Adolescence is commonly defined as a period of transition between childhood and adulthood with distinct physical and psychological challenges that must be successfully navigated en route to maturity. One of these challenges is so deeply embedded in this period of development that it found its way into its definition. The challenge of transition, specifically the passage from one state, stage, subject or place to another, is often accompanied by an emotional and psychological maelstrom that can alter the trajectory of even the most grounded and secure adolescent. When coupled with the enduring effects of trauma, poverty, racism and a host of other impediments to healthy development a transition can raze what little remains of the fractured foundation on which so many of our young adults stand.
The difficulties that attend periods of transition are surely not unique to adolescents, and evidence of their potentially deleterious effects on the health and stability of vulnerable populations abounds. Health and social service providers are now subject to various process and performance measures through which they must affirm the value of their services to their recipients, payers and other key stakeholders, and many of these measures pertain to transitions between care settings (e.g., institutional to community) and interventions that would promote recipients’ stability during such transitions. These measures bear the imprimatur of the National Committee for Quality Assurance (NCQA), New York State Department of Health (DOH), Clinical Advisory Groups (CAGs) and a host of other authorities charged with the application of evidenced-based practices within the service delivery process.
Important as these advances are, however, they neglect to address the profoundly disruptive transitions many adolescents encounter as they migrate between systems of care (e.g., child to adult) and navigate myriad (and often incongruent) regulations, eligibility requirements, treatment philosophies, provider competencies, services and resources. In a report on the findings of its Youth Initiative Work Group, the Center for Rehabilitation and Recovery of The Coalition of Behavioral Health Agencies summarized several recommendations for improvement in our systems serving youth, specifically Transition Aged Youth (TAY) (i.e., individuals aged 16-25), that encompass a variety of domains including educational and employment offerings for TAY with special needs (The Coalition of Behavioral Health Agencies, 2007). This is of special interest to the staff of my agency’s vocational rehabilitation program inasmuch as it has increased its capacity to serve this population in recent years, and it is poised for continued expansion following implementation of a renewed contract with the office of Adult Career and Continuing Education Services – Vocational Rehabilitation (ACCES-VR).
Several years ago, Search for Change (SFC) expanded its mission to support young adults with unique educational and vocational rehabilitation needs. Until then, our agency had served adults only (i.e., individuals aged 18 or older) in accordance with its original mandate. We recognized many adolescents would benefit from our offerings, especially as a paucity of services for this population leaves many with few alternatives for meaningful support. We also recognized we would need to cultivate new competencies and a broader understanding of systems serving youth in order to effectively deliver on our new promises. In embracing the challenges and rewards inherent in this process we have witnessed deficiencies in our social service infrastructure that must be addressed lest they fail many of the vulnerable adolescents that depend on it.
Our staff has observed several examples of discontinuity between systems serving children and adults that pose unnecessary obstacles for youth in transition. This is especially disconcerting in view of the prevalence of serious mental illness among this cohort that exacerbates risks associated with transition. Research suggests one in ten children and adolescents experiences a mental health condition severe enough to cause marked functional impairment (National Alliance on Mental Illness, 2001). Exposing such highly vulnerable individuals to poorly coordinated or disjointed support services is certain to compromise their stability and prospects for long-term success. The mere existence of a two-pronged mental health system that serves children on one pole and adults on another suggests a structural discontinuity that impedes service integration and the application of holistic, person- and recovery-oriented supports for those who need it most. The Youth Initiative Work Group urged key stakeholders charged with oversight of child and adult systems to conduct a comprehensive review of their systems’ access and eligibility requirements and to align them to the greatest extent possible (The Coalition of Behavioral Health Agencies, 2007). They also urged stakeholders to consider the unique needs of youth in transition between these systems and to expand the array of supports available to support them. The current systems, best characterized as programmatic and bureaucratic “silos,” all but ensure disparate approaches to serving youth in transition and enduring deficiencies in coordination and communication that can compromise the health and welfare of individuals entrusted to their care.
Other obstacles cited in The Coalition’s report and observed by my agency’s vocational rehabilitation staff include differential eligibility criteria for publicly-funded benefits (e.g., Medicaid, Supplemental Security Income, etc.) to which children and adults are subject; an absence of core competencies in child and adolescent development among professionals who primarily serve adults (but must now embrace adolescents and young adults); and a scarcity of social, emotional and residential support services for youth in transition, far too many of whom have experienced poverty, homelessness, abuse, familial strife and other traumatic events. These obstacles notwithstanding, some policymakers and others charged with oversight of youth services have demonstrated a renewed commitment to support this population, especially within the realm of educational and vocational services. The rapid growth and diversification of SFC’s TAY service offerings is merely one indication of this promising trend. Our entrée into this arena enabled us to provide fundamental job skills training and support services to young adults who were unable to obtain them within traditional educational settings. We are now engaged in a pilot project that shepherds vulnerable adolescents through transitions between secondary and post-secondary education, periods fraught with stress, uncertainty, heightened vulnerability and associated risk factors. We are poised for continuing diversification of our service offerings under the terms of a new contract that includes a sizable investment in TAY services.
Auspicious as these developments are, they are not without certain challenges. ACCES-VR has experienced an influx of young adults that threatens to overwhelm some of the Vocational Rehabilitation Counselors (VRCs) assigned to process their requests for assistance. Rapidly rising caseloads have led VRCs to rely on their contracted providers to deliver many services formerly within their purview.
This, in turn, has required providers to develop new capacities and competencies essential to effectively serve this population. In recent months our vocational rehabilitation staff has undergone comprehensive trainings in benefits advisement, developed procedures and protocols necessary to engage families of youth in transition and explored a menu of new service offerings integral to recipients’ attainment of their educational and vocational goals. For instance, the transportation needs of young adults and other vulnerable populations are both critical to their progress and frequently overlooked. We recently established an agreement with one payer whereby transportation will be provided to select recipients who are unable to access it through other means. This elemental service enables many young adults to acquire and to retain positions of employment that would otherwise be inaccessible to them.
As we survey a rapidly changing landscape of health and social services, we note many opportunities to strengthen the safety net for youth in transition. Health Homes serving children, an expanded array of Home and Community Based Services and a movement toward value-based reimbursement under Medicaid Managed Care are but a few of the transformative initiatives that promise to advance the Triple Aim among this vulnerable population if properly applied. It is incumbent on payers, providers, families of service recipients and other stakeholders to remain vigilant lest these initiatives fail to achieve their desired aims and perpetuate the fragmentation that has frustrated our vulnerable youth for much too long.