Overview of the Apex Data App

Apex Data is an application that was developed and is maintained by Apex Education. The application is cross platform available on iOS (Apple) and Android devices, as well as through any web-browser. It includes several standardized adolescent screening and assessment tools. Providers can select from the menu of tools depending on the specific needs of the individual taking the survey. Apex Data also includes youth and parent satisfaction and experience of care surveys that can be administered in a variety of settings.

The Just Health Screening Tool

Just Health is a comprehensive health behavior screening tool that includes several validated screeners. It was originally developed for use in school-based health centers but may also be used by independent school health professionals, standalone clinics, or other healthcare providers. There are two versions: Just Health Adolescent and Just Health Child (as of Fall 2020). Just Health Adolescent is used to identify risks and protective factors in home and school life, safety, mental health, sexual and reproductive health, and substance use among youth ages 11 to <21 years. Just Health Child serves younger middle school and elementary-aged populations. Both versions of the tool are based on the American Academy of Pediatrics’ Bright Futures guidelines¹.

Just Health Adolescent includes questions grouped into the following domains:

• Profile: Race, ethnicity, gender identity, sexual orientation, grade level

• Home/School: Relationship with family, friends, and peers, living situation, school experiences, & school connectedness

• Health Behaviors: Eating behaviors, physical activity, screen time, seatbelts, etc.

• Safety/Injuries: Violence and abuse

• Feelings/Well-Being: Self-harm, depression, anxiety, and suicidality

• Sexual and Reproductive Health: Sexual behavior, including risk for pregnancy and sexually transmitted infections (STIs)

• Substance Use: Tobacco and other substance use²

• Development/Future Goals: Future plans

The C-SSRS (for suicidality), PHQ-9 Modified for Teens (for depression) and GAD-7 (for anxiety) are embedded in the Just Health Adolescent questionnaire. The GAD-7 will queue up if the GAD-2 screening results are positive. The PHQ-9 Modified for Teens will queue up if either the PHQ-2 or self-harm screening results are positive. Three core C-SSRS questions are asked of everyone, and follow-up questions are queued up if suicidal ideation is endorsed.

Just Health Adolescent also includes a comprehensive sexual history. The additional sexual health questions are based on the Centers for Disease Control and Prevention 5 “Ps” of sexual health: Partners, Practices, Protection from STDs, Past History of STDs, and Prevention of Pregnancy³.

Lastly, Just Health Adolescent includes the CRAFFT 2.1, a validated substance use screening tool⁴. The individual is asked how many days in the past 12 months he/she used alcohol, marijuana, or other illicit substances. If the individual answers yes to any of the three CRAFFT pre-screener questions, the full CRAFFT is queued up. If the individual answers no to the three CRAFFT pre-screeners, only the CAR question is asked. Beginning in 2018-19, Just Health Adolescent includes a comprehensive list of substances individuals might be using to get high. Individuals who answer yes to any of the three CRAFFT pre-screeners will be asked to complete the full CRAFFT, after which they will be asked to check which specific substances they have used in the past 30 days to get high.

Just Health Child can be self-administered for younger adolescents or interview-based for children. It includes age-appropriate questions about gender, sexual orientation, school, home and family, safety, and provides the opportunity for the child to ask questions. Both versions of Just Health inform providers on the need for further individual assessment and guide prevention and intervention efforts to improve health outcomes.

Administration of Just Health

Who is qualified to administer and review Just Health?

Clinic coordinators, assistants, and clerks may give the Apex Data app with screening tools to individuals to complete before seeing a provider. However, only physicians, nurse practitioners, physician assistants, or qualified mental health providers should review the results of Just Health and discuss them with the individual the same day the questionnaire is administered. Health educators, licensed practical nurses, and registered nurses may also review Just Health in collaboration with the primary care provider. Before administering Just Health to a patient, providers using Just Health should be familiar with the questions included and qualified to address the health behaviors and concerns that may be identified. If providers are not comfortable with any aspect of Just Health, additional training should be pursued.

When is Just Health administered?

Just Health should be administered at an individual’s first visit to the clinic or on an annual basis. In addition, Just Health should be reviewed and updated or administered if applicable as part of the individual’s annual well-exam or physical.

Caution: If the provider determines that there is insufficient time to review Just Health with an individual the day it is taken, Just Health should NOT be administered.

How is Just Health administered?

There are two ways Just Health can be administered. Individuals can complete Just Health in the SBHC on a tablet (iPad or Android) via the Apex Data App. Just Health (and all the screening tools) can also be administered through a web app, allowing individuals to receive a link via text or email. Then, individuals can securely complete Just Health on their smartphones, laptop, or personal computer (PC). Refer to sample workflows to use web, iOS, or Android platforms of the Apex Data App for screening during in-person and telehealth visits.

The provider and/or other healthcare staff should assist individuals who have difficulty reading or understanding any aspect of Just Health. Both English and Spanish versions of Just Health are available.

Confidentiality

Individuals are entitled to understand the extent and limits of confidentiality for all aspects of the care they receive, including Just Health. Based on minor consent laws in the state where you practice, many of the answers to questions in Just Health should be kept confidential. Providers should consult their legal counsel for advice on this issue as it pertains to Just Health.

Frequently, healthcare staff and providers may assume that individuals understand confidentiality, but conversations often reveal otherwise. Just Health includes two screens that appear before the individual begins the questionnaire. The screens distinguish between the non-confidential and confidential questions. The screens include the following language:

“If you have parent/guardian permission to be seen at this clinic, questions about your physical health will go into your health record, which your parent/guardian may see if they request your chart or the information is important to take care of you. This includes questions like how many fruits and vegetables you eat, or if you have any tooth pain.

Young people like you can be seen for their sexual and mental health without permission from their parents or guardians. Your responses to questions about your feelings, sexual practices, and use of drugs or alcohol are completely confidential (private) and will not be shared with anyone unless there is a concern about safety (yours, or someone else’s).”

Due to the potentially sensitive nature of the questions asked in Just Health and the fact that many students may not read these screens in their entirety, healthcare staff and providers are encouraged to offer individuals verbal explanations about confidentiality before administering and reviewing Just Health. Below is an example of a verbal explanation that may be given by providers or support staff:

“To help us take better care of you, we want to ask you some questions about your life. Let us know if you don’t understand any of the questions on the device. Your answers to questions about your mental and sexual health and substance use, including tobacco use, are private. We will not share your answers with anyone unless we are concerned about your safety or someone else’s. Do you have any questions about this?”

Providers are encouraged to explore approaches to discussing confidentiality with individuals as part of their quality improvement efforts. The examples offered above are simply a starting point. Providers may prefer to write their own “scripts” based on knowledge of their patient populations and standards of practice.

Review and Documentation of Answers, Including Provider Review Features

Using the Provider Review feature on the device, healthcare staff can review an alert report for Just Health immediately after the individual completes the survey. The Provider Review feature is available on every device but can only be accessed by the clinical staff. The alert report is color-coded to highlight answers of concern that require immediate action on the part of the provider and other answers that require additional discussion but are not of an urgent nature.

The provider should then review the Just Health answers with the individual. The Provider Review feature for the Just Health allows providers to comment and the comments are displayed on the Alert Report.

• The provider reviewing the Alert Report should be present and allow enough time to review, interpret, and respond during the visit.

• Just Health is not a diagnostic tool, providers are encouraged to ask additional questions when reviewing the Alert Report with the individual. Comprehensive risk determination requires perspective gained from reviewing risk determined for each section of Just Health.

• If the provider finds that the individual didn’t understand a question and therefore answered it incorrectly or wants to change an answer, the provider may change the answer with the individual’s permission. To change an answer, refer to the Apex Data App guide on changing answers.

• Providers should determine risk using clinical judgment that balances potentially problematic risk factors with understanding of the resilience and protective factors individuals report.

• The provider should sign and date the Alert Report through the Provider Review feature at the time it is reviewed with the patient.

• There is an option for other providers to co-sign the Provider Review, such as with case consultation and warm hand-offs to other providers, within the limits of confidentiality.

Please see state-specific and/or project-specific instructions for completing additional aspects of the Provider Review.

Other Standalone Tools

In addition to the Just Health screening tool, providers can select from a menu of validated, standardized screening and assessment tools, depending on the specific needs of the individual. Four of these tools are embedded in Just Health, while another four are not embedded and are available to be used in addition to or instead of Just Health. These include the following:

Embedded in Just Health:

CRAFFT 2.1 + Substance Specific Follow-up  The CRAFFT is a validated substance use screening tool embedded in Just Health Adolescent but also available as a stand-alone tool. After the individual takes the CRAFFT, a score is displayed on the provider report. A comprehensive list of substances individuals might be using to get high follows the CRAFFT. Individuals who answer yes to any of the CRAFFT pre-screeners will be asked to check which specific substances they have used in the past 30 days to get high.

C-SSRS⁵  The Columbia-Suicide Severity Rating Scale (C-SSRS) is a series of questions that supports suicide risk assessment. The answers help determine if someone is at risk of suicide and the severity of that risk.

GAD7⁶  The Generalized Anxiety Disorder 7-item (GAD7) scale is embedded in Just Health Adolescent but is also available as a stand-alone tool. It is a brief measure for assessing generalized anxiety disorder. The total score as well as scores by diagnosis (mild, moderate, or severe anxiety) are displayed to assist the provider in determining next steps.

PHQ-9 Modified for Teens  The PHQ-9 Modified for Teens is a depression assessment tool that is embedded in Just Health Adolescent but is also available as a stand-alone tool. After the individual takes the PHQ-9 Modified for Teens, a severity score is displayed on the provider report.

Not embedded in Just Health

ACE Questionnaire⁷  The Adverse Childhood Experiences (ACE) Questionnaire measures sources of stress that a child might have or is experiencing. These stressful experiences can be associated with unhealthy behaviors and impact health and well-being. A score is displayed on the provider report.

SCARED Child Version⁸  The SCARED Anxiety Assessment is a stand-alone tool available for children ages 8-11 to complete for themselves. The SCARED Parent Version is not available on the app. The total score as well as scores by diagnosis are displayed to assist the provider in determining next steps.

Vanderbilt Assessment Scales⁹  The Vanderbilt Assessment Scales is an assessment tool completed by the parent/guardian to assist the provider in the diagnosis and monitoring of attention deficit hyperactivity disorder (ADHD).

VIPRS & IVPIS^{10, 11} Screens  The Violence Injury, Protection and Risk Screen (VIPRS) is a validated fourteen-question violence risk prediction tool. It strongly predicts which individuals are likely to perpetuate future violence. The Interpersonal Violence Perpetration and Injury Scale (IVPIS) is a 7-item scale that was used in the National Longitudinal Study of Adolescent to Adult Health (Add Health) to define serious violence perpetration. It assesses the youth’s involvement in serious violent activities in the past year.

Storage of the Screening and Assessment Reports

The answers to all of the screening and assessment tools are part of the medical record. Please contact Apex (support@apexeval.org) for guidance on uploading the screening and assessment results into the electronic health record and managing the screening and assessment records.

• The Alert Report should be stored in the confidential section of the individual’s medical record. This is to avoid breaching individual confidentiality if parents/legal guardians request access to health information.

• If appropriate, any additional information provided by the individual concerning risk behaviors, assessment of risk, and counseling provided should all be documented in the confidential section of the medical record. The plan, including referrals if indicated, and follow-up, should be discussed with the student and documented in the confidential section of the medical record as well.

Data Syncing and Aggregate Reporting

The results of each individual’s Just Health and other assessment tools are automatically synced to Apex. The transmission of this identifiable data to Apex is allowable under HIPAA with an executed Business Associate Agreement (BAA). Apex and participating providers sign a BAA before implementing the use of Apex Data.

With individually synced records, Apex sends quarterly aggregate reports. The quarterly aggregate reports can serve as a quick reference for providers to identify patterns of health behaviors across their patient populations, as well as assist healthcare staff in program planning, including health education activities.

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¹Bright Futures. (2017). American Academy of Pediatrics: https://brightfutures.aap.org/Pages/default.aspx

²Knight et al (2002), Validity of the CRAFFT substance screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 156(6):607-614.

³US Department of Health and Human Services. (2011). A Guide to Taking a Sexual History. Atlanta, GA: Centers for Disease Control and Prevention, National Center for HIV Viral Hepatitis STD and TB Prevention: https://www.cdc.gov/std/treatment/sexualhistory.pdf

⁴The CRAFFT pre-screener answer options were modified with permission from Boston Children’s Hospital, the developers of the tool.

⁵The Columbia Lighthouse Project: https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/

⁶Spitzer R.L., Kroenke K., Williams J.B.W., & Lowe B. (2006) A brief measure for assessing generalized anxiety disorder. Arch Intern Med. 166, 1092-1097.

⁷Adverse Childhood Experiences: The ACEs Study. (2017). Center for Youth Wellness: https://centerforyouthwellness.org/the-science/

⁸Menga S., Birmaker B., Chiappetta L., Brent D., Kaufman J., & Bridge J. (2000). Screen for Child Anxiety-Related Emotional Disorders (SCARED): Convergent and Divergent Validity. Depression and Anxiety. 12, 85-91.

⁹National Institute for Children’s Health Quality Vanderbilt Assessment Scales: https://www.nichq.org/resource/nichq-vanderbilt-assessment-scales

¹⁰Sigel, E., Harpin, S., & Tung, G. (2014). Increasing Documentation and Referral for Youth at Risk for Violence Through the Primary Health Care Setting. Clinical Pediatrics. 54(5), 451-457.

¹¹Resnick, M.D., Ireland, M., Borowsky, I. (2004). Youth violence perpetration. What protects? What predicts? Findings from the National Longitudinal Study of Adolescent Health. J Adolescent Health, 35, e1-10.