Addressing Organizational Barriers to Adolescent Access to High-Quality,Low-Cost,Confidential Sexual and Reproductive Health Services in a Community Health Center

Assessment of Need

Federally qualified health centers (FQHCs) are a critical source of health care for nearly 3 million adolescents in medically underserved U.S. communities, providing care to 10% of all 12- to 18-year-olds (Mead et al., 2015). Designed to offer subsidized, high-quality care to low-income individuals, FQHCs are well-positioned to play a significant role in providing comprehensive sexual and reproductive health (SRH) services to vulnerable adolescents despite substantial financial and structural barriers (Mead et al., 2015). In an effort to increase the capacity of publicly funded health centers to provide adolescent SRH services, the Centers for Disease Control and Prevention (CDC) funded the Teen Access and Quality (TAQ) initiative (Brittain et al., 2020). As part of TAQ, Sexual Health Initiatives for Teens–North Carolina (SHIFT-NC), a non-profit in Durham, North Carolina, partnered with Lincoln Community Health Center (LCHC), an FQHC system also in Durham, from 2015 to 2020. We received institutional review board approval for this project through Chesapeake Institutional Review Board (Protocol #00022471).

In 2019, 66% of LCHC adolescent clients were Latinx and 26% were Black; these demographic groups, respectively, experience adolescent pregnancy rates 11 and 5 times higher than White adolescents in Durham County (Garrison, 2017; SHIFT-NC, 2019). To reduce unintended pregnancy, SRH service providers need to address the barriers adolescents encounter in accessing SRH services, including prohibitive financial costs, inadequate access to highly effective contraceptives, and a lack of confidentiality (Brittain et al., 2020). LCHC faced significant challenges in providing confidential, low-cost contraceptive and sexually transmitted infection services for adolescents because it does not receive Title X funds, serves a large number of uninsured patients, and operates in a state that did not approve Medicaid expansion. LCHC has a strong commitment to equity and only offers services that can be provided to all patients, regardless of their insurance status. Therefore, LCHC absorbs costs for uninsured patients.

At the start of our collaboration, we initiated an assessment in 2016 exploring LCHC’s practices regarding adolescent SRH services using three tools: an assessment of organizational policies, a survey of provider attitudes and practices, and a survey of adolescent patient satisfaction. We identified three main areas for improvement from the results of these tools: (1) standardizing SRH service provision to adolescent patients, (2) decreasing structural barriers to confidential adolescent SRH services, and (3) increasing receipt of minor’s rights information and time alone with a provider.

Description of Strategy

We created six strategies to improve the quality of adolescent SRH services at LCHC (Table 1). These strategies were the result of a close collaboration between a clinic champion (an LCHC provider) and a quality improvement (QI) specialist from SHIFT-NC. Our strategies included the following:

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Table 1

LCHC’s Strategies to Improve Adolescent Access to Confidential SRH Services, Details of Each Strategy’s Implementation, and Related Outputs

Strategy	Implementation details	Outputs
Relationship building and galvanizing internal support	We assessed baseline staff support for the initiative and used this to establish an internal clinic improvement team at LCHC, led by the clinic champion and QI specialist. We encouraged community collaboration via quarterly stakeholder meetings among LCHC, other local health centers, and youth serving organizations (YSOs). During these meetings, YSO leaders discussed with LCHC leadership the barriers that their adolescent clients faced in accessing confidential and low-cost SRH services in Durham, highlighting the need for adolescents to register themselves for confidential care. We utilized the synergy of these efforts plus the increased awareness resulting from trainings on SRH topics to bolster internal momentum for organizational change.	Partnership established between QI specialist and LCHC clinic champion Consistent project QI team meetings established at LCHC Ongoing communication between LCHC and YSO leaders Support for procedural and policy changes at LCHC to improve adolescent access to confidential SRH services
Establishing an LARC program	Within the first year of our project, LCHC received funding from a state-level maternal and child health grant that supported no-cost LARC devices for uninsured patients. This grant removed a significant barrier to providing LARC services and resulted in the creation of a weekly LARC clinic as well as an associated provider training and a credentialing program to increase LARC access throughout the organization.	Funding for uninsured patients to receive no-cost LARC devices Identified the need for additional staff training about contraceptive options, guidelines, and counseling Providers trained and credentialed in the insertion and removal of LARCs Schedule blocked for once-weekly LARC clinic Increased staff motivation to improve SRH services
Building knowledge through staff training	One of the key components of our project was staff training. We introduced new training for all staff who interacted with adolescents [Pediatric and Family Medicine providers, medical assistant (MA)/nursing, front desk, and call center] about various aspects of LARC methods. The LARC program also spurred the implementation of trainings covering other topics related to adolescent SRH, including minor’s rights, protecting adolescent patient confidentiality, adolescent development, and shared decision making for contraceptive counseling. Our training series highlighted to LCHC leadership and staff the opportunities for subsequent practice and policy improvements for adolescent SRH appointments.	Training about adolescent development to the pediatrics and family medicine teams Training about shared decision making in contraceptive counseling to pediatrics and family medicine teams Training about birth control basics for MAs Training for call center staff on key messages for ensuring confidential SRH services for adolescents Training for front desk and billing staff about LARC methods Creation of laminated flip charts for each exam room displaying tiered-effectiveness contraceptive counseling tool and minor’s rights information in English and Spanish
Changing workflow to allow for adolescent access to SRH services	We employed process mapping to understand the existing workflow for adolescent patients in the Department of Pediatrics where the majority of LCHC’s adolescent patients are seen. We then created an improved workflow that incorporated parent education and time alone with the MA and provider for all adolescents starting at age 13 years as follows: We trained LCHC staff to provide parents with a brochure on minor’s rights in NC and guidance on expectations for their adolescent’s visit, including time alone with a provider, on check-in. We trained the MA to bring the patient to the exam room for vitals without the parent and utilize a new sexual activity screening question to assess SRH concerns. The MA also collected a first-catch urine sample for all adolescent patients to facilitate testing when the provider determined that a pregnancy or STI test was warranted. The MA communicated the results of the sexual activity screening questions to the provider, and the provider decided at which point they would invite the parent into the exam room, ensuring that every patient had time alone with a provider to discuss sensitive health concerns. One provider/MA team piloted the new workflow with feedback given to the workgroup. After the final revision to the workflow, we documented and disseminated the written procedure to the pediatric clinical team and provided coaching sessions to support its implementation.	Created parent education brochure and letter explaining rationale and procedure for adolescents’ time alone with provider and minor’s rights Front desk provided parents with letter and brochure on check-in MA brought adolescent into exam area for vitals without parent MA asked sexual activity screening question MA communicated results of sexual activity screening to provider so that the provider was prepared to address SRH issues appropriately during visit MA collected a urine sample from all adolescents to be used if provider determined that pregnancy or STI testing was warranted Provider had time alone with adolescent patient to discuss sexual activity and any other confidential concerns
Developing a universal adolescent health assessment tool	In collaboration with LCHC’s medical/nursing staff, we adapted the Guidelines for Adolescent Preventive Services screening tool, developed by the American Medical Association to reflect language and content that was more relevant and inclusive of our adolescent patient population. We formed a small group of providers and nurses who worked directly with adolescents. They reviewed the original version of the tool and suggested changes regarding gender identity, sexual attraction, specific types of sexual activity, vaping, common terms related to illicit drugs, and interest in HIV testing and PrEP. After revising the tool, we presented a draft to all pediatric providers, MAs, and nursing staff. We then	Created an adolescent screening tool tailored to our clinic and patients Raised awareness of and support for revised tool implementation among providers and staff who see adolescents Provider explored sexual attraction, gender identity, type of sex engaged in, and/or interest in sex Provider discussed sexual health history including pregnancy and STI history Provider discussed sexual health behavior including use of condoms, birth control, and withdrawal Provider assessed interest in HIV testing and PrEP education
	presented the tool to LCHC’s committees where it was approved for organization-wide use. Once approved, we distributed the final tool and made it accessible to providers and clinical staff other than those in pediatrics, such as family medicine and adult medicine. We then integrated the tool into the general pediatric workflow. After its launch, we completed ongoing assessments to determine how effectively the tool was being integrated into practice.	Provider explored other health behaviors and history relevant to adolescent health (mental health, substance use, safety, healthy eating, exercise, and family health history)
Changing billing and registration protocols	Our initial approach was to assess strategies used by other FQHCs in NC to implement confidential adolescent registration and billing. After identifying effective strategies, we presented our findings to LCHC leadership, including a discussion of NC state law that provides minors the right to access SRH services. We discussed barriers to implementing confidential billing and registration such as the financial burden of confidential services and maintaining compliance with HRSA’s patient proof of income requirements, and we brainstormed ways to address these barriers. We presented data about the number of adolescents accessing SRH services at LCHC, projecting the cost of this care if subsidized by LCHC. The need for low-cost, confidential adolescent SRH services escalated after the local Planned Parenthood affiliate lost its Title X funding in 2019 and LCHC reached a consensus to subsidize the care of adolescents seeking confidential services. We developed a confidential registration policy, and LCHC verified its compliance with HRSA proof-of-income requirements. We also developed a confidential billing policy. We trained front desk, call center, and billing staff on key messages to ensure adolescent access to SRH services before implementing the policy. After training, we implemented the policy on a small scale and conducted a secret shopper Plan–Do–Study–Act cycle to test and improve the functionality of the policy.	Compiled information about other NC-based FQHC’s strategiesMinors new to clinic seeking confidential services were able to register themselves as patients without parental involvement with $0 income using “student” as their occupationAdolescents were able to confidentially opt into SRH services at check-in by nonverbally indicating reason for a visit on a laminated list of SRH servicesFront desk staff indicated to provider and staff in the visit note that the visit must be confidentialProvider offered the needed/requested services and left visit note “open” after completing the appointmentBilling staff removed charges (private insurance was not billed) and ensured a bill from LCHC was not sent homeLCHC absorbed the cost of the confidential servicesProvider closed the note the day after the visit once charges had been removed

Note. LCHC = Lincoln Community Health Center; QI = quality improvement; SRH = sexual and reproductive health; MA = medical assistant; LARC = long-acting reversible contraception; NC = North Carolina; STI = sexually transmitted infection; PrEP = pre-exposure prophylaxis; FQHC = federally qualified health centers; HRSA = Health Resources and Services Administration.

Implications for Practice

Providing high-quality, low-cost, confidential SRH services to adolescents is challenging for many CHCs due to lack of staff training, competing priorities with other high-need populations, and costs associated with subsidizing confidential services. Although it may be impractical for other CHCs to implement this approach holistically, the application of any of the identified strategies could improve the quality of adolescent SRH services. From our experience in implementing this approach we learned that (1) cross-sector collaboration and community focus helped garner both initial and sustained support for change initiatives, (2) training increased staff knowledge of adolescent SRH topics and also galvanized support for the implementation of further change in clinic operations, (3) involving LCHC staff from all disciplines in the QI process better informed the design and application of practice improvements and built staff investment in implementing changes, (4) small-scale piloting of change strategies increased engagement and confidence in enacting changes while also uncovering potential issues with new protocols before implementation on a broader scale, and (5) a clinic champion and improvement team dedicated to meeting regularly facilitated QI work, staff trainings, and progress toward outlined strategies.

We recognize that our CDC grant funding supported the clinic champion’s time, as well as the SHIFT-NC QI specialist’s time, to facilitate the improvement team and provide trainings. A challenge for other CHCs seeking to improve adolescent SRH services may be funding to support staff time away from clinical care, as well as an external QI specialist, although these resources and expertise may be available within the organization or through other partnerships. Given our experience, we believe that our approach provides practical guidance for CHCs to effectively improve SRH services for adolescents.