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2003 Model Practice Application (Public)

Application Name: 2003 Model Practice Application (Public) : Florida Department of Health in Collier County : Teen Choices
Applicant Name: Dr. Joan M. Colfer, MD, MPH
Practice Title
Teen Choices
Submitting LHD/Agency/Organization
Collier County Health Department


Teen Choices is a voluntary program aimed at reducing repeat teen births. It targets girls who are currently pregnant with or parenting their first child. Referrals come from a variety of sources. The younger teens are given the higher priority for inclusion. Over 150 girls have been case managed. The program uses a multi-strategy approach, including a comprehensive assessment, goal-directed and client-determined support plan, and intensive care coordination and support using a home visiting model. The comprehensive assessment includes a health assessment, a socio-economic evaluation, and an evaluation of family interaction and support mechanisms. The goal-directed support plan addresses education, career planning, health care needs, daily living skills, parenting skills, and developing and maintaining a healthy caring relationship with a supportive adult. The frequency of contacts is based on the support required to move the teen toward making healthy life choices.

Responsiveness and Innovation
Between 1998 and 2000, the repeat birth rate for women aged 15-19 in Collier County was 23.2 percent as compared to 21.6 percent for the State. There was a clear need for an innovative approach to the problem of teens having repeat births. When adolescent girls have repeat births, their prospects for a future without poverty decline significantly as compared to women who delay their first birth until aged 20 or older. They complete less school, are more likely to have large families, and are more likely to be a single female parent. Babies born to mothers aged 15-17 have less supportive and stimulating home environments, poorer health, lower cognitive development, worse education outcomes, higher rate of behavior problems, and higher rates of teen childbearing themselves. A repeat birth for an adolescent mother drastically reduces her chances of breaking the cycle of poverty and achieving economic self-sufficiency. Delaying a second pregnancy until she reaches economic self-sufficiency increases her chances for a long-term healthy outcome for herself and her child.

A home visiting model was used to deliver service. Research—reported in several articles—has found that this model is the most effective way to work with teens to prevent repeat pregnancy. Once the teen mothers can envision a brighter future for themselves and their children, they can begin to make positive, rather than self-destructive, choices. The program is innovative in many ways. Hours are flexible to accommodate teens in school and/or at work. The program is tailored for each individual and is culturally sensitive. The curriculum focuses on the mother and her infant and encompasses the whole family group. It includes skills for self-sufficiency, such as budgeting, education on baby spacing, and relationships.

Agency Community Roles
Collier County Health Department started the program in 1998 and has continued to manage it. The program manager worked with community leaders in the Collier County Teen Pregnancy Prevention Initiative to spread the word about the new program. The Healthy Start Coordinator was supportive and encouraged Healthy Start staff to make referrals for those teens needing more intense case management than could be provided by their staff. Over the years, the program built a strong relationship with the social worker at the area school for parenting teens. This has helped provide more inclusive case management.

The program manager also spoke to many public groups about the consequences of teen pregnancy and about the Teen Choice program in order to encourage community participation in carrying the message that teen pregnancy was a problem and that it required a community, multi-strategy approach. After a presentation one of the local churches agreed to provide mentors as needed for teens without a strong supportive adult presence in their life. The program manager interacts frequently with the parenting teacher at the teen parenting school to coordinate services and to provide consistent messages and reinforcement without a duplication of services. There is coordination with many of the community service providers and health care organizations. The program manager actively participates on a variety of local and regional community boards and committees addressing the teen pregnancy issue, such as Naples Alliance for Children, Collier County Teen Pregnancy Prevention Initiative, and the Work Force Development Board. Working through these groups interventions are developed and added to the teen pregnancy prevention arsenal case managers can use. For example, the teen pregnancy prevention committee of the Naples Alliance for Children was successful in funding an after-school program in the middle school.

Costs and Expenditures
The biggest cost is salary and benefits for program personnel. Each staff member can manage the cases of approximately 25-30 teens at one time. Teen Choices is staffed with a program manager, an RN who does all the assessments and plans, and a paraprofessional. Staff members really need to like teenagers, and extra training is provided to prepare them to work with adolescents and their special needs. Since a home visiting model is used, staff needs transportation. An annual budget includes $3000 for transportation, $1000 for educational materials, and $800 for staff education.

The program has been successfully funded for the last four years, and this year a grant was written to expand the program to focus on Hispanic clients. Grant awards have not been announced for the coming year.

Outcome Process Evaluation
An evaluation component has been part of the program since its inception. For the first two years an outside evaluator, Dr Susan Philliber, who is experienced in teen pregnancy program evaluations, evaluated the program. The evaluation is now performed internally utilizing the same methodology by the epidemiologist. The two main areas of evaluation focus on improving education and reducing the numbers of repeat births. Baseline data is collected when a new teen is enrolled, when she leaves the program and at the end of the evaluation period.

Performance and Outcome Measures for last reporting period ending June 2000:

  • 65% improved or maintained their education.

  • 1% had a repeat birth compared to 21 % for Collier County.

Lessons Learned
  • The home visitor has to have patience and skill in engaging the family.

  • The biggest challenges are times of crisis for the teen (e.g., no place to live). Collaborative relationships with agencies prepared to assist need to be developed early and maintained.

  • Teens are reluctant to file for child support which leaves them financially vulnerable. The program has increased participants’ awareness of paternity and child support issues but you need to be careful that this does not become a barrier to the teen’s participation.

  • Many of the teens lack the skills to be more assertive when making phone calls, e.g., for doctor’s appointments. Role-playing with the participants has helped but this requires a greater time commitment than originally planned.

  • Collier County lacks public transportation. Transportation issues need to be factored in when developing resources and a service network.

  • Collier County has a diverse population to serve with unique cultures and this has to be respected. The Hispanic community is increasing and many of these teens leave school early under pressure from the father of their babies or the need to help support the family.

  • While education is a key component, you need to be flexible and work with the immediate needs of the teen, which may mean helping her develop workforce skills outside the formal high school environment.

  • Although the program follows a curriculum, there must to be room to tailor it to the needs of each teen. A cookie cutter approach does not work.
Key Elements Replication
The key elements needed to replicate this practice are:
  • At lease two full-time staff members with nursing experience.

  • Non-judgmental staff that likes working with teens and has experience with home visiting and adolescent health.

  • Transportation; curricula, and policies regarding home visiting protocols, confidentiality and record keeping; and an evaluation process.