Full Service Reproductive Health in a School-Based Health Clinic

FullFull ServiceService ReproductiveReproductive HealthHealth inin aa SchoolSchool--BasedBased HealthHealth ClinicClinic

Bridging the Access Gap for Youth

Tom Sincic, MSN, FNP [email protected] GoalsGoals forfor TodayToday z Define the Contraceptive Access Gap z Advantages of providing on site contraception. z Components of an individualized contraceptive plan. z Overcoming barriers to on site dispensing z ? DefiningDefining thethe AccessAccess GapGap

z “Inability to get contraceptive of choice when needed” z Contributors ¾Communities ¾Schools and School Boards ¾Families ¾Social Workers ¾Health Care Providers ScenarioScenario 11 15 year old female walks into clinic requesting pregnancy test. First sexual intercourse was 2 days ago with a condom that “broke”. Menses are irregular with last menstrual period “awhile ago”. ScenarioScenario 22 First visit for 17 year old male is in asthma evaluation. Twice daily use of Albuterol inhaler but ran out a couple of days ago. Has had sexual intercourse with two female partners. Once with a condom and once without because “I didn’t have one”. ScenarioScenario 33 16 year old female in clinic for routine sports physical. Has boyfriend of one year. Never sexual intercourse. Has had a “close call”. Will have sex “when ready”. ScenarioScenario 44

16 year old female walks into the clinic a speaks to receptionist about needing “a test”. When in exam room states that shes been having six with boyfriend of six months for 2-3 months. Using condoms “mostly”. Now noticing some vaginal discharge. Last sexual intercourse two weeks ago. Last menstrual period 5 days ago for 3 days. ScenarioScenario 55 14 year old female for first visit with a sore throat. Lives in foster care. Has history of abuse but has never really been in counseling. Has had 4 sexual partners. LMP was 4 weeks ago. Last sexual intercourse was 2 months ago with 17 year old boyfriend of 2 months. CommunitiesCommunities

z Attitudes and Policies ¾Age of Consent and Medical Consent ¾Confidentiality Laws ¾Plan B access ¾Others Sexual Consent Age Laws (USA) http://www.coolnurse.com/consent.htm

USA by State: Female/Male Male/Male Female/Female

Alabama 16 illegal illegal

Arizona 18 illegal illegal

California 18 18 18

Colorado 17 17 17

Connecticut 16 no current law no current law

Delaware 16 (f)18 (m) no current law no current law

Georgia 16 16 16 Idaho 16 (f) 18 (m) illegal illegal

Indiana 16 16 16

Iowa 14(f) 18(m) no current law no current law

Kentucky 16 no current law no current law

Montana 16 (f) 18 (m) 18 18

New 17 16 16 Mexico

North Carolina 16 illegal illegal 18 18 18 Oregon

South 14 (f) 16 (m) illegal illegal Carolina

Texas 17 illegal illegal

Utah 16 - f 18 (m) illegal illegal

Virginia 18 illegal illegal

West 16 no current law no current law Virginia

US Military 16 don't ask, don't tell don't ask, don't tell MedicalMedical ConsentConsent LawsLaws andand ConfidentialityConfidentiality

¾ Allow Consent—26 states ¾ No law—25 states

Consent does not equal confidentiality

http://www.guttmacher.org/graphics/gr030406_f1.html PlanPlan BB AccessAccess

z Plan B Battles Embroil States By Marc Kaufman Washington Post Staff Writer Monday, February 27, 2006; Page A01 z Legislation in New Hampshire, for instance, would require parental notification before the drug is dispensed, and more than 20 other states will consider bills that give pharmacies the right not to stock the drug and pharmacists the right not to dispense it, even to women with valid prescriptions. PlanPlan BB AccessAccess z Passage last year of a Texas bill that eliminated the drug from a demonstration family-planning program, and to an Arkansas bill that kept emergency contraception off a list of covered contraceptives. SchoolsSchools andand SchoolSchool BoardsBoards

z Attitudes and Policies ¾Can’t excuse self from school for medical visits ¾Allow reproductive health without condoms ¾Others DoDo youyou knowknow thisthis person?person? MeetMeet JenniferJennifer JackoJacko

The Oregonian Sunday, May 14, 2006 Background: In 1993, Jennifer Jako, then 20, was featured in an article about women infected with the virus that causes AIDS. At the time, the Lake Oswego woman was measuring her life expectancy in months, or perhaps a few years. SchoolsSchools andand SchoolSchool BoardsBoards Lake Oswego Review 01/12/06 http://www.lakeoswegoreview.com/article/9903_2 No go on condom survey According to the students, Principal Bruce Plato did not favor the idea, because he felt providing condom machines would send the wrong message to students and the community. Superintendent Bill Korach told board members that he felt the survey was “inappropriate” and that the school board’s decision to proceed down this road “could be viewed by individuals as supporting or encouraging student sexual behavior.” FamiliesFamilies

• Attitudes ¾Belief that access=permissiveness ¾Need to know ¾Control issues ParentsParents NeedNeed toto KnowKnow 2002 REPORT CARD The Ethics of American Youth Press Release and Data Summary http://www.josephsoninstitute.org/Survey2002/survey2002- pressrelease.htm

9 Lying to parents. Though one would expect a high percentage of young people to admit lying to their parents in the past year, the increase from 1992 to 2002 is substantial (83% vs. 93%). 9 Students attending religious schools were more likely to lie to a parent (95% vs. 91%) but students with personal religious convictions lied at the same rate as the national average. 9 The percentage of students who admit lying to their parents two or more times increased from 70% in 1992 to 81% in 2002. SocialSocial WorkersWorkers andand FosterFoster CareCare

¾ Time ¾ Fail to get kids into preventive service ¾ No specific plan for pregnancy prevention ¾ 50% pregnant by age 19 in one study ¾ 59% said their program does not have a specific plan for teen pregnancy prevention. ¾ 72% report their program in programs for youth who are not pregnant or parenting ¾ 37%of staff in programs designed for pregnant and parenting teens in avoiding pregnancy. ¾ Others

http://www.teenpregnancy.org/ http://www.teenpregnancy.org/resources/reading/foster_care/default.asp Fostering Hope: Preventing Teen Pregnancy Among Youth in Foster Care HealthHealth CareCare ProvidersProviders

¾ Privacy Issues ¾ Access to timely care—what happens when you call for appointment- ¾ “I tried to get her in put they needed to get the records first” ¾ Public—locations not adolescent oriented and still often with parent/guardian accompaniment ¾ Planned Parenthood—follow up, location, problem focused rather than client focused. InsurersInsurers (Both(Both publicpublic andand private)private)

¾ Limited Coverage—costs ¾ Select providers ¾ Constant refills—frequently refills often less than monthly TheThe ProblemProblem withwith thethe AccessAccess GapGap LessonsLessons learnedlearned from:from:

TheThe HolyHoly Bible:Bible: GenesisGenesis ChapterChapter 33

RomeoRomeo andand Juliet,Juliet, ActAct 2,2, SceneScene 22 by William Shakespeare

BrokenBroken WingsWings by Kahlil Gibran

Bundling:Bundling: ItsIts Origin,Origin, ProgressProgress && DeclineDecline InIn AmericaAmerica by Henry Stiles, M.D. Lessons learned from: Holy Bible: Genesis Chapter 3 Now the serpent was more subtile than any beast of the field which the LORD God had made. And he said unto the woman, Yea, hath God said, Ye shall not eat of every tree of the garden? 2 And the woman said unto the serpent, We may eat of the fruit of the trees of the garden: 3 but of the fruit of the tree which is in the midst of the garden, God hath said, Ye shall not eat of it, neither shall ye touch it, lest ye die. 4 And the serpent said unto the woman, Ye shall not surely die: 5 for God doth know that in the day ye eat thereof, then your eyes shall be opened, and ye shall be as gods, knowing good and evil. 6 And when the woman saw that the tree was good for food, and that it was pleasant to the eyes, and a tree to be desired to make one wise, she took of the fruit thereof, and did eat, and gave also unto her husband with her; and he did eat. Lessons learned from: Romeo and Juliet, Act 2, Scene 2 by William Shakespeare JULIET O Romeo, Romeo! Where fore art thou Romeo? (2.2.33) Deny thy father and refuse thy name; (2.2.34) Or, if thou wilt not, be but sworn my love, And I'll no longer be a Capulet. JULIET How camest thou hither, tell me, and wherefore? The orchard walls are high and hard to climb, And the place death, considering who thou art, If any of my kinsmen find thee here. ROMEO With love's light wings did I o'er-perch these walls; (2.2.66) For stony limits cannot hold love out, And what love can do, that dares love attempt; Therefore thy kinsmen are no stop to me. (2.2.69) JULIET If they do see thee, they will murder thee. ROMEO A lack, there lies more peril in thine eye Than twenty of their swords! Look thou but sweet, And I am proof against their enmity. (2.2.73) JULIET I would not for the world they saw thee here. (2.2.74) ROMEO I have night's cloak to hide me from their sight; And but thou love me, let them find me here: My life were better ended by their hate, Than death prorogued, wanting of thy love. (2.2.78) Lessons learned from: Broken Wings by Kahlil Gibran I was eighteen years of age when love opened my eyes with its magic rays and touched my spirit for the first time with its fiery fingers, and Selma Karamy was the first woman who awakened my spirit with her beauty and led me into the garden of high affection, where days pass like dreams and nights like weddings. It is wrong to think that love comes from long companionship and persevering courtship. Love is the offspring of spiritual affinity and unless that affinity is created in a moment, it will not be created in years or even generations. When I could no longer resist the impulse, I went, on the weekend, once more to Selma's home -- the shrine which Beauty had erected and which Love had blessed, in which the spirit could worship and the heart kneel humbly and pray. When I entered the garden I felt a power pulling me away from this world and placing me in a sphere supernaturally free from struggle and hardship. Lessons Learned From: Broken Wings by Kahlil Gibran

Now, while my father and my suitor are planning the day of marriage, I see your spirit quivering around me as a thirsty bird flickers above a spring of water guarded by a hungry serpent.

In That Unknown Temple, I Met Selma Once Every Month and Spent the Hours With Her …. LessonsLessons learnedlearned from:from: Bundling:Bundling: ItsIts Origin,Origin, ProgressProgress && DeclineDecline InIn AmericaAmerica by Henry Stiles, M.D. BundlingBundling :: ItsIts Origin,Origin, ProgressProgress && DeclineDecline InIn AmericaAmerica

ALBANY: KNICKERBOCKER PUBLISHING COMPANY. 1871. Entered according to Act of Congress, in the year 1871, BY HENRY R. STILES, In the Office of the Librarian of Congress, at Washington.

Bundle—”To sleep on the same bed without undressing; applied to a man and woman, specially lovers, thus sleeping.” Webster, 1864 TheThe ProblemProblem withwith thethe AccessAccess GapGap TheThe ProblemProblem withwith thethe AccessAccess GapGap WhatWhat HappensHappens whenwhen thethe GapGap isis narrowed?narrowed?

Impact of “Full Service Model” on ¾ students ¾ families ¾ the school ¾ community. ImpactImpact onon StudentsStudents (Minneapolis Study) Health Behavior News Service www.hbns.org. Release Date: Oct. 30, 2003 American Journal of Public Health: www.ajph.org

¾ Vouchers for free birth control at community clinics: 41 percent of students received all of the contraceptives. ¾ Vouchers: 21 percent of students received all the condoms ¾ Direct distribution : 99 percent of the students received all of the contraceptives ¾ Direct distribution: 100% condom. ¾ Students requesting contraceptives — 11 percent — remained steady FiveFive yearyear PregnancyPregnancy TrendTrend ImpactImpact ¾ Teen mothers less likely to graduate from high school and more likely than to live in poverty and to rely on welfare ¾ Children of teenage mothers often born at low birth weight, with health and developmental problems, and are frequently poor, abused, and/or neglected ¾ Teenage pregnancy poses substantial financial burden estimated at $7 billion annually in lost tax revenues, public assistance, child health care, foster care, criminal justice system (Annie E. Casey Foundation, 1998). http://www.plannedparenthood.org/pp2/portal/files/portal/me dicalinfo/teensexualhealth/fact-teen-pregnancy.xml http://www.http://www.healthyteennetworkhealthyteennetwork.. orgorg

Wilhelmina A. Leigh Joint Center for Political and Economic Studies at NOAPPP Annual Conference November 10-13, 2003 Arlington, VA http://www.noappp.org/ www.jointcenter.org/healthpolicy/docs/presentations/WL- NOAPPP-2003.ppt CostCost ofof TeenTeen PregnancyPregnancy

SingleSingle--birthbirth costcost savingsaving …… savingsaving inin statestate oror locallocal expendituresexpenditures thatthat wouldwould havehave resultedresulted overover aa 2020-- yearyear periodperiod ifif eacheach ofof thethe teenteen birthsbirths inin thethe initialinitial yearyear ofof thisthis periodperiod hadhad beenbeen postponedpostponed untiluntil thethe mothermother waswas atat leastleast ageage 2020 EstimatedEstimated CostCost ofof TeenTeen PregnancyPregnancy

Example:Example: California,1985California,1985 -- 20042004 (Brindis(Brindis && JeremyJeremy 1988)1988) ----

SingleSingle--birthbirth costcost == $17,942$17,942

SingleSingle--birthbirth costcost savingsaving == $7,177$7,177 CostCost ofof TeenTeen PregnancyPregnancy

SingleSingle--cohortcohort costcost savingsaving ......

savingsaving inin statestate oror locallocal expendituresexpenditures thatthat wouldwould havehave resultedresulted overover aa 2020-- yearyear periodperiod ifif allall ofof thethe teenteen birthsbirths inin thethe initialinitial yearyear ofof thisthis periodperiod hadhad beenbeen postponedpostponed untiluntil thethe mothersmothers werewere atat leastleast 2020 yearsyears ofof ageage EstimatedEstimated CostCost ofof TeenTeen PregnancyPregnancy

Example:Example: California,California, 19851985 -- 20042004 (Brindis(Brindis && JeremyJeremy 1988)1988) ----

SingleSingle--cohortcohort costcost == $717.6$717.6 millionmillion

SingleSingle--cohortcohort costcost savingsaving == $287$287 millionmillion FullFull ServiceService ModelModel Components of Care ¾ In Reach ¾ Ease of Access ¾ On-Site Availability of Methods ¾ Individualization ¾ Supporting Successes and Monitoring Failures ¾ Engaging Parents and Guardians InIn ReachReach

¾ Orientation—“Room 102 We’re here for You” ¾ Classroom presentations—Telling students that they can get these services ¾ Identify High Risk—Bridge project EaseEase ofof AccessAccess

¾ Priority Pregnancy Prevention Policy ¾ Open Access Policy ¾ Gold Card It is the policy of the School-Based Health Center (SBHC) Program that students presenting in School-Based Health Clinics with potential risk for pregnancy will be given priority access. Health care systems need to anticipate potential situations of pregnancy prevention method failures, including abstinence as a method failure, in their adolescent population in order to minimize unplanned (unwanted) pregnancies. The need to determine and expeditiously address potential pregnancy prevention method failures exists for both the unscheduled and the scheduled patient. The provider of best practice will be flexible, be able to anticipate potential failures, and be prepared to spontaneously address them. This card entitles bearer to all services available at the Teen Health Clinic

Name of member Date

OnOn--sitesite AvailabilityAvailability ofof MethodsMethods

¾ Abstinence planning ¾ Condoms ¾ Spermicides ¾ Oral contraceptives ¾ DepoProvera ¾ NuvaRing ¾ OrthoEvra ¾ Plan B ¾ IUD’s at select locations IndividualizationIndividualization

¾ Assessment ¾ The other “vital sign”—“when was the last time you had sex?” ¾ Comprehensive sexual health history ¾ Health issues that may impact method choice ¾ Mental health issues may interfere with consistency ¾ Cognitive function may impair ability to manage ¾ Personal or personality issues that may impair consistency ¾ Choice ¾ Their choice ¾ Making a recommendation with permission ¾ Flexibility ¾ Be ready to change in response to problems SupportingSupporting successessuccesses andand monitoringmonitoring failuresfailures

¾ When to follow up? 1 day? 1 week? 1 month? ¾ Appointment slips—need to scan ¾ Tracking List ¾ Classroom contact: notes and calls ¾ Calls to home ¾ Outreach workers

UsingUsing NewNew TechnologiesTechnologies

¾ Cell phones ¾ Email ¾ Voicemail ¾ Text messaging PregnancyPregnancy AuditAudit ToolTool EngagingEngaging FamiliesFamilies

¾ Parental engagement policy ¾ Tracking parental engagement ¾ Communicate with confidentiality OvercomingOvercoming thethe AccessAccess GapGap

¾ Dealing with your Personal Fears ¾ Program Resolve ¾ Minnesota Organization on Adolescent Pregnancy Prevention and Parenting ¾ School-Based Health Centers and the Birth Control Debate http://www.guttmacher.org/pubs/ib_1200.html ¾ Community Connections ¾ Parent Engagement DealingDealing withwith PersonalPersonal FearsFears NPRNPR andand KaiserKaiser FamilyFamily FoundationFoundation SurveySurvey 20042004

¾ Controversial topic --"teens can obtain birth control pills from family planning clinics and doctors without permission from a parent"--found inappropriate by 28 percent of the public, but seven out of 10 (71 percent) thought it was appropriate. ¾ Majority of Americans (55 percent) believes giving teens information about how to obtain and use condoms will not encourage sexual intercourse earlier (39 percent say it would), and 77 percent think such information makes it more likely the teens will practice safe sex now or in the future (only 17 percent say it will not). ¾ http://www.npr.org/programs/morning/features/200 4/jan/kaiserpoll/publicfinal.pdf ¾ http://www.npr.org/programs/morning/features/200 4/jan/kaiserpoll/principalsfinal.pdf OvercomingOvercoming thethe AccessAccess GapGap

¾ Dealing with your Personal Fears ¾ Program Resolve ¾ School-Based Health Centers and the Birth Control Debate ¾ Minnesota Organization on Adolescent Pregnancy Prevention and Parenting http://www.guttmacher.org/pubs/ib_1200.html ¾ Community Connections ¾ Parent Engagement FurtherFurther DiscussionDiscussion Do you believe Confidential access to information and services can help to reduce risky behaviors, particularly behaviors that can lead to adolescent pregnancy.

Will you supports minors’ right to consent to and access confidential health care services related to contraception?

What will you do?

Administrative Guidelines and Procedures

Section: Administrative Guidelines Number AG 29

Original Date: 12/02 Title: Parent or Legal Guardian Involvement Review Date: 7/04 Next Review Date: 7/06 Page: 1 of 2 Approved: Valerie Whittlesey Attachments:

ADMINISTRATIVE GUIDELINE

School-Based Health Center (SBHC) Program staff involve parents or legal guardians in making decisions about their child’s health care whenever possible. It is also recognized that, in specific situations, parent or legal guardian involvement is not possible. In cases where the student does not want to involve a parent or legal guardian and their consent is not required, staff should explore the involvement of other significant adults in the child’s life.

PROCEDURE

I. SBHC staff will determine the age of each SBHC client at the client’s initial visit to an SBHC clinic.

II. SBHC staff must obtain the consent of a parent or legal guardian for general medical treatment if a client is under 15 years of age; however, a client may seek family planning and sexually transmitted disease services without parent/guardian consent, at any age. Mental health (counseling services) may be provided to a person 14 years or older without parent or legal guardian consent, although the law requires the involvement of the parent or legal guardian by the end of treatment, except in certain, specific situations. (See Oregon Revised Statutes:109.610, ORS 109.640, ORS 109.675.)

III. SBHC staff will review program “Statement of Student Confidentiality” with each client, advising them of their rights under the law. Document review on health education matrix.

IV. SBHC staff will contact or will develop a plan regarding contact with minor (under age 18) clients’ parents or legal guardians before or after the initial visit.

V. SBHC staff will document in the client’s medical record any instance when the client gives a verbal authorization for release of information to a parent/guardian. School-Based Health Center Program Administrative Guidelines AG 29 Page 2 of 2

VI. If a minor client declines the opportunity for parent or legal guardian contact, SBHC staff will continue to explore the minor client’s decision. SBHC staff will offer assistance and support with parent or legal guardian involvement when the minor client is ready. SBHC staff will document in the medical record a minor client’s reasons for not involving the parent or legal guardian in treatment. An example might be that the client is not living with the parent or legal guardian.

VII. SBHC staff efforts to involve a parent or legal guardian in the care of a minor client will be documented in that client’s medical record, including the response of the parent or legal guardian to their efforts.

VIII. SBHC staff will periodically communicate with a minor’s parent or legal guardian after the initial contact, whenever appropriate. The preferences of parents or legal guardians regarding frequency of contact should be followed when appropriate to the situation. These preferences will be recorded in the minor’s medical record.

IX. When there is a question regarding the client’s mental competence to consent to care, SBHC staff will consult their supervisor.

RELATED REFERENCE

MCHD Administrative Guideline 111(1) Parental Involvement http://mint.co.multnomah.or.us/health/hdpolicy/100/111_1.pdf

MCHD Administrative Guideline 509(1) Custody Issues http://mint.co.multnomah.or.us/health/hdpolicy/500/509_1.pdf

State of Oregon Revised Statutes ORS 109.610 Right to treatment for venereal disease without parental consent, ORS 109.640 Right to medical or dental treatment without parental consent; physicians may provide birth control information to any person, ORS 109.675 Right to diagnosis or treatment for mental or emotional disorder or chemical dependency without parental consent http://landru.leg.state.or.us/ors/109.html

ATTACHMENT

Confidentiality Form

MULTNOMAH COUNTY OREGON

SCHOOL-BASED HEALTH CENTER PROGRAM POLICIES AND PROCEDURES

SECTION: Clinical Policy NUMBER: CP 27 ORIGINAL DATE: 10/01 TITLE: Priority Access to Pregnancy REVIEW DATE: 10/01 Prevention Services NEXT REVIEW DATE: 8/03 PAGE: 1 OF 4 APPROVED: Valerie Whittlesey ATTACHMENTS: 0

POLICY STATEMENT

It is the policy of the School-Based Health Center (SBHC) Program that students presenting in School-Based Health Clinics with potential risk for pregnancy will be given priority access.

Health care systems need to anticipate potential situations of pregnancy prevention method failures, including abstinence as a method failure, in their adolescent population in order to minimize unplanned (unwanted) pregnancies. The need to determine and expeditiously address potential pregnancy prevention method failures exists for both the unscheduled and the scheduled patient.

The provider of best practice will be flexible, be able to anticipate potential failures, and be prepared to spontaneously address them.

PROCEDURE

To detect pregnancy prevention method failures, any requests for service that suggest—even remotely—a family planning need should be triaged at the time of contact with the SBHC clinic. Exceptions are allowed for those clients known to staff who express a clear request for DMPA/method refill, or who request a pap or annual exam when it is known to be due. When making service decisions, SBHC staff should keep in mind the age and maturity level of the patient. Younger, less mature adolescents often lack the problem recognition and problem-solving skills of older teens.

I. Identifying Service Need

When an unscheduled patient comes in to an SBHC clinic, she may present with a variety of direct or indirect indications of a birth control method failure:

SCHOOL-BASED HEALTH CENTER PROGRAM - Policies and Procedures CP 27 Page 2 of 4

A. I need a pregnancy test B. I'm having problems with my period C. I need a checkup D. I want to talk to someone, a nurse, about ------, or in private E. I might be pregnant F. I need some birth control G. I need a pap H. I need an STI check I. I had an accident J. My friends told me I should come in K. I have an itch L. I have a yeast infection M. Shows “I need” cards

II. Responsibilities of the Senior Office Assistant

A. Say “yes we will see you” B. Determine eligibility for services C. If established, pull client chart D. If client is new, have them begin to fill out paperwork E. Assess contact information F. Encounter appropriately G. Have the client wait for triage H. Offer same-day appointment if available and acceptable I. Communicate with licensed personnel; LPN, RN, PA, NP, and provide chart when available J. If specific request: consider giving forms e.g., ECP consent, FP consent, sexual health history, or pregnancy test questionnaire K. May need urine sample—communicate to nurse of client’s need to urinate L. Avoid too many questions

III. Responsibilities of the LPN/CHN/NP

A. The first available licensed staff person should triage the client B. Re-prioritize: rearrange schedule to triage, as teen pregnancy prevention is a county benchmark and top priority C. Make contact with client, and have client get UCG at that time if needed, or fill out forms if not yet done D. Have ongoing communication with client about waiting time

SCHOOL-BASED HEALTH CENTER PROGRAM - Policies and Procedures CP 27 Page 3 of 4

E. Communicate with other staff about possible need to see client (decide who is most appropriate and available) F. Begin appointment with client even if only minimal paperwork is completed G. Have ongoing communication with other clients about possible delays or reschedule, or as necessary offer to reschedule by CHN or NP H. Obtain the following relevant sexual history/information:

1. Date of last menstrual period 2. Reliability, consistency, and correct use of any method by either partner 3. Any time client used protection since last menstrual period 4. Date of last sexual intercourse with/without condom

I. LPN consults with NP or CHN about next steps

IV. Responsibilities of the CHN/NP

A. Determine level of risk from triage information B. "Re-prioritize" as team C. Direct LPN or other staff as needed D. Offer and provide ECPs as needed E. Provide other services to client as needed, or schedule appointment F. Assess client, including emotional state—give mental health referral if appropriate G. Assess level of parent involvement—invite inclusion where possible H. Make a BCM plan with client—do not have client leave without a plan I. Address and problem solve, if possible, the causes of failure (or re-appoint to do so) J. Re-schedule patient appropriately, including consideration for reprioritizing/rescheduling other clients

V. Telephone Procedure

When interactions with clients at potential risk for pregnancy take place by phone, the above procedure is followed with these additions/exceptions:

Responsibilities of the Senior Office Assistant:

A. Take the client’s name and current phone number, discuss how to contact B. Determine eligibility for services (if not eligible refer to Central Triage) C. Pull chart if client has one D. Offer client an appointment for that day, if available E. Offer to put on hold or call back (ideally within one hour or time acceptable to client), or give central triage phone number SCHOOL-BASED HEALTH CENTER PROGRAM - Policies and Procedures CP 27 Page 4 of 4

Responsibilities of the LPN/CHN/NP

A. Re-prioritize so the first available licensed staff person can speak to the client B. Call the client back on a timely basis C. Have ongoing communication with clients in the clinic as necessary D. Have ongoing communication with other staff

VI. Telephone Triage

A. Communicate with client about service delays to clients in clinic B. Assess opportunity to "freely speak" C. Assess ability to come to clinic D. Assess re-contact information E. Do triage according to "In clinic Triage" considerations F. LPN consults with NP or CHN if taking call G. Assess ability for service to be provided by phone e.g., ECP or OCP start/restart H. Address and attempt to correct reasons for BCM failure I. Determine if help is needed refilling method prior to next clinic visit J. Give Central Triage number K. Schedule appointment in timely manner to establish reliable BCM or address other unmet needs L. Document service in chart and do a telephone encounter

Minnesota Organization on Adolescent Pregnancy, Prevention and Parenting (Excerpts from Legislative Policy Agenda 2005)

Legislative and Policy Agenda 2005 MOAPPP’s MISSION To strengthen policies and programs related to adolescent pregnancy, prevention and parenting in Minnesota.

MOAPPP’s VALUES 1. All adolescents have a need and a right to be healthy, safe and respected by peers and adults, and to fill meaningful roles in their communities. 2. To most effectively reduce the incidence of teen pregnancy, an evidence-based, holistic approach should be implemented in communities. 3. To assure healthy youth, families and communities, early and continuous investment in prevention and intervention must occur.

MOAPPP’s Public Policy Goal To ensure that evidence-based public policies are adopted and implemented on state and local levels. Public policies related to adolescent pregnancy, prevention, and parenting must be based on current research. MOAPPP’s role is to educate policymakers and policy influencers about credible research so that policies and programs reflect best practice.

Adolescent pregnancy is a complex issue requiring prevention and intervention strategies at all stages of a child’s and adolescent’s life. In order to address adolescent pregnancy, prevention, and parenting in a comprehensive manner, Minnesota policies should:

• Support adolescent pregnancy prevention programs based on evidence of their success and/or their use of proven strategies. • Support adolescent parent programs based on evidence of their success and/or their use of proven strategies. • Ensure comprehensive sexuality education for youth that includes medically accurate and developmentally appropriate information on abstinence and contraception. • Ensure that youth have access to confidential health care services. • Address health disparities by supporting programs and services to communities and populations with highest rates of teen pregnancy. • Support service learning and youth development programs, particularly those that occupy out-of-school time. and

Minors’ Access to Confidential Health Care MOAPPP supports minors’ right to consent to and access confidential health care services related to emergency medical care, contraception, pregnancy related care, treatment for STIs, mental health services, and treatment for drugs and alcohol use. Confidential access to information and services can help to reduce risky behaviors, particularly behaviors that can lead to adolescent pregnancy.

The confidentiality that is assured by a minor’s right to consent is a basic principle essential in promoting the health of adolescents. Research indicates that adolescents are less likely to access health services without the guarantee of confidentiality.6 Mandated parental involvement for contraception would discourage few teenagers from having sex, but would likely result in more teenagers using the least effective methods or no method at all.7 Research has shown that most adolescents do discuss their use of reproductive health services with their parents and even more adolescents discuss an unintended pregnancy with their parents.8 Also, health care professionals help adolescents reconnect and communicate better with parents and adults.6 Related research shows that mandatory parental consent laws do not convince adolescents to share their health concerns with their parents, but rather increases health risks to adolescents.8,9

MOAPPP’s Vision Minnesota provides minors the right to access confidential health care as granted by the Minnesota Statute 144.341-347.

6 Ford CA and English A. Limiting confidentiality of adolescent health services, what are the risks? [Editorial] JAMA. 2002; 288:752-753. 7 Jones RK, Boonstra, H. Confidential reproductive health services for minors: The potential impact of mandated parental involvement for contraception. Perspectives on Sexual and Reproductive Health. 2004;36(5): 182-191. 8 Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA. 2002; 288:710-714. 9 Council of Scientific Affairs, American Medical Association. Confidential health services for adolescents. JAMA. 1993;269:1420-1424.

Minnesota Organization on Adolescent Pregnancy, Prevention, and Parenting 1619 Dayton Avenue, Suite 111 Saint Paul, MN 55104-8392 651.644.1447 1.800.657.3697 www.moappp.org [email protected] MULTNOMAH COUNTY HEALTH DEPARTMENT SCHOOL-BASED HEALTH CENTER PROGRAM Name: ______Date of Birth: ______Today’s Date: ______LAST FIRST MIDDLE INITIAL Name of health care provider:______

Drug Allergies: ______Drug Reactions: ______Date of last dental visit: ______Immunization History (check box if unknown): Year of last Tetanus shot:______Unknown Year of last Measles, Mumps, Rubella (MMR): ______Unknown Year of last Hepatitis B: ______Unknown Year of last Tuberculosis (TB) skin test: ______Unknown (For sports participation, side 1 of this form to be completed and signed by parent or guardian prior to exam) STUDENT MEDICAL HISTORY FAMILY MEDICAL HISTORY Has this student had any of the following conditions? Has a blood relative had the following conditions? (Please list only: mother, father, brother/sister, grandparent.) YES NO YES NO Who? Serious or chronic illness such as tuberculosis, Allergies ______diabetes, seizure, cancer, hepatitis, mono? Asthma ______Surgeries or overnight hospitalizations? Urinary, kidney problems, undescended testicles? Birth Defect ______Missing or damaged organs (eye, kidney, testicle)? Bleeding Disorders ______Problems with heart or blood pressure? Breast Cancer ______Chest pain with exercise? Wheezing? Coughing? Other Cancers ______Dizziness or fainting? Diabetes ______Frequent headaches? Drug/Alcohol Abuse ______Blood clot problems? Anemia? Gall Bladder Problems ______Allergies, asthma, severe bee sting reaction? Glaucoma ______Learning or slowed development or special education Headaches ______needs? Heart attacks/disease ______Vision, hearing or speech problems? Mental illness including depression? Hepatitis ______Drug or alcohol use or treatment? High Blood Pressure ______Wear eyeglasses, contact lenses, dental bridges, Kidney Disease ______bracesor a retainer? Lung Disease ______Take any medication on a regular basis?(Include non-prescription.) Mental Illness/Depression ______If yes, what:? ______Obesity/Overweight ______Is there a history of: Sickle Cell Anemia ______Concussion, loss of consciousness, convulsions? Seizures ______Injuries or disease to neck, back or other bones or Stroke ______joints? Thyroid Disease ______Is there a reason why this student should not participate in sports or was ever refused participation Tuberculosis ______for medical reasons? O t h e r ______Have any of your blood relatives died suddenly at less than 50 years of age of causes other than an accident or violence? Use this space to explain any of the above YES answers or provide additional information. ______

x ______x ______Student signature Parent/guardian signature N a m e : ______

______DOB:______/______/______ID#______Reviewer Date Sex: M F (Continued on back) ADOLESCENT PERSONAL & FAMILY HEALTH HISTORY POR-915 Rev. 05/09/05 Page 1 2566 PARENT/GUARDIAN QUESTIONNAIRE FOR ADOLESCENT HEALTH HISTORY **Note: The following questions are sensitive in nature. We ask them so that we may better help your child with his/her health care needs. YES NO 1. Do you have any concerns about your child’s health, safety or welfare that you would like to discuss? 2. Do you have concerns that your child may be using tobacco, alcohol or drugs? (Circle areas of concern) 3. Do you think your child will graduate from high school? 4. Are you satisfied with your child’s school work and attendance? (Circle areas of concern) 5. Are you involved with activities at your child’s school? 6. Give examples of how your child contributes to your family, school or community: (Use comment section below) 7. Does your child talk to anyone about problems or concerns? Who? ______8. Do you have concerns about how your child gets along with family, friends, neighbors or teachers? (Circle) 9. Would you describe your child’s behavior as aggressive during grades 1 through 8? 10. Does your child seem sad or worried or depressed or express feelings or display behaviors that seem out of the ordinary for someone his or her age? 11. Does your child adjust well to change or misfortune? 12. Do you have concerns regarding your child’s sexual orientation? 13. How often do you know where your child is when you are not with him/her: (Please check one) Never Sometimes Most of the time Always 14. Have you discussed with your child your beliefs and values about sexual activity? 15. Has your child had sexual intercourse? Check if unsure If yes, what are your concerns about your child’s involvement in sexual activity? (Use comment section below) If no, what are your expectations regarding sexual activity? (Use comment section below) 16. Would you like age related information for yourself regarding parenting, pubertal changes, sexuality, preventing drug/alcohol/tobacco abuse, mental health or other areas of health? (Circle those you want) 17. Do you need assistance with housing or employment? Or medical care? (Circle those you want help with) 18. Is your family experiencing any difficulties that we should be aware of while caring for your child? (Use comment section below) 19. We have on our staff a nurse, a nurse practitioner or physicians assistant, and mental health consultant. Would you like to discuss any of these concerns with one of these health professionals?

How should we contact you? ______Comments: ______Thank you for your time and comments.

Parent Signature: ______

Reviewer: ______Date______/______/______

Action Plan: None See Progress Notes Dated:______/______/______

N a m e : ______

ADOLESCENT PERSONAL & DOB:______/______/______ID#______FAMILY HEALTH HISTORY Sex: M F

POR-915 Rev. 05/09/05 Page 2 2566 STUDENT QUESTIONNAIRE FOR ADOLESCENT HEALTH HISTORY Note: The following questions are sensitive in nature. We ask them so that we may better help you with your health care needs. HEALTH HABITS SCHOOL HEALTH YES NO YES NO Are you unhappy with your physical appearance. Is there a chance that you might not graduate? Have you ever tried to lose weight? What are your career interests for after high school? ______If yes, how? ______Have you failed any courses in the last year? Do you often skip meals? If yes, which are your problem courses? Have you ever tried tobacco (cigarettes or chew)? During the past 2 weeks, have you skipped or cut one Age first used:______Last used:______or more classes? Amount per day:______Have you ever been suspended/ dropped out? Are your working or doing volunteer work? Are you exposed to cigarette smoke at home? ______hours/wk What is your GPA?______Have you ever tried alcohol? MOOD/MENTAL HEALTH Age first used:______Last used:______How many times in the last 30 days:______How do you get along with your family/household members? (Circle) 1 2 3 4 5 Have you ever tried - steroids, crank, marijuana/pot, POORLY ————————————————————————————— GREAT LSD/acid, PCP, cocaine, heroin, glue, other? (Circle all that apply.) How do you get along with your friends/peers? (Circle) 1 2 3 4 5 Age first used:______Last used:______POORLY ————————————————————————————— GREAT How many times in the last 30 days:______On the whole, how do you like yourself? (Circle) Are there any health practices you would like to change? 1 2 3 4 5 Do you wear a seat belt? NOT VERY MUCH —————————————————————————— A LOT Always Sometimes Never What do you do best? ______How often do you exercise in a week? ______ 3 - 4 1 - 2 Never What one thing would you change about your life or yourself? ______SAFETY ______YES NO Who cares about you? ______Is there a gun/firearm in the home? ______If yes, how is it stored? ______Who do you care about? ______Who do you talk with about your problems or concerns? Have you ever had a friend or relative seriously hurt or killed from violence? Friends Family Teacher Other No one Is there verbal or physical fighting occurring in YES NO your house? Have you ever felt really sad or depressed for two Is there alcohol or drug abuse in your home? weeks or more? Have you ever been physically, emotionally or Have you ever considered or attempted suicide? sexually abused? When?______Has anyone touched you sexually in a way that made Are you presently in or have you had counseling? you feel uncomfortable or without your permission? Have you ever run away, been in a juvenile Have you gotten into trouble because of your anger or detention, or had legal problems? temper? Have there been any major changes in your family’s Have you hit or been hit by a boyfriend or girlfriend? life in the past year? (Check all that apply) Marriage Serious illness Births During the past 12 months, have you ever feared for Separation Loss of job Deaths your safety when in your home, neighborhood, or Divorce Move to a new house coming to or leaving school? Other:______Have you or anyone close to you (friends or family) been affected by gangs? Have you ever lived in foster care or a group home? Have you been verbally, physically or sexually Would you like to talk about personal issues harassed while at school? privately with someone in the clinic? (Continued on back) N a m e : ______

DOB:______/______/______ID#______

Sex: M F ADOLESCENT PERSONAL & FAMILY HEALTH HISTORY POR-915 Rev. 05/09/05 Page 3 2566 SEXUAL HEALTH YES NO If you ever had intercourse (includes vaginal, oral or anal), complete this section: Have you discussed sexual issues with your family? Age at first intercourse:______Have you begun dating? Number of sexual partners past and present: Do you currently have a boyfriend or girlfriend? Male______Female______If so, how old is he or she?______Number of sexual partners in the past 2 months (60 days): Are you interested in receiving information on preventing pregnancy? Male______Female______Would you be interested in learning about programs How often did you use a condom with intercourse? that serve gay, lesbian and bisexual youth? Always Sometimes Never Would you like to talk privately with someone in the YES NO clinic about any sexual or relationship concerns? Do you have difficulty talking about using condoms to Have you been taught how to correctly use a condom? prevent sexually transmitted diseases with the person Have you ever felt pressured to have intercourse? you have intercourse with? Have you ever had intercourse? (Includes, vaginal, Thinking about the last time you had intercourse, did oral or anal) If yes, also complete next column. you drink alcohol or use drugs before you had intercourse? If no, is postponing sexual intercourse a choice you are making? Until when?______Have you ever had a sexually transmitted disease (STD)? If you plan to become a parent how old do you want to be? Age______Are you interested in STD testing, HIV/AIDS testing? How old was your mother when she had her first Thinking about the last time you had intercourse, did pregnancy? Age______ Don’t know you do anything to prevent pregnancy? Do you have difficulty talking about birth control with MENSTRUAL - Females only, complete this section: the person you have intercourse with? Age at first period:______Have you or your partner ever wanted to have a baby? Have you or your partner ever gotten pregnant? First day of last normal menstrual period:______MONTH / DAY What birth control method(s) are you using to prevent pregnancy (postpone parenting)?______YES NO ______Do you have monthly periods? PREGNANCY HISTORY – If you or your partner have ever been Do you keep a menstrual calendar? pregnant, complete this section: Do you have menstrual cramps? List number of times each of the following has happened to you or your partner? If yes, what do you do to relieve them? ______a. Pregnancy______b. Miscarriage______Do you have any bleeding between periods? c. Abortion______d. Unknown outcome______Have you ever had a pelvic exam? If yes, date of last exam:______If you have any children, complete this section: Date of last pap smear:______YES NO Are you presently parenting? Are you providing financial support? Is the child/children living with you?

PHYSICAL SYMPTOMS Check any of the following that are causing you problems or that you have concerns about: weight /height eyes/vision neck bladder/urine fevers sleep ears/hearing heart genitals blood/anemia tiredness nose breasts/chest back concentration/thinking dizziness throat lungs/breathing bones/joints moods/feelings headaches mouth/teeth stomach/digestion skin/acne pain (Where?)

Reviewer:______D a t e : ______

N a m e : ______

ADOLESCENT PERSONAL & DOB:______/______/______ID#______FAMILY HEALTH HISTORY Sex: M F

POR-915 Rev. 05/09/05 Page 4 2566 MULTNOMAH COUNTY HEALTH DEPARTMENT SCHOOL-BASED HEALTH CENTER PROGRAM Name: ______Date of Birth: ______Today’s Date: ______LAST FIRST MIDDLE INITIAL Name of health care provider:______

x ______x ______Student signature Parent/guardian signature N a m e : ______

How should we contact you? ______Comments: ______Thank you for your time and comments.

Parent Signature: ______

Reviewer: ______Date______/______/______

Action Plan: None See Progress Notes Dated:______/______/______

N a m e : ______

ADOLESCENT PERSONAL & DOB:______/______/______ID#______FAMILY HEALTH HISTORY Sex: M F

DOB:______/______/______ID#______

Reviewer:______D a t e : ______

N a m e : ______

ADOLESCENT PERSONAL & DOB:______/______/______ID#______FAMILY HEALTH HISTORY Sex: M F

POR-915 Rev. 05/09/05 Page 4 2566 Pregnancy Audit Tool #

Please fill in EVERY section PLACE LABEL HERE Client Age w/current FY: ______name: pregnancy:

SITE: ______# of pregnancies client has Epic ID: had (include this one):

# of births client has had Date of + pregnancy test: Was pregnancy test done (include this one): at an SBHC clinic: Yes No

Was client pregnant at her 1st Pregnancy reason: Race: visit to an SBHC clinic? Planned African American

Unplanned Asian Caucasian Yes No Ambivalent Hispanic Other Unknown/Undocumented Native American

Pregnancy outcome: Comments regarding client’s Age at which voluntary pregnancy: sexual activity started: TAB Unknown SAB Still pregnant at review Number of sexual partners: Infant > 5lbs Infant < 5lbs

Did parents/guardian have Was there a history of family planning If YES, how would you knowledge of the client’s need services at an SBHC clinic? classify their contraceptive for family planning services: use in the last six months?

None Yes No Yes No Unknown Reliable method w/consistent use N/A (Reason:______) Inconsistent use OR low reliability method

Was client receiving family If YES, where? (choose one only) Did the client have a planning services elsewhere? history of physical or Private physician sexual abuse or sexual Planned Parenthood exploitation? Yes No HMO Yes No Unknown Other ______Client (at time of + test): (Choose only one) is enrolled at your school or is enrolled at another SBHC site school:______is enrolled at an alternative school: (including GED at PCC):______is enrolled at another non-SBHC school:______If client is a community client (no longer enrolled in school and age 19 or younger, choose one of the following: (You do Not need to fill out an audit tool if client is a community client age 20 or older) is a graduate of high school (or GED) is a dropout: Number of months since last attended school:______Last school attended:______other (please explain):______