Medical Professional Publications

Adolescent Reproductive Health: Stepping Up the PCP Game

Primary Care Matters

(From the June 2017 Issue of MedStat)

Molly Falasco, MDWritten by Molly Falasco, MD

As a newly minted graduate from pediatric residency, the thought of founding a flagship Reproductive Health Clinic in a reputable primary care practice seemed daunting. However, the Section of Adolescent Medicine at Nationwide Children’s trained me well. Plus, I was already Nexplanon-certified. So, why not? I accepted a position at Pediatric Associates, Inc. in Whitehall, Ohio, in hopes of affecting change in a higher needs population and this was the perfect opportunity to do so. In our Partners For Kids (PFK) population, our practice has had an average of 16 teen pregnancies per year (girls ages 13-18).

I wanted the Reproductive Health Clinic (RHC) to provide comprehensive reproductive health care — addressing a myriad of topics including contraception, menstruation, and sexuality, all from the convenience of the medical home. A major component of the clinic would include insertion/removal of Nexplanon, a long-acting reversible contraceptive (LARC). From gathering educational resources and configuring contraception protocol, to integrating new progress and procedure templates into our EMR, getting the clinic up and running was quite the undertaking. I started working at Pediatric Associates in July 2016 and held my first RHC in November 2016. Ultimately, I have been able to hold RHC every Friday afternoon since its advent.

After nearly six months of flying solo, I have already appreciated the positive impact that RHC has had on my practice. By taking the time to educate and empower young women in reproductive health, I truly believe that this clinic helps stop the cycle of poverty. Oftentimes I feel that the typical adolescent well-child check does not afford me enough time to address this important topic in sufficient detail. With 30 (sometimes more) minutes per patient, however, the RHC provides ample time for menstrual and contraception consultation, STI testing, and even same-day Nexplanon insertion. It is also important to consider that Dr. Bill Long and I are the only two primary care providers in the practice that provide this otherwise sub-specialized service. The RHC conveniently operates within the medical home, which eliminates the problems with arranging and compliance with subspecialty care and strengthens the relationship between PCP and patient. Together, Bill and I have seen 50 young women for this service and have inserted 38 Nexplanon devices (at the time of this writing).

As with any new medical program, the RHC has faced a few hurdles. The process of adequate sexual/menstrual history-taking, test-ordering, consent, and the actual insertion (or removal) of Nexplanon can be a time-consuming process. As a result, I may only see a handful of patients on any given Friday afternoon. Compared to other age groups, I have found teenagers to be less reliable with their schedules and the RHC has struggled filling last-minute no-shows. We now call patients the day before/day of their appointments to confirm attendance. For any gaps in the RHC schedule, I will see ill visits instead. While we counsel on all contraceptive methods, our RHC does not directly place IUDs (intrauterine device, another LARC) or provide the Shot (Depo Provera), both of which require a referral to Adolescent Medicine or Gynecology.

Moving forward, I see opportunities to improve the RHC. Firstly, I am looking to streamline RHC protocol to optimize my time and generate more revenue for the practice. Having staff members who are more comfortable and efficient with the process will leave time for goal-oriented consultation, testing and prescription, and possible Nexplanon placement. We are considering a Nexplanon-certified nurse practitioner to allow more patients to be seen simultaneously. Secondly, while IUDs require more training and equipment, I would at least like to investigate our ability in providing the Depo Provera shot. Thirdly, I would like to expand the RHC to male adolescents as well, especially regarding safe sex counseling and STI testing. I would like to be able to hand out condoms to both males and females in the clinic. All in all, I believe the RHC has been a fantastic success in terms of providing an important service to adolescents and I hope the program will continue to grow.

The articles in this ongoing series will feature news and items of interest to pediatric primary care providers. If you would like to contribute, email William.Long@NationwideChildrens.org.

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