School-Based Health Centers 101


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An introduction to how a school-based health center is defined, where they are located, who they serve, and what they provide.

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  • By the end of our time together today, you will be able to: 1. define what a school-based health center is; 2. explain why school-based health centers are better than sliced bread and the best way to deliver health care for children and adolescents; 3. talk about the big picture of school-based health centers including where they are at in the US and where they are located in your community; (You will be able to tell me What a SBHC is Why have a SBHC Where are they and how many)
  • The following six slides represent the most common pieces or components that frame and define what a school-based health center is. Unlike most other health care centers, partnerships are key for SBHCs. Schools and community health organizations come together to provide health services (medical, mental health, oral health) that promote the health and educational success of our children and adolescents. Typically, a health agency is one of the key partners and is the sponsoring agency of the SBHC.
  • Collaboration is key to making a local decision concerning the range and types of services found in a school-based health center. And the providers within the SBHC work closely with their educational partners such as the school nurse, and their community partners and other service providers to provide the best care to the students.
  • Each SBHC will develop and implement a policy and procedure on parental consent. We will touch more on this later in the presentation. And typically, a SBHC is open every school day and has a staff providing , comprehensive services that is supported by an interdisciplinary team which means there are providers from different disciplines such as primary care, mental health, alcohol and other drug prevention and intervention, health education, and oral health.
  • Since SBHCs are open during the school day and mostly the school hours, SBHCs need to make provisions for care beyond their typical operating hours, and for needs that are beyond their scope of service. Unique to SBHCs, since they are in the school, the providers have opportunities that your typical medical provider does not have: access access access and the ability to work long term with the students emphasizing prevention and early intervention.
  • SBHCs provide services that are age appropriate and focus on the key indicators that influence the health needs of children and youth. This influences what kind of provider you hire and determines your resource needs. And we have talked a bit about the types of services and they are listed more fully here. The services are determined by the needs of the community, the local decision making process, provider type, and availability of resources.
  • SBHCs are supported financially by a combination of sources such as grants, foundations, donations, co-pays, billing and reimbursement for services, and fund raisers. Money comes from many levels and from various partners including health and educational partners. Students are most often seen regardless of their ability to pay. So in wrap up, key to remember, that as a health provider, SBHCs are unique. They are where the kids are for most of the day; They focus on what influences positive health outcomes; They work with and within the educational and community partners in the provision of services and follow-up care; They take the time provide health promotion and guidance; and they impact not only the health of our children and youth, they also provide a positive effect on the learning environment and the success of students academically. And this is all done through collaboration and partnerships, with the voice of the local community key in the planning and start up of a SBHC.
  • So, we have talked a little about WHAT is a SBHC. We know that SBHCs are a unique way to provide health care to students. So what? Why have a SBHC?
  • We want to hear from you. We are going to do an activity now. -I want you to imagine a student in need of a SBHC. I want you to actually picture someone at a specific age. You can do this in a variety of ways: You can go back in time to when you were a school-aged child or adolescent and pick an age and remember what it was like. Or you can think of your own child or adolescent. Or think of family members, neighbors, etc as a student. However you do this, picture the person you have selected; what is their age? Now here is the challenge and the fun part. Using the first letter of your first or last name (or draw an alphabet card from the center of the table/bucket) come up with a ‘Why” SBHCs. Here is an example: I am picturing my daughter who is a senior in high school so she is 18. I am going to use my “A” (first letter of my last name). Why a SBHC for her? Anxiety! A SBHC would be able to help her with her medications, provide support and mental health counseling, be a safe haven for her, and help her develop coping skills through 1:1 or small groups. Any questions? You have a couple of minutes to prepare, then we will share. OK, tell me who the student is, their age, and your letter you are using. Now answer the question: Why? (write up the answers to why on flip chart)
  • Comment on the exercise and link throughout the next few slides. SBHCs are critical to providing care to the uninsured. Access to health care is simplified by being in the school so the geographic barriers to care are diminished or gone. Adolescents, without age appropriate health guidance, early identification and support, can be seriously affected with poor health outcomes during their youth and can be set up for longer term health and mental health problems SBHCs are able to connect and often be the hub of the system of care that is typically oriented to specialist and silos. If a student has health or mental health problems, they are at risk for not meeting their educational potential.
  • Dr. Phillip Porter, and early architect of the SBHC movement, recognized that students, especially adolescents, need health care where they spend the majority of their time.
  • Since the early days of SBHCs, the movement has worked to provide evidence beyond the anecdotal evidence provided by the providers and the students and their families that SBHCs do make a difference. Through many years of research projects, national and state data collection including surveys and census, the leaders in the SBHC field can make compelling reasons for SBHCs. In addition, there have been many initiatives that have blossomed from the needs of the field. The National Assembly on School-Based Health Care (NASBHC) has been very instrumental in developing cutting edge tools, resources, and Collaboratives that support the work of the centers. With the SBHC being a unique model of care, the traditional trainings and resources for other providers just didn’t meet the needs of the young and growing field.
  • What do we know? From the research, we can talk about the relationship between a SBHC and Emergency Room use: Having a SBHC can reduce the inappropriate ER use. (a student can’t get to their doc, doesn’t have insurance, etc and has a really bad sore throat. It gets so bad, they finally go to the ER to get treatment-one example) We also know that by getting the help sooner and treating conditions in the early stages, there were fewer hospitalizations. And through age appropriate preventive care in a SBHC, students did not go to the ER for their concerns that could be addressed in the SBHC. SBHCs create timely and trusted access, and provide care earlier in the development of a condition or disease, resulting in less use of an ER as a primary care facility.
  • How about asthma? Students enrolled in SBHC significantly reduced their ER visits for asthma in a NY study. With growing rates of asthma and increasing severity of asthma attacks, it is critical to address asthma before it reaches the point of calling the ambulance. The SBHC is able to provide timely care, often help the students obtain their medications, provide quick access to nebulizer treatments and preventing a full blown asthma attack, and help the student recognize some of the triggers to asthma attacks and what to do prevent them.
  • In regards to SBHCs and mental health, we know that they serve harder to reach populations and do a better job meeting their mental health needs than a more traditional primary care provider. And not surprising, adolescents report that they were 10-21 times more likely to seek mental health care at a SBHC than a community provider.
  • As mentioned earlier, SBHCs have a positive impact in the education arena. We know that by having a center in a school, the center is contributing to the overall milieu, helping students get care earlier and decreasing some potential classroom problems, and keeping kids well. It is hard to teach kids who are sick or at higher risk for poor outcomes.
  • Academic performance is negatively affected by: read the list or some of it Conversely, academic performance is positively affected by: Resiliency, development assets, and school connectedness. SBHCs can partner with education to support these indicators.
  • Encourage educators to accept that there is a link between health and academics…and instead focus on health-related results and indicators Medical and mental health status impacts academic outcomes SBHCs impact medical and mental health status So…SBHCs can contribute, at least indirectly, to improved academic outcomes
  • What else do we know from the research about SBHCs in relation to health care? Many of the students who use the SBHC use the center as their medical home, and do not have a medical home elsewhere.
  • SBHCs save parents and employers time, and keep kids in the classroom as they don’t have to leave school for health care visits. SBHCs can send for a student to do follow up care very easily. SBHCs develop relationships with students, often do annual risk assessments, and identify problems earlier SBHCs provide care access to services that allows students to get timely and appropriate care, keeping them out of the ER for their primary care needs.
  • Census 2004-05 identified 1709 school-connected programs nationwide. This number includes school-based, mobile and linked programs. 1335 or 78% of known programs responded to the survey. These data on practices and operations during the 2004-05 school year were collected from October 2005 through October 2006. Efforts were made to confirm that non respondents were open during the 2004-05 school year. This presentation describes the 1235 sites providing a minimum of primary care service, defined as having a staffing profile with a nurse practitioner, physician assistant or physician on school grounds. The programs not providing primary care services on school grounds are not presented here.
  • Settings for school-based health centers (SBHCs) are as varied as the types of schools in the United States. As schools nationwide re-design for students’ academic success, SBHCs adapt to meet the age-appropriate needs of the students they are serving . 80% of the programs report serving at least one grade of adolescents. 41% are designated as Title One schools. 6% of SBHCs are in alternative schools. 41% of SBHCs in schools with more than 1000 students.
  • COMMUNITY SBHCs are located in geographically diverse communities, with the majority (59%) in urban communities. Nearly one in three health centers is in rural schools. Sponsorship of SBHCs is most typically by a local health care organization, such as a hospital (29%), community health center (22%), and health department (17%) , Other community partners include nonprofit organizations, universities and mental health agencies. Only 14% are sponsored by the school system.
  • STUDENTS Students in schools with SBHCs are predominantly minority and ethnic populations that have historically experienced health care access disparities. 69% of SBHCs report that more than half of their student population is eligible for free and reduced lunch – a marker for underserved students.
  • Although the school population is the school-based health center’s primary target, many (55%) provide services to patients other than enrolled students: students from other schools in the community (33%); family members of students (29%); faculty and school personnel (19%); out-of-school youth (16%); and other community members (12%).
  • The majority of SBHCs provide the basic tools of primary preventive care. The most common components in the SBHC scope of service are comprehensive health assessments, anticipatory guidance, vision and hearing screenings, immunizations, treatment of acute illness, laboratory services, and prescription services.
  • Health centers serving middle and high school aged students (n= 977) who responded to these questions ( from 897 to 931) were more likely to offer abstinence counseling (76%) and provide on-site treatment for sexually transmitted diseases (62%), HIV/AIDS counseling (64%), and diagnostic services such as pregnancy testing (78%) than contraceptive services (30%). Family planning services most often encompassed birth control counseling (65%) and follow up (48%). A minority of health centers neither provided on-site nor referred to an off-site provider for any reproductive health services.
  • Health centers serving middle and high school aged students (n= 977) who responded to these questions ( from 897 to 931) were more likely to offer abstinence counseling (76%) and provide on-site treatment for sexually transmitted diseases (62%), HIV/AIDS counseling (64%), and diagnostic services such as pregnancy testing (78%) than contraceptive services (30%). Family planning services most often encompassed birth control counseling (65%) and follow up (48%). A minority of health centers neither provided on-site nor referred to an off-site provider for any reproductive health services.
  • More than two-thirds of school-based health centers are prohibited from dispensing contraception – a policy whose source is most often the school district.
  • Mental health services are often delivered by school-based health center primary care staff. School-based health centers offer a variety of on-site mental health and counseling services through several modalities, including individual, one-on-one counseling, student group counseling, family therapy, consultation and case management. These services are more likely to be provided when mental health professionals are included as center staff. Those services most frequently reported as provided by centers without mental health professionals on staff include referrals (63%), mental health diagnosis ( 63%) and screening (62%).
  • School-Based Health Centers 101

    1. 1. School-Based Health Centers (SBHCs) 101: An Overview and Framework for Building Programs
    2. 2. Objectives <ul><li>Participants will be able : </li></ul><ul><li>Define school-based health center (SBHC) </li></ul><ul><li>Explain why SBHCs are an effective health care delivery system for children and adolescents </li></ul><ul><li>Describe characteristics of SBHCs </li></ul>
    3. 3. SBHC: National Definition <ul><li>Partnerships created by schools and community health organizations to provide on-site medical, mental health, and/or oral health services that promote the health and educational success of school-aged children and adolescents. </li></ul><ul><li>One of the partners, usually a health agency (community health center, local health department, hospital, mental health agency, or 501 C3 agency), or a school system, becomes the sponsoring agency. </li></ul>
    4. 4. SBHC: National Definition <ul><li>Services provided by the school-based health care team are determined locally through a collaborative process that includes families and students, communities, school districts, and individual and agency health care providers. </li></ul><ul><li>The school-based health care team works in collaboration with school nurses and other service providers in the school and community. </li></ul>
    5. 5. SBHC: National Definition <ul><li>SBHCs have a policy on parental consent. </li></ul><ul><li>Although the model may vary based on availability of resources and community needs, SBHCs are typically open every school day, and staffed by an interdisciplinary team of medical and mental health professionals that provide comprehensive medical, mental health and health education services. </li></ul>
    6. 6. SBHC: National Definition <ul><li>SBHCs make provisions for care beyond the centers’ operating hours or scope of service. </li></ul><ul><li>Because of the unique vantage point and access to students, the health center team is able to reach out to students to emphasize prevention and early intervention. </li></ul>
    7. 7. SBHC: National Definition <ul><li>Services typically offered in SBHCs are age appropriate and address the most important health needs of children and youth. </li></ul><ul><li>These services may include but are not limited to: </li></ul><ul><ul><li>primary care for acute and chronic health conditions </li></ul></ul><ul><ul><li>mental health services </li></ul></ul><ul><ul><li>substance abuse services </li></ul></ul><ul><ul><li>case management </li></ul></ul><ul><ul><li>dental health services </li></ul></ul><ul><ul><li>reproductive health care </li></ul></ul><ul><ul><li>nutrition education </li></ul></ul><ul><ul><li>health education and health promotion. </li></ul></ul><ul><ul><li></li></ul></ul>
    8. 8. SBHC: National Definition <ul><li>SBHCs are supported by local, state, and federal public health and primary care grants, community foundations, students and families, and reimbursement from public and private health insurance. </li></ul><ul><ul><li></li></ul></ul>
    9. 9. Why School-Based Health Centers?
    10. 10. Group Activity <ul><li>Why School-Based Health Centers? </li></ul><ul><ul><li>Think of yourself as a school aged child, pick your age, or </li></ul></ul><ul><ul><li>Think of your own child or adolescent, or </li></ul></ul><ul><ul><li>Think of family members, neighbors as a school aged child </li></ul></ul><ul><ul><li>Using the first letter of your first or last name, or draw an alphabet card, come up with a reason for having a SBHC in your community </li></ul></ul>
    11. 11. Why SBHCs? <ul><li>Uninsurance among children, especially adolescents </li></ul><ul><li>Geographic and financial barriers to health, mental health, and oral health </li></ul><ul><li>Dangerous health outcomes associated with adolescents </li></ul><ul><li>Nonexistent/fragmented/singular discipline systems of care </li></ul><ul><li>Decreased educational attainment </li></ul>
    12. 12. <ul><li>“ Health services need to be where students can trip over them. Adolescents do not carry appointment books, and school is the only place where they are required to spend time.” </li></ul><ul><ul><li>Philip J. Porter, M.D. </li></ul></ul><ul><ul><li>Early architect of the SBHC movement </li></ul></ul>
    13. 13. The Evidence Base for SBHCs <ul><li>Research published in professional literature </li></ul><ul><li>National and state data </li></ul><ul><ul><li>National State Initiative Survey </li></ul></ul><ul><ul><li>NASBHC Triennial census </li></ul></ul><ul><ul><li>White papers </li></ul></ul><ul><li>Training and technical assistance in the field </li></ul><ul><ul><li>Results of beta testing tools and resources </li></ul></ul><ul><ul><li>Collaboratives </li></ul></ul><ul><ul><ul><li>Pre and post assessments, chart reviews, progress reports, storyboards, consultation calls </li></ul></ul></ul>
    14. 14. What the Literature Tell Us About Emergency Room Use and SBHCs <ul><li>Reduced inappropriate emergency room use, </li></ul><ul><li>Increased use of primary care, and </li></ul><ul><li>Fewer hospitalizations </li></ul><ul><li>Santelli J, Kouzis A, et al. Journal of Adolescent Health 1996; 19:267-275 </li></ul><ul><li>Prevention-oriented care in SBHCs results in decreased utilization of emergency departments </li></ul><ul><li>Key JD, Washington EC, and Hulsey TC, Journal of Adolescent Health 2002: 30;273 </li></ul>
    15. 15. What the Literature Tell Us About Asthma and SBHCs <ul><li>Greater than 50% reduction in asthma-related emergency room visits for students enrolled in SBHCs in New York City </li></ul><ul><li>Webber MP et al. Archives of Pediatric and Adolescent Medicine. 2003; 157: 125-129 </li></ul><ul><li>$3 million savings in asthma-related hospitalization costs for students enrolled in SBHCs in New York City </li></ul><ul><li>Analysis by the Empire Health Group for the NY Coalition of School-Based Primary Care, 2005 </li></ul>
    16. 16. What the Literature Tell Us About Mental Health and SBHCs <ul><li>SBHCs attract harder-to-reach populations, especially minorities and males and do a better job at getting them crucial services such as mental health care and high risk screens. </li></ul><ul><li>Adolescents were 10-21 times more likely to come to a SBHC for mental health services than a community health center network or HMO. </li></ul><ul><li>Juszczak L, Melinkovich P, Kaplan D. Journal of Adolescent Health 2003; 32S:108-118. </li></ul><ul><li>Kaplan D, et al. Archives of Pediatric and Adolescent Medicine. 1998 </li></ul><ul><ul><li>Jan;152(1):25-33. </li></ul></ul>
    17. 17. What Science Tell Us About Education and SBHCs <ul><li>Health has both direct and indirect effects on school failure </li></ul><ul><li>Good education predicts good health </li></ul><ul><li>Inequities in health and education are closely linked: </li></ul><ul><ul><ul><li>young people who experience inequities in educational achievement also experience inequities in health care access </li></ul></ul></ul><ul><li>Public health and education are linked toward a common cause: student success </li></ul>
    18. 18. What We Know Intuitively <ul><li>Healthy students make better learners </li></ul><ul><li>You cannot teach a child who is not healthy </li></ul><ul><li>A child who succeeds in school is more likely to enjoy lifelong health </li></ul>
    19. 19. What Science Tells Us About Education <ul><li>Academic performance is negatively affected by: </li></ul><ul><ul><li>Alcohol, tobacco, and other drug use </li></ul></ul><ul><ul><li>Emotional problems </li></ul></ul><ul><ul><li>Poor diet </li></ul></ul><ul><ul><li>Intentional injuries </li></ul></ul><ul><ul><li>Physical illness </li></ul></ul><ul><ul><li>Low self-esteem </li></ul></ul><ul><ul><li>Risky sexual behavior </li></ul></ul><ul><ul><li>Lack of access to health care </li></ul></ul><ul><ul><li>Unstable home environment </li></ul></ul><ul><li>Academic performance is positively affected by: </li></ul><ul><ul><li>High levels of resiliency, developmental assets, and school connectedness. </li></ul></ul>
    20. 20. The Health-Academic Outcomes Connection SBHCs Health Risk Behaviors Educational Outcomes Educational Behaviors Substance use Mental health Poor diet Intentional injuries Physical illness Self-esteem Sexual behaviors Attendance Dropout Rates Behavioral Problems Graduation GPA Standardized test scores Geierstanger, S. P., & Amaral, G. (2004). School-Based Health Centers and Academic Performance: What is the Intersection? April 2004 Meeting Proceedings. White Paper. Washington, D.C.: National Assembly on School-Based Health Care.
    21. 21. SBHC Outcomes and Tactics Reduce barriers to learning Increase attendance Improve student health Meet government regulations <ul><li>Identify students at-risk for health and behavioral problems </li></ul><ul><li>Assist in IEP development </li></ul><ul><li>Provide mental health services </li></ul><ul><li>Treat acute conditions </li></ul><ul><li>Manage chronic conditions </li></ul><ul><li>Provide preventive health services </li></ul><ul><li>Treat acute conditions </li></ul><ul><li>Administer medication to students with chronic conditions </li></ul><ul><li>Enroll students in health insurance </li></ul><ul><li>Provide mental health services </li></ul><ul><li>Refer students to services not provided in the SBHC </li></ul><ul><li>Provide preventive health services </li></ul><ul><li>Treat acute conditions </li></ul><ul><li>Manage chronic conditions </li></ul><ul><li>Conduct sports physicals </li></ul><ul><li>Provide mental health services </li></ul><ul><li>Immunize students </li></ul><ul><li>Participate in community initiatives on public health such as obesity and emergency planning </li></ul><ul><li>Maintain health records for migratory students </li></ul>
    22. 22. The Medical Home <ul><li>Half of SBHCs estimate more than 30% of their enrollees use the center as their medical home </li></ul><ul><li>40% of SBHCs estimate 50% or more of their enrollees use the center as their medical home </li></ul>
    23. 23. Efficiencies in SBHCs <ul><li>Parents do not need to take time off </li></ul><ul><li>Follow-up is less labor intensive </li></ul><ul><li>Ability to identifying problems earlier </li></ul><ul><li>Costly emergency room visits reduced </li></ul>
    24. 24. National Data and Trends Census 2007-08
    25. 25. SBHCs by State (n=1910) State Total # of Open SBHCs   State Total # of Open SBHCs Alabama 5   Nebraska 1 Alaska 3   Nevada 6 Arizona 81   New Hampshire 1 Arkansas 2   New Jersey 40 California 160   New Mexico 79 Colorado 45   New York 206 Connecticut 79   North Carolina 49 Delaware 28   Ohio 20 District of Columbia 4   Oklahoma 11 Florida 245   Oregon 51 Georgia 3   Pennsylvania 28 Illinois 60   Puerto Rico 2 Indiana 87   Rhode Island 2 Iowa 16   Saskatchewan 1 Kansas 2   South Carolina 7 Kentucky 20   South Dakota 6 Louisiana 64   Tennessee 21 Maine 26   Texas 70 Maryland 71   Utah 5 Massachusetts 59   Vermont 5 Michigan 90   Virginia 19 Minnesota 16   Washington 20 Mississippi 31   West Virginia 50 Missouri 3   Wisconsin 8
    26. 26. SBHCs by Location (n=1226) In school building 95.7 percent On school property 2.9 percent Mobile 1.4 percent
    27. 27. SBHCs by Types of School (n=1096)
    28. 28. SBHCs by Community Characteristic (n=1235)
    29. 29. SBHCs Users by Race/Ethnicity (n=1096)
    30. 30. SBHCs by Population Served (n=1096 )
    31. 31. SBHCs by Sponsoring Agency (n=1096)
    32. 32. Services Offered by SBHCs
    33. 33. Primary Care Services Provided by SBHCs (N=1046-1075)
    34. 34. Reproductive Health Services Offered by SBHCs to Adolescents On Site (n= 1030-1068)
    35. 35. Oral Health Services Offered by SBHCs (n= 1010-1046)
    36. 36. Contraception Prohibition at SBHCs (N=1095)
    37. 37. Mental Health Services Offered by SBHCs With (n=878) and Without (n=348) Mental Health Providers