolescent-Friendly Environments
- 4 Cs of Total Teen
- Section in Review
Preparing Organizations to Implement
- Program Orientation
- Adolescent-Friendly Environments
- Clinic Assessment
- Large-Scale Environmental Considerations
- Small-Scale Environmental Considerations
- Adolescent-Friendly Providers and Staff
- Characteristics of Adolescent-Friendly Providers
- Provider Self-Assessment
- Section in Review
Coordination
- Key Components of Coordination
- Clinic Workflow
- During the Visit
- Total Teen Assessment
- Vital Check
- Micro Visits and Referrals
- Workflow Modifications
- Electronic Record Modifications
- Medical Billing Codes
- Consent and Assent
- Parent/Guardian Consent
- Adolescent Assent
- Micro Visits
- Section in Review
Collaboration
Communication
- Informational Resources
- Information for Adolescent Patients
- Information for Providers
- Talking with Adolescent Patients
Care
Introduction
About Total Teen
Total Teen is an easy to implement set of processes that integrate sexual and mental health consultations into all primary care visits for adolescents (ages 12 and older). Total Teen includes an adolescent health assessment, immediate care, and referrals based on identified needs. By adopting Total Teen, organizations can streamline and standardize a holistic approach to adolescent healthcare without increasing the burden on providers. This toolkit contains all information and supporting resources needed for healthcare organizations to successfully implement Total Teen.
Development Process
Total Teen was developed through the Comprehensive Healthcare for Adolescents Initiative (CHAI) project from Fall 2020 through Summer 2021. The CHAI project worked with six organizational partners and a teen advisory group (TAG) to gather insights on the healthcare experience for adolescents. Using human-centered design, through a six- stage Design Sprint that occurred over six months, a network of subject-matter experts (SMEs) used the insights to gain a deeper understanding of the root problems faced by adolescents and brainstorm innovative solutions. One of those solutions is Total Teen. Network partners represented a variety of content expertise to contribute their knowledge and experience to this process, while the TAG provided continuous feedback throughout the design process.
Key Components and Organizational Commitments
By implementing this program, your organization will provide adolescents with quality, individually-tailored healthcare. This approach requires providing adolescents ample time to complete the health assessment privately on a tablet and offering confidential one-on-one time between adolescent patients and providers (i.e. micro visits) to address assessment results or other questions. Additionally, your organization must commit to providing follow-up services on-site or through adolescent-friendly referral partners. To build trust and promote transparency, it is important to communicate the clinic’s new workflow, confidentiality policy, and accompanying procedures to patients, their parents/guardians, and other relevant stakeholders. To support and enable confidential conversations, it is essential to create adolescent-friendly environments, ensure staff and providers embody adolescent-friendly characteristics, and provide accessible resources for patients.
Purpose of Total Teen
Total Teen is a standardized set of clinic processes that integrates sexual and mental health into all primary care visits for adolescents ages 12 and older.
The goals of Total Teen are:
- To increase access to sexual and reproductive healthcare services in primary care settings.
- To increase access to mental healthcare services in primary care settings.
- To improve adolescent patient experiences in healthcare settings.
Program Needs and Significance
Adolescence is a unique period in development marked by an increased sense of agency and an increased possibility for engaging in risky health behaviors, which may lead to lifelong consequences for an individual’s health and safety. For example, adolescents are particularly susceptible to unintended outcomes, such as sexually transmitted infections and unintended pregnancy, compared to other age groups. As such, it is critical they have unconstrained access to quality, comprehensive sexual and reproductive health (SRH) information and services, which is shown to minimize risky behavior in youth and
improve SRH outcomes.
Similar to SRH, improper or lack of mental healthcare can negatively impact adolescent development and outcomes regarding mental health, relationships, education, and employment. However, adolescents may have trouble assessing and addressing their mental health (MH) needs. Evidence suggests low mental health service utilization among adolescents, thus creating the need for improved processes among healthcare providers to address adolescents’ unique mental health needs.
Providing quality comprehensive SRH and MH services to adolescents involves adopting adolescent-friendly practices, such as explaining patient rights to confidentiality, offering one-on-one time between an adolescent patient and their healthcare provider, using screening or trigger questionnaires, and creating comfortable environments inclusive of adolescent needs and preferences. By implementing Total Teen, healthcare organizations can institutionalize these adolescent-friendly practices and facilitate their ability to support the many physical, social, and emotional needs of adolescents during a critical period in their development.
Importance of Health Screenings
Primary care visits represent opportunities for adolescents to receive screening, education, and guidance related to SRH and/or MH. Unfortunately, some primary care providers frequently miss opportunities to have critical conversations about potentially sensitive topics (e.g., SRH and MH) with adolescents. Regarding sexual health, patients feel providers should initiate discussions; however, providers are often uncomfortable and lack confidence in discussing sexual health topics. Regarding mental health, adolescents typically limit discussions with providers to focus on somatic symptoms and fail to disclose psychological complaints they experience. Thus, adolescents not only forgo seeking SRH and MH services, but fail to discuss questions and needs during primary care visits.
Screening questionnaires can facilitate discussions between adolescents and providers regarding SRH and MH by identifying potential needs. Through follow-up conversations about screening results, providers can offer immediate services and referrals, as appropriate, to address identified needs. Follow-up conversations and services should increase access to care while improving patients’ perceptions of providers. Thus, patients are more likely to seek and utilize these healthcare services in the future.
Importance of Confidentiality
Confidentiality protections exist to encourage healthy decision-making. Without these protections, many adolescents are less willing to disclose potentially sensitive information (e.g., substance use, mental health, sexual history) and may forgo care altogether. Despite the established importance of confidentiality, providers may be unfamiliar with laws and policies regulating confidential care for minors. As a result, they may overcompensate by including parents/guardians in all aspects of the adolescent’s care, even when access inhibits these key services. In fact, research shows many adolescents in the United States have never had a private discussion with their provider about any topic.
There is a need to establish policies and procedures which ensure adolescents are educated about their rights to confidential services and allow them to exercise those rights. In doing so, healthcare organizations and providers can enhance trust, communication, satisfaction, adherence, and likelihood of returning for continued services.
As stated by Pasternak et al (2019, p.5), “It is the position of the Society for Adolescent Health and Medicine (SAHM), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) that policies should be developed to not impede the provision of confidential healthcare to adolescent patients.”
As long as policies do not violate state or federal laws, healthcare settings are able to establish specific policies regarding conditional confidentiality for adolescent patients. Confidentiality should be upheld, except in instances that warrant mandatory reporting and child protection concerns, specifically if the safety of a patient or others is at risk. Organizations should ensure all staff know the steps for reporting cases to the appropriate authorities.
“It is the position of the Society for Adolescent Health and Medicine (SAHM), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) that policies should be developed to not impede the provision of confidential healthcare to adolescent patients.”
Importance of Adolescent-Friendly Environments
Creating an adolescent-friendly environment is important in ensuring a comfortable and
safe space for adolescents. Pediatric clinics cater to young children (10 and under) and
family medicine practices commonly cater to older adults. Adolescents (teens) may
feel too old for pediatric environments while feeling apprehensive of or intimidated by
adult clinics. This perception can often contribute to healthcare visits being a stressful
experience for adolescents.
As a result, organizations have opportunities to address the unique needs of
adolescents. Various strategies exist to create healthcare settings that support and
enable adolescents to feel confident communicating their health needs, including but
not limited to:
- PHYSICAL SPACE. Creating waiting areas that represent local, teen culture contributes to adolescents’ comfort and decreases patient anxiety.
- PERSONNEL. Staff who are welcoming and accommodating facilitate adolescent engagement with the organization. Particularly, young people connect better with staff perceived as friendly, relatable, and culturally understanding.
- PROCESS. Leveraging novel resources, such as technology, provides adolescents with an opportunity to connect with their care team out-of-office. Patients can stay engaged in their healthcare by expressing concerns and as they arise, access health records, and learn about health promotion through texting, apps, patient portals, and e-messaging.
Strategies that create a welcoming environment and connection to providers above have been identified as key constructs in establishing adolescent-friendly care. These domains align with the World Health Organization (WHO) framework of adolescent-friendly health care, as well as with principles of patient-centered care.
4 "C"s of Total Teen
Just as Total Teen was developed using a human-centered design process and approach, it must be implemented in a patient-centered manner to help ensure successful outcomes. Patient-centered care (PCC) is a key element of high-quality care centered on the qualities of personal, professional, and organizational relationships. PCC is an approach to care that focuses on the patient rather than an illness or diagnosis. In addition, PCC encourages patients to actively engage in their own care while emphasizing communication, partnerships, and health promotion in the provider-patient consultation. PCC is associated with improved health outcomes, positive health-seeking behaviors, patient satisfaction, and improved health service utilization.
Similar to PCC, adolescent-friendly care is a theoretical framework for improving the quality of care. However, adolescent-friendly care focuses on quality service delivery for young people. Key domains of the adolescent-friendly care framework include healthcare accessibility, staff attitudes, communication, evidence-based guideline-driven care, age-appropriate environments, healthcare involvement, and health outcomes. Webb et al. (2017) report PCC and adolescent-friendly care frameworks provide a strong theoretical basis to meet the health care needs of adolescents. These theoretical frameworks help guide what is defined as the 4 Cs of adolescent patient-centered care: Coordination, Collaboration, Communication, and Care.
The contents of this toolkit are organized by using the 4 Cs approach. Each of the 4 Cs are composed of organizational, interpersonal, and individual level elements to be addressed. An overview of each component is given below.
- Coordination: The process and practices that must occur among organizational leadership and administrators to ensure Confident Teen can be implemented effectively and efficiently to meet the needs of adolescent patients.
- Collaboration: The need to utilize an interdisciplinary approach to ensure adolescent healthcare needs are met and facilitating referrals and warm hand-offs to other adolescent-friendly providers as needed.
- Communication: The interpersonal communication between providers and patients, which includes the verbal and nonverbal actions to support adolescents in their healthcare experience.
- Care: The process of ensuring confidential care is provided to adolescent patients to meet their needs and help them learn to navigate the healthcare system independently.
Section in Review
SRH and MH needs often go unmet and form a complex web of potential challenges to adolescent development. Implementing Total Teen presents an opportunity to embed SRH and MH into primary care visits. The following list summarizes key information about the background and significance of Total Teen:
- Total Teen screens adolescent patients (ages 12 and up) for SRH and MH needs during primary care visits and prompts micro visits, referrals, and follow-up services based on results.
- Total Teen incorporates adolescent-friendly processes (a screening questionnaire, confidential follow-up discussions, and comfortable environments) to improve access to and experiences with healthcare.
- These processes foster independence for teens, build skills for navigating and engaging in the healthcare system, and allow adolescents the opportunity to advocate for their own SRH and MH.
- Organizations must implement Total Teen in an adolescent patient-centered manner to help ensure successful outcomes.
The next section, Preparing Organizations to Implement, discusses steps to create an adolescent-friendly environment that supports and enables implementation of Total Teen.
Preparing Organizations to Implement
Program Orientation
Total Teen includes a mandatory program orientation that will prepare your organization for implementation. The program orientation includes various components (both online/asynchronous, and in-person) to ensure your team is prepared to implement Total Teen successfully, and identifies opportunities to pursue professional development as needed. The in-person component of the program orientation will serve as a time for members of the CHAI team to work through key components of TT with members of your team. To ensure this time is as productive as possible, we strongly recommend organizations include the following people from your team:
- Site Champion (one person that is the “go-to” for CHAI programs at your
organization) - Front desk staff / Patient services representative (someone that interacts with
patients in non-medical care role (e.g. receptionist, etc.)) - Clinician / Provider (a care provider)
- Organization representative (a decision-maker regarding policies and procedures,
etc.)
Adolescent-Friendly Environments
The clinic environment plays a major role in adolescents’ experiences with healthcare services. Therefore, the physical clinic environment should facilitate open communication between adolescent patients and the healthcare team. This section provides resources for the clinic team to ensure their environment is comfortable, accepting, and welcoming of adolescents from all walks of life.
Clinic Assessment
The first step in ensuring your clinic is adolescent-friendly is to complete a clinic assessment. The first two tools listed below are comprehensive assessments focused on various factors related to adolescent-friendly healthcare, while the third tool will help the team focus on the physical environment.
1. Youth-Led Health Center Assessment Tool
Source: Adolescent Health Initiative
This resource will link you to an assessment tool, a facilitator guide, and accompanying video with adolescents reflecting on what is important to them when accessing health care services. This tool is intended to be completed by a small group of adolescents, so your organization can experience the first-person point of view of at least three teens to find out what they notice while waiting for their appointments.
Click here to download the Youth-Lead Health Center Assessment Tool.
2. Youth-Friendly Services Assessment Tool & Guide
Source: Healthy Teen Network
This resource is an interactive tool, including a guide and complete bibliography, which helps assess if your clinic delivers services in a youth-friendly manner. The tool is comprehensive with a focus on service-delivery as well as the clinic environment.
Click here to access the Youth-Friendly Services Assessment Tool and Guide.
3. Physical Environment Assessment Tool
Source: The CHAI Project at Texas A&M University
This tool will help you assess various aspects of the physical environment of your clinic space. Through this instrument you will analyze the large-scale environment, down to small-scale details and accessories that contribute to the look and feel of your clinic space. A copy of the tool is provided at the end of this section.
These tools can assist your organization in identifying gaps and areas for improvement. Specific tactics are described in the sections below to guide you in modifying your clinic environment (i.e., both large and small-scale environments).
Click here to download the Physical Environment Assessment Tool.
Large-Scale Environmental Considerations
Entering a healthcare facility can be nerve-wracking — from large, crowded, public spaces to information-rich, sterile exam rooms. Adolescents can experience multiple spaces and settings within the larger facilities during a single appointment. Fortunately, healthcare organizations can leverage the design of these spaces to promote comfortable, equitable, and engaging areas for adolescents to feel comfortable and ready to approach their appointment.
The concepts below are briefly explained for contextual purposes. Organizations are encouraged to utilize the included Physical Environment Assessment Tool to explore how their organization approaches these concepts.
Design Considerations
Public Spaces can be overwhelming and lead to “information-overload”, so avoid having too many text-heavy posters or postings. These spaces can also be off-putting in design, making adolescents feel out of place. Feature decor that does not cater to one particular age group or demographic. Instead, try to have welcoming decor that is inviting to all groups and demographics.
Private Spaces, especially small spaces, can quickly become cluttered. Be careful to not over-decorate with information-rich content. Too much information can be overwhelming and the clutter may increase patient anxiety.
Bathrooms are opportunities to provide hidden services such as anonymous question submission, and advertisements for local programs or resources. Some clinics have even created a sample labeling system for patients to confidentially notify providers they are in a dangerous situation (e.g., providing patients with black and red sharpies to self-label urine samples; the red sharpie was to be used if the patient was experiencing violence or danger at home). If tear cards that advertise services are provided, be sure to tear the first two-three cards away from the display so the adolescent isn’t reluctant to be the “first” to remove an information tear card.
Small-Scale Environmental Considerations
Experiences and perceptions of a space can vary greatly depending on a person’s race, ethnicity, sexual orientation, gender identity, age, ability level, income, and other factors. While this is not an exhaustive list, it is meant to provide examples of areas to address in order to enhance the adolescent’s clinic experience.
Informational Posters
Click here to download a PDF of sample posters.
Technology Requirements
Your organization will make the Total Teen Assessment accessible to adolescents via a tablet or iPad. It is recommended your organization have at least two tablets for the Total Teen Assessment to accommodate for patient caseload and the number of providers
seeing patients simultaneously.
When setting up the assessment on tablets, adjust the screen lock/sleep settings so the device does not lock out adolescents. A lockdown screen can be used to limit distractions and access to other apps while completing the assessment. Organizations can also add adolescent friendly websites to the tablets for patients to browse while waiting to see their provider (see the Communication section for a list of health
resources for teens).
Adolescent-Friendly Providers and Staff
Adolescent friendly environments do not stop at the physical space; they are also impacted by the staff and providers within the facility. Clinics providing services to adolescents should ensure their staff and providers demonstrate adolescent-friendly characteristics (see table below). It is often the receptionist at check-in who sets the tone for the entire visit.
Adolescent-friendly providers are uniquely qualified to provide services in a way to further empower teens to take ownership over their health and healthcare experience. Provider-level approaches are used to help adolescents, their families, and friends to feel welcome, comfortable, accepted, and safe. This includes the personality traits and characteristics, and interpersonal tactics of providers (e.g., clinicians, physicians, nurses, receptionists, pharmacists, etc.), which equip them to work competently and sensitively with adolescents.
Characteristics of Adolescent-Friendly Providers
Below are characteristics of adolescent-friendly providers and staff, along with examples of those characteristics in action.
Provider Self-Assessment
All staff in your organization should complete a self-assessment to assess their respective competency in the characteristics of adolescent-friendly service delivery. The tools listed below are recommended and will also identify potential opportunities for professional development and changes in your service delivery approach. All staff who are a point of contact with adolescents should complete the assessment, not just medical providers.
“Giving providers a direct role in their own assessment could enhance the effectiveness of supervisory visits because the provider has already considered his or her performance and assessed its strengths and weaknesses. Self-assessment also has the potential to reinforce medical standards and to increase worker accountability” (USAID).
1. Adolescent-Friendly Provider Self-Assessment Tool
Source: The CHAI Project at Texas A&M University
The Adolescent-Friendly Provider Self-Assessment tool was derived using compelling questions from existing, more comprehensive assessment tools from the International Planned Parenthood Federation (2008) and Engender Health (2002). This tool is intended to serve as a starting place for self-assessing adolescent-friendly practices among staff and providers, and identify areas of opportunity for professional growth and development. To learn more about these assessments, these sources are included in the References section at the end of this manual.
Click here to download the Adolescent-Friendly Provider Self-Assessment Tool.
2. Youth-Friendly Services Assessment Tool
Source: Healthy Teen Network
The Healthy Teen Network Youth-Friendly Services Assessment Tool is an interactive tool, including a guide and complete bibliography, to help assess if your clinic delivers services in a youth-friendly manner. Though this tool was listed previously as a clinic assessment, it is listed here again because it includes sections on staff and provider-level approaches.
Click here to download the Youth-Friendly Services Assessment Tool.
3. Being Youth-Friendly
Source: The University of Michigan Adolescent Health Initiative (AHI)
The University of Michigan Adolescent Health Initiative has a tool within their Spark program titled “Being Youth-Friendly.” This tool introduces “elements of an adolescent-centered environment and outlines key staff and provider behaviors that are essential to providing youth-friendly care.” The University of Michigan also has other Spark initiatives to assist providers and staff with training for adolescent patient-centered care.
Click here to download the Being Youth-Friendly Tool.
Adolescent-Friendly Provider Trainings
Adolescent patient-centered care requires continual efforts by staff and providers to ensure they are meeting the needs of their patients and providing quality confidential care. Total Teen entails organizational practices to assist your organization in providing services, but is not all-encompassing of the training and resources needed. Additional training and professional development should be considered based on opportunities for growth and improvement identified through clinic- and self-assessments. The training listed below is recommended by the CHAI team as a starting place when considering new ways to provide services and further develop staff and providers’ skill sets.
- Motivational interviewing and coaching
- Contraceptive counseling
- Mental health first aid
- Trauma-informed care
- Youth diversity, equity, and inclusion
- Conditional confidentiality
- Adolescent-patient-centered care youth to provider dialogues
Section in Review
The clinic environment, including both physical space and social climate, influences patient experiences. This section focused on creating an adolescent-friendly environment to aid Total Teen implementation. The following list summarizes key information and tasks from this section:
- Clinic spaces are an important factor in adolescent patients’ healthcare experiences. Organizations should determine whether a clinic is adolescent-friendly by completing clinic assessments.
- After completing a clinic assessment, organizations should identify ways to make their clinic spaces more adolescent-friendly using built structures, interior factors, and accessories.
- All clinic staff should periodically assess their respective competency in adolescent patient-centered care using validated tools and identify opportunities for professional development and improvements in service delivery.
The next section focuses on Coordination, the first pillar of adolescent patient-centered care. This section will discuss clinic workflow and implementation processes, including potential action items regarding follow-up specialty care coordination and keeping stakeholders informed.
Coordination
The first pillar of adolescent patient-centered care is coordination, which entails processes and practices that must occur among organizational leadership and administrators to ensure Total Teen can be implemented effectively and efficiently to meet the needs of adolescent patients. Total Teen coordination includes modifying clinic workflows and patient care practices, coordinating follow-up specialty care, and sharing information among stakeholders.
When implementing Total Teen, your organization will adopt/improve upon a holistic approach to supporting adolescent health. Total Teen includes a brief, but comprehensive assessment, clinic workflow, and support mechanisms to carry out adolescent-friendly activities. The Key Components of Coordination graphic illustrates key steps of program preparation.
Key Components of Coordination
Clinic Workflow
Click here to download a sample Total Teen Clinic Workflow.
During the Visit
Patient Check-In
The clinic workflow starts when the adolescent arrives for their appointment. As with standard clinic workflows, adolescent patients and parents/guardians enter the waiting room and approach the front desk to start the check-in process.
During the check-in process, administrative staff should:
- Encourage the adolescent to complete any paperwork independently and ask their parents/guardians for assistance as needed.
- Give the parents/guardians a consent form to complete (as required by your organization).
- Give the adolescent an assent form to complete (as required by your organization).
More information on consent and assent processes is provided later in the Coordination section.
Total Teen Assessment
Design
The Total Teen Assessment uses four question sets to assess SRH needs (1 question set), MH needs (2 question sets), and substance use (1 question set).
Delivery
The assessment is administered electronically via a tablet or iPad. The assessment should be preloaded on devices for easy use. A lockdown screen can be used to limit distractions and access to other apps while completing the assessment. Organizations can also add adolescent-friendly websites to the tablets for patients to browse while waiting to see their provider.
Click here to download the Total Teen Assessment.
Click here to download a Guide to Discussing Results.
Vital Check
Once check-in is complete, a provider (typically a nurse, clinical assistant, or medical assistant) will escort the adolescent into the exam area. At this time, parents/guardians will remain in the waiting room.
The provider will proceed with the adolescent’s vital check (e.g., measuring height, weight, blood pressure, etc.). During this time, the provider will give the adolescent a tablet or iPad, explain the purpose of the Total Teen Assessment, and ask them to complete it independently.
The Total Teen Assessment will calculate scores on the tablet or iPad to identify potential needs for sexual and reproductive health (SRH) and mental health (MH) services, separately. The scores for both SRH and MH will be immediately calculated and displayed in an adolescent-friendly format that focuses on opportunities to improve the adolescent’s overall health based on identified needs.
When the provider enters the exam room, they will review the assessment scores and discuss the Total Teen results with the adolescent. Refer to the Care section for more information regarding the Total Teen Assessment; a copy of the assessment is provided at the end of this section.
Micro Visits and Referrals
A vital aspect of Total Teen is the immediate SRH and/or MH micro visit adolescents receive if they score moderate to high, or indicate need for services. Micro visit logistics will vary by organization (detailed information is provided later in the Coordination section). In lieu of micro visits, or in addition to them, referrals should be made to other adolescent-friendly specialists or service providers based on the patient’s needs. Providers should share adolescent-friendly resources to support positive health behaviors.
After arranging micro visits and providing resources, parents/guardians may be invited to join for the rest of the appointment. The provider will then resume originally scheduled services.
Workflow Modifications
Modifying clinic workflows can be a tedious but necessary task to ensure Total Teen is adopted as intended and adolescent health outcomes are documented. The following tips are recommended when modifying your existing clinic workflow to incorporate the essential steps of Total Teen.
-
- Map out the current workflow of your clinic (graphics tend to be easier to follow and are recommended over narrative-based workflows).
- Identify ideal places in your existing workflow to incorporate steps from the Total Teen workflow.
- Work with clinical and administrative personnel to create an updated clinic workflow.
When mapping your current workflow, request assistance and input from both clinical and administrative personnel. Feedback from different professionals will allow you to identify where the components of Total Teen best fit your organization. It is essential to ensure the revised clinic workflow is time efficient and produces intended changes.
Electronic Record Modifications
Work with your IT department or Electronic Medical Records/Electronic Health Records (EMR/EHR) representative to modify your EMR/EHR to include fields for the Total Teen Assessment scores. Fields should be added to enter scores for the following:
- Sexual Activity Habits Screening Tool (Sexual and Reproductive Health Screening Tool)
- Healthy Relationships
- Contraception
- STIs/STDs
- PHQ-9 (Depression Screening Tool)
- GAD-2 (Anxiety Screening Tool)
- S2BI (Substance Use Screening Tool)
Additionally, your organization should consider creating a protocol to document whether a patient completes a SRH and/or MH micro visit and whether patients were referred to another provider for additional services. To help maintain patient confidentiality, this information must be documented securely and separately from appointment information accessible to parents/guardians. Each organization should determine the best documentation process, taking into consideration state and local laws, EMR/EHR functionality and capabilities, and internal policies and practices.
Medical Billing Codes
Total Teen increases access to adolescent healthcare services by providing an opportunity to complete micro visits during primary care appointments. Micro visits can often be billed in 15-minute increments. It is important organizations bill appropriately for new services to allow for cost reimbursement from insurance providers.
It is up to your organization to best determine the billing needs and process of the appointments and services (including micro visits) provided to your adolescent patients. An example of Potential Billing Codes is provided at the end of this section.
Click here to download a PDF of potential medical billing codes.
Consent and Assent
Your organization should implement the Total Teen Assessment and micro visits as “opt out” processes to ensure adolescents have access to the services if a need or want is identified. As such, the consent and assent process should inform adolescents and parents/guardians that Total Teen is standard clinical practice for patients ages 12 and older. Your organization may require documentation of parent/guardian consent; if so, it is recommended you modify standard consent-to-treat forms to include the Total Teen Assessment and micro visits.
The following sections provide information and context for consent and assent processes associated with the Total Teen procedures for adolescent patients and their parents/guardians. Additional information on communicating about the assessment and micro visits with adolescents and parents/guardians is provided in the Communication section.
Parent/Guardian Consent
States have different laws regarding minor access to confidential services. Therefore, it is the responsibility of your organization to determine the best consent process for parents/guardians based on state and local laws and other governing bodies. If you are unsure of the access and consent laws in your state, consult your organization’s administration and/or legal counsel.
Click here to download a PDF of potential medical billing codes.
- Determine the consent process for parents/ guardians within your organization and a process to opt out of services
- If your organization requires a formal consent form:
- Read the Consent Form for Parents/Guardians example at the end of this section and modify as needed
- Incorporate the Consent Form for Parents/Guardians into your organization’s patient intake process
Adolescent Assent
To fully embrace the adolescent-centered nature of Total Teen, your organization should inform adolescent patients about the assessment and associated micro visits. Your organization should also inform adolescents they have the right to opt out of these services, however they will continue to be offered these services during future visits. Determine an appropriate assent process for adolescent patients in your clinic and create or modify forms as needed.
Micro Visits
Depending on their Total Teen Assessment results, adolescent patients may be encouraged to complete a micro visit to discuss their SRH and/or MH needs. Therefore, your organization will either have qualified staff to provide the micro visit, or identify appropriate providers for referrals so adolescents can access services. If micro visits will be facilitated by providers in your organization, preparation for the visits will be included in your implementation meeting.
As you consider and plan these logistics, it is imperative you coordinate to ensure privacy, comfort, and confidentiality are accounted for, while necessary qualifications are met to provide various services. If your organization is unable to provide services in-house, then there should be a network of adolescent-friendly referral partners readily available.
Section in Review
This section focused on the clinic workflow, potential modifications to the workflow, organizational tasks for assent and consent processes, and micro visit logistics. The list below summarizes key information and tasks from this section:
- When implementing the Total Teen program, your organization may have to modify existing clinic workflows and procedures for adolescent appointments.
- Modifications to EMR/EHR fields are recommended to document Total Teen Assessment results.
- Organizations are responsible for determining the best consent and assent processes based on state and local laws and other governing bodies.
- Logistics for micro visits need to be carefully considered to identify appropriate providers with the capacity to meet adolescents’ SRH and MH needs.
The next section focuses on collaboration, the second pillar of adolescent patientcentered care. Emphasis is placed on identifying and establishing a network of adolescent-friendly referral partners.
Collaboration
The second pillar of adolescent patient-centered care is Collaboration. Collaboration ensures organizations have an adolescent-friendly network of providers and resources. A key component of adolescent-friendly care is not only providing confidential services, but connecting patients to additional services (including those requiring internal or external referrals) in a timely manner.
Establish a Network of Adolescent-Friendly Referral Partners
Healthcare organizations should have an identified network of trusted providers to whom they can refer adolescents. Specifically, you will know which sexual and reproductive health and/or mental health providers can provide timely, high-quality, confidential services to your adolescent patients. It is crucial referrals for future services be made on the same day to reduce barriers to accessing follow-up services. The network may include referral partners who are in-network, out-of-network, and/or community-based service providers. Consider services both local and national in scope; local providers may offer in-person services, while providers in other geographic regions may provide telehealth services.
Additionally, you should ensure the providers you refer patients to offer adolescent-friendly services and will not shame, refuse, or dismiss adolescent needs. Clinics should periodically assess if their referral sites adhere to adolescent-friendly standards (refer back to Preparing Organizations to Implement for details about adolescent-friendly services and providers). Consideration of adolescent-friendly services is important to establishing rapport and trust between the provider and the adolescent.
At the end of this section are templates to use for developing your database of adolescent-friendly referral partners. This template serves as a starting point; it is not all-encompassing and should be adapted to meet your organization and community’s needs. Within the database, it is strongly recommended you develop three lists to distinguish:
- Sexual and reproductive health providers
- Mental health providers
- Other providers and resources
These lists are essential to providing multiple sources of support for adolescents’ encounters with the healthcare system. As the Total Teen Assessment is designed to identify SRH and MH needs, it is critical your organization take the time to establish a robust and well-rounded database of adolescent-friendly referral partners.
Click here to download Steps to Establish a Network of Adolescent-Friendly Partners.
Tips for Referral Best Practices
- Have patients identify sources of support they are comfortable contacting as needed.
- Incorporate more than just referrals in your practice; provide patients with adolescent-friendly resources (both local and national) that provide reliable information based on the patients’ needs.
- For patients that have a referral within one month:
- Confirm they attended their appointment.
- If the patient did not attend the appointment, help them schedule a new one.
- For patients with referrals exceeding one month:
- Identify a staff member who can contact the patient every two weeks to check-in on the status of their referral appointment.
- For patients with more acute needs, consider scheduling regular check-ins (until they are able to see a specialist) to monitor symptoms and concerns. If symptoms appear to worsen, discuss options for more immediate treatment or intervention.
Click here to download a Sexual and Reproductive Healthcare Providers worksheet.
Communication
The third pillar of adolescent patient-centered care is communication, which is the interpersonal communication between providers, patients, and various stakeholders. Communication about Total Teen should begin before healthcare appointments, and continue throughout the appointment.
During appointments, conversations between providers and adolescent patients may be centered around sensitive topics. Motivational interviewing (MI) and coaching are two types of communication techniques deemed effective with difficult conversations and sensitive topics, and addresses ambivalence to change. Providers and other adolescent points of contact in the clinic should consider completing MI or coaching training as part of their professional development.
Informational Resources
Adolescent-friendly resources related to sexual and reproductive health (SRH) and mental health (MH) should be available and displayed throughout the clinic facility (e.g., waiting rooms and exam rooms). After completing the Total Teen Assessment, encourage the adolescent to browse some available resources while they wait for their primary care provider. Visual displays may include:
- Informational posters, cards, or pamphlets
- QR codes (which link to online and/or local resources adolescents can access through their personal devices)
Consider developing a list of adolescent-friendly resources for your patients. The list should state what each resource offers for adolescents, and provide a direct link to the resource. The list should specify if the resource provides information or services (whether virtual, in-person, or both). For service-based resources, include the services provided, population(s) served, cost of services, and experience working with adolescents. Example Health Resources for Teens can be found at the end of this section to use as a starting point. It is important to include both local and national scale resources that provide accurate and reliable information for teens; include local non-profits, businesses, or social service organizations.
When possible, work with your communications team to create a version of this list that can be distributed to adolescents and made available online. This list should use graphics and be catered towards adolescents in a way that is visually appealing.
Click here to download Health Resources for Teens.
Considerations for Accessing Online Resources
Adolescents may need guidance on how to securely access the information provided through the QR codes or other links. Many sites on the “Health Resources for Teens” list are equipped with a “quick exit” function, which clears browser history and closes the web page being viewed. Consider informing adolescents about the importance of clearing the browser history on personal devices (and those distributed by schools) that are not private and may be seen by parents/guardians or others who are able to access and monitor their devices.
The resources shared in this list are adolescent-friendly, but adolescents may decide to explore the internet for other sources of information. Adolescents should be briefed on online safety topics such as protecting sensitive information and avoiding malicious websites. Organizations are encouraged to refer adolescents to online safety resources, such as:
- NetSmartz, an online safety program created by the National Center for Missing & Exploited Children to increase youth awareness of online risks and to prevent victimization by making safer choices on- and offline.
- Common Sense Education’s Digital Citizenship, which provides lessons to help youth (grades K-12) understand how to use technology responsibly.
Information for Parents/Guardians
Advanced notification to parents/guardians about Total Teen, before arriving for appointments, is highly recommended and may be important for staying on time with provider appointments and scheduling. Consider including information about Total Teen in appointment reminders, along with ideal patient arrival times to ensure scheduled appointments remain on-time.
During the check-in process, parents/guardians should be informed of the following:
- Their adolescent may complete the Total Teen Assessment.
- Their adolescent may complete a micro visit to discuss sensitive health matters.
- The importance of allowing their adolescent the opportunity to be autonomous and independent.
To make Total Teen part of regular care, we recommend organizations implement it as an opt-out practice. Refer back to the Coordination section for information on Consent and Assent recommendations and procedures.
Click here to download Sample Script: Check-In.
Information for Adolescent Patients
To fully embrace the adolescent-centered nature of Total Teen, it is important to inform adolescents about the practices and provide them with a choice to participate. When communicating with adolescents about Total Teen, it is important to speak directly to them, and not just their parent/guardian, to facilitate a sense of autonomy.
Use the Sample Script at the end of the section during the check-in process to inform both the adolescent and their parents/guardians about the new procedures. Consider adapting the language to best fit the needs of your community and patient population.
Information for Providers
Total Teen incorporates an assessment to screen for SRH and MH needs into all visits and provides immediate follow-up consultations for appropriate services. The assessment not only screens for needs, but facilitates discussion between patients and providers about questions and concerns regarding sensitive health topics. These types of discussions allow providers to more holistically evaluate patient health and connect patients to services that may otherwise not be accessed. Detailed information on the assessment is provided in the Care section.
As a provider, you should assure adolescent patients their conversations with you will remain confidential under most circumstances. You should discuss confidentiality policies with them, including conditions under which you cannot uphold confidentiality. It is crucial you clearly explain to adolescent patients what information cannot be kept confidential, and warrants mandatory reporting. It is critical that you be very clear and concrete about what constitutes mandatory reporting, and what will remain confidential. You do not want patients worried that you will report minor things (e.g., smoking a cigarette) and then withhold information from you. A Confidentiality Sample Script is provided at the end of this section to use as a starting point.
Providers should remember that to maintain confidentiality, not all conversations with adolescent patients should be documented in medical records. As HIPAA regulations generally allow a parent/ guardian to have access to medical records for their children under the age of 18, it is imperative that providers document any details regarding confidential conversations in a secure manner that is not accessible to parents/guardians. It is the responsibility of each organization to determine the best process for providers to take notes on confidential conversations in a manner that is secure and separate from appointment information accessible to parents/guardians.
Administering the Total Teen Assessment
The Total Teen Assessment helps providers identify adolescents’ health needs, while connecting them to appropriate support and services. After the adolescent patient checks in and while the vital check is being conducted, a clinic staff member (e.g., a medical assistant, nurse, etc.) will provide the patient with an iPad or tablet with the assessment preloaded. Below is a set of talking points for administering the assessment; a sample script for Administering the Assessment is provided at the end of this section.
- Inform the adolescent you have a short assessment for them to complete.
- Give the adolescent the clinic-provided tablet with the assessment on-screen.
- Explain to the adolescent what the Total Teen Assessment is and how it works.
- Let the adolescent know their results are private and confidential (i.e., they will not be discussed or shared with their parents/guardians unless the adolescent wants to).
- Give the adolescent privacy to complete the assessment on their own.
- Before leaving the room, let the adolescent know a QR code will appear on the last screen, which they can use to access interactive activities and educational resources while they wait.
Once the assessment is complete, a clinic staff member (e.g., a medical assistant, nurse, etc.) can leverage the assessment score to identify key talking points and set them up with a micro visit as needed. Organizations should refer to their workflow to identify which personnel will be responsible for this task.
Once the assessment results are available, you should:
- Explain the results and potential needs identified through their results.
- Ask the adolescent if they have ever discussed SRH or MH with another healthcare provider.
- Allow the adolescent to ask questions and discuss concerns they may have.
- Recommend or provide adolescent-friendly resources for the patient to explore.
The next steps will vary by adolescent depending on their assessment results. You should recommend immediate micro visits and make referrals to adolescent-friendly providers as needed. Refer back to the Coordination Section for specific actions to take based on assessment results.
Click here to download Sample Script: Confidentiality.
Talking with Adolescent Patients
Conversations with adolescent patients will vary based on multiple factors, including but not limited to: comfort, knowledge and awareness, culture, communication styles, experiences, etc. However, in every conversation, the provider should take the following actions:
- Introduce themself (name and pronouns).
- Ask the patient their name and pronouns.
- Ask the patient something about themselves to establish rapport (e.g., school, friends, hobbies, etc.).
- Thank the patient for coming in and completing the Total Teen Assessment.
- Ask the patient for permission to discuss the assessment results.
- Define patient-provider confidentiality, explaining what constitutes conditional confidentiality and mandatory reporting.
- Ask patients what questions they have for the provider.
Throughout the appointment, providers may ask teens a range of questions to learn more about patients , their health habits, and potential needs. Below is a list of potential questions to guide the confidential conversations. Both open and closed-ended questions are included. Some teens will be uncomfortable talking with an adult or professional about sensitive topics, therefore use your judgment and experience to find what works best with each patient. A sample script for Opening the Conversation is provided at the end of this section.
Click here to download Sample Script: Opening the Conversation.
Discussing the Assessment Results After completing the Total Teen Assessment, the primary care provider should review the results with the adolescent to determine next steps (e.g., providing resources, completing a micro visit, providing a referral to another provider or specialist, or scheduling a follow-up appointment at a later date, etc.). Follow the steps listed below when discussing assessment results with adolescents:
- Explain patient-provider confidentiality and disclose what constitutes mandatory reporting (give examples).
- Discuss assessment results with the patient so together you can decide on next steps.
- Allow the patient to ask any questions they may have.
- Remind the patient about confidentiality.
After reviewing both the SRH results (healthy relationships, STIs, and contraception) then the MH results (depression, anxiety, and substance use), follow the steps below based on the patient’s scores:
A sample script for Discussing Assessment Results is provided at the end of this section. Patients with moderate to high needs may require services from a specialist or another clinic. If making a referral, it is important to state:
- Why you are making a referral to another provider.
- Who the provider is you are referring the adolescent patient to.
- What makes the provider adolescent-friendly and trustworthy.
- What the adolescent can expect from the provider they are being referred to.
Once you and the adolescent patient finish talking about their results and associated confidential matters, invite their parents/guardians to join the rest of the appointment. It is your responsibility to ensure any confidential topics discussed during the one-on-one time are not disclosed to parents/guardians, unless stated by the adolescent.
Tips for Talking with Adolescent Patients
- Use age-appropriate language, and recognize the developmental differences in adolescent patients (compared to children or younger patients).
- Ask patients to repeat information back to you in their own words to ensure their understanding.
- Be aware of body language; avoid expressing shock from a patient’s response.
- Maintain a tone of mutual respect and understanding; take care to not sound condescending.
- Reassure patients and make them feel in control of what they are going through; recognize the strengths in their stories and experiences.
- Validate the patient; listen to them and make it a two-way discussion rather than a checklist of questions and answers.
Section in Review
Communication throughout the entirety of an adolescent’s appointment is vital in making them feel comfortable and assured they have autonomy in their health. This section focused on communication in the clinic, communication with parents/ guardians, and communication between providers and adolescent patients. The following list summarizes key information and tasks from this section:
- Adolescent-friendly resources related to SRH and MH should be available and displayed throughout the clinic facility (e.g., waiting rooms and exam rooms).
- Assuring adolescent patients that their conversations with providers are confidential can encourage and facilitate honest discussion about sensitive topics.
- Providers should discuss conditional confidentiality with their adolescent patients. It is especially important to describe circumstances where confidentiality cannot be upheld.
- After completing the Total Teen Assessment, the provider should review the results with the adolescent to determine next steps (i.e., providing them with resources, completing a micro visit, scheduling a follow-up appointment at a later date, or referring the patient to another clinic or specialty provider, etc.).
The next section focuses on the final pillar of adolescent patient-centered care with an emphasis on confidential care and providing patients with a safe space to talk about sensitive topics.
Care
The fourth and final pillar of Total Teen is care, which refers to the process of providing confidential care to adolescent patients to meet their needs and facilitate independent navigation of the healthcare system. Care within Total Teen includes an adolescent-friendly environment, adolescent-friendly providers and staff, an assessment tool, and follow-up micro visits or referrals.
Total Teen Assessment
The Total Teen Assessment includes evidence-based question sets related to sexual and reproductive health and mental health. The assessment is administered electronically via a tablet or iPad to match adolescent communication preferences and to ensure confidentiality. The assessment screens patients for additional needs and provides adolescents with the opportunity to seek additional services (i.e., SRH and/or MH) through micro visits or referrals. Scores are calculated immediately based on the responses and displayed at the end for providers and patients to discuss together.
The following sections describe the three main components of the assessment (sexual and reproductive health, mental health, and substance use). The question sets focused on SRH and MH should not be modified without consulting the developers of Total Teen for approval. However, the demographics questions can be adjusted to meet organizational and EMR/EHR needs.
Click here to download Total Teen Assessment.
Sexual and Reproductive Health Question Set
The first question set in the assessment focuses on patients’ sexual and reproductive health (SRH) needs. While questionnaires exist for public health surveillance and documenting the detailed sexual health history of patients, the developers of Total Teen found no known validated tools used to assess adolescents’ need for SRH services at the time of development. However, national associations recognize the importance of assessing adolescent sexual health behaviors to ensure needs are met through programs and services. Therefore, the developers reviewed existing questionnaires to develop a question set that could be scored, based on answers, to identify level of SRH risk among adolescent patients.
Patients answer questions pertaining to relationships, sexual history, sexual activity, contraceptive use, and sexually transmitted infections. Skip-logic is used for patients who indicate they are not sexually active to display relevant questions based on their answers and experiences. Below is a summary of how scores are determined to identify potential need for services.
The Sexual and Reproductive Health question set concludes by asking if the adolescent would like to speak to a provider about SRH questions. If an adolescent answers “yes” to this question, regardless of how they scored on the assessment, providers should discuss questions and concerns as able, or initiate a referral as appropriate.
Mental Health Question Set
The second question set assesses patients’ mental health needs using the PHQ-931 and GAD-2.32 The PHQ-9 comprises 9 questions to assess major depressive disorder. Scores are calculated based on responses ranging from 0 to 3 (“not at all” to “nearly every day”). The GAD-2 comprises 2 questions to screen for generalized anxiety disorder. Similarly, scores range from 0-3 (“not at all” to “nearly every day”). Results are delineated by each assessment, with the PHQ-9 score ranging from 0-27 and the GAD-2 score ranging from 0-6. Below is a summary of how scores are determined based on the literature.
The Mental Health question set concludes by asking if the adolescent would like to speak to a mental health provider. If an adolescent answers “yes” to this question, regardless of how they scored on the assessment, they should be referred to an appropriate provider.
Substance Use Assessment
The final question set comprises nine questions focused on substance use and is based on the Screening to Brief Intervention (S2BI) Tool. The questions ask about use of tobacco, alcohol, marijuana, and other substances. Responses range from “never” to “weekly or more.” If the adolescent indicates use on a monthly basis for any of the substances in question, this indicates moderate need. If the adolescent indicates weekly use for any of the substances in question, this indicates high need. For any “yes” responses, regardless of frequency, an immediate consult or a referral for mental/behavioral health counseling is recommended. More severe cases (i.e., more frequent use and moderate to high need) will require a brief, motivational interview to be conducted by a licensed behavioral health counselor.
Administering the Assessment
The Total Teen Health Assessment is meant to be administered to adolescents during their vital check. Therefore, medical assistants or nurses will likely administer it following the steps below: (refer back to the Communication section for accompanying scripts to use).
- During the vital check, hand the tablet to the adolescent patient and briefly describe the assessment and its purpose.
- Let the adolescent know they will immediately receive assessment results when finished and encourage them to browse adolescent-friendly resources while they wait to see their provider.
Reviewing Assessment Results
Upon completing the assessment, the results will be presented to adolescents to help them understand their scores. This information is presented in an adolescent-friendly format that focuses on opportunities to improve their overall health based on identified needs. The next page, intended for providers’ use, displays the patient’s individual responses (delineated by question and section) to identify the patient’s needs for further discussion and referrals.
When reviewing assessment results with patients, providers should complete the actions listed below. For potential scripts and best practices for communicating with adolescent patients, refer back to the Communication section.
- Greet the patient and initiate introductions. Start by introducing yourself and having the patient introduce themselves. Consider beginning with small talk to get to know the patient and establish rapport before jumping into the assessment results.
- Acknowledge completion of assessment and results. Thank the patient for completing the assessment and ask permission to discuss results with them.
- Explain the assessment results. Explain what the assessment results and scores indicate, noting positives first.
- Address the assessment results. Scores may not indicate a need for follow-up services. However, scores and associated health behaviors should be addressed and discussed. This is a chance to commend positive health habits and recommend other positive, preventative habits.
Providing Immediate Services
Total Teen aims to increase access to SRH and MH services. The assessment provides a means for identifying adolescents in need of additional SRH and MH services. For patients with assessment results indicating moderate-to-high need, healthcare organizations should provide immediate care when able, or connect patients to other adolescent-friendly service providers as appropriate.
Sexual and Reproductive Health (SRH)
SRH follow-up discussions and micro visits may focus on topics including, but not limited to:
- Contraceptive counseling and prescriptions
- STI transmission, testing, and treatment (including HIV)
- Gender identity
- Sexual orientation
- Puberty (growth and development)
- Healthy relationships
- Sexual partners
Contraceptive Counseling
Clinicians providing SRH follow-up care and services should be trained in adolescent-friendly contraceptive counseling to help adolescents make informed decisions regarding contraception. If clinicians are able to prescribe hormonal or procedure-based contraceptive methods the adolescent wants to try, they should do so. When discussing contraceptive options, it is pertinent the provider discusses the realities of parents/ guardians seeing contraceptive prescriptions on insurance documents or being notified when picking up a prescription.
Contraceptive counseling should not be limited to female patients, but rather should be provided for all adolescent patients. As part of the counseling process, free condoms should be offered to all patients. Providers can encourage patients to talk to their partners about coming in to learn about the different contraception options available.
During this time, providers also need to be prepared to discuss matters around LGBTQ+ identities, orientations, and experiences.
STI Testing and Treatment
Ideally, healthcare organizations should provide STI testing on-site to eliminate barriers and expedite potential treatment and follow-up care. If your organization is not able to provide STI testing on-site, assist the adolescent patient in scheduling an appointment with an adolescent-friendly referral partner.
Mental Health (MH)
Mental health services should be provided to adolescents who need mental health or substance use support. Organizations adopting Total Teen will either provide face-to-face counseling services, telehealth services, or facilitate referrals with partner organizations and providers. Any additional costs incurred might not be covered by insurance and should be addressed with the patient.
Mental Health consultations may focus on topics including, but not limited to:
- Stress relief
- Coping strategies
- Anxiety
- Depression
- Substance use
- Relationships
Section in Review
This section focuses on strategies to provide more holistic adolescent-friendly care through the Total Teen Assessment and providing immediate SRH and MH services as needed. The following list summarizes key information and tasks from this section:
- The Total Teen Assessment provides a means for identifying SRH and MH needs among adolescent patients. Organizations should tailor the assessment to fit their community without compromising the evidence-based question sets included.
- Immediately after completing the assessment, results should be discussed with patients in a confidential manner to discern appropriate next steps (providing micro visits and referrals as appropriate).
- Every appointment should conclude with the provider commending the patient’s positive health behaviors and promoting other positive health behavior changes.
- Providers should ensure they maintain patient-provider confidentiality throughout the micro visit and remaining appointment so as not to disclose any unapproved information to parents/guardians.
- Providers should involve adolescent patients in decision-making as often as possible.