Screening for risks

Changing practices to improve adolescent health care

The healthcare industry has been laser-focused on prevention since it became obvious that stemming the tide of disease in our country required an upstream solution. From tackling prediabetes in adults to preventing childhood disease with infant immunizations, health professionals are onboard — with most finding a way to incorporate disease prevention into everyday practice.   


But one area of preventive care is often overlooked. According to the Centers for Disease Control, a full 75% of the morbidity and mortality in adolescents is a direct result of preventable risk behaviors.1 Such organizations as the American Medical Association, American Academy of Pediatrics and American Academy of Family Physicians all recommend annual screening of adolescent risk behaviors. But despite these statistics and evidence-based recommendations from leading organizations, teens have been overlooked in standards of care to date. A survey of AAP’s fellows revealed that fewer than 25% of providers regularly screen teens for risk behaviors.2  


Rapid Assessment for Adolescent Preventative Services, or RAAPS, is an adolescent risk-screening tool that was born out of research and a practical need to overcome some of the most common barriers to adolescent risk screening: time, provider confidence, lack of counseling tools and resources, and teen engagement.  


RAAPS was designed to be quick and effective for ease-of-use in a retail setting, and screening teens in this setting is especially important. Because teens utilize health care less than any other segment of the population, a visit with them may be the only health care they receive for that year — or longer.


Despite the need to screen for risky behaviors, it can be a struggle to connect with teens using a traditional interview style or incorporate long surveys into the practice workflow. Prior to RAAPS, a 72-question survey — known as Guidelines for Adolescent Preventive Services, or GAPS — was the best option for providers, but this survey took nearly 30 minutes for teens to complete and was not a good fit in a clinic environment.  


Rapid Assessment for Adolescent Preventative Services, or RAAPS, is an adolescent risk-screening tool used to overcome some of the most common barriers to adolescent risk screening, including time, provider confidence, lack of counseling tools and resources, and teen engagement.


RAAPS was developed to fit easily into the workflow. The team of industry leaders and academic experts at the University of Michigan incorporated evidence-based literature and completed a validation study to ensure identification of the top contributors of morbidity and mortality in adolescents.
Equally important as the science that went into the survey was the group of consulting experts: teens themselves. The team had strong teen involvement in every aspect of development to make the survey more engaging and to help teens feel more comfortable answering sensitive questions. This collaborative development process led to some innovative features that increase both engagement and effectiveness in the teen population.  


For example, the RAAPS survey can be completed on any device with Internet access — such as an iPad, Kindle or Android-powered tablet — which provides the mobility and flexibility for the survey to be used in almost any care setting, as well as minimizes “shoulder surfing” by both casual observers and protective moms. Audio and multilingual options help improve health literacy, which is especially important among underserved populations. The short, 21-question format decreases survey fatigue, and the technology interface provides better quality data. As research shows, teens are more likely to provide honest answers with technology than with face-to-face or paper surveys.3


Because adults aren’t the only ones who forget half of what they hear in an appointment, teens can choose to e-mail themselves the individualized health messages they receive from the RAAPS system that are specific to their identified risk behaviors following completion of the survey questions. These messages can serve as reminders of what was discussed and as a resource that can be referred to at a later time, increasing their exposure to the messages and increasing the chance that they will make positive behavior changes.


The team also added innovative features just for health professionals. Risk assessment can uncover a broad range of risk behaviors, and clinicians have indicated that they have significant experience talking with teens about some topics, but not others, particularly sex and mental health.  


Evidence-based talking points were developed for each question to help professionals in their discussions with teens across all of the potential risk behaviors. Health messages appear for professionals as a PDF document linked directly to each teen’s completed survey. These health messages focus on what has been proven to be most effective in messaging to teens: providing ideas for changing behaviors, rather than focusing on why they should change, and including such self-efficacy messages as, “You can make a difference in your life and the lives of your friends by making safe driving choices.”  Each message includes national or government websites specifically for teens, as well as hotline numbers where applicable. Since 2001, there has been a massive growth in teens using the Internet to seek health information, yet few take steps to ensure the credibility of the online sources they are finding.  RAAPS is giving them reputable resources.  


RAAPS users report that these messages have helped them increase the effectiveness of their counseling sessions and, most importantly, build trust and rapport to support ongoing discussions, not just one-time encounters.


Another useful feature is access to risk data. Prior to having an online system, clinicians would have to counsel hundreds of teens with paper surveys and had no way of easily tracking individual outcomes or reviewing all of the risk data that had been collected, outside of time-intensive chart reviews full of human error. So, when building the reporting features, the RAAPS team asked clinicians what questions they had about their teen populations and created reports that responded to such questions as:  

  • What is the effectiveness of the risk counseling I am providing?
  • What are the greatest risks in my teen population?
  • Are my programs and services focused on the greatest risks?

Teen risks change over time, and having accessible data that reveals changing trends is critical for professionals serving adolescent populations. For example, a review of RAAPS 2012 data shows a significant increase in mental health risks among teens, even surpassing the usual issues of teen drinking, drugs and unprotected sex.


Used in care settings ranging from hospital outpatient clinics to school-based health centers, and with a benchmark database of more than 33,000 completed surveys, RAAPS’ innovative approach has engaged teens and improved the effectiveness of both the identification and reduction of risk behaviors. And the data from RAAPS has been used to change service at all levels.


Consider a case study in Michigan, which began as a pilot and rapidly expanded across the state. The data from this initiative has been collected and analyzed at the state level and used to inform changes in Medicaid programming. Increased awareness from this project of the unique needs in teen populations also spurred adoption of an adolescent risk assessment guideline for Michigan.


Despite these successes, risk screening is not yet a standard practice among care providers serving the adolescent population. With 75% of all illness and death in the teen population attributable to preventable risk behaviors, and more than 75% of providers failing to routinely screen adolescents for these behaviors, the issue cannot be ignored. To learn more about RAAPS, visit RAAPS.org.


Jennifer Salerno is a nurse practitioner and former director of the University of Michigan Regional Alliance for Healthy Schools (RAHS) school-based health center program and the UM Adolescent Health Initiative, where she developed the RAAPS screening tool. Salerno is currently a consultant to the Michigan Department of Community Health, overseeing grant funding for the transformation of adolescent healthcare delivery in Michigan. She serves as a board member and adviser on many state and national organizations focused on adolescent health.

References:

1 Centers for Disease Control and Prevention [CDC]. (2012). The youth risk behavior surveillance system - United States 2011. MMWR  61(4). Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf.
2 American Academy of Pediatrics (AAP) Periodic Survey of Fellows #71, conducted in 2008.
3 Paperny, D. M., Aono, J. Y., Lehman, R. M., Hammar, S. L., & Risser, J. (1990). Computer-assisted detection and intervention in adolescent high-risk health behaviors. The Journal of Pediatrics, 116(3), 456-462.
 

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