The Journal of School Nursing2022, Vol. 38(6) 526–532© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520975745journals.sagepub.com/home/jsn
Abstract
Nationally, there are low rates of high school–age youth receiving health care transition (HCT) preparation from health care providers. This pilot study implemented and assessed the use of a structured HCT process, the Six Core Elements of HCT, in two school-based health centers (SBHCs) in Washington, DC. The pilot study examined the feasibility of incorporating the Six Core Elements into routine care and identified self-care skill gaps among students. Quality improvement methods were used to customize, implement, and measure the Six Core Elements and HCT supports. After the pilot, both SBHCs demonstrated improvement in their implementation of the structured HCT process. More than half of the pilot participants reported not knowing how to find their doctor’s phone number and not knowing what a referral is. These findings indicate the need for incorporating HCT supports into SBHCs to help students build self-care skills necessary for adulthood.
Keywordsschool-based clinics, health education, qualitative research, evidence-based practice
School-based health centers (SBHCs) are an important model of health care delivery that provides comprehensive health care to students in 48 states. During the 2016–2017 school year, 1,860 high schools in the United States (11%) had access to a SBHC (Love et al., 2019). SBHCs offer a range of primary care and behavioral health services to a population of youth who commonly reside in impoverished communities (Love et al., 2019). They have been shown to reduce disparities and improve health and education outcomes (Keeton et al., 2012).
In the District of Columbia, there are seven SBHCs funded by DC Health. Two of which are managed by an academic health system, two by a community health center, and three by a children’s hospital. Two of these SBHCs, managed by MedStar Georgetown University Hospital, are featured in the health care transition (HCT) pilot study described in this article. They offer full-service preventive and sick care, behavioral health services, reproductive health services, prenatal care, and social support services (District of Columbia Health, 2020a, 2020b). Each of these SBHCs employs a team of health care providers that includes a nurse practitioner and/or physician, nurse-midwife, psychology extern and/or social worker, and patient services supervisor.
HCT is the process of moving from a child/familycentered model of pediatric care to a patient-centered model of adult health care. While transition to adulthood is widely recognized as a critical developmental stage often associated with risk and vulnerability, assistance with HCT is an often overlooked component of pediatric and adult health care (Lebrun-Harris et al., 2018). Nationally, most youth aged 12–17 with (83.3%) and without (86.1%) special health care needs report not receiving HCT planning support from their health care providers (Lebrun-Harris et al., 2018). Further, many young adults do not continue care with a primary care provider (PCP) as they enter adulthood, resulting in their significantly lower ambulatory utilization rates and higher emergency room rates (Bonnie et al., 2015; Spencer et al., 2018). Having a structured HCT process in place is an effective way for ensuring access and use of ambulatory care into adulthood, gaining consumer satisfaction, engagement, and improving population health (Gabriel et al., 2017; Schmidt et al., 2020).
Drawing on the evidence-based HCT recommendations called for in the clinical report published by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP), a collaborative partnership was formed in 2017 to pilot and replicate a structured HCT process in SBHCs using the Six Core Elements of HCT™ (Cooley et al., 2011; White et al., 2018). This partnership involved the National Alliance to Advance Adolescent Health (the National Alliance), which operates the national HCT resource center (Got Transition™), and MedStar Georgetown, which operates two SBHCs as part of its comprehensive care delivery network. The Six Core Elements include the following: (1) transition policy, which describes the clinic’s approach to HCT; (2) transition tracking and monitoring, which allows for monitoring of youth receipt of each core element; (3) transition readiness, which examines youth self-care skill needs; (4) transition planning, which ensures the development of a plan of care with readiness assessment (RA) findings, goals and prioritized actions, and a medical summary; (5) transfer of care, which includes preparing a transfer package and assisting with finding an adult PCP; and (6) transfer completion, which ensures transfer completion and feedback (Got Transition, 2014).
With funding support from DC Health, this 3-year effort aimed to answer the following research questions: (1) Can SBHCs incorporate the Six Core Elements into routine care? and (2) What are self-care skill needs among students aged 18 and older regarding their own health and using health care? We addressed these questions through (1) customization and piloting of the Six Core Element tools and HCT processes in one SBHC (Got Transition, 2014) using quality improvement (QI) methods, (2) replication of the Six Core Element tools and HCT processes in a second SBHC, (3) measurement of the implementation of the Six Core Elements, and (4) assessment of HCT readiness self-care skill needs among students. This represents the first time the Six Core Elements were used in SBHCs.
This pilot study, which sought to increase HCT services in SBHCs using QI methods, included two SBHCs, A and B, at public high schools in Washington, DC, and focused on students in Grades 9–12 during the 2017–2019 school years. SBHC A was the first site to pilot the study, and SBHC B replicated the pilot study from SBHC A the following year. Institutional review board’s approval was obtained from MedStar Georgetown University Hospital (IRB#2016-0817) and DC Health (IRBPH#2017-21) for those aged 18 and older in this pilot study as well as a memorandum of agreement with DC Public Schools.
The 2018 AAP/AAFP/ACP clinical report on HCT recommends the Six Core Elements of HCT and was used as the guiding framework for this study (White et al., 2018). Both SBHCs elected to customize three HCT tools from the Six Core Elements, which included a transition policy (Online Appendix 1), a transition RA (Online Appendix 2), and a one-page resource about finding an adult doctor after leaving high school (Online Appendix 3).
The intent of the transition policy was to inform students about the medical and HCT services available at the SBHC and their rights regarding privacy and consent. The transition policy was publicly displayed in the SBHC entryway and exam rooms, handed out to newly enrolled SBHC students, and reinforced verbally by SBHC staff during initial visits with students.
The transition RA was used to assess what students know and want to learn about their own health care and how to use health services in preparation for adult health care. The transition RA included two questions where students could rate, on a scale from 0 (not) to 10 (very), how important it is and how confident they are in their ability to change from the SBHC to an adult doctor after leaving high school. At both SBHCs, the patient services coordinator shared a blank transition RA with the student while they waited for their preventive care visit. In SBHC A, the transition RA was completed by the student on an iPad. In SBHC B, the transition RA was completed by the student in paper form. Results from the completed transition RA were reviewed by the PCP as part of the preventive care visit and added into the electronic medical record (EMR) with identified self-care skill needs noted in the patient’s problem list. HCT education was provided through one to two small group sessions with lunch provided at each school. The sessions focused on helping students understand how to navigate adult health care and maintain insurance in college.
The resource on “How to Find an Adult Doctor” was created for students to identify conveniently located primary care practices accepting Medicaid along with information on accessing health insurance, behavioral health care, and sexual/reproductive care after they leave high school. The resource was shared with students who visited the SBHC, used in small group lunch sessions with SBHC staff, and disseminated along with school-wide information about graduation. All the customized HCT tools for this pilot study were reviewed by staff and students in a Plan-Do-Study-Act cycle to ensure the questions and information were clear, easy to understand, and written at an appropriate reading level. All customized HCT tools were also translated and available in Spanish.
To assess the extent to which the SBHCs offered and improved the recommended HCT services during the pilot study period, Got Transition’s current assessment of HCT activities was customized for use in SBHCs. This assessment has been widely used in other health care settings to measure HCT process improvements (Jones et al., 2019). The assessment rates the level of implementation of each of the Six Core Elements from Level 1 (basic) to Level 4 (comprehensive). The summation of reported levels for each core element is the overall score. The scores can range from 8 to 32, with 8 being the lowest score of HCT implementation—scoring Level 1 on each core element—and 32 being the highest—scoring a Level 4 on each core element. For complete definitions and criteria of each level within each of the Six Core Elements, see Online Appendix 4. This assessment was administered by the National Alliance and was completed by the clinical lead from each SBHC before the start of their respective school year (baseline) and at the 12- month time point (post-baseline). The same clinical lead at each SBHC completed the assessment both times. The National Alliance analyzed the results to determine changes in levels of each core element, the overall score, and any differences between SBHC A and SBHC B. Because this was the first time the Six Core Elements were implemented in a SBHC setting, the National Alliance sought feedback from the clinical leads at both SBHCs via a combined qualitative interview to elicit feedback about their experience incorporating the Six Core Elements into routine care processes, using QI methods, and sustaining the process beyond the pilot study period.
To examine the self-care skill needs of students, the SBHCs obtained consent from 25 students, who were aged 18 and older, to complete a transition RA as part of this pilot study. Their transition RA results were de-identified and securely shared with the National Alliance for analysis. None of the students in the pilot completed the transition RA more than once. The transition RA results from both SBHCs were analyzed together and are shown in Table 1.
In 2018, SBHC A registered 54% (255) of students enrolled in School A (468), and SBHC B registered 44% (305) of students enrolled in School B (690). Almost all students in SBHC A identified as African American (99%), and in SBHC B, 54% identified as African American and 45% as Hispanic/Latino (District of Columbia Public Schools, 2017). Schools A and B report 95% and 65% of students eligible for free and reduced price lunch, respectively (District of Columbia Hunger Solutions, 2019).
Improvements were made in both SBHCs in implementing the Six Core Elements over a 12-month period. Out of a total possible score of 32 on the current assessment of HCT activities, SBHC A improved from a baseline of 8 to 16 over the course of a year, while SBHC B, which replicated the pilot study from SBHC A, improved their score from 8 to 20, 12 months post-baseline. Both SBHCs showed the greatest improvement from baseline in transition policy (Table 2). After 1 year, SBHC A scored highest on transition policy (Level 3) and transfer completion (Level 3); SBHC B scored highest on transition policy (Level 4) and transition readiness (Level 4), followed by transition planning (Level 3) and transfer of care (Level 3). Both SBHCs did not show improvement in youth feedback or youth leadership.
The SBHCs’ clinical leads reported that having a transition policy, offering RAs, and sharing the resource on finding an adult doctor were “important additions to our program and were very useful for students who are graduating.” The challenges mentioned for incorporating HCT into routine care were related to standardizing the HCT process, needing to create EMR reminders, incorporating additional time during busy preventive care visits, and including all SBHC team members in the process. When asked about plans for continuing to offer HCT services to students enrolled in the SBHCs, both medical directors responded affirmatively. A few suggested changes included possibly shortening the RA, having nurses use an HCT checklist, and improving the functionality of the EMR system to include HCT.
The SBHCs’ medical directors offered suggestions for replicating the pilot study in additional SBHCs in DC and nationally. These included adding HCT requirements in SBHC contracts, recognizing HCT-related billing codes, expanding HCT QI and learning collaborative opportunities, and allowing a sufficient time period of at least two years to implement HCT QI processes in SBHCs.
Consented students who completed the RA reported a moderately high rating of importance and confidence in their ability to make the change from the SBHC to an adult doctor after leaving high school. On average, students gave a rating of 7.6 out of 10 on the importance of changing from the SBHC to an adult doctor after graduation and a 7.7 out of 10 on their confidence in their ability to change from the SBHC to an adult doctor.
Table 1 shows HCT RA self-care skill needs, from the lowest to the highest proportion of respondents marking “yes I know this skill.” The self-care skill needs with the lowest proportion of respondents marking “yes I know this skill” were related to knowing how to find the doctor’s phone number (52%) and knowing what a referral is (52%). The self-care skill needs with the highest proportion of respondents marking “I want to learn this skill” were related to making their own doctor appointments (42%) and carrying important health information, such as an insurance card, allergies, medications, and emergency contact information (40%).
While previous studies in primary and specialty care, managed care, and FQHCs have shown positive HCT process improvements in implementing the Six Core Elements (Jones et al., 2019; White et al., 2018), this was the first time that a structured HCT process has been introduced into SBHCs. This pilot study demonstrated the feasibility of and progress in instituting a structured HCT process into SBHCs. The pilot also revealed needed areas of improvement for SBHCs, particularly around youth feedback and leadership. Efforts such as establishment of formal youth advisory boards provide students the opportunity for leadership positions and student input on HCT improvements. Additionally, this study highlighted students’ self-care skill needs such as knowing how to navigate care (e.g., finding doctor’s phone number, making an appointment, and carrying important health information such as an insurance card). These results, albeit from a small sample, indicated the need for early and ongoing HCT education for high school students.
Although this study has several strengths, there are limitations to consider. Due to the small sample size, the transition RA could not be evaluated using a pre- and post-test method. This was the result of low recruitment rates of students aged 18 and older at each of the SBHCs, many of whom joined the pilot study toward the end of the school year. In addition, it was difficult to track students after graduation and leaving the SBHCs, and therefore, further complicated obtaining data on students’ experiences with the HCT intervention and their ability to successfully transition to adult primary care compared to same-age students accessing services at SBHCs without an HCT intervention. Moreover, another concern was the potentially stigmatizing wording of the transition RA item, “If it applies to me, I know where to go if I have mental health needs.” This could be improved by rephrasing to “I know where to go if I would like to get counseling or help for behavioral health.” Finally, prior to the pilot implementation, student feedback by SBHC staff was requested during the development of a tailored transition RA, such as the use of specific terms. Given that SBHCs are often staffed by nursing professionals, students were asked for feedback over whether they preferred the term “doctor,” “primary care provider,” or “nurse practitioner” when referencing clinical staff. The majority of students preferred the term “doctor” and seldom distinguish between clinic staff members. This study did not obtain feedback from all clinic staff, only the medical leads. Even with these limitations, this pilot study demonstrated HCT process improvements and continued needs for HCT skill-building among students.
Since this initial SBHC HCT pilot study, three additional SBHCs in DC and SBHCs in Michigan, Illinois, and Connecticut have begun to replicate a similar approach. Expanding the availability of HCT preparation support in SBHCs represents an important strategy for improving state and national performance on HCT and reducing disparities in continuity of care among low-income youth who are leaving the convenient care that SBHCs offer (Lebrun-Harris et al., 2018).
SBHCs interested in replicating this HCT approach can pursue a similar strategy by using or customizing the measurement and clinical tools described in this pilot study. Each SBHC could begin by deciding which core elements to integrate into the clinic process and how best to accomplish this. This may be done by aligning HCT priorities with existing clinic priorities. The implementation guide produced by Got Transition can be used to guide the improvement process (White et al., 2020). At the outset, special attention should be given to strengthening youth feedback and leadership. Building a youth advisory group to elicit input from youth with different perspectives (e.g., different ages, ethnicities, and races) into the improvement process can offer critical insight into reaching peers in planning for HCT. In addition, feedback from all SBHC clinic staff about their experience integrating HCT processes should be elicited. Further, it is important to foster strong, productive relationships with school leadership as well as partner with other health personnel within the school, including school nurses, special educators, school mental health clinicians, peer support groups, health educators, physical education teachers, and graduation counselors, to garner support from those with firsthand insight on what they experience and how the system and communication can be improved.
In schools without SBHCs, school nurses can play a critical role in developing HCT policy, programs, and tailored support for students with chronic illness. Opportunities to incorporate the Six Core Elements and HCT tools described in this pilot study can be used as part of student and/or parent orientation, school health education curriculum, and high school exit planning efforts. Due to numerous competing priorities that make incorporating HCT into existing school programming a challenge, starting with small additions can be a first step. For example, since many school nurses see students with chronic illness regularly, school nurses could start by assessing student self-care skills using the transition RA to identify and prioritize self-care skill gaps in the student’s knowledge and work with them to improve their needed self-care skills. Several resources from Got Transition could also be used to help students learn about self-care skills, including instructions on how to add health information into smartphones and information about privacy and consent changes that occur at age 18. If the students are nearing graduation, school nurses can help them consider how to find an adult health care provider in their postgraduation locale.
With respect to future research, additional studies are needed to better understand effective strategies to engage students in managing their own health care and learning the importance of staying connected to health care. Similarly, effective strategies are needed to encourage parents and health care providers in supporting this independence. Examining the design and use of college health systems may offer many instructive insights into adolescent engagement, building health literacy, and peer supports for young people.
By utilizing the Six Core Elements, health care providers in SBHCs have a unique opportunity to help students improve their HCT literacy, communicate their own health needs, and understand how to use health services. HCT is a team effort, with important roles to be played by schools and health care systems.
The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by the District of Columbia or the U.S. Government.
Patience H. White, Samhita M. Ilango, and Margaret A. McManus contributed to conception, design, acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Ana M. Caskin and Maria G. Aramburu de la Guardia contributed to acquisition, analysis, and interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project is supported by the District of Columbia Health under Grant Number CHA.PSMB.NAAAH.122015.
Samhita M. Ilango, MSPH https://orcid.org/0000-0003-4610-9928
The supplemental material for this article is available online.
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Patience H. White is professor of medicine and pediatrics at George Washington University School of Medicine and co-director of Got Transition.
Samhita M. Ilango is a health research/policy analyst at The National Alliance to Advance Adolescent Health/Got Transition.
Ana M. Caskin is a pediatrician at Medstar Georgetown University Hospital and the medical director of the school-based health center at Anacostia High School in Washington, DC.
Maria G. Aramburu de la Guardia is a is a pediatrician at Medstar Georgetown University Hospital and the medical director of the school-based health center at Roosevelt High School in Washington, DC.
Margaret A. McManus is the president of The National Alliance to Advance Adolescent Health and co-director of Got Transition.
1 The National Alliance to Advance Adolescent Health/Got Transition, Washington, DC, USA
2 MedStar Georgetown University Hospital, Washington, DC, USA
Corresponding Author:Samhita M. Ilango, MSPH, The National Alliance to Advance Adolescent Health/Got Transition, Washington, DC 20036, USA.Email: silango@thenationalalliance.org
