Mary Tonsmeire is the adolescent health care coordinator for the Juneau Teen Health Center, which now operates out of three schools in the Juneau area. In this interview Tonsmeire recounts the history of the development of the health centers touching on a wide variety of issues such as parental consent, mental health, birth control, dispensed medications, and pointers on how to start a health center in a school in your community. This is a unique institution in Alaska, and a fascinating read about an innovative health care delivery system for teens. This transcript of the interview has been edited for clarity and length.

Links to selected topics

History of the Juneau Teen Health Center
"Had you been on the school board in September, how would you have voted on this issue?"
Community partners add to the variety of services offered
Parental consent is required for students to access expanded services
New school plans included space for the teen health center
Who do the health centers serve?
How are the health centers funded?
Overview of services provided at the teen health centers
Just who is staffing the health centers?
Adolescents do have the right to reproductive health services

Early Planning for the Juneau Teen Health Center

AHPR: What is your position with the Juneau Teen Health Clinic and how did you become involved with it?    
    
Tonsmeire: A brief history was that in the late 1980s, the community of Juneau had what was called the Blue Ribbon Commission. It was an overview of the community and a whole variety of what the citizens of the community saw as [important issues] -- whether it was harbors or roads or transportation or a whole variety of different issues. And certainly among those issues -- this is all second hand information for me -- was health care. One of the small strands on health care was the strong feeling by the community that Juneau had a lot of good quality health services for our adolescents -- teens -- but the kids weren't accessing the services. They were looking for a resolution to that. Like, is there a way that we can have our teens do a better job accessing the existing services? One of the action steps that was eventually developed was to have a position, and rather than make the position a school district position, they choose to make the position a municipal position. It was under what was then the Department of Health and Social Services, and they called the position the adolescent health care coordinator.

They hired into that position in January 1990. I applied and was accepted into the position and began working at JDHS, Juneau-Douglass High School, which was our only traditional high school at that time. I was located in a small area in the counseling department and my position was not well developed. It was primarily the mission of connecting kids to services, and I was starting in the middle of a school year. When I began talking to staff, at the time, about what they saw as students who needed assistance in connecting to services, the initial students that were referred to me primarily were pregnant and parenting students. So I began working with students who needed to be connected to primary health care or were applying for Denali KidCare, accessing day care, learning how to fill out those forms. I began working with a whole variety of community providers around improving the coordination of services for students who were pregnant or had delivered and were returning to school.

Out of that experience, we began with a small group of us that began meeting on a regular basis to see, as a group, is there a better way that we can streamline coordination of services so students don't have to make so many different appointments in their week when they're trying to juggle having a baby or child care and going to school. A lot of these students had to use public transportation and our buses at that time ran once an hour. There were just a variety of different issues. The group began working together to develop what later became the Juneau Teen Parent Program. We wrote a grant and began with a parenting class and began having a specific class in the school that was for pregnant and parenting students to give them sort of a home, a class during their day was where they could address those needs and where we had access to them to help them access services, etc.

Certainly, other than a health class, there were no parenting classes at that time in our school. So, from that we continued to look at what the different issues were as a group. The group was SEARHC [SouthEast Alaska Regional Health Consortium], which was Indian Health Services, Tlinqit and Haida, Headstart, Juneau Public Health Center, some primary health care providers, day care assistance, etc., were part of that original group. We reached a point where we were at the table and saying, "OK, this is what we've done. We've done this and this and this and we're trying to coordinate that. If there is one more task that we can take on for the next year, what would it be?" Everybody sat there and looked at each other and said, "Prevent pregnancy." It was perfectly clear that that would be the one thing that we could do that would make the young adolescents' lives far better was -- rather than waiting until they were pregnant and parenting to coordinate services -- provide them with some coordinated services prior to pregnancy. Back to selected topics list

"Had you been on the school board in September, how would you have voted on this issue?"

You didn't have to look very far to discover that in the United States at that time there was this model called School Based Health Services, and there were established school based health centers in both Seattle and Portland. We began communicating with those cities and those sites and learning more about what it would look like to have school based health services and how they managed them and how they worked with the community on providing those services. We, as a group, decided that it would be worthwhile to speak with the school district regarding would the school district be open to us providing school health based services. We were proposing a very small proposal. It was three hours after school, two days a week, staffed by an advanced nurse practitioner one day and public health the next day.

We wrote a small grant for that maternal and child health grant. We brought the proposal to the superintendent and to the school district with the feeling that they would say either "yes" or "no," but the proposal went into an extended -- over a year -- community debate. [There was a] huge public forum and meetings [with] much discussion about the idea of reproductive health available within the school. We were proposing more than just reproductive health. Having seen the models in Seattle and Portland, we recognized that it was important that these practitioners do sports physicals and sore throats and acne and any adolescent health issue should be addressed and at least referred to the appropriate provider in the community.

We were looking at trying to provide a more comprehensive model of health care than was offered at Public Health at that time. Public Health was primarily, and only, reproductive health. We were proposing at this site that we would do something a little broader. They ended up turning the proposal down in the fall of 1992. In September, they turned it down. And I believe it was in October we had an election, a school board election. And for whatever reason, the newspaper chose to have a column. They have a matrix that they run on the candidates and where they stand on a whole variety of different issues, that they publish in the paper. That year they asked all the candidates who were running for school board, "Had you been on the school board in September, how would you have voted on this issue?" Everyone who said they would have opposed it did not get elected. Everyone who said that supported it got elected, and we had been turned down five to four in September.

The new school board took that as a mandate to ask us to come back and present another proposal. We tweaked the original proposal and brought forward a proposal, and we began offering services in the 92-93 school year, in January. Again, it was just a few hours, two days a week, we would take over the school nurses' office in the after school hours and we began doing that. Within that first four months of beginning to provide services, it became real clear real fast that we needed to add mental health. To begin trying to provide any kind of comprehensive services for adolescents and not have access to a mental health clinician just wasn't going to work. In the 1993-1994 school year -- because my position came out from the Department of Health and Social Services, and because the Department of Health and Social Services was at that time where community mental health services were -- my administrator, my supervisor released one of the mental health clinicians to the high school. I think it was three or four hours a week so that we had a slot that, as we were seeing kids for primary health care, that we could refer into. Because it was located in the counseling department, the school counselors also had access to referring clients into it. Back to selected topics list

Community partners add to the variety of services offered

As we established and developed our model, the initial foundation, which has expanded over time, is a memorandum of agreement between what we call the "community partners." At this time we have six community partners. Our community partners are the city and borough of Juneau. I represent the city of Juneau, and the admin assistant who works with me, [we] are the municipality's contribution to the project. The Juneau School District, which provides us with access to computers and mail-outs, and provides us a setting within the school that has bathrooms and sinks and what we need to provide medical services today. Another partner is Southeast Alaska Regional Health Corporation [SEARHC], which is Indian Health Services, and they provide advanced nurse practitioner hours to provide primary health care other than reproductive health.

We have another grant from Maternal Child Health, State of Alaska, where we provide some on-site reproductive health services. We have a contract with AWARE [Aiding Women in Abuse and Rape Emergencies], which is the domestic violence shelter here in Juneau. It provides counseling, masters level counseling, for students around any sort of relational issues -- past physical or emotional abuse, sexual abuse, etc. Another partner is JYS -- Juneau Youth Services. JYS provides us with mental health services counseling with masters level clinicians. And then of course the State of Alaska Public Health provides us with our reproductive health services through two public health nurses. All of our labs, our STD testing, etc, goes through State of Alaska, and our coordination around birth control goes through State of Alaska. [We] have these community partners who come together and every two years sign a memorandum of agreement that they will coordinate services through the teen health center. Back to selected topics list

Parental consent is required for students to access expanded services

Then the next layer on top of that is that at the beginning of each school year, a consent goes out to every parent who has a high school student enrolled. The consent gives the parents three choices: they can sign a consent that opens the door to all of our services to their child so their child can get sports physicals and strep throat tests and any variety of health care, nutrition counseling services. Or, they can sign a withhold consent and should their child seek services at any of our sites, the child is explained that their parent has signed a withhold consent and clearly wants to be involved in their health care, and if the student has health issues that they don't want their parents involved in, we would tell them where in the community they could get those services but that we cannot provide them. We have to honor the withhold consent.

If the parent ignores the form and does not send back either a positive consent or a withhold consent, the parents are informed that under state law, we can provide reproductive health. For those students we can only offer reproductive health. So for those students, we can only offer reproductive health services. That's how we do it. Over the years since the 92-93 school year we have gone from providing four hours of service with one day of public health nurse and one day of advanced practitioner to today we're extending, this year, into the alternative high school trying to establish on-site services at the alternative high school. This is a real stretch for us. We now have two high schools. Our community built a new high school in the valley, so we do not have more students but our students are spread out between three sites now: Thunder Mountain in the valley, JDHS downtown, and an alternative high school called Yaakoosge [Daakahidi], which is near JDHS.

AHPR: That's an extraordinary story. Approximately what percentage of the parents of students do give consent?

Tonsmeire: The vast majority. I bet [at] any one time we have, I would say somewhere between 150 to 200 withhold consents from a population of, I think, over 1,800 kids. So everybody else doesn't necessarily mean they're a full consent. They're either nothing or a full consent. Historically over time our full consents have increased over the years. As, I think, as the community became more comfortable. Back to selected topics list

New school plans included space for the teen health center

AHPR: When you say you're currently in three high schools, does that include the alternative high school?

Tonsmeire: We're just now getting a place to stock our immunizations.

AHPR: The alternative High School makes a total of three, is that correct?

Tonsmeire: Yes, and our population right now is approximately, I think just under 700 students at Thunder Mountain, closer to 900 students at JDHS, and 150 at the alternative high school.

AHPR: At each of those sites, you have what? A suite of rooms?

Tonsmeire: It depends on the site but yes, I think a suite of rooms is a nice way to say it. We have a site at Thunder Mountain and that was a really a wonderful, strong affirmation that occurred of our services. Another significant point in our development was the community debated for like 10 years on whether or not we should have two high schools -- what should the two high schools look like and what should they be, etc. -- but from the very beginning there was always a teen health center in the new high school. There was never a question of whether they should put one at both buildings. I just really felt that was 10 years of work that preceded the beginning planning stages. Where should they locate the teen health center?

So yes, we have a suite of rooms that were designed for us at Thunder Mountain, a small suite of rooms that were designed to have a school-based health center at Thunder Mountain. And at JDHS we have a classroom that was cut into a suite of rooms so that we have a private bathroom and the sink. We must have a bathroom and a sink -- that's what we really have to have -- to provide the primary health care piece. And there has to be a level of privacy for that bathroom.

AHPR: How many hours a week do each of these sites operate?

Tonsmeire: Between our two sites last year, we had a total of about 40 hours of clinician time. But that was six hours here and six hours there. We try to be operational at JDHS on Tuesdays and Thursdays. And we try to be operational at Thunder Mountain on Wednesdays. We are going to shift; it's going to be Mondays and Wednesdays. Our Friday services we try to alternate between the two sites. And then on top of that, we're trying to find a way to coordinate services at Yaakoosge. Yaakoosge is very physically close but is in a separate building.

AHPR: Are your hours mostly after the regular school hours?

Tonsmeire: No, they're during the school day. Back to selected topics list

Who do the health centers serve?

AHPR: Could you clarify what your relationship to the school district is? In other words, you're on school property and you're using school facilities, but it's not sponsored by the school district. How exactly is that relationship?

Tonsmeire: We are community health providers located in the high school. The school district is one of our major partners in the memorandum of agreement. The school district and our memorandum of agreement goes before the school board once a year. Our consents that I mentioned go out in the packet that goes out to every parent at the beginning of the school year -- what classes your child is in, etc., [and among] all of those releases that you sign as a parent -- in that packet is a teen health center consent. Every year you have a prompt to think about, "Do I want my kid to continue to use those services?" or "I haven't signed the consent in the past, but my student now is a senior, maybe I want to rethink that and sign a positive consent." It's not unusual for students to enter the high school as freshmen and have a withhold consent and by the time they reach their senior year, have a positive consent as the student gets older and the parent feels that it's more appropriate for them to access services.

AHPR: Are your patients only the students at those high schools?

Tonsmeire: We will serve high school age students. We will not serve middle school students. But if a young person is 20 and has dropped away from the school and is now re-enrolled in the alternative high school, we will serve anyone who has not graduated high school and is high school age. As long as in some mechanism, at some point, that their parent had an opportunity to sign a consent either yay or nay. Sometimes we get students in HomeBRIDGE [Juneau's home school program]. Some of the HomeBRIDGE students will want to participate in sports, and parents will call up and refer their child in for a sports physical. We are also OK with parents who have a withhold on file signing a positive consent today, us giving the student a sports physical today, and them handing us a withhold consent at the end of the appointment. As long as we had the full consent for the appointment and the parent understands that while a student is with a clinician the student has the right to access any information that they want.

AHPR: Do you have a count of total weekly visits in the two main schools, or some average maybe?

Tonsmeire: We did over 2,000 visits last year. Last year, we were up significantly in appointments over previous years. As we went into trying to staff two high schools -- that was the 08-09 school year -- that was when we began needing to staff both Thunder Mountain and JDHS. Prior to that school year, we went through a professional planning process, and out of that process came a re-affirmation, a re-commitment of the partners and expansion of hours in order to address the issue of two sites. As we increased our clinician hours, our appointments went up to 1,500, approximately, a year. Then last year we began dispensing birth control on site and our visits went up to 2,000 per year. We had always prescribed birth control but students had to go to either the public health center or SEARHC to pick them up. It was part of the original agreement that we would not dispense birth control on site. The only medications that we dispensed on site that we got approval for over 10 years ago was anti-biotics for sexually transmitted diseases. Last year we were able to get the support we needed to begin dispensing birth control on site, so our visits increased significantly last year. Back to selected topics list

How are the health centers funded?

AHPR: Everybody, of course, is going to want how the health clinic is funded.

Tonsmeire: Each of the partners comes to the table with what they can contribute. Sometimes the mental health counselor from AWARE is an in-kind contribution. The public health center nurses who come in and staff the Teen Health Center every week at different locations -- and will extend into the alternative high school this year -- are in-kind hours from the State of Alaska Public Health. The nurse practitioners that come in and provide reproductive and primary health care services are funded through a combination of municipal grant and Maternal/Child Health grant.

My position and the admin assistant position, we are city employees and we are the city's contribution to the project. SEARHC provides one advanced nurse practitioner a week for four hours that is the Indian Health Service contribution to the project. Each of the providers and we pay through a grant. We pay for additional mental health hours from Juneau Youth Services but honestly, we get much, much more from the grant than what we pay for. So, I mean it's a patchwork of agencies, a patchwork of support -- financial and otherwise.

AHPR: The other question that a lot of the planners and professionals are going to ask is the question of liability. How is that covered?

Tonsmeire: The providers are working under their home agency. Back to selected topics list

Overview of services provided at the teen health centers

AHPR: You may have already discussed this, but I wanted to ask what kinds of services are provided. You've talked about some of them. Is this essentially the same kind of primary care that somebody would get, or the same spread of primary care services as if they went in to one of those walk-in clinics that are around town?

Tonsmeire: Well, the walk-in clinic would probably have more lab services than we have. The walk-in clinic would probably be open every day of the week for eight hours. We have nurse practitioners for 3½, 4 hours twice a week in populations of 1,000 kids. So, I would say we have significantly less hours. We have the ability to prescribe -- and the prescriptions are called out to local pharmacies -- but then the student has to, in order to pick up the prescription, has to be able to access either money or insurance. Our nurse practitioners can order x-rays but the parent has to take the student to the hospital and pay for the x-rays, etc. We try not to be a medical home. Our interest isn't in becoming a student's medical home, but of those 2,000 appointments -- some interesting information -- almost half of them are mental health.

Everybody wants to talk about reproductive health and that is the hot topic, but reproductive health honestly is only about 25 percent of what we do. Historically, one of the areas that we truly provide, and a need that isn't addressed out at that walk-in clinic that you're describing, is allowing students' access to a masters level clinician without filling out a zillion pieces of paper. Oh, and then another thing is 50 percent of our visits are minority and our population in the school is not 50 percent minority. Our minority population is around 23 percent. I think a lot of the kids we see, their parents are uninsured or underinsured. They work for Walmart or they're a hair dresser self-employed. We see a lot of kids that it's more difficult for them to access health care than others.

AHPR: That's really a great service you all are providing.

Tonsmeire: We work hard not to carry kids with ongoing, chronic issues. They really do need a primary provider. They really do need someone who is open 52 weeks a year, five days a week, and we really try to work with those families to fill out Denali KidCare forms or get to the appropriate services in town. Our reproductive health services always lead with abstinence. We truly, truly believe that abstinence is the best choice -- reproductive health choice -- for any teen, but when teens are sexually active, I think it's important that they get good, solid medical information and testing.

AHPR: In terms of the services you do offer, is there a waiting list or can kids get services most of the time they come to the door? How does that work?

Tonsmeire: Pretty much we will schedule them in -- like a student coming in today to be seen might not be seen until Thursday or Friday of this week because the clinician who's coming in tomorrow, Tuesday, is already full and we will put them on what we call "back up." We move the kids through appointments, and passes go out that release them from class. If we discover that a student who is scheduled for the 9:00 appointment is not in school, we'll pull the name of the student who showed up early this morning with a fever and a sore throat and see if we can work them in. If we feel that it's better for the student to access their primary health care, we always encourage kids to do that. There's times when no matter how hard we try, everybody waits to the day before the sports physical is due and 20 kids show up. Our sports physicals are good. They're not that "stand in line" sports physical. We take a good 25, 30 minutes with every student. We go over a very comprehensive health history and try to give the student a good physical. So on any given day, we can only do at most eight to ten sports physicals. So those would be times when we really can't serve all the kids who want the service. And we do some level of prioritizing based on what we feel is need. If we feel that something can wait easier until Friday to be seen, we will move kids out of appointments to get someone who honestly is very sick in, so we try to juggle our services and serve the kids the best way we can. Back to selected topics list

Just who is staffing the health centers?

AHPR: Are students ever charged for the services in your facilities or is their insurance, if they have it, ever billed for those services?

Tonsmeire: No, but I mentioned to you that we went through a significant planning process in the 2007-2008 school year where we looked at how we had always done business, all the different components. All the partners were at the table, and one of the things we did discuss and think about was billing. Should we consider billing? After much discussion the decision was: no.

AHPR: In terms of staffing at your facilities, you have advanced nurse practitioners and what other types of people actually staff your facilities?

Tonsmeire: We have one physician's assistant and the other primary health care is advanced nurse practitioners. We have mental health clinicians. All of our mental health clinicians have masters. I wish we could have a stable nutritionist but our nutrition physician is sort of a "comes and goes" position. We have had and we continue to try and get a nutritionist to come in at least on a monthly basis so that students can be referred to a registered dietitian. And we have public health nurses providing traditional public health services: immunizations, STD testing, birth control.

AHPR: Do you think that this a model that could work at other schools across the state? I ask because in my experience, it sounds really quite unique. I think they are starting, I think there's a space for a clinic here at one school in Anchorage -- one middle school I think it is -- but other than that I'm not really aware of such a comprehensive type of clinic in schools in Alaska.

Tonsmeire: I've spoken at conferences up north at various times over the years, and what I try to emphasize when I'm speaking at those kinds of settings, is to be sensitive to how different all of our communities are in Alaska, and to return to that fact that we began offering services eight hours a week - just two days in the school nurse's office after school. Sometimes by just beginning to do what you can do in your community, whether it's seeing if you can have a relationship with a mental health unit, or outpatient mental health services that are currently providing services to young people in the community, but finding that they frequently don't show up for their appointments -- is there a way that you can coordinate those services at the school where you might get better compliance and easier access. I don't think that people should look at this complex thing that we have going right now and say, "Oh no, no, no. I couldn't do it." I think that folks should look at where we began, and that was a public health nurse one day a week to do STD testing to link students to the existing public health center and to give information on reproductive health: what's normal, what's not, what's available.

AHPR: It might be a little premature to ask this question, but do you anticipate changes to the structure, funding, or services at your clinics in the coming years as a result of health reform at the federal level?

Tonsmeire: Possibly. I don't know. I think it depends on what else reform at the federal level ends up looking like. Back to selected topics list

Adolescents do have the right to reproductive health services

AHPR: Are there any local or state policies that do affect or could affect the work of the clinic in a positive or negative way?

Tonsmeire: Well, there is the fact that adolescents have the right in our state to free and confidential information, treatment and testing in the area of reproductive health, and that facilitates teens accessing those particular services. I really think it significantly helps in identifying STDs early and treating them, and I really think that it gives students accurate and personal information. It's one thing to go into classrooms and do reproductive health presentations. That's a really wonderful form of education, but whenever we can take that level of education and bring it down to an individual in a very personal setting and talk about you and your risk factors and your history, I think it becomes so much more relevant, and being able to offer that to young people is really important. I think the other thing that we do is we teach kids how to access health care over their lifetime, and I think that's really important -- how to identify when they're having a problem, and how to get help. I think that's a good life skill.

Other states, depending on the state, will allow adolescents to seek some level of mental health services without parental consent. Our state does not, so any of those counseling appointments that we provide, those students have consents on file. The parents may have signed the consent a year ago or two years ago and are not aware that their student is talking to a counselor now. We certainly will notify families if there's ever a concern around an issue of harm, and we work very, very hard with students to bring their parents into those counseling sessions because it's very, very hard to make counseling progress without involving parents.

AHPR: I've reached the end of the list of questions I wanted to cover, and I tremendously appreciate the time you've spent going over these issues. Do you have any last words that you would like to say on any related subject to the readers of Alaska Health Policy Review?

Tonsmeire: If there is anything that you can do in your community to make mental health services more available to your adolescents, I would really, really urge you to do that. That, in this community, was an area that we could all come to some level of agreement upon -- that we have a lot of concern about our adolescents and their issues with depression and substance abuse and our suicide rates and all of that. If there's something that we could do to help our young people feel safe when they access mental health services, I think that would be very important.

AHPR: Well, thank you so much, Mary, I really appreciate you taking the time for this. I think it's been a great interview and I think there's going to be a lot of interest in what you've said.

Tonsmeire: Thank you. Back to selected topics list

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Lawrence D. Weiss, PhD, MS, Editor
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