This document summarizes a presentation on measuring sustainability indicators and implementing strategies to improve sustainability of school-based health centers (SBHCs). It discusses the development of a sustainability assessment tool used in Colorado SBHCs. Key findings include partial implementation of funding strategies, management practices, and marketing/outreach. Recommendations focus on expanding facilities, partnerships, and marketing, while continuing advocacy and sustainability assessments. The Colorado Health Foundation aims to improve SBHC sustainability through various initiatives, technical assistance, and collaboration.

1. Making Sustainability Real: Measuring Indicators and
Implementing Inventions towards Sustainability
2013 Elev8 Fall Learning Institute
Moderator: Kimi Sakashita, MPH, Associate Director
Alameda County Center for Healthy Schools & Communities
Presenters:
Sara Geierstanger, MPH, Senior Evaluator
Philip R. Lee Institute for Health Policy Studies
University of California, San Francisco
Erica Snow, MS, MPA, Senior Program Officer
The Colorado Health Foundation
Naomi Shapiro, RN, PhD, CPNP, Clinical Professor
School of Nursing
University of California, San Francisco

2. Presentation Overview
 Development and use of an SBHC sustainability indicators
measurement tool, as well as results from administration in
Colorado (Sara)
 Motivation for a major foundation to focus on SBHC sustainability,
the tools they developed, and how sustainability assessment
results are guiding interaction with and funding of grantees (Erica)
 Mutual benefits of university-school health collaboration and its
contribution to school health center sustainability (Naomi)
 Questions and Discussion

3. The Colorado Health Foundation’s
School Based Health Care Initiative
 4-year investment in school-based health care
 Support the planning and implementation of at least 20 new or
expanded school-based health care programs (SBHC)
 Improve the effectiveness of SBHCs at reaching underserved
populations
 Identify and address policy barriers
 Ensure the financial sustainability of SBHCs

4. School-Based Health Centers
0
10
20
30
40
50
Goal Achieved
---------------------------------------------------
8
36
20
October 15th
• 2 implementation proposals
• 2 planning proposals
Expanded
New

5. SBHC
Implementation Grantees
Rocky Mountain Aurora School
Youth Services/Roaring District/RMYC
Fork School District
Grand River Community Health
Hospital District Services, Inc.
Eagle County Denver Health
School District
Montrose County Summit Community
School District Care Clinic
Sheridan Health
Services
Metro Community
Provider Network
Durango 9-R
School District Cripple Creek
School District
Southwest Open School Pueblo Community
Health Centers

6. Policy Wins
 Two provisions in the Patient Protection and Affordable Care
Act
 Authorization of a federal SBHC grant program
 Creation of an emergency appropriation that has provided
Colorado SBHCs $2.9 million in capital funding
 Passage of HB11-1019, which exempts SBHCs from
deductible and co-payment requirement from privately
insured patients
 Increase in state general line-item for the SBHC grant
program by approximately $4.3 million

7. SBHC Application Process
 Step 1: Complete Readiness Assessment
 Step 2: Develop Business Plan
 Step 3: Implementation

8. Initiative Process
3.8
4.0
4.2
3.2
3.8
4.2
1
2
3
4
5
Develop Readiness
Assessment
Develop Business
Plan
Financial Template
MostHelpful/Challenging
Helpfulness
Difficulty

9. Evaluation
 Selected Philip R. Lee Institute for Health Policy Studies at
the University of California, San Francisco to conduct
evaluation
 Timeline: January 2010 – January 2014
 Purpose: Determine if TCHF’s Initiative process was effective
in driving Colorado SBHCs toward increased self-
sustainability

10. Evaluation Methods
2011 2012 2013
Planning Grantee Interviews 8 5
Sustainability Self-Assessment Tool 16 40
Implementation Grantee Interviews 8 9 13
Key Stakeholder Interviews 11 9
Case Study Interviews 15

11. Development of the
Sustainability Self-Assessment Tool
Facility
Staffing
Services
Community
Partnerships
Funding
Strategies
Management
School
Integration
Marketing &
Outreach
Tool developed by our UCSF/PRA evaluation team in 2010.

12. Use of the
Sustainability Self-Assessment Tool
 First administered to 16 Alameda County School Health
Centers by UCSF for 2010-11.
 Revised and administered to Colorado SBHCs
 16 Group 1 grantees for 2010-11
 16 Group 1 grantees for 2011-12
 24 Group 2 grantees for 2011-12
 Administered to XX Elev8 SBHCs for 2011-12 by the School
Based Health Alliance.
 Tool is now available on the School Based Health Alliance
web-site and being used by other researchers.

13. Sustainability Scores Summary
4.0
3.9
3.9
3.8
3.7
3.4
3.4
2.9
Facility Indicators
Staffing
Provision of Services
Funding Strategies
Management
Community Partnerships
School Integration
Marketing and Outreach
1=Not in Place 4=Full
Implementation
2=In Planning 3=Partial
Implementation
<2.99
Not in place/planning
3-3.49
Partial implementation
≥3.5
Near/at Full implementation

14. Facility Indicators
Group 1
Baseline (N=16)
Group 1 Change
(N=16)
Group 2
Baseline (N=24)
SBHC includes at least the following functional elements:
Computers/telecommunications 4.00 0 4.00
One exam room. 4.00 0 4.00
Waiting/reception area. 3.81 .13 4.00
Counseling room/private area. 3.88 0 4.00
Privacy, confidentiality, safety 3.75 .06 4.00
Dedicated space only for SBHC 4.00 -.13 4.00
Average Score 3.92 0.01 4.00

15. Staffing Indicators
Group 1
Baseline (N=16)
Group 1 Change
(N=16)
Group 2
Baseline (N=24)
Staff training 3.50 .38 3.96
Organizational chart 3.50 .38 3.92
Culturally appropriate hiring 3.69 .19 3.96
Written job descriptions 3.75 .06 3.92
Average Score 3.61 0.25 3.94

16. Provision of Services
Group 1
Baseline
(N=16)
Group 1
Change
(N=16)
Group 2
Baseline
(N=24)
Needs assessments 3.38 .44 3.29
Address barriers to (safety, transportation, hours) 3.69 .31 3.96
24-hour, 7 days per week coverage 3.06 .25 3.88
Follows clinical practice guidelines 3.56 .13 4.00
Conducts student outreach 3.94 .06 4.00
Has an administrator for overall program management 3.94 .06 4.00
Extends eligibility to all students 4.00 0 4.00
Services are welcoming and respectful of student
diversity
4.00 0 4.00
Complies with federal and state regulations 3.94 0 4.00
Collects student and parent feedback 3.69 0 3.75
Coordination of care among SBHC staff 3.63 -.19 4.00
Average Score 3.71 0.10 3.90

17. Funding Strategies
Group 1
Baseline
(N=16)
Group 1
Change
(N=16)
Group 2
Baseline
(N=24)
Has a sliding fee scale 3.31 .50 3.96
Conducts Medicaid outreach and application assistance 3.81 .19 4.00
Medicaid and third party revenue returned to SBHC 3.44 .13 4.00
Effective and efficient billing system 3.25 .06 3.83
Written billing policies for SBHCs 3.38 -.07 3.96
Average Score 3.44 0.16 3.95

18. Management
Group 1
Baseline
(N=16)
Group 1
Change
(N=16)
Group 2
Baseline
(N=24)
Tracks student health and academic outcomes 2.69 .63 3.96
Evaluates practice management measures 3.31 .31 3.96
Plans for continuous quality improvement 3.50 .25 3.96
Involvement of provider in clinical policies and procedures 3.56 .20 4.00
Written policy on exchange of information with school staff 3.19 .19 4.00
Written record of progress toward selected measures. 3.19 .13 3.96
Annual budget describes funding, including in-kind 3.88 .06 3.96
E.H.R. facilitates the provision of care 3.13 .06 3.96
Obtains consent for sharing SBHC records 4.00 0 4.00
Develops and updates business/strategic plan 3.75 -.06 3.96
Reports revenues and expenses 3.75 -.13 3.96
Works with community advisory council 3.94 -.50 3.88
Solicits youth involvement 2.94 -.56 3.00
Average Score 3.45 0.04 3.89

19. School Integration
Group 1
Baseline
(N=16)
Group 1
Change
(N=16)
Group 2
Baseline
(N=24)
Partners in school-wide programs 2.50 .69 3.21
Advocates for school health programs and policies 1.88 .69 4.00
Joint funding opportunities with the SBHC 3.00 .63 3.00
Active in school-wide committees 3.44 .40 3.50
Policy about roles of SBHC and the school nurse 3.25 .38 3.54
Involved in school health program decision-making 1.94 .20 3.61
Co-locates with the school health staff 2.88 .19 3.63
Provides in-services to school staff/consults teachers 3.69 .13 3.33
Advocates for district health programs and policies 2.44 .13 3.79
Communication and coordination with school health staff 3.75 -.13 4.00
Average school stakeholder support 3.94 -0.11 3.55
Average school stakeholder engagement 2.66 0.02 2.79
Average school health provider collaboration 3.12 0.17 3.52
Average Score 2.96 0.26 3.50

20. Community Partnerships
Group 1
Baseline
(N=16)
Group 1
Change
(N=16)
Group 2
Baseline
(N=24)
Solicits participation from other key community stakeholders. 4.00 0 4.00
Communicates and coordinates with primary care provide 3.75 -.06 3.71
Parent and local community support 3.86 -0.15 3.37
Parent and local community engagement 2.18 0.08 2.22
Lead medical agency/community partner collaboration 3.22 -0.12 3.78
Average Score 3.40 -0.05 3.42

21. Marketing & Outreach
Group 1
Baseline
(N=16)
Group 1
Change
(N=16)
Group 2
Baseline
(N=24)
Strategy for addressing opposition 2.93 .47 2.04
Uses data to promote school health services 3.25 .44 3.26
Uses a variety of marketing and outreach strategies 3.94 -.06 3.00
Crafted messages for different audiences 3.87 -.33 3.04
Has a written marketing plan 2.81 -.69 2.21
Average Score 3.36 -0.15 2.71

22. Recommendations
 Continue to support SBHC facility expansion
 Continue to focus on funding and management
 Encourage SBHC partnerships with school-wide programs
 Continue to focus on SBHC marketing strategies
 Advocate for government policy/funding for SBHCs
 Continue to assess, monitor and improve sustainability factors!

23. Results into Action
 Funding
 Support State SBHC association and partner with Colorado Dept.
Public Health and Environment in SBHC learning forums
 Continue advocacy support for SBHCs
 Case study highlighting “Best Practices to Improve Billing”
 Case study “Providing services to Uninsured Clients”
 Position SBHCs as part of community health networks
 Continue to support integration of mental and oral health

24. Results into Action
 Marketing and Outreach
 Technical assistance to SBHCs via private marketing firm
 Kaleidoscope video- Foundation’s storytelling campaign
 Community Partnerships
 Youth group development at Foundation
 Reexamine how to better engage families and students, e.g. focus
groups
 School Integration
 Healthy Schools Collective Impact project with Community Wealth
Partners

25. Questions and Discussion
 Contact Information
 Sara Geierstanger: Sara.Geierstanger@ucsf.edu
 Erica Snow: esnow@coloradohealth.org
 Naomi Shapiro: naomi.schapiro@nursing.ucsf.edu