Toolkit for Improving Family Planning Services in School Settings

Increasing Access to Adolescent-Friendly LARC Services in School-Based Health Centers

Lisa Kim, Elizabeth Cook, Jenita Parekh, & Jennifer Manlove

La Clínica, a federally qualified health center, has developed the following two staff training programs to increase students’ access to and the quality of adolescent-friendly contraceptive services:

• A provider training program in which providers are trained to counsel and insert/remove long-acting reversible contraceptives (LARCs)
• A LARC doula program in which medical assistants and health educators learn to create a positive and welcoming environment for adolescents during LARC procedures

In this case study, we describe key recommendations from the development and implementation of the provider training and LARC doula programs, based on interviews with providers and clinic staff.

See a webinar presentation by La Clínica de La Raza describing this innovative approach here. (Begins at 36:47)

The case study also describes the programs’ background and context, what the programs look like in practice, and the ways in which La Clínica’s LARC provision draws on three foundational approaches that are integral in providing high-quality family planning and sexual health services to youth. At the end of the case study, we provide resources for other organizations interested in implementing similar programs at their site.

La Clínica is a federally qualified health center that provides comprehensive health care services through eight school-based health centers (SBHCs) in the San Francisco Bay area of northern California. Five of the SBHCs are located within high schools or middle schools, and the other three are located near schools and serve the surrounding communities. The largest participating high school has more than 2,000 students, and the smallest has about 200 students. La Clínica serves a racially and ethnically diverse population of students and community members in under-resourced neighborhoods. In particular, the center serves a large population of Spanish speakers and immigrants—specifically, newly arrived immigrants—which La Clínica calls “newcomers.” La Clínica also partners with AmeriCorps to host eight volunteer health educators to serve at each SBHC. Through La Clínica-run SBHCs, students and community members access a variety of primary and preventative services, including family planning services.

In 2014, the American Academy of Pediatrics updated their recommendations stating that LARCs, including intrauterine devices (IUDs) and the contraceptive implant, should be offered as first-line contraceptive methods for adolescents due to high safety, efficacy, and long-term satisfaction rates. These recommendations motivated La Clínica to consider ways to increase their capacity to provide LARC services. At the time, only 2-3 providers were trained to provide LARC services across their SBHCs, so students interested in a LARC method would have to schedule appointments for a time that aligned with the schedule of a trained provider. La Clínica strongly felt they needed to provide LARCs on site and on demand to minimize contraceptive barriers and offer full-spectrum contraceptive care. Furthermore, providers (even those who had been previously trained) expressed fears about performing LARC procedures and desired more in-depth training. These factors prompted La Clínica to develop a provider training program with procedures where providers are monitored by a proctor during LARC appointments to increase the number of qualified and confident providers.

As the number of trained providers slowly increased, several studies exploring adolescents’ experience during LARC procedures were released in 2019, indicating that one of the greatest barriers to LARCs for adolescents was fear of pain. La Clínica recognized the need for adolescents to feel supported and comfortable during a LARC procedure and created the LARC doula program as a result. La Clínica describes LARC doulas as “individuals who are trained to provide emotional, physical, and informational support before, during, and after a LARC procedure.” At La Clínica, medical assistants and AmeriCorps health educators serve as LARC doulas.

To fund components of the provider training and LARC doula programs, La Clínica seeks different funding opportunities from local foundations and county, state, and federal grant programs. The provider training program requires more financial resources than the LARC doula program because of the need to cover multiple providers’ time. Most recently, La Clínica won a one-year $49K grant from The Joseph & Vera Long Foundation, allowing them to cover some providers’ time. For the LARC doula program, since existing staff add LARC doula responsibilities to their ongoing responsibilities, funding is not needed to cover their time. However, any additional funds from the provider training grant are used to cover a few hours of time for the trainer and to buy materials for LARC doulas to use.

Provider training program

One La Clínica nurse practitioner spearheaded the creation of the provider training program and serves as the lead trainer. The provider training program is designed for providers to demonstrate their ability to adequately perform a skill before conducting the skill on their own. Providers are typically trained in cohorts of 2-3 and participate in each of the following sequential steps:

Considerations for scheduling proctored procedures

La Clínica recognizes the need to balance access to LARCs with the need to train providers and reinforce their skills through (ideally) back-to-back proctored procedures. The opportunity to participate in proctored procedures depends on the volume of patients electing for LARCs at any given site. Depending on the volume of LARC appointments across the eight SBHCs, the provider being trained either conducts proctored procedures at their own site or travels to another site that has a higher number of appointments.

In some scenarios, if a patient desires a LARC on the same day and no provider is available at that time, providers will often use a “bridge method,” which is a birth control method that will be used only until the time of the patient’s LARC appointment. Patients may also be switching from one method to another and can reasonably continue with their current method for a short time until their LARC appointment is scheduled. In other scenarios, patients may want to wait due to indecision or the desire to be “mentally prepared” for the procedure. Clinic staff attempt to schedule these appointments as a proctored procedure, if possible, to train providers.

LARC doula training program

The health education supervisor oversees the LARC doula program and trains all AmeriCorps health educators and medical assistants. Depending on the number of AmeriCorps health educators and medical assistants, 7-8 individuals are trained each year. The training is split into the following three components:

Differences in Training for Health Educators and Medical Assistants

La Clínica initially trained only their health educators to serve as LARC doulas. However, due to the pandemic, La Clínica had only two health educators during the 2020-2021 academic year. This shortage resulted in La Clínica training their medical assistants to increase the number of LARC doulas available to meet patient need. As a result, La Clínica adjusted the training material for medical assistants since health educators and medical assistants undergo different trainings when first hired. La Clínica included the following items in the medical assistant training:

• Detailed information about different birth control methods
• Information on the importance of trauma-informed care and related concepts (e.g., sex positivity, gender neutrality)
• Tips on how to respond to difficult questions and talk about birth control with teens
• A bias activity (see Implicit Bias Activity) to ensure individuals are aware of their unconscious biases and take steps to minimize its impact

Steps of a LARC doula visit

While a LARC doula visit looks different for each patient, following is a general outline of a visit.

Before a LARC procedure

1. A health educator conducts a basic health education session on different birth control methods and provides a brief description of the role of a LARC doula.

Day of the LARC procedure

2. A medical assistant completes the rooming process, which involves greeting the patient and leading them to the patient room, updating health records, and answering any questions.
3. The provider enters the room, introduces themselves, and asks the patient if they would like to have a LARC doula present during the procedure.
4. If the patient requests a LARC doula, either a trained health educator or medical assistant enters the room, stands near the patient’s head, and builds rapport with the patient.
   1. Patients are given options of items they can use during the procedure (e.g., iPillow, heating pack, fan) as well as different relaxation techniques. Patients can choose to listen to music (typically, relaxing spa music) or listen to their own music with their headphones.
5. Once the provider starts the insertion process, the LARC doula engages the patient in the way they prefer.

After the LARC procedure

6. The LARC doula thanks the patient and reviews an aftercare sheet with them. Patients are asked to fill out a survey assessing their experience with a LARC doula.
7. The patient schedules a follow-up appointment.

La Clínica’s LARC services relate to three out of four foundational approaches that our team has identified as integral to effectively providing family planning and sexual health services to youth in school-based settings. The four foundational approaches are: 1) embedding equity, 2) prioritizing adolescent-friendly care, 3) maximizing outreach and access, and 4) leveraging partnerships (not addressed via La Clínica’s LARC services). For a detailed description of the four foundational approaches, visit the Foundational Approaches section of the toolkit. This case study highlights the ways in which La Clínica clearly integrates three of these foundational approaches in their LARC services.

La Clínica’s mission is to provide culturally appropriate, high-quality, and accessible health care services to all. As part of the provider and LARC doula training programs, La Clínica incorporates information related to the history of medical racism, systems of power and oppression, the role of reproductive coercion in the U.S., and gender and sexuality (see Race/Racism Applied Presentation). Trainers pull from external resources, including Sister Song’s and National Women’s Health Network’s joint LARC guiding principles to inform the training content. In learning about the history of medical racism and LARC coercion, providers and clinic staff understand the importance of providing care in a way that ensures patients make informed and voluntary contraceptive choices. Staff also participate in implicit bias activities and discuss ways to minimize the impact of unconscious bias.

One LARC doula we spoke with emphasized the importance of doula services for certain populations, particularly newcomer students and younger students. Newcomer students may not be familiar with the U.S. healthcare setting or their rights as a patient, including the right to confidential services. A doula, particularly someone who speaks the same language as the patient, can share more information about SBHC services and re-emphasize their right to confidential services. Providers also mentioned how they make sure to spend extra time with newcomer patients to talk through the many confidential services they can receive at the SBHC. Another group for which doula services increase equity is younger students (typically ages 13-15). Even when they want an IUD placed, younger students may be particularly fearful of the procedure, as many of them have never had a pelvic exam. Having a doula whose priority is to listen to patients’ needs and preferences, especially if the patient changes their mind about getting an IUD, is an important way to increase equity.

La Clínica prioritizes adolescent-friendly care in multiple ways. The LARC doula program itself was developed to create a safe and comfortable environment for adolescents choosing LARCs. As described earlier, LARC doulas’ work is to help a patient retain a sense of control during a LARC insertion. Patients are encouraged to participate and direct the procedure as they feel comfortable (i.e., use different materials for physical comfort or listen to music). Patients are explicitly told that the procedure is “not done to them but with them.” Furthermore, a benefit of having health educators and medical assistants serve as LARC doulas is that they are typically closer in age and able to build rapport with patients. LARC doulas are also encouraged to offer suggestions to clinic staff about how their role could improve to meet patients’ needs. In one instance, a LARC doula shared with her site supervisor that some patients were getting warm and felt uncomfortable and asked if the clinic can purchase portable fans for patients. After testing portable fans with patients, La Clínica decided to order them for all their sites.

In addition to the LARC doula program, La Clínica staff described several other ways they prioritize adolescent-friendly care when providing LARC services. Before a LARC appointment, health educators conduct a basic health education session to provide information about different birth control methods and address common fears that patients have regarding LARCs. Some questions that they answer include: Is it going to hurt? Can I have sex right after the procedure? Why will I need Ibuprofen? Am I going to become overweight? When talking about how LARCs are administered, one provider described intentionally using casual, non-technical language and emphasizing that patients can say no at any time and are “not locked into anything.” Providers also ask students what they have heard from friends and peers about LARCs to dispel any myths. Another provider shared the importance of considering how patients prefer to receive information. Since adolescents tend to be more receptive to online resources, the provider often uses Bedsider and encourages patients to visit the website.

La Clínica is also working to expand services for the LGBTQ population. All staff receive training on LGBTQ care and learn the importance of using correct pronouns and appropriate language when working with LGBTQ patients. Many clinic staff wear a button on their shirt that states their own pronouns, which not only helps patients know what pronouns to use for each staff member, but also signals that clinic staff are aware and accepting of all gender identities and welcome conversations about it. For patients who would like to explore their gender identity and request further supports, staff refer them to providers who specialize in gender care within the family medicine department at La Clínica. As part of the physical assessment, La Clínica staff also explicitly ask questions about patients’ gender identity. Providers are expected to add secure notes—which cannot be seen by patients—to patients’ electronic medical records to indicate important information related to patients’ gender identity and sexual orientation.

La Clínica staff noted services they offer to raise awareness of SBHC services and increase students’ interest in LARCs: LARC doulas, adolescent screening visits (ASVs), and senior send-off visits. The LARC doula program serves as a recruiting tool—patients share their experience with a LARC doula with their friends, which results in their friends visiting the clinic themselves. La Clínica also conducts ASVs at the beginning of each school year to identify students’ needs, including family planning, and connects them to services. ASVs provide an opportunity for SBHC staff to introduce the clinic and their services and set a positive impression of the clinic. Health educators also lead senior send-off visits to connect graduating seniors to health care services beyond the SBHC, including family planning services. Senior send-off visits help ensure continuity of care. SBHC staff, particularly health educators, play an important role in increasing access and use of services. For a more detailed description of ASVs and senior send-off visits, see Maximizing Outreach and Access.

The lead trainer at La Clínica emphasized the importance of finding someone who has extensive clinical knowledge and experience and is willing to invest the time necessary to adequately train others. Providers who have been trained spoke more of intangible qualities they admired in the La Clínica trainer—someone who “puts [us] at ease, makes [us] feel comfortable, and makes [us] feel like [we] can do it.” While having someone like the La Clínica trainer is ideal, one provider said,

SBHCs should identify providers, either internal or external to the center, who not only have the clinical skillset and time, but also are supportive and understanding. For SBHCs that may not have direct access to a highly qualified trainer, consider engaging with different organizations, such as the Reproductive Health Access Project, to connect with a network of trained professionals.

Training providers requires significant financial resources, particularly because of the need to have two providers available for proctored procedures (i.e., one provider performing the procedure and the other serving as the proctor). La Clínica seeks multiple funding streams to cover providers’ time and attempts to align schedules to “make them financially doable.”

SBHCs should identify different funding streams, including local grants, and brainstorm ways to build flexibility into providers’ schedules for training.

A common barrier to providing LARC services is provider fear and anxiety regarding the procedure. Providers we interviewed described several fears, including measuring and puncturing the uterus or having patients pass out or scream due to pain. Providers also shared how past trainings they participated in were inadequate, and they did not feel comfortable with LARC insertions until participating in La Clínica’s provider training program. Providers felt that La Clínica’s tailored competency review portion of the training and one-on-one proctored procedures alleviated their fears and solidified their skills.

SBHCs should create a space for providers to discuss potential fears they have and assess their knowledge and experience with LARCs to create a more individualized and positive training experience.

Due to staffing shortages caused by the pandemic, La Clínica decided to train their medical assistants to serve as LARC doulas (in addition to health educators). This experience demonstrated that any staff member can learn to be a LARC doula with sufficient training. While anyone can serve as a LARC doula, some characteristics that staff noted as making a successful LARC doula include the ability to build rapport with patients and appropriately read and react to patients.

SBHCs should consider training other staff members, including those who may not have direct clinical experience, to step into the role.

In promoting and offering LARC services, it is crucial for providers and clinic staff to understand and acknowledge the history of medical racism and contraceptive coercion in the U.S. La Clínica intentionally incorporated such information as a foundational piece of the training programs (see Embedding Equity).

SBHCs that offer LARC services should consider implementing trainings or including content in established trainings around medical racism and contraceptive coercion. Providers and LARC doulas can provide more equitable and patient-centered care by understanding and reflecting on how this history has impacted the way certain populations engage with family planning services.

La Clínica recognized that to integrate the provider training and LARC doula programs across their sites, they had to advocate for the necessity of these practices. Before implementing both programs, La Clínica held an all-staff meeting at each SBHC site to “really get everyone on the same page.” For the provider training program, in particular, La Clínica faced some challenges with garnering approval from organizational leadership who did not feel they had a high enough volume of patients to justify providing LARC services. SBHC staff described participating in multiple, ongoing conversations with leadership to highlight the importance of providing LARCs on site.

La Clínica heavily relied on materials provided by Bixby Center for Global Reproductive Health at the University of California, San Francisco and a local Federally Qualified Health Center (FQHC), The Native American Health Center. Providers shared that there are many online resources available for free that SBHCs can turn to. La Clínica staff themselves expressed enthusiasm for sharing with other clinics the materials they have developed, particularly for the LARC doula training.

SBHCs should identify and modify already produced materials rather than “reinventing the wheel” when implementing the provider training or LARC doula programs.

As discussed earlier, La Clínica pursues several funding opportunities to sustain the provider training and LARC doula programs. When applying for funding, SBHCs may be required to report data demonstrating the benefits of the programs. One provider we spoke with acknowledged the need for data gathering to evaluate the effectiveness of the provider training and LARC doula programs.

Gathering data, such as the number of students choosing services or how patients perceive the programs, not only helps SBHCs be more successful at raising funding, but also helps staff identify strengths and areas of improvement. Once SBHCs establish the provider training or LARC doula programs, staff should develop tools to better understand patient experiences during LARC procedures and showcase the value of such programs.