The National Alliance to Advance Adolescent Health Share

The National Alliance's publications include fact sheets, issue briefs, reports, and journal articles. They address a wide range of health care topics important to adolescents, such as analyses of Medicaid benefit and coverage policies, current data on racial and ethnic disparities in health status and access to care, and findings from our surveys of pediatricians' perspectives on adolescent care. All of The National Alliance's publications, with the exception of journal articles, are available to download in Adobe PDF. For additional resources on health care transition, please visit

Aligning National Title V Performance Measures on Transition, Medical Home, Preventive Care, and Insurance: Suggested Strategies for States
by Margaret McManus, Daniel Beck, and Patience White. Got Transition 2016.
This report offers strategies for state Title V agencies that have selected transition as one of their to help them link performance improvements and innovations for transition with medical home, adolescent well care, well care for women, and adequate health insurance.

State Title V Health Care Transition Performance Objectives and Strategies: Current Snapshot and Suggestions
by Margaret McManus, Daniel Beck, and Patience White. Got Transition, February 2016.
This report analyzes FY 2016 State Title V Action Plans of the 32 states that have selected transition as one of their priorities over the next five years. The report offers specific suggestions for 1) aligning transition objectives with the new national transition measure in the upcoming National Survey of Children's Health and the Six Core Elements of Health Care Transition, and 2) selecting measurable strategies related to expanding availability of adult providers, evaluating health care transition implementation, and expanding quality improvement and educational efforts using the Six Core Elements.

Incorporating the Six Core Elements of Health Care Transition Into a Medicaid Managed Care Plan: Lessons Learned From a Pilot Project
by Margaret McManus, Patience White, Robin Pirtle, Catina Hancock, Michael Ablan, Raquel Corona-Parra. Journal of Pediatric Nursing. 2015;30:700-713.
This article describes the results of and lessons learned from incorporating the Six Core Elements of Health Care Transition into a DC Medicaid managed care plan that serves SSI-eligible youth and young adults. It summarizes the extent of transition improvements within the plan and receipt of recommended transition core elements among a pilot group of young adult enrollees needing to transfer from pediatric to adult health care.

Pediatric to Adult Transition: A Quality Improvement Model for Primary Care
by Margaret McManus, Patience White, April Barbour, Billie Downing, Kirsten Hawkins, Nathalie Quion, Lisa Tuchman, W. Carl Cooley, and Jeanne McAllister. Journal of Adolescent Health. 2014;56:73-78.
This article examines the results of implementing the Six Core Elements of Health Care Transition in five large pediatric and adult academic primary care sites in the District of Columbia, as part of a two-year learning collaborative. Using the Health Care Transition Index, the study compares improvements in specific indicators of transition performance in pediatric and adult practices. It also discusses quality improvement lessons learned.

Measuring the “Triple Aim” in Transition Care: A Systematic Review
by Megan Prior, Margaret McManus, Patience White, and Laurie Davidson. Pediatrics. 2014;134:e1648-e1661.
This article identifies published measures used to evaluate transition within the “Triple Aim” framework of experience of care, population health, and costs. Within this framework, the article describes the specific measures used in the 33 studies that met inclusion criteria. It also includes a critical discussion of transition measurement gaps and suggestions for developing a cores set of transition measures.

The Promise and Potential of Adolescent Engagement in Health
by Margaret A. McManus. Journal of Adolescent Health. 2014:314.
This editorial discusses a new youth engagement tool developed by Sebastian et al. in the Journal of Adolescent Health and recommends incorporating transition readiness assessment in future measures of adolescent engagement consistent with Got Transition’s “Six Core Elements of Health Care Transition.” It also addresses the need to consider the continuum of adolescent engagement pertaining to direct care as well as to involvement of youth as staff, peer educators, advisory group members, and other leadership positions.

Lack of Comparability Between CHIP and ACA Qualified Health Plans
by Margaret A. McManus and Harriette B. Fox, July 2014.
This fact sheet provide a detailed examination of comparability between separate CHIP programs and child-only qualified health plans in Colorado, Georgia, Oregon, Texas, and West Virginia for children with family incomes between 134% to 300% FPL. It examines cost-sharing requirements, including deductibles, copayments and coinsurance, and out-of-pocket limits, and benefit coverage and treatment limitations in 28 benefit categories. Implications for CHIP reauthorization are also discussed.

Many Low Income Older Adolescents Likely to Remain Uninsured in 2014
by Harriette B. Fox, Margaret A. McManus, and Annalia G. Michelman, October 2013.
This fact sheet identifies the states in which adolescents ages 19 and 20 living at or below the poverty level are likely to remain without health insurance protection in January 2014, despite the passage of the Affordable Care Act. It examines several avenues to state Medicaid coverage: optional Medicaid eligibility for “Ribicoff Children” up to age 21, Section 1115 demonstration waivers covering childless adults, and the ACA’s optional Medicaid expansion for uninsured individuals ages 19 through 64. It also describes the obstacles these older adolescents confront in securing private health insurance coverage through employment and in exchanges.

A Research Agenda for Adolescent-Centered Primary Care in the United States
by Harriette B. Fox, Margaret A. McManus, Charles E. Irwin Jr, Kelly J. Kelleher, and Ken Peake. Journal of Adolescent Health. 2013:307-310.
This commentary presents a set of prioritized research recommendations on adolescent-centered primary care developed by experts participating in The National Alliance to Advance Adolescent Health's invitational conference in 2012. The recommendations pertain to increasing adolescent and parent engagement and self-care management, improvement preventive care and identifying conditions early, and integrating physical, behavioral, and reproductive health services. The commentary also addresses federal and private foundation funding priorities related to the adolescent research agenda.

Current Status of Transition Preparation Among Youth With Special Needs in the United States
by Margaret A. McManus, Lauren R. Pollack, W. Carl Cooley, Jeanne W. McAllister, Debra Lotstein, Bonnie Strickland, and Marie Y. Mann. Pediatrics. 2013;131:1090-1097.
This article provides an analysis of US transition performance from pediatric to adult health care based on the 2009-2010 National Survey of Children with Special Health Care Needs. It examines the association of population, condition, and health care characteristics with successful transition preparation. It also identifies adolescent populations least likely to receive needed transition support and offers delivery system and payment suggestions for improvement.

Private Coverage Under California's Affordable Care Act: Benefit and Cost-Sharing Requirements Affecting Children and Adolescents With Special Health Care Needs
by Peggy McManus and Harriette Fox, May 2013.
This issue brief examines the extent to which California’s essential health benefits benchmark plan meets the needs of children and adolescents, including those with special needs. It also examines the cost-sharing requirements that will be used by health insurance plans sold in California’s Health Insurance Exchange. It identifies potential issues of concern in the benchmark’s essential health benefits, with special attention to families’ out-of-pocket cost liabilities within all five levels of coverage, including subsidized coverage.

A Primary Care Quality Improvement Approach to Health Care Transition
by Patience H. White, Margaret A. McManus, Jeanne W. McAllister, and W. Carl Cooley. Pediatric Annals. 2012;41:e1-e7.
This article describes a quality improvement approach for implementing health care transition supports in pediatric and adult primary care practice settings, which is based on the 2011 AAP/ACP/AAFP's Clinical Report on Health Care Transition and the Six Core Elements of Health Care Transition. It includes detailed sample tools, strategies, and lessons learned from primary care practices in the District of Columbia that have implemented the Six Core Elements.

Medical Home Innovations: Where Do Adolescents Fit?
by Ian Walker, Margaret McManus, and Harriette Fox, December 2011.
This report provides a summary of the activities underway in 12 innovative medical home programs and discusses how the health needs of adolescents are being addressed. Findings are based on interviews with leaders in public, private, and multi-stakeholder programs. The report examines each of the seven principles central to the medical home model: personal provider, physician-directed practice, whole person orientation, care coordination, quality and safety, enhanced access, and payment for excellence. It describes the progress that has been made in changing primary care practices and plans underway for future improvements.

State EPSDT Policies for Adolescent Preventive Care
by Harriette B. Fox, Katherine K. Rogers, and Margaret A. McManus, September 2011.
This fact sheet presents findings from an analysis of state policy documents that establish guidelines for providers delivering EPSDT preventive services to adolescents. It examines state Medicaid policies including the EPSDT periodicity schedule; comprehensive health history and developmental assessments; physical examinations, laboratory tests, and immunizations; health education; and referrals. Particular emphasis is given to the early identification of problems related to nutritional health, mental health, sexual behavior, substance use, and violence and injury potential and to health education for key topics under Bright Futures. Also examined are state policies regarding adolescents’ private time with providers.

Future Directions for the Office of Adolescent Health
by Harriette B. Fox and Bruce P. Frohnen, February 2011.
This report presents the views of clinical and policy experts on how the HHS Office of Adolescent Health can best carry out its legislative charge to improve adolescent health outcomes through increased coordination. The report, based on more than 30 interviews, provides recommendations for interagency coordination around program design and evaluation, research, and health care provider training activities as well as for the coordination of efforts aimed specifically at preventing mental and behavioral health disorders and improving systems of care. Also included are perspectives on the need for a national plan to improve adolescent health.

Strengthening Preventive Care to Better Address Multiple Health Risks Among Adolescents
Presentations by Harriette B. Fox, Margaret A. McManus, Susan K. Maloney, Angela Diaz, and Anne Morris, November 2010.
This report summarizes the presentations at the Adolescent Preventive Services Institute at the American College of Preventive Medicine 2010 Annual Meeting. It reports on the prevalence and co-occurrence of teen risk behaviors, the underutilization of clinical preventive services for adolescents, and barriers to the delivery of preventive care. The report also presents evidence-informed strategies for improving clinical and community prevention and includes a description of the Mount Sinai Adolescent Health Center as an innovative primary care model.

Concern for Our Teens: Opinion Leaders Speak Out on Adolescent Health
by Bruce P. Frohnen, Margaret A. McManus, Stephanie J. Limb, and Celia R. Straus, July 2010.
This report examines the perspectives of opinion leaders in business, academia, and the military on adolescents' health and access to care. It also addresses the leaders' opinions on the role of their community in health education and public and private policy actions needed to improve adolescent health. Information was obtained through interviews with leaders from a cross section of large and small firms in both manufacturing and service sectors; public, private, and community colleges; and several branches of the military.

Parents’ Perspectives on Health Care for Adolescents
by Harriette B. Fox, Margaret A. McManus, and Shara M. Yurkiewicz, June 2010.
This report presents parents’ perspectives on teen health problems and ways to better address them. It reports on what parents understand to be the most pressing health problems teens today face, what their experiences have been in accessing needed services for their adolescent children, what they see as their appropriate role in helping teens to obtain care and stay healthy, and how they think providers can help them. The report also presents parents’ recommendations for an ideal health care site for teens. Information was obtained from seven parent focus groups, including three with Spanish-speaking parents, conducted in Chicago, DC, Los Angeles, and Miami.

Adolescents’ Experiences and Views on Health Care
by Harriette B. Fox, Susan G. Philliber, Margaret A. McManus, and Shara M. Yurkiewicz, March 2010.
This report presents adolescents’ perspectives on their health care experiences and their ideas about how best to structure a health care delivery system that is responsive to their needs. It addresses several topics, including health issues facing adolescents; experiences with seeking and receiving health care; views on parental involvement; and preferences for the design, services, and staff at an ideal health site. Information was obtained through focus groups and supplemental questionnaires conducted in four cities with over 200 adolescents.

Significant Multiple Risk Behaviors Among U.S. High School Students
by Harriette B. Fox, Margaret A. McManus, and Katherine N. Arnold, March 2010.
Based on an original analysis of the 2007 Youth Risk Behavior Survey, this fact sheet provides national information on multiple health risk behaviors among high school students. It examines 12 types of significant health risk behaviors that include unsafe sexual behaviors, unhealthy eating and exercise patterns, mental health and substance use problems, and behaviors that contribute to violence. It reports on the prevalence and co-occurrence of these health risk behaviors and also differences by gender, race and ethnicity, and grade level. Implications for preventive interventions are also discussed.

Adolescent Medicine Training in Pediatric Residency Programs
by Harriette B. Fox, Margaret A. McManus, Jonathan D. Klein, Angela Diaz, Arthur B. Elster, Marianne E. Felice, David W. Kaplan, Charles J. Wibbelsman, and Jane E. Wilson. Pediatrics. 2010; 125: 165-172.
This article examines the adequacy of pediatric residency training in adolescent medicine. It addresses several aspects of training, including the extent to which important adolescent medicine topics are covered through formal education and practical application, the types of faculty involved in training, and the opportunities to establish ongoing therapeutic relationships with adolescents. Information for the study was obtained through a 2007 survey of pediatric residency program directors and adolescent medicine faculty.

Pediatricians' Interest in Expanding Services and Making Practice Changes to Improve the Care of Adolescents
by Harriette Fox, Margaret McManus, Karen O’Connor, Jonathan Klein, Angela Diaz, and Charles Wibbelsman, September 2009.
Based on a 2008 national survey of practicing pediatricians, this fact sheet examines pediatricians’ interest in adding or expanding preventive, mental health, and reproductive health services for adolescents if payment barriers were removed. It also identifies the specific practice and staffing changes they would have an interest in making, as well as the types of support and training they perceive would be most helpful to them in providing comprehensive primary care to adolescent.

Health Reform and Adolescents
by Harriette B. Fox and Margaret A. McManus, June 2009.
This issue brief documents the significant health risks and conditions of adolescents and the financing and delivery system barriers that affect their access to appropriate care. It urges Congress to consider coverage expansions under Medicaid and CHIP, benefit and payment improvements, grant programs to support interdisciplinary models of primary care, and funds to improve training for adolescent health providers.

Structuring Health Care Reform to Work for Adolescents
by Harriette Fox, Margaret McManus, Stephanie Limb, and John Schlitt, November 2008.
This issue brief on health reform and adolescents examines four major themes for restructuring the health care financing and delivery system -- placing greater emphasis on prevention, redesigning primary care, changing payment incentives, and relying more on evidence-based care. For each topic, reform proposals are summarized, issues of concern to adolescents are reviewed, and new options for addressing adolescent needs are presented.

Pediatric Perspectives and Practices on Transitioning Adolescents with Special Needs to Adult Health Care
by Margaret McManus, Harriette Fox, Karen O'Connor, Thomas Chapman, Jessie MacKinnon, October 2008.
Based on a 2008 national AAP survey of practicing pediatricians, this fact sheet examines pediatricians' perspectives on the appropriate age to begin planning for transition and their practices regarding the provision of transition support services to adolescents with special needs. It also identifies the economic and non-economic barriers that pediatric practices face in providing transition services and presents options for improving training, financing, adult provider availability, and adolescent and parent education.

Adolescent Medicine at the Crossroads: A Review of Fellowship Training and Recommendations for Reform
by Harriette B. Fox, Margaret A. McManus, Jane E. Wilson, Angela Diaz, Arthur B. Elster, Marianne E. Felice, David W. Kaplan, Jonathan D. Klein, and Charles J. Wibbelsman, April 2008.
This special report examines the current state of adolescent medicine fellowship programs. It contains information on the supply and recruitment of fellows; the nature and content of clinical, research, and leadership training; the institutional and financial challenges facing training programs today; and offers recommendations for building the field. Information was obtained primarily from a national survey of adolescent medicine fellowship program directors, along with key informant interviews, and an extensive literature review.

State Policies Affecting the Assurance of Confidential Care for Adolescents
by Harriette B. Fox and Stephanie J. Limb, April 2008.
Based on interviews with state Medicaid staff and managed care organization officials and a review of states' minor consent laws, this fact sheet examines the mailing home of explanation of benefit statements for publicly insured adolescents. It looks at how and why Medicaid agencies and their contracting managed care organizations mail EOBs home and also examines whether state policies to exclude particular services from EOB mailings are consistent with state policies allowing minor consent.

Advancing Medical Education Training in Adolescent Health
by Harriette B. Fox, Margaret A. McManus, Angela Diaz, Arthur B. Elster, Marianne E. Felice, David W. Kaplan, Jonathan D. Klein, and Jane E. Wilson. Pediatrics. 2008; 121: 1043-1045.
This commentary examines the strengths and weaknesses of four major options for establishing opportunities for training pediatricians in adolescent medicine. The options include extending the length of the mandatory adolescent medicine rotation, introducing more flexibility in residency programs to allow for formalized optional training tracks in adolescent medicine, creating a combined pediatrics/adolescent medicine residency, and increasing the availability of one-year adolescent medicine clinical training programs after completion of categorical training in general pediatrics. Information for this commentary was based on 2007 surveys of adolescent medicine fellowship program directors, pediatric residency program directors, and adolescent medicine faculty in pediatric residency programs.

Under One Roof: Primary Care Models That Work for Adolescents
by Marian Sandmaier, Alyssa D. Bell, Harriette B. Fox, and Margaret A. McManus, May 2007.
This report describes a model of comprehensive, interdisciplinary physical, behavioral, and reproductive health care for adolescents operating in three different health care settings — a hospital outpatient department, office practice, and community health center. The strengths and flexibility of the three models are profiled in detail, along with the financing challenges these programs confront. Information was obtained through a site visit and multiple telephone interviews with the programs' providers and administrators.

The Public Health Insurance Cliff for Older Adolescents
by Harriette B. Fox, Stephanie J. Limb, and Margaret A. McManus, April 2007.
Drawing on data from multiple sources, this fact sheet examines Medicaid and SCHIP eligibility policies affecting older adolescents -- those ages 19 and 20. Included are mandatory coverage pathways, such as parents and pregnant women, and optional pathways, including Ribicoff children, medically needy, adolescents formerly in foster care, and the working disabled. The fact sheet examines states’ use of the available options and income eligibility levels applicable to older adolescents

Preliminary Thoughts on Restructuring Medicaid to Promote Adolescent Health
by Harriette B. Fox, Stephanie J. Limb, and Margaret A. McManus, January 2007.
This issue brief examines state Medicaid benefit and payment policies affecting adolescents and concludes that they are inadequate to support the type of care that adolescents require. It includes a proposal for an enhanced set of health promotion and primary care benefits designed specifically for adolescents that can be offered through EPSDT or as an alternative benefit package under the Deficit Reduction Act and suggestions for possible changes to payment policies to support comprehensive preventive and primary care service delivery for adolescents.

Racial and Ethnic Disparities in Adolescent Health and Access to Care
by Harriette B. Fox, Margaret A. McManus, Matthew Zarit, Gerry Fairbrother, Amy E.Cassedy, Christina D. Bethell, and Debra Read, January 2007.
Based on data from the National Health Interview Survey and the National Survey of Children's Health, this fact sheet examines racial and ethnic differences among Hispanic, Black, and White adolescents ages 12 through 17 for 12 indicators pertaining to health and risk status, access to care, service utilization, and unmet needs. It also examines the influence of income, insurance, mother's or household education, and primary household language on these differences.

Racial and Ethnic Disparities in Health and Access to Care Among Older Adolescents
by Harriette B. Fox, Margaret A. McManus, Matthew Zarit, Amy E. Cassedy, and Gerry Fairbrother, January 2007.
This fact sheet uses data from the National Health Interview Survey to examine disparities in health status, access, and service use among Hispanic, Black, and White adolescents ages 18 through 21 and the influence of income, insurance, and mother's education on these disparities.

Making the Case for Addressing Adolescent Health Care
by Margaret A. McManus and Harriette B. Fox, January 2007.
Drawing on data from multiple studies and national surveys, this fact sheet documents that the compelling needs of our nation's adolescents are being poorly addressed through our current system of health care financing and delivery. It argues for more effective teen-friendly health care in which intensive health promotion interventions are available, physical and behavioral health care are integrated, and the unique perspectives and vulnerabilities of adolescents are addressed.

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