Healthcare Operations Change Initiative Proposal

MENTAL HEALTH IN SCHOOL BASED HEALTH CENTERS 1
Expanding Mental Health Care Access through School Based Health Centers
Leah M. Schreder
Saint Mary's University of Minnesota
Schools of Graduate & Professional Programs
HP 652 Health Policy
Susan Doherty
December 20, 2015

Introduction
Access to mental health care for children and teens is an area of need when addressing
healthcare operations. An effective way to address these needs is through School Based
Healthcare Centers (SBHCs). SBHCs are not a new idea and were first introduced in the 1900’s,
initially based on contagious illness containment (Keeton, Soleimanpour, & Brindis, 2012).
According to Keeton, Soleimanpour, and Brindis (2012), the first school nurse was hired and
began treating children using a variety of methods, which decreased the rates of absenteeism by
90%. Since then, SBHCs have evolved to cover projects helping teenage mothers, increasing
access to overall care and immunizations, and to meet the mental health needs of the underserved
population. SBHCs offer a convenient way for those children who are underserved to have
access to mental health treatment plans through proximity. The stigma of mental health care is
decreased since services can be provided without having to go offsite while attending school.
Even with the advancements in mental health care access, much more is needed to fill in
gaps in access. One specific change in policy is to induce an increase in predictable, steady
funding for SBHCs. Besides making funding more predictable and expanding it, more outreach
programs are needed within the school setting based on increasing knowledge of cultural needs
and disparities. Lastly, the evaluation of SBHCs and quality of service should be improved and
specific outcomes and models need to be defined as the number of centers increase.
Justification for Change
Since the Affordable Care Act (ACA) was passed, many cultural groups suffering
disparities in health care access have seen a decrease in inequality, however, children have not
gained additional access to insurance through eligibility levels within Medicaid or Children’s

Health Insurance Program (CHIP) (Estes, Chapman, Dodd, Hollister, & Harrington, 2013).
Approximately 20% of adolescents meet diagnostic criteria for a mental disorder with severe
impairment, however, only about one-third of identified adolescents obtain treatment (Keeton,
Soleimanpour, & Brindis, 2012).
Children’s mental health affects many social and economic areas, in a cyclical
relationship, creating a need for additional change. The American Public Health Association’s
(APHA) Center for School, Health, and Education (2011) reported the strongest predictor of high
school dropout status is mental/emotional dysfunction and substance use. In addition,
educational disparities, or adults with a low level of education, are more likely to develop
cardiovascular disease, cancer, infections, lung disease, and diabetes (APHA Center for School,
Health, and Education, 2011). To infer that the levels of academic achievement and health status
are strongly correlated to good mental health would be deemed appropriate. Therefore,
addressing mental health needs in children will reduce future economic and societal problems.
Overview of Professional Organization, Regulation, and Laws
The most closely linked professional organization related to SBHCs and children’s
mental health is the APHA’s Center for School, Health, and Education. The center is organized
around the premise of preventing school dropouts and improving graduation rates by addressing
learning barriers such as bullying, hunger, and distress (APHA Center for School, Health, and
Education, 2015). APHA’s Center for School, Health, and Education focuses on increasing the
number of SBHCs to meet health care needs in children and adolescents. The Substance Abuse
and Mental Health Services Administration (SAMHSA) (2015, October 13) is also supportive of
the promotion of mental health wellness in schools in order to provide a safe learning
environment for students. SAMHSA (2015, October 13) reported that over the last two decades,

the amount of mental health conditions have continued to increase, which is one reason why
SAMHSA offers grants programs and other resources that promote mental and emotional health
in schools and on campuses.
In 2004, the W.K. Kellogg Foundation developed the School-Based Health Care Policy
Program (SBHCPP), which focused efforts on making SBHCs financially stable, increasing
access to children and families, and supported consumer-centered care (APHA Center for
School, Health, and Education, 2015). At this time, 1709 school-connected programs that had a
difficult time maintaining adequate reliable sources of revenue were identified, serving the most
vulnerable populations, which included uninsured and underinsured children (APHA Center for
School, Health, and Education, 2015). SBHCPP’s design was based on developing infrastructure
needed for SBHCs, strengthening the capacity of the National Assembly of School-Based Health
Care to advocate for policy change to increase sustainability of SBHCs (APHA Center for
School, Health, and Education, 2015). Eventually, the federal recognition of SBHCs as
providers able to obtain reimbursement through Children’s Health Insurance Program
Reauthorization Act (CHIPRA) was accomplished (APHA Center for School, Health, and
Education, 2015).
The National Conference of State Legislatures (October 2011) provided information on
federal provisions, information and conditions for grant money, including states’ roles in
implementing health reform within the area of SBHCs. The ACA set aside $50 million for
grants in each fiscal year between 2010 and 2013 (National Conference of State Legislatures,
October 2011). The money was for basic construction and to support operations of SBHCs.
Some of the federal provisions under section 4101 (a) described eligibility for grants wherein
SBHCs needed to be primarily described as “a health clinic in or near a school, is organized

through school, community, and health provider relationships, is administered by a sponsoring
facility, and provides primary health services to children in accordance with state and local law
through health professionals” (National Conference of State Legislatures, 2011). Additionally,
preferences for grants were made to SBHCs that served higher proportions of children eligible
for Medicaid or CHIP (National Conference of State Legislatures, 2011). The states’ roles in
SBHC regulation have been to provide oversight of SBHCs as well as stand as the primary
funding source.
Stakeholders
Adolescents are especially in need of mental health care due to the fact that they engage
in risky behaviors that can affect their present health and health status in the future (Keeton,
Soleimanpour, & Brindis, 2012). They require additional guidance when it comes to sensitive
needs such as mental health care. SBHCs provide care that is connected to high levels of
satisfaction and studies have shown that students are much more likely to keep appointments
through SBHCs (Keeton, Soleimanpour, & Brindis, 2012). It would be beneficial to provide a
service that is both highly satisfying and increases maintenance of services. Patients are more
likely to continue care and treatment when relationships and services are meeting their personal
needs.
SBHC providers are constantly challenged with the task of providing evidence or data
that their work is improving health and educational outcomes for its patients. There is a
correlation between evaluations and production of increases in access, improved outcomes, and
achieved, high levels of satisfaction. The issue remains that financial resources are limited along
with the narrow range of services while restrictions based on privacy keeps monitoring
challenging, or at the very least extremely laborious. SBHC providers also have a difficult time

finding a steady source of income from year to year. Relying on private donations is difficult to
predict and is problematic when SBHCs provide services to all students with or without
insurance.
Payers for SBHCs are diverse and school based centers finance their operations based on
the types of financial revenue they acquire. Keeton, Soleimanpour, and Brindis (2012) reported
NASBHC’s 2008 national census of SBHCs reported the use of non-patient billing revenue. The
sources used were: state government (76% of SBHCs), private foundations (50%), sponsoring
organizations (49%), school districts (46%), and federal government (39%) (Keeton,
Soleimanpour, & Brindis, 2012). The study also concluded that most SBHCs bill public
insurance programs (Keeton, Soleimanpour, & Brindis, 2012). The sustainability of SBHCs will
be the passage of legislation providing more funding through the state and federal government.
SBHCs survival will also be based on the amount of community support and resources that are
available, which can be difficult, specifically because most SBHCs are already serving a
majority of uninsured or underinsured population where resources are already limited.
Procedure and Practices
SBHCs are health providers that provide services to every student in need. Within their
practice and procedures should be an outreach to patients. Such activities could begin with
surveys or screenings for the intended population. Because services are provided within or near
schools, school personnel should have a clear understanding on procedures of intake in order to
become primary sources of referrals. Providers working within SBHCs should have knowledge
of best practices and be provided trainings on how to interact with the population of students,
including cultural trainings and trainings on the sensitive nature of mental health needs. SBHCs
integrate within the school community, building educational opportunities and healthy

relationships with staff, parents, and students. SBHCs should develop programs to introduce
healthy activities that promote mental health and a sense of community, with positive programs
defining mental health initiatives such as preventing bullying, understanding depression, and
breaking down stereotypes of mental health diagnoses. Case management should be used to
follow and provide services to those with chronic mental health needs, especially monitoring of
medication and frequent documentation based on teacher observations within school. SBHCs
should set regular meetings to discuss changing health needs within the school setting as well as
provide assistance to school staff as to managing their own stress and wellness within the
workplace. Besides day-to-day procedures and practices, SBHCs should be financially stable
putting effort into budget management and expense reimbursement. If needed, depending on the
amount of expenditures and the state in which the center resides, fiscal audits should be included
in the SBHCs practices and procedures also.
Ethical Considerations
Children and teens with mental health care needs have several types of ethical issues
worth considering when discussing a change initiative. Cultural disparities have been discovered
in access to general healthcare itself, although within SBHCs, studies have found that disparities
are very slight with few significant discrepancies. When discussing general health care services,
SBHCs delivered equitable access regardless of demographics or socioeconomic status
(Parasuraman & Shi, 2015). Parasuraman and Shi (2015) also concluded that very few
significant discrepancies were found when considering gender, race/ethnicity, and insurance
status. In contrast, when focusing on adolescents with serious emotional concerns and female
adolescents, differences in unmet needs were found in mental health care (Parasuraman & Shi,
2015). Unmet mental health needs for female and underserved adolescents were observed the

most while these groups were at the highest risk of being undiagnosed or developing mental
health disorders (Parasuraman & Shi, 2015). Ethically, SBHCs will need to address the
inequality of female and adolescents with serious emotional concerns to ensure mental health
care is provided in the most equitable way possible across the board. Other ethical issues that
need to be addressed are use of active consent to provide services versus passive consent.
Passive consent may be helpful to students who desperately need care and parental supervision is
not consistent where consent may be delayed. It would allow some cases to begin treatment
immediately; where as active consent would hinder the immediate response to needed care.
However, passive consent may put organizations at risk for legal issues, depending on the
satisfaction of results or outcomes.
Proposed Changes in Policy, Procedures, and Practices
In order to provide students in need of mental health care the care they need, SBHC
providers need change their procedures to increase the use of quality measures that will identify
areas of organization weakness and areas that need improvement. Those measures should
generally focus on qualities of a strong SBHC operation such as capacity, efficiency, and
sustainability (California School-Based Health Alliance, 2014). The quality of care should also
be measured in terms of access and timelines, as well as, coordination and continuity. Areas
such as general preventive behaviors and management of chronic disease, in terms of mental
health, could be measured to assess areas in need of improvement (California School- Based
Health Alliance, 2014).
Improvements in SBHCs, and changes in practice, include increasing outreach programs.
Likewise, SBHCs need to maintain and build stronger relationships with students, as well as,
parents and guardians. Review of the outreach measures should be set on a regular schedule to

be discussed with a sample group including providers and SBHCs employees, along with school
administration, the school board, and other school staff members. Brochures should be produced
to clearly outline services provided and the unique benefits to having them provided within the
SBHC. SBHCs need to continue open communication with parents by offering “open houses” so
that parents may be able to visit the organization physically and ask questions face-to-face.
Outreach could additionally include activities that are not specifically based on showing the
community what is offered at the care center, but may simply build relationships that would
increase trust, such as hosting family sporting events or partnering with local businesses to
fundraise through banquets or other events such as silent auctions. SBHC employees could
further consider volunteering to improve the community as whole, such as gathering groups to
clean up local parks, beaches, or picking up on a main street in town spreading information about
the center by word of mouth (Mackie, 2014).
Based on funding numbers previously provided, a stabilization and eventual increase of
federal and state funding for SBHCs must be part of a change in policy. Without more federal
and state funding, it’s difficult to predict the expansion of much needed SBHCs. Healthcare
reform focuses on increasing accountability for all healthcare organizations, including SBHCs.
Increasing measures of quality should provide validation of the important role SBHCs have in
providing mental health care, especially to youth. Due to mental health care’s sensitive nature
and the need for immediate care, it should be easy to provide numbers using outcome measures
and data proving the importance of providing increased access for this vulnerable population
within schools.

Impacts of Change
Making changes within the SBHCs mental health funding process will create many
benefits to society as a whole. Keeton, Soleimanpour, and Brindis (2012) report that uninsured
and underinsured children and adolescents are at a high risk for not having healthcare needs met,
such as mental health services. That risk would be decreased and children and adolescents
would have a predictable, sustained follow up on mental health care with more access to
healthcare. When children are not well, either physically or emotionally, parents need to stay
home with them, creating economic hardship for the family. In the research done by Keeton,
Soleimanpour, and Brindis (2012), “adolescents were 10 to 21 times more likely to prefer
visiting an SBHC over CHC for mental health care, and enhanced availability of care was cited
as one of the likely reasons for this preference”. Based on the information, it would be probable
that more children and teens would be reached to provide much needed services.
Because mental health is linked to other health risks such as cardiovascular disease,
diabetes, and other chronic ailments outlined previously, these rate would decrease and affect
that amount of money spent on treating these diseases. In addition, providing more services
would increase the need for more healthcare providers creating more jobs in the healthcare field,
including medical equipment. Creating clinics within schools would increase jobs in other
industries as well, such as construction.
Influencing, Advocating, and Lobbying for Change
Advocating and lobbying for change should be centered mainly on outcome based
measurements. It’s difficult to argue with statistics and actual numbers based on measurements
defining the unique characteristics of SBHCs. Information should be presented in an informative
way focusing on benefits in healthcare but also benefits to society. Specific community numbers

should be included in preparing for advocating SBHCs. Lobbying would include the same types
of information while adding quality measures into the information, toward pushing for an
increase in federal and state funding. Selling SBHCs should be the focus, so that SBHCs can
work on increasing accountability and quality without the worry of extreme financial shortages.
Conclusion
In closing, the amount of access to mental health care and accountability within SBHCs
cannot be duplicated in another setting. The population that is served by these centers, children
and teens, are dependent on others to take necessary steps to provide mental health care.
Outreach for these programs simply need to be where the population maintains their daily routine
to increase access to the care they need provided. SBHCs reduce the amount of transportation
needed to receive services, the time associated with parents needing work leave to provide
services, and increase the likelihood of follow-up services after care. SBHCs should be
recognized as an essential need for children and teens to provide mental health care in the most
sensible, appropriate setting possible and programs for increased revenue should be expanded.

References
American Public Health Association’s Center for School, Health, and Education. (2015).
Retrieved from http://www.schoolbasedhealthcare.org/
American Public Health Association’s Center for School, Health, and Education. (2011). The
dropout crisis: A public health problem and the role of school-based health care.
Retrieved from http://www.schoolbasedhealthcare.org/wp-
content/uploads/2011/09/APHA4_article_DropOut_0914_FINAL3.pdf
California School- Based Health Alliance. (2014). Key performance measures for school-based
health centers. Retrieved from http://www.schoolhealthcenters.org/wp-
content/uploads/2014/10/CSHA-Key-Performance-Measures-for-SBHCs.pdf
Department of Health & Human Services, USA. (2010). Connecting kids to coverage:
Continuing the progress the 2010 CHIPRA annual report. Retrieved from
http://www.insurekidsnow.gov/professionals/reports/chipra/2010_annual.pdf
Estes, C., L., Chapman, S., A., Dodd, C., Hollister, B., & Harrington, C. (2013). Health policy:
Crisis and reform. Burlington, MA: Jones & Bartlett Learning.
Keeton, V., Soleimanpour, S., & Brindis, C. D. (2012). School-Based Health Centers in an Era
of Health Care Reform: Building on History. Current Problems in Pediatric and
Adolescent Health Care, 42(6), 132–158. http://doi.org/10.1016/j.cppeds.2012.03.002
Mackie, D. (2014, September, 30). Why marketing your small business through community
outreach really works. Retrieved from http://blog.fundinggates.com/2014/09/small-
business-marketing-ideas-community-outreach/
Parasuraman, S. R., & Shi, L. (2015). Differences in Access to Care Among Students Using
School-Based Health Centers. The Journal Of School Nursing: The Official Publication

Of The National Association Of School Nurses, 31(4), 291-299.
doi:10.1177/1059840514556180
SBHC Best Practices Checklist. Reteived from http://thelatrust.org/wp-
content/uploads/2012/12/SBHC-Principles-Checklist-July-2014.pdf
Substance Abuse and Mental Health Services Administration. (2015, October, 13). School and
campus health. Retrieved from http://www.samhsa.gov/school-campus-health

Mental health care services can be provided to children and teens by increasing the
quality and number of School Based Health Centers (SBHCs). Evidence has shown the need for
mental health care for children and teen continues to increase. In addition, research has shown
that students are highly satisfied with services provided by SBHCs and more likely to keep
appointments. After care and follow up care of SBHC providers is easily attained, being in close
proximity of patients. Although the need is increasing, funding for SBHCs continues to be
unstable and unpredictable.
 Approximately 20% of adolescents meet diagnostic criteria for a mental disorder with
severe impairment, however, only about one-third of identified adolescents obtain
treatment (Keeton, Soleimanpour, & Brindis, 2012).
 NASBHC’s 2008 national census of SBHCs reported the use of non-patient billing
revenue. The sources used were: state government (76% of SBHCs), private foundations
(50%), sponsoring organizations (49%), school districts (46%), and federal government
(39%) (Keeton, Soleimanpour, & Brindis, 2012).
 Adolescents were 10 to 21 times more likely to prefer visiting an SBHC over CHC for
mental health care, and enhanced availability of care was cited as one of the likely
reasons for this preference (Keeton, Soleimanpour, and Brindis, 2012).
 A 50% decrease in absenteeism and a 25% decrease in tardiness two months after
receiving school-based mental health counseling (American Public Health
Association’s Center for School, Health, and Education, 2011).
Recommendations for Change:
1.) Increase outreach programs 2.) Increase federal and state funding 3.) Increase quality

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