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HomeMy WebLinkAboutAgenda - 02-01-1993 - III-B 1 ORANGE COUNTY BOARD OF COMMISSIONERS Action Agenda Item No. .Zi-B ACTION AGENDA ITEM ABSTRACT Meeting Date: February 1, 1993 SUBJECT: Comprehensive Adolescent Health Care Project Grant Application DEPARTMENT: HEALTH PUBLIC HEARING: Yes X No ATTACHMENT(S) : INFORMATION CONTACT: HEALTH DIRECTOR'S OFFICE X2412 1. Letter from the coalition for Healthy North Carolina Youth TELEPHONE NUMBER: Hillsborough - 732-8181 2. Request for Proposals Chapel Hill - 968-4501 Mebane - 227-2031 3. The Grant Proposal Durham - 688-7331 PURPOSE: To authorize the Orange County Health Department to submit, on behalf of the Orange County Coalition for Healthy North Carolina Youth, a grant application for a comprehensive adolescent health care project. BACKGROUND: In the most recent Orange County Health Department Community Diagnosis, five of the eight top health problems, high number of unwanted pregnancies, poor pregnancy outcomes, increasing numbers of communicable diseases, increasing number of injuries due to motor vehicle accidents and increasing use of drugs and alcohol relate significantly to adolescent health care issues. The overall goal of the project is to: Enhance the physical, mental and social health of adolescents in Orange County by increasing access to and utilization of comprehensive health services. The objectives are the following: 1. Establish a primary health care clinic in the Carrboro (Southern Orange County) branch of the Orange County Health Department to serve 250 adolescents the first year by September 20, 1993. 2. Increase utilization of existing adolescent clinic in Hillsborough by twenty percent by June 30, 1994. 3. Develop an interagency network system to insure comprehensive care for adolescents in Southern orange County. 4. Establish a follow up record at both clinical sites. 2 5. Establish mode of transportation from schools to clinic to provide transportation for at least four students per clinic day by September 20 1993. 6 . Develop access to mental health services at both clinical sites. 7 . Increase availability of mental health services in school system in Hillsborough (Northern Orange County) by September 30, 1993. 8. Increase availability of mental health services in Chapel Hill/carrboro school system (Southern Orange County) by September 1994. 9 . Establish a follow up network in the Chapel Hill/Carrboro school system that insures linkage from school to clinic and clinic to school. 10. Develop an organized system to access any possible funds for care. The project is needed because adolescence is a time of great need when very important preventive work can be done. Many adolescents are unable to fulfill their potential due to physical and mental health problems which go untreated. Adolescents are the only population in the United States that has not experienced an improvement in health status over the past 30 years. In fact, a recent random survey of adolescent student health cards in the southern part of the county indicated that 16% had no medical provider and 19% used the emergency room for primary health care. The model in Northern Orange which incorporates the Health Department clinic, the Adolescents in Need program and the services of the school nurse has proven to be successful in accessing comprehensive care for adolescents. The clinic currently serves over 300 adolescents each year in over 400 visits. Based upon the percentages of Southern orange students with no regular primary care provider, this model is very much needed to serve this population. The grant is needed to provide the resources necessary to establish this service. The North Carolina General Assembly has appropriated $200,000 to fund four adolescent programs. Initial funding will be for a period of 15 months beginning in April 1993 through June 1994 with annual renewals available for the subsequent four years. $12,500 is available for the first three months. Funding is level at $50,000 for the first three years with years four and five reduced by 30 percent each. No matching funds are required. The funding will be used for a clinic manager, school nurse and physician time at .11 FTE each, medical and office supplies, medical equipment, and other operating expenses necessary to establish the clinic. Orange County's proposal was developed by a team of professionals representing the Adolescents in Need Program, both school systems and the Health Department with input from the area Mental Health Center. The development of an Orange County Coalition for Healthy North Carolina Youth is underway with invitations being extended to other key agencies, the local community health center - OCCHS, and private providers. RECOMMENDATION(S) : The manager recommends authorizing the Health Department to submit the grant application on behalf of the orange County Coalition for Healthy North Carolina Youth to the Division of Maternal and Child Health, the Department of Environment, Health and Natural Resources. ORANGE COUNTY ADOLESCENT HEALTH/CLINIC EXPANSION AND RENEWAL ORANGE COUNTY HEALTH DEPARTMENT DANIEL B. REIMER HEALTH DIRECTOR PROJECT TO SERVE ORANGE COUNTY CHAPEL HILL, CARRBORO, HILLSBOROUGH 4 NEEDS STATEMENT The adolescents of Orange County have significant problems with unintended pregnancy, poor pregnancy outcomes, sexually transmitted diseases, chronic disease, substance abuse, mental health problems, school dropout, poverty, poor access to health care, violence including homicide and suicide, injury, homelessness and delinquency. Orange County is an environment of contrasts. The county consists of seven townships with a total population of 93,851 persons. Three of the townships are urban with over two thirds of the county's population and the remaining five are rural. Eighty percent of the county residents are white, sixteen percent black, two and one half percent Hispanic, one percent American Indian and one half percent other. Throughout the proposal references to the county will be made as Southern Orange County which consists of Chapel Hill and Carrboro and Northern Orange County which consists of Hillsborough, Cheeks, Little River, Cedar Grove, Bingham and Eno. Orange County has 13,488 youth between the ages of 10 and 19. Of these, forty seven percent are males, fifty three percent females and twenty percent live in rural communities. There are two public school systems within the county, Orange County Schools (Northern Orange County) and the Chapel Hill/Carrboro City Schools (Southern Orange County) with a combined enrollment of approximately 9,145 students in grades six through twelve. Orange county is home to a state university and major medical center which is the largest employer in the county. The unemployment rate is slightly over two percent but there are nearly four thousand cases of public assistance per month and fourteen percent of residents live below the poverty level. Over sixty percent of mother's in Orange County work outside of the home. Despite the seemingly abundant availability of health care, the health needs of the urban and rural adolescent of Orange County are not being met. In a recent Orange County Health Department Community Diagnosis, five of the eight top health problems, high number of unwanted pregnancies, poor pregnancy outcomes, increasing numbers of communicable diseases, increased number of injuries due to motor vehicle accidents and increasing use of drugs and alcohol relate significantly to adolescent health care issues. Access to health care is a major problem for adolescents in both Northern and Southern Orange County. The primary barriers to services are unavailability of clinical sites and clinical hours, transportation to services, visibility of services in and outside of the school, quality confidential care that can be assured to any adolescent despite income or socioeconomic level, flexibility of services that considers the inherent differences in a culturally and racially diverse population and coordination of services with a means of intersecting services to enhance delivery and results rather than fragment. The primary sources of medical care for adolescents in Orange County are private physicians, Orange County Health Department (OCHD), University of North Carolina Hospital (UNCH) and UNCH-Emergency Room (UNCH-ER) and Orange-Chatham Health Services (OCCHS). At the present time there is no single numerical indicator as to who provides the bulk of medical care for Orange County adolescents. The OCHD is the only source of free medical care for adolescents in the county and in 1992 it provided unduplicated services to 887 adolescents ranging from the age of 11 to 21 with over 400 follow up visits. A crude estimate of how many adolescents do not have a known medical provider was found in a random survey of two middle schools' health information forms in Southern Orange County. Sixteen percent of health forms indicated that students did not have a known medical provider and nineteen percent indicated the use of the emergency room for primary medical care. Similar findings were found among fifth graders attending a grade school in Southern Orange County with twenty percent of health forms reporting no physician. In other words, there appear to be many adolescents that do not have an identifiable source of primary care. Approximately ten percent of children attending the public schools in Orange County are known to have a chronic disease (ex. cystic fibrosis, diabetes, hemophilia, sickle cell disease, seizures) or significant health problem ( asthma, acne, attention deficit disorder, obesity, dysmenorrhea, injuries) causing some degree of morbidity (absenteeism, poor self image, poor school performance). This estimate is similar to national figures but is probably lower than the actual number because those reported are largely of those students who return health information forms at the beginning of the year. According to school nurse records, Northern Orange County has twelve percent of sixth graders, fifteen percent of middle school students and thirteen percent of high school students that have significant health problems. In Southern Orange County, two percent of teens have health problems requiring an emergency medical plan at school. When mental health problems are included the percentage almost doubles. There are a large number of adolescents with primary medical and psychological problems causing some degree of morbidity, such as absenteeism, poor self image and poor school performance that are unknown to a primary care provider. Pregnancy In the U.S., over one million teens aged 10 to 19 become pregnant each year with a national rate of 109 pregnancies per 1,000 females and 44 abortions per 1,000 females between the ages of 15 and 19. Although, Orange County's total pregnancy rate (71.7 per 1,000) and pregnancy rate in the fifteen to nineteen year age group (62.6 per 1,000) continue to be lower than national and state rates, there is a significant number of unwanted pregnancies as indicated by a high number of abortions and the number of pregnancies in adolescents aged ten to seventeen. Orange County has the highest total abortion rate in the state (34.0 per 1,000) and ranks in the top ten counties for abortion rates in the fifteen to nineteen year old age group (46.1 per 1,000). In the past year there have been forty three known pregnancies in adolescent females within the two school systems, with eighty six percent of the pregnancies in high school students (ages 15-17) and the remainder in middle school students (ages 13 - 14). There is a striking discrepancy between total pregnancy rates (county rates, w 59.3, nw 121.4) and total abortion rates (county rates, w 24.6, nw 69.9) for the white and nonwhite populations in the state and county. A similar finding is seen in the fifteen to nineteen year old age group ( county pregnancy rates, w 47.5, nw 113.7, county abortion rates, w 36.6, nw 76.1). This same discrepancy between white females and nonwhite females found with total rates of inadequate prenatal care, Low Birth Weight (LBW) births, fetal deaths, neonatal deaths and infants deaths, Examination of the ten to nineteen year old age groups reveals that nonwhite females have significantly higher rates of inadequate prenatal care, LBW births and fetal deaths in contrast to white females having higher rates of neonatal deaths and infant deaths in the county and statewide. In other words, there are many unwanted pregnancies in adolescent females significant racial differences in pregnance related issues which appear to impact on the final pregnancy outcome. Sexually Transmitted Diseases In 1992, over 385 adolescents were seen at the OCHD-Sexually Transmitted Disease (STD) clinic for diagnosis and treatment of an STD with the majority (98%) between the ages of fifteen and twenty one. In North Carolina, for the year of 1991-1992, there were 29 adolescents between the ages of twelve and nineteen that tested positive for HIV and twenty one known cases of AIDS in the thirteen to nineteen age group. Orange County ranks in the top ten 6 counties for the rate of AIDS cases. Sexually transmitted diseases, especially AIDS, are of increasing concern for our adolescent population. Nutrition The nutritional needs of adolescents have become of significant concern as evidence indicates that children are more sedentary, fatter, less fit with immediate and long-term health consequences. It is estimated that eighteen percent of adolescents in Orange County are obese. Additionally, more adolescents are developing eating disorders such as anorexia nervosa and bulimia. The prevalence of obesity ,anorexia and bulimia among U.S. females ages 15-19 is 22%, 0.5% and 2.0%, respectively. Mental Health Despite the lack of baseline data to support advocating for the mental heath needs of adolescents in Orange County there is substantial anecdotal evidence to warrant the need for more mental health services. In four years of service at the Adolescent Clinic in the OCHD, it has become apparent that a substantial proportion of adolescents seeking care for medical problems suffer from psychological problems serious enough to warrant mental health treatment. It is the most prevalent issue not adequately addressed by the present health care system. In the school based Adolescents in Need project, the majority of adolescents followed on a regular basis have mental health problems causing significant morbidity. Problems range from post-traumatic stress syndrome secondary to the aftermath of physical or sexual abuse, loneliness, depression, suicidal ideations, loss of a parent through divorce or death, family dysfunction secondary to alcoholism, depression, schizophrenia and school truancy. In a review of forty four ongoing cases by school psychologist in Northern Orange County, forty three percent of clients were being followed for depression and suicidal ideations. During the present school year, in Northern Orange County, there have been two hospitalizations of adolescents for suicidal ideations and depression and one completed suicide in a child with known mental health problems. In Southern Orange County, three children, from three different schools were admitted for inpatient treatment of a mental health problem within the same week. Finally, over 900 contacts were made to a students involved in a Peer Helper Program (PHP) during an eight month period. Referrals were diverse with many centering around sexuality, loss/grief, depression, stress, academic pressure and relationships. Nationally, the prevalence rate for emotional and behavioral problems among urban and rural youth, aged 12 to 17, is 19.1% and 16.5%, respectively.Anecdotal evidence indicates that the mental health needs of adolescents in Orange County are diverse and unmet with the present system of care. Substance Abuse Tobacco and alcohol are the primary drugs abused by North Carolina youth. One out of every four North Carolina adolescents uses cigarettes or smokeless tobacco on a regular basis compared to one out of ten who use marijuana, cocaine or other drugs besides alcohol. According to a 1987 survey, drug use among North Carolina youth was found to be equal to or exceed the national average with almost 13 percent of students reported coming to school drunk or high at least once in the previous year. It is estimated that twenty percent of all students in the school system are projected to have or develop a problem with chemical dependency, serious enough to warrant intervention. A Student Assistance Program (SAP) in Southern Orange County Schools serves students for whom chemical dependency is a real or potential obstacle to personal or academic success. This past year 227 students were referred to SAP with twice as many white females being referred than the previous year and five students at one of the middle schools were referred for in-patient care. Substance abuse is a common problem in adolescents in Orange County and warrants further organized efforts at prevention and recovery. 7 Mortality In North Carolina the five leading causes of death among adolescents ages 15 to 19 are accidents, homicide, suicide, cancer and cardiovascular problems. Nationally, more than forty percent of deaths of sixteen to nineteen year olds are caused by motor vehicle accidents and ten percent by suicide. In Orange County, between 1988 and 1990, the rates of death among people under the age of 20 by accidents, both motor vehicle (9.90/100,000 ) and other (1.41/100,000), are 32% and 85% lower than the state, respectively. However, the suicide rate for Orange County adolescents (5.66/100,000) is 22% higher than that of the state and homicide accounts for four percent of deaths under the age of twenty. Social In Orange County almost thirteen percent of children aged 0-17 live at or below the poverty level. Approximately, 2,050 (21%) of Orange County Public school students receive free or reduced rate for meals. During 1987, 98 cases of child abuse or neglect were substantiated in children and adolescents aged 0-17 in Orange County. According to the North Carolina Advocacy Institute, Orange County ranked 90th in the state for reported cases. Nationally it is estimated that there as many as 1 million homeless and runaway adolescents each year. In Orange County nobody really knows how many children and adolescents are homeless, either living in homeless families or on their own, but in a recent survey done by social service agencies in Northern Orange County it was found that sixteen females aged 16 to 19 were found eligible for a group home setting secondary to homelessness as defined by presently living outside of their nuclear family and lack of a consistent place to live. Delinquency is a major problem in Northern and Southern Orange County. Presently, there are thirty five Northern Orange County youth involved in active probation cases and forty five Southern Orange County youth. The crimes are significant in that, if committed by adults, they would be punishable by the law. There are twenty adolescents who have been referred to the juvenile court as high risk for committing crime and are connected to a court counselor for appropriate referral and intervention. Academic Indicators School absenteeism secondary to medical and psychosocial problems is a significant issue for adolescents in Orange County. During the 1991 school year, there were 492 out of school suspensions and six long-term suspensions (remainder of year) for students in fourth through twelfth grade in Northern Orange County. The 1991 state dropout rate was 3.4 percent compared to Orange County's unduplicated dropout rate of 1.78 percent. The major reasons cited for dropping out were poor school attendance, health problems, child care issues and chronic discipline problems. Summary Orange county enjoys a low unemployment rate, a low school dropout rate, a low pregnancy rate, and a multitude of medical services. The real picture, however, is of a county with a high number of its citizens living below the poverty level, too many students out of school before completion of their education and a large number of adolescents who do not, for various reasons, have a regular source of medical care. Psychological services are limited. The quality of life depicted by the unemployment rate and average income figures does not give us a picture of the group of adolescents who live daily with chronic medical and psychological issues that can be best addressed by a comprehensive approach to medical care that is unencumbered by roadblocks such as confidentiality, transportation and finances. 8 OUTREACH PLAN In 1981 the UNC Department of Pediatrics developed a service project in Northern Orange County called Adolescents-in-Need. Links were established with the Orange County School System, the Orange County Health Department, Department of Social Services, Juvenile Court, Mental Health Center and church community that have proven to be essential in establishing preventive programs for adolescents. The program utilizes a nurse practitioner/social worker team based in the school system to meet with adolescents considered to be at high risk, including pregnant teens, parenting teens, teens at risk of becoming pregnant, depressed teens, teens not attending school regularly, and teens in need of mental health counseling. Counseling, guidance, referral and family home visits were provided to reduce the risk of untimely pregnancies, reduce the risk of dropping out of school, teach the teens to access the service delivery system and increase their self esteem. Referral networks were developed and the needs of adolescents, in terms of service delivery, became a goal of the entire county. Adolescents completed their education, pregnancy rates dropped, adolescent fathers were involved in their child's birth and resources such as scholarships for day care and day care services were developed. Major conclusions of the program were that a broader range of health care services was needed to address the medical, social and behavioral needs of adolescents in Orange County. Services were needed that focused on prevention and behavioral counseling with extension of services to the early adolescent age group. Further recommendation was that adolescents should be able to go to one location for evaluation and subsequent referral, as needed. In 1988, a program of primary health care services for adolescents was developed in Northern Orange County, at the OCHD, as a supplement to the existing Adolescents-in-Need Project. Through county funding, an Adolescent Clinic, located in the OCHD, is staffed by a physician and nurse one half day per week. Transportation is offered from school to clinic and the providers see 8-10 students per clinic day. Adolescents present with complaints ranging from acne to orthopedic problems to sexuality issues. On arrival to the clinic, adolescents fill out a screening form that helps them define how they are feeling (physically and emotionally) and facilitates recognition of stressors in their lives. This information is then used by providers to discuss issues relevant to the individual adolescent and make referrals back to local agencies to meet the unmet needs. The clinic staff consists of a medical provider from the Adolescents-in-Need Project and a school nurse employed by the Health Department. This creates a loop from school to clinic to Adolescents in Need Project (to home if necessary) and back to the school. This insures a flow of information between school, clinic and home. The Teen Clinic/Adolescents-in-Need concept currently reaches youth with information about services through the school nurse employed by the local health department, the school nurse employed by the school system, guidance counselors from the middle schools and the high school, coaches at these three schools,juvenile court counselors, mental health providers, health department staff, and peer helpers at the high school. The referral process flows from clinic to project and project to clinic. Thus students can receive information about the health and counseling services from any number of entry points. For the expansion concept in Southern Orange County we propose contacts with the helping agencies in that area. The steering committee will consist of representatives from the major agencies such as DSS, Mental Health, Public Health, Housing, local medical providers, schools, court counselors, etc. These members will advocate for clinic use and make referrals to the clinic on a regular basis through their agencies. The Chapel Hill/Carrboro School System has a number of parent and student organizations that will provide a unique opportunity to spread the word about the clinic. The School Health Advisory Board, made up of parents, professionals and -i- students plan health related activities for the school system. This group is currently active in several major teen health issues. The Peer Counseling program at the high school will be a wonderful avenue of information to students as its counterpart in Northern Orange has been. A cultural awareness group, Drive-a-Teen, Proconian(school newspaper), Student Government and Teen Awareness are samples of student groups who will be informed of clinic services and availability. We plan to make this student avenue the primary format for information sharing. In addition to existing student groups we hope to establish teen advisory groups in each school system to guide us on the best ways to advertise services and insure the quality of services. The school nurse is the most frequent referral and follow up source in our existing system. The school nurse in the Chapel Hill/Carrboro School System will also be a major referral source. These providers have been involved in the planning of this project and will actively utilize the clinic services as a referral source. School guidance counselors are the second most frequent source of referral in the existing project. We plan to educate the counselors in Southern Orange about availability of services. Counseling services to males has increased in the current program because many males have been reached through sports physicals. We will inform the coaching staff at each school about the clinic's availability for sports physicals. Other health department clinics will be informed about the clinic's mission and can refer students seen in STD or Family Planning Clinics to the teen clinic for primary care. This networking will be facilitated by the staff person who will be available during the first cycle of the grant to set up the clinic and the supporting network. This person will spend his/her time meeting with the above groups as he/she sets up the physical aspects of the clinic and have periodic meetings with key individual providers from each agency. DESCRIPTION OF SERVICES The target community has a wealth of medical services available to its population. A major teaching hospital, a community health clinic and private physicians reach many people. The proposed clinic/outreach program will compliment these services by reaching students who still do not access primary care. School nurses report that previous bills, fear and confusion in the larger hospital setting, too many familiar faces in clinics, long waiting times for appointments, and transportation from school cause students to shy away from health care. When services are finally accessed, the continuity of care is frequently sacrificed by financial concerns causing the adolescent to change providers. The history of the existing model ,adolescent clinic model shows that these needs have been met for a large population of students who needed accessible inexpensive care. Services are provided to adolescents through the Orange County Health Department in a variety of programs which are free of charge except for sliding scale fees for dental work.. The Child Health Program provides well child exams, screening, and acute care. Services specific to the Northern Orange County branch are prenatal care which includes home visitation by health department nurses of high risk pregnant mothers and the Baby Love Program, nutrition and social work consultation and the Adolescent Clinic. The Adolescent Clinic provides evaluation and treatment of all primary care problems. When necessary, referrals for specialized care are made expediently and followed up by health department staff. Both clinical sites, Northern and Southern Orange County, provide comprehensive family planning, evaluation of treatment of sexually transmitted diseases, a minority AIDS education program implemented in the schools and dental services. The dental services included are routine cleanings, extractions and restorations. A full time nurse is provided for each school system by the health department to 10 provide services to middle and high school students. Southern Orange County has a Peer Mediation Program which focuses on education in dispute settlement. The Orange Person Chatham Mental Health Center (OPC-MHC), staffed with highly skilled psychologists, psychiatrists and social workers, does well in meeting the mental health needs of the adolescent in an acute crisis or with a substance abuse problem. Due to long waiting lists and fees for service, it is difficult to refer an adolescent not in an acute crisis for ongoing care or psychological testing in an attempt to better understand their behavior. The substance abuse counselor provided by OPC-MHC works with students through individual and group counseling as well as consultation to provide services to students involved with drugs and alcohol. Services are provided in the school and in a private setting at the Center. Plans to increase access and services to adolescents will be done through increasing individual referrals to the OPC-MHC through the clinic and school and by providing more on site services by a skilled provider for low morbidity psychological problems. The two School Systems serve adolescents through a variety of services provided by students, teachers, social workers, school psychologists, school nurses and health educators. In the Orange County School System students are involved in providing services through a Peer Helper Program which trains students in listening and information gathering skills which allows them to help facilitate referrals for peers in need of help in dealing with issues such as sexuality, loss, depression, medical problems, stress, academic pressure, family and relationship problems. Teachers provide ongoing services to students through the classroom and a Student Assistance Program that works toward improving school performance. In the chapel Hill/Carrboro School System teachers provide unique services to the students through the Student Assistance Program which serves students for whom chemical dependency is a real or potential obstacle to personal or academic success. Social workers and school counselors are active through out the school systems providing counseling for a broad range of issues from poor school performance to future education plans. A social worker is employed by both school systems who provides dropout prevention services for the middle and high school students. School psychologists provide on site psycho-educational testing and counseling. School nurses, employed by the school system and health department work to provide on-site screening and medical services and system wide health education. Both schools employ health educators who work together with other school personnel and the school nurse to plan and implement educational activities. Both school systems have staff on board who deal with substance abuse counseling and education. Other county agencies providing services to Orange County adolescents are Planned Parenthood of Orange an Durham County, Department of Social Services, Dispute Settlement Center, Orange County Women's Commission, rape Crisis, Orange County Parks and Recreation and the Juvenile Court system. The Adolescents-in-Need Project of the UNC Division of Community Pediatrics serves at risk students in the Orange County School system. This project serves as a portal of entry for students when no services exist or service is fragmented. A medical/social work team provides counseling and guidance to students in their homes and at school. Linkages to school and service providers produces a model that strives to insure comprehensive health and social services to students. If funding is granted it will provide for a project as described above to be developed in the chapel Hill/Carrboro School system, increased medical and mental health services in Northern Orange County, and allow for a coordinated network of services for adolescents in both school systems. The medical aspect of this project enables one site to pull together resources and develop a comprehensive treatment plan involving existing resources, family, and the adolescent. The medical focus of the clinic often gives legitimacy to a student's request for help ®1 911 and frequently the presenting complaint is a minor problem to deal with as the more complex issues of behavior and family emerge through the medical visit. the clinic site is often used for screening to assess why an adolescent is not succeeding in school and to rally the necessary services to guarantee that success. Through this interface of systems-medical, school, individual and family-comprehensive medical and social plans for students are developed that enable them to receive the services needed to insure success. Enhancing the existing clinic with mental health services and developing a new clinic in Southern Orange County modeled after the existing Adolescent Clinic, complete with follow-up back to school and community resources, allows students access to a very comprehensive plan that addresses mental, social and medical health issues that keep them from realizing their full potential. APPLICANT QUALIFICATIONS The Orange County Coalition for Healthy N.C. Youth is made up of representatives of agencies that developed the original Adolescents-in-Need Project and the teen clinic in Northern Orange County(DSS, Mental Health, Orange County Schools, Health Department, Juvenile Court) as well as representation from the schools in the target area in Chapel Hill/Carrboro. Two members of the Adolescents-in-Need Project serve on the Coalition. The Adolescents-in- Need Project and staff have been recognized at the state and national level. A recent publication on how to develop a program such as theirs, along with staff consultation, has facilitated the replication of 10 similar sites across N.C. The pediatrician in the Adolescents-in-Need Project is the medical provider for the current clinic. She is board eligible for adolescent medicine and board certified in pediatrics. Current Adolescents-in-Need staff and Health Department staff on the coalition were involved with the development of the model teen clinic in 1988. The Health Department has administrative and nursing representation and will continue its leadership in adolescent clinic development. Members of the Coalition have been successful in developing day care for teen parents in Orange County, lowering the teen pregnancy rate and the school dropout rate in the county and developing a spirit in the county that places the needs of adolescents as a high priority. County government continues its financial support of the existing teen clinic and the Adolescents-in- Need Project. In delivery of comprehensive health care, mental health needs continue to rise as a concern. To address this rise in mental health needs the coalition has a local mental health provider and an administrator who will offer expertise in the establishment of the mental health component at each clinic site. Thus we have an experienced coalition complimented with people in the Southern Orange service system who are eager to expand the concept to their school system as well as the political and cultural background to help lay the groundwork for a clinic. 12 ABSTRACT The Orange County Coalition for Healthy N.C. Youth plans to develop a primary care teen clinic setting in the Chapel Hill/Carrboro Office of the Orange County Health Department. The clinic will be modeled after a successful clinic in the Hillsborough office established in 1988. This clinic will offer primary care services provided by staff from the Adolescents-in-Need project, residents from the University of North Carolina's Division of Community Pediatrics, and nursing staff who currently serve the schools as school nurses. The target population to be served in the Southern Orange clinic will the 20% of adolescent students identified as having no medical provider. Clinic services will be available to these students who do not use the existing medical resources due to access problems including transportation, money, confidentiality or fear of larger medical complexes., The clinic in Northern Orange will continue to provide services to the same type of student identified above. The current model offers comprehensive care from the school to the clinic to appropriate community agencies and back to school. The teen can enter the loop at any of the above points. The key to success has been the continuity of the school nurse who also works in the clinic, and the Adolescents-in-Need project, providing direct medical services in the clinic and medical and social work guidance through follow-up counselling in the homes and school contacts to students in the school system and adolescents referred by the clinic. The current clinic serves 300 adolescents per year. The school nurse serves approximately 200 students per month and the AIN Project serves 100 students per month. The AIN model has been in existence since 1981 and has proven successful in Orange County. It has been replicated 10 sites across North Carolina. The teen clinic has been in operation since 1988. A key element in the existing clinic and the proposed clinic will be access to mental health care for adolescents in the clinics. This service exists now only on a limited referral basis. We hope to establish mental health counseling on an as needed basis at the clinic and work on options to enhance mental health services in the schools. Accessibility will be addressed through a transportation plan that will pick students up at school and deliver them to the clinic. Fee for services will only be an issue as Medicaid and private insurance funding is worked out. Confidentiality will be addressed as per health department policy. If an adolescent needs to be treated for an illness other than STD's the parents will be contacted. The services that an adolescent is entitled to without parental permission will be offered in that manner In the first quarter of funding we plan to pay 20% of a medical providers salary to do the necessary networking with the Health Department, Mental Health Center, existing medical providers including private providers, UNC Hospitals and Orange Chatham Comprehensive Health, schools and communities in order to facilitate a fully operating adolescent clinic in Southern Orange County in September of 1993. The clinic will be staffed by a nurse, a clinic manager, a medical provider from the Adolescents-in-Need project and the chief resident in pediatrics if needed. In the existing clinic efforts will focus, in the first year, on expansion of medical service and the inclusion of mental health services. The key to success of the existing program has been the network of services available through the agencies involved. A great deal of effort will be put into continuing this follow up relationship and developing the network in the Southern Orange community. The home visit component, the clinic to school link and the providers offering follow up in the community have proven to be the keys to success and will be the foundation on which the new endeavor will be built. Individuals who have proven that comprehensive services can be provided to adolescents will be the line level providers in the new clinic concept. efrr- g.3 A 13 GOALS AND OBJECTIVES: Goal: To enhance the physical, mental and social health of adolescents in Orange County by increasing access to and utilization of comprehensive health services. Objective 1 - Establish a primary health care clinic in the Carrboro (Southern Orange County) branch of the Orange County Health Department so serve 250 adolescents the first year by September 20, 1993. 1 a) Prepare site for clinical services by purchasing equipment and setting up exam rooms in an age appropriate manner by July 31, 1993. 1 b) Identify and hire staff for clinic by August 31, 1993 1 c) Orientation of staff to clinic by September 13, 1993 1 d) Present the proposed adolescent clinic concept to faculty and school board by June 15, 1993. Objective 2 - Increase utilization of existing adolescent clinic in Hillsborough by twenty percent by June 30, 1994 2a) Market through P.E. coaches and classes 2b) Inform school personnel of the adolescent clinic's availability and scope through a group meeting and written information 2c) Develop a teen advisory board consisting of adolescents from existing civic organizations 2d) Market through Peer Helper program Objective 3 - Develop an interagency network system to insure comprehensive care for adolescents in Southern Orange County 3a) Identify individuals at each agency or institution involved in the network system for delivery of comprehensive care, ie. DSS, juvenile court system, mental health, health department, schools, University of North Carolina Hospitals, private providers, OCCHS, planned parenthood, Interfaith Council, Coalition for battered women, Adolescents in Need project 3b) Organize a meeting with above individuals prior to September 20, 1993 3c) Write a service manual with designated providers from each of the above institutions by September 30, 1993 and distribute to each of the above organizations 3d) Group to develop a method of measurement of keeping track of referrals and follow up Objective 4 - Establish a follow up record at both clinical sites 4a) Determine what percentage of adolescents seen for primary medical care need follow and attempt to provide necessary follow up services with monthly logs to begin with the next school year, September 1993. 4b) Keep daily log in adolescent clinic of referrals and follow up visits scheduled. 4c) Determine what percentage of adolescents with scheduled follow up actually are seen. Objective 5 - Establish mode of transportation from schools to clinic to provide transportation for at least four students per clinic day by September 20, 1993 5a) Investigate options for mode of transportation 5b) Determine mode of transportation 5c) Implement mode of transportation 5d) Introduce transportation mode to school system and parents 14 • Objective 6 - Develop access to mental health services at both clinical sites Objective 7 - Increase availability of mental health services in school system in Hillsborough (Northern Orange County) by September 30, 1993. Objective 8 - Increase availability of mental health services in Chapel Hill/Carrboro school system (Southern Orange County) by September 1994. 8a) Activate school psychologist and mental health Objective 9 - Establish a follow up network in the Chapel Hill/Carrboro school system that insures linkage from school to clinic and clinic to school. 9a) School nurse will be clinic nurse. Objective 10 - Develop an organized system to access any possible funds for care 10a) Explore possible reimbursement sources by October 1, 1993 1 Ob) Implement reimbursement protocol by January 1, 1994 227- 43 Budget: April 1, 1993 to June 30, 1993 1 . Salaries CAHCP FUNDS Other Funds Total Clinic Manager $1,200.00 Physician $2 ,500.00 2 . Fringe Benefits $934 .00 3 . Office Supplies Expendables $400 .00 File Cabinet $200 .00 Educational $1,000 .00 4. Telephone $1,000 .00 5. Postage $100. 00 6. Travel Continuing Medical Education $400.00 Mileage $400.00 7 . Office Equipment Computer $2,000.00 Printer $500.00 8. Other Coalition Activities $1,700.00 TOTAL $12,334.00 16 BUDGET: July 1, 1993 to June 30, 1994 1. Salaries CAHCP FUNDS Other Funds Total Clinic Manager $3,660.00 Nurse $4,036.00 Mental Health Provider $7, 000.00 Physician $16, 000.00 2. Fringe Benefits $7, 075. 00 3. Office Supplies $500.00 Expendables 4. Telephone $1,200.00 5. Postage $200.00 6. Travel Continuing Medical Education $600 .00 Mileage $600 .00 7 . Medical Equipment Audiometer $800.00 Titmus Vision Tester $1,000. 00 Oto-opthalmascope $400.00 Three Blood Pressure Cuffs $200.00 Stethoscope $50.00 Exam lamp $160.00 8. Pharmaceuticals $2,000.00 (ocp's, antibiotics, condoms, foam, acne, asthma) 9. Medical office $1, 000 .00 supplies 10. Educational Supplies $2,000.00 11. Transportation $1,000.00 12 . Advertising $400.00 13 . Other $200 .00 TOTAL $50,081.00