Veda johnson

Health,Education & School
Based Health Centers

Veda Johnson, MD
Associate Professor of Pediatrics
Emory University School of Medicine
November 9, 2012

“It is easier to build strong children than
to
repair broken men.”
Frederick Douglass (1817–1895)



“Free the child's potential, and you will
transform him into the world.”
Maria Montessori (1870–1952)

The Problem
 Educational
Underachievement
 Challenging Health Issues

 Insufficient Student Support

The Problem
Educational


Underachievement

Educational Achievement –
Nationally
National Center for Education Statistics
Table 11.1. Percentage distribution of students at National Assessment of Educational Progress
Table 11.1. (NAEP) reading achievement levels, by race/ethnicity and grade: 2005 and 2007

Grade, year, and American Indian/Alaska
achievement level Total1 White Black Hispanic Asian/Pacific Islander Native
4th grade, 2007
Below Basic 33 22 54 50 23 51
At Basic 34 35 32 32 32 30
At or above Proficient 33 43 14 17 46 18
At Advanced 8 11 2 3 15 4

8th grade, 2007
Below Basic 26 16 45 42 20 44
At Basic 43 43 42 43 39 38
At or above Proficient 31 40 13 15 41 18
At Advanced 3 4 # 1 5 2!

12th grade, 2005
Below Basic 27 21 46 40 26 33 !
At Basic 37 36 38 40 38 41
At or above Proficient 35 43 16 20 36 26 !
At Advanced 5 6 1! 2! 5 ‡
# Rounds to zero.
! Interpret data with caution.
‡ Reporting standards not met.
1
Total includes other race/ethnicity categories not separately shown.

NOTE: Achievement levels are performance standards showing what students should know and be able to do. Basic denotes partial mastery of knowledge and skills that are fundamental for proficient work at a given grade.
(Below Basic, therefore, denotes less than this level of achievement.) Proficient represents solid academic performance. Students reaching this level have demonstrated competency over challenging subject matter. Advanced
signifies superior performance. NAEP reports data on student race/ethnicity based on information obtained from school rosters. Race categories exclude persons of Hispanic ethnicity. The NAEP assessment was not administered
to grade 12 in 2007. Detail may not sum to totals because of rounding.

SOURCE: U.S. Department of Education, National Center for Education Statistics, National Assessment of Educational Progress (NAEP), 2005 and 2007 Reading Assessment, NAEP Data Explorer.

Percentage distribution of 4th-grade students at
National Assessment of Educational Progress (NAEP)
reading achievement levels, by race/ethnicity: 2007

Georgia Reading proficiency
 4th graders (2009)
 37% read at below basic
 34% read at basic
 29% read at proficient or better
 18% of Low income and minority students
 15% of Black students
 44% of Higher income students
 8th graders (2009)
 33% below basic
 40% @ basic
 27% @ proficient or better

Georgia, 4th grade Reading
proficiency

mathematical achievement levels, by race/ethnicity:
2009

2009

Percentage of 8th-graders at or above Basic on the National
Assessment of Educational Progress (NAEP) mathematics
assessment, by race/ethnicity and number of days absent from
school in the past month: 2009

Average freshman graduation rate for public high school
students, by race/ethnicity: School year 2006–07

Georgia Students
 Absent >15days from school
 Avg. 8.8%
 Range: 1.5%– 19.4%

Kid’s Count 2011

 Graduate from School on Time
(beginning in 9th grade)
 32% don’t graduate on time (nationally
24%)

Kid’s Count 2008-9

The Problem
 Student Health

Health
 Nationally
 Approximately 28 million children
nationwide from economically
disadvantaged households are at risk for a
variety of negative outcomes including:

1) increased rates of health problems and
mortality;

2) emotional and behavioral problems.
 3) increased risk of academic
underachievement, school drop-out, and
unemployment; and

National Survey on Child’s Health 2007-8;
Sponsored by MCH and HRSA – Phone
survey by parents

Number of Chronic Conditions Reported*
Number of conditions Percent of Children
*Of 16 specific health conditions.
None 77.7
1 13.6
2 3.9
3 or more 4.8

National Survey on Child’s Health
2007-8
Asthma 9.0
Learning Disabilities 7.8
ADD/ADHD 6.4
Speech Problems 3.7
ODD or Conduct Disorder 3.3
Developmental Delay 3.2
Anxiety Problems 2.9
Bone, Joint, or Muscle Problems 2.2
Depression 2.0
Hearing Problems 1.4
Vision Problems* 1.3
Autism Spectrum Disorder 1.1
Epilepsy or Seizure Disorder 0.6
Diabetes 0.4
Brain Injury or Concussion 0.3
Tourette Syndrome

Dental Care
 More than 16 million children still lack
access to basic dental care despite
efforts by states to improve their
dental health policies, according to the
2011 50-state report card from Pew.

The State of Children’s Dental Health: Making
Coverage Matter graded states' ability to serve
insured and soon-to-be insured children.

Health
 Georgia
 Adverse outcomes are widespread among
children in the state of Georgia. Georgia
ranks 37th in the nation overall for child
well-being (Kid’s Count 2012).
 43rd - child economic well-being
 30th – Overall child health ( child &teen deaths,
etc.)

38th - overall education

Health…
 Georgia
 We have the 2nd highest childhood obesity
rate in the country (37% OW/OB)
 29% of our adolescents had significant
episodes of depression during the past 12
months.
 26% of our children live in poverty and
approx. 300,000 children are uninsured.

National Survey on Child’s Health
2007-8; Sponsored by MCH and
HRSA

National Survey – Asthma (Race)

National Survey – Asthma (Income)

National Survey – ADD/ADHD
(Race)

National Survey – ADD/ADHD
(Income)

National Survey - Medical Home

(Race)

(Income)

National Survey of Child’s Health (2007):
Absenteeism

The Solution
 Leveraging health to
improve academic
outcomes.
 Leveraging academic

success to improve
health outcomes.

Health and Academic Success
 How does health
affect the
academic success
of our children?

Former Surgeon General
Dr. Antonia Novello
“Health and education go hand in hand: one
cannot exist without the other. To believe any
differently is to hamper progress. Just as our
children have a right to receive the best
education available, they have a right to be
healthy. As parents, legislators, and educators, it
is up to us to see that this becomes a reality.”

 Healthy Children Ready to Learn: An Essential
Collaboration Between Health and Education,
1992

Health and Education
 Association between health and
academic success
 Students learn best when they are healthy
 Students learn best when they are present
 Students learn best when they are
connected to the school emotionally and
socially
 Students learn best when there is hope

The National Association
of State Boards of Education …
"Health and success in school
are interrelated. Schools cannot achieve their
primary mission of education if students and
staff are not healthy and fit physically,
mentally, and socially.”
— Fit, Healthy, and Ready to Learn: Part 1
–
Physical Activity, Healthy Eating, and
Tobacco Use Prevention, 2000

Health

 The World Health
Organization defines
health as a “state of
complete physical,
mental, and social well-
being, and not merely
the absence of disease
or infirmity.”

Determinants of Health…
Determinants
of health and Beyond
illness that are individual
outside of the behaviors
individual

Beyond genetic
predispositions

Social Determinants of
Health…
 Definition of social
determinants of health:
The economic & social
conditions that influence
health …
 ‘The conditions in which

people are born, grow,
live, work and age.’
 Source:www.who.int/social
_determinants/en/
accessed 10-4-11

Health…
 Factors in the social environment that contribute to or
detract from the health of individuals and communities:
 Income
 Housing
 Education
 Transportation
 Access to services
 Physical Environment
 Socioeconomic status/position
 Discrimination by social grouping
 Social or environmental stressors
 Source: www.cdc.gov/sdoh accessed on 11-9-07

Health…
 Major social
determinants of
health include:
 Social Position
 Where you live
 Race
 Stress

Health…
 Health inequities associated with
socioeconomic status of children
 Childhood Development
 Asthma
 Obesity
 Diabetes
 Behavioral Health
 Oral Health

Health and Education…
 Poor school performance is linked to health-
related issues such as hunger, physical and
emotional abuse, and chronic illness such as
asthma and obesity.
 Poor academic outcomes are linked to risky
health behaviors such as substance use,
violence, and physical inactivity which in turn
affect students' school attendance, grades,
test scores, and ability to pay attention in
class.

 High school drop out rates are affected
by:
 Forces within the school system
 School readiness
 Elementary and Middle school underachievement

Student disengagement, behavior issues, absenteeism,
and failing grades in 9th grade
 Forces outside of school

Health issues

Psycho- social issues

Caretaking responsibilities

A caring adult.

American Cancer Society
“[Children] …who face violence, hunger,
substance abuse, unintended pregnancy, and
despair cannot possibly focus on academic
excellence. There is no curriculum brilliant
enough to compensate for a hungry stomach
or a distracted mind.”
— National Action Plan for Comprehensive
School Health Education. 1992

Health and Academic Success
 How does
academic success
affect the health
of our children?

 Education is a direct
predictor of health
 Academic
underachievement
contributes significantly
to the health disparities
observed in children from
lower socioeconomic
positions.

 Education is a direct
predictor of health…
 Academic success is a
predictor for adult health
outcomes
 Adults with higher
educational achievement
are more likely to be more
knowledgeable, have better
jobs and better
opportunities to achieve
and maintain healthy

 In addition – ‘Academic success is an
important indicator for the overall well-
being of students’
 According to the
Youth Risk Behavior Surveillance System (YRBSS)
, students with higher grades are less likely to
have participated in risky behaviors such as:
 Carrying a weapon
 Current cigarette use
 Current alcohol use
 Being currently sexually active
 Watching television 3 or more hours per day
 Being physically active at least 60 minutes per day on fewer than 5

Percentage of High School Students Who
Carried a Weapon,* by Type of Grades Earned
(Mostly A’s, B’s, C’s or D’s/F’s), 2009**

* For example, a gun, knife, or club on at least 1 day during the 30 days before the survey.
**p<.0001 after controlling for sex, race/ethnicity, and grade level.

United States, Youth Risk Behavior Survey, 2009

Percentage of High School Students Who Were
in a Physical Fight,* by Type of Grades Earned

*One or more times during the 12 months before the survey.


Percentage of High School Students Who Ever
Used Marijuana,* by Type of Grades Earned

*Used marijuana one or more times during their life.


Percentage of High School Students Who Felt
Sad or Hopeless,* by Type of Grades Earned

*Almost every day for 2 or more weeks in a row so that they stopped doing usual activities during the 12
months before the survey.

How do we improve the academic
achievement for students by improving
their health?

The National Governors’
Association
“Policymakers need to focus on eliminating the
barriers that affect these lower-performing
students’ readiness to learn. Among these
barriers are physical and mental health
conditions that impact students’ school
attendance and their ability to pay attention in
class, control their anger, and restrain self-
destructive impulses.”

 Improving Academic Performance by
Meeting Student Health Needs, 2000

 What we know…
 School health programs and policies can be an
efficient way to prevent or reduce risky health
behaviors and avoid serious health problems
among students.

 They may also help close the educational
achievement gap between disparate
socioeconomic groups of students.

Coordinated School Health
Program
 1995 – Institute of Medicine committee
adopted the term ‘coordinated school health
program’ based on the concept of
‘comprehensive school health’ originated in
the 1980’s by Diane Allensworth and Lloyd
Kolbe.


Kolbe founded the Division of Adolescent and School
Health (DASH) at CDC.

Coordinated school health
programs
 Recommended by CDC as a strategy to
improve the health and academic
performance of students
 It is a coordinated approach to school
health that creates a system of care that
addresses the needs of the whole child by
connecting health with education
 Creates a school environment that
promotes and supports healthy lifestyles
for students, teachers and staff

Components of a coordinated
school health program

Allensworth and Kolbe, 1987

programs
 Benefits:
 Engages parents, teachers,
students, families, and communities
 Helps keep students healthy
 Supports learning and success
in school
 Reinforces positive behaviors
 Helps students develop knowledge and
skills to make smart choices

programs…

School based health centers exemplify the basic
tenets of a coordinated school health program

School Based Health Centers
(SBHCs)

Definition:

Comprehensive school based health clinics
are primary care medical centers that blend
medical care with preventive and
psychosocial services as well as organize
broader school-based and community-based
health promotion efforts.

SBHCs…
 History:
 School-based medical services began in
1890s to address contagious diseases in
classroom
 School nurses replaced MDs in 1902 (MDs
going off to war)
 Comprehensive school-based health
center concept began in the late 60s –Dr.
Philip Porter (Mass)
 Developed a ‘system of care’ that Increased
access and coordinated healthcare for poor

SBHCs…
 Qualities:
 Recognized as an effective model of healthcare
that can significantly reduce barriers to medical
services for children living in poor communities
 Holistic integrated approach to care that
emphasizes access, quality, and improved
outcomes that reduces health disparities
 Provide a savings to the public by reducing
inappropriate emergency room usage among
children and adolescents.

SBHC’S…
Common Features of School-Based Health
Centers:
 They are located in schools or in close proximity (school-linked).

 The health center works cooperatively within the school to
become an integral part of the school.

 The health center provides a comprehensive range of services
that meet the specific physical and behavioral health needs of
the young people in the community as well as providing for the
more traditional medical care needs.

 A multidisciplinary team of providers care for the students: nurse
practitioners, registered nurses, physician assistants, social
workers, physicians, alcohol and drug counselors, and other
health professionals.

SBHC’S…
Common Features…
 The clinical services within the health center are provided
through a qualified health provider such as a hospital, health
department, or medical practice.

 Parents sign written consents for their children to enroll in the
health center.

 The health center has an advisory board consisting of
community representatives, parents, youth and family
organizations, to provide planning and oversight.

SBHC’s…
Seven Basic Principles:
 Supports the school
 Responds to the community
 Focuses on the student
 Delivers comprehensive care
 Advances health promotion
 Implements effective systems
 Provides leadership in adolescent and child health

SBHC’s…
 Nationally (National Census – 2007/08)
 Over 2200 SBHCs
 56.7% in urban settings
 27.2% in rural settings

16.1% in suburbs
 Georgia
 Only 2 SBHCs from 1994 – 2009
 Currently 6

SBHCs…
 Research demonstrates that SBHCs
effectively addresses the needs of the
underserved through:
 Increased access to quality healthcare
 Improved health outcomes
 Decreased healthcare costs
 Improved school attendance and academic
performance

Decreased health care costs –
Whitefoord Elementary School - Based
Health Clinic
 Adams EK, Johnson V. An elementary school-based health
clinic: can it reduce Medicaid costs? Pediatrics. 2000;105(4 pt
1):780–788
 Compared Medicaid costs to children enrolled in a
SBHC to those not enrolled in a SBHC

Summary of findings:
 Decrease in total Medicaid costs per child over 2 year period
w/SBHC
 Significant decrease in In-Patient costs
 Significant decrease in prescription drug use costs
 Significant decrease in emergency room costs
 Decrease more significant across all categories if child used
SBHC as medical home
 For children with asthma, decrease in Medicaid cost for total
yearly expenditures with significant decreases in inpatient and
drug costs.

Whitefoord Elementary and Sammye
E. Coan Middle School Based Clinics
 Pediatric and adolescent
primary care health clinics
providing comprehensive
health services for the
students, their siblings, and
other children within the
community

 Initiated by the Dept of
Pediatrics at Emory
University Nov. 1994

 Removed the provision of
health care from the
institution and placed it into
the community

Whitefoord & Coan….
 Goal : Increasing access to
quality health care and
improving the academic
achievement of students

 Address the physical, mental
and emotional health of the
child

 ‘Care for the child in the
context of family, home and
community’
 Developed the Whitefoord
Community Program, a
community-based support
program for families of children
enrolled in the clinic

Whitefoord Community Program
 Created to address the
needs of families as defined
by the community

 Mission: …‘working together
with families and the
community to ensure that
every child has what he or
she needs to succeed in
school’.

 Components:
 School based health clinics
 Child Development Program
 Family Learning &
Community Development

Staffing
 Mid-level Providers
(NP/PA)*
 Pediatricians/Medical
Director*
 RN/Clinic Manager
 Medical Assistant*
 Dentist and Dental Asst
 Social Worker/Mental
Health Providers*
 Health Educator
 Secretaries
 Clerical Assistant

*Core Staff

School Based Clinic Services
 Management of acute and
chronic illnesses and injuries
 Routine and sports physicals
 Immunizations
 Dental care
 Mental Health Assessments
and Counseling
 Social services
 Psycho-educational Testing
 Referral to Sub-specialist
 24 hr. coverage

Accomplishments
 Increased access to
physical, mental and dental
health care

 Increased immunization
rates for children and
adolescents

 Improved school
attendance/?performance

 Every child in school
receives health education
instruction on drug and
substance abuse, violence
prevention, safety, general

Accomplishments…
 Improved health outcomes
for children with chronic
illnesses (e.g. asthma,
diabetes)

 Improved risk factors for
overweight/obese students
 Reduced BMI’s
 Reduced cholesterol levels
 Reduced insulin resistance

 Reduced cost to the state’s
Medicaid program
 Reduced ER use and
hospitalization of students
with asthma

Accomplishments…

 Facilitated the recovery of many emotionally troubled
children.
 Pre-K program
 School aged children and adolescents
 Improved the academic achievements for children
with ADHD and Learning Disorders.
 Reduced the referrals of children with ADHD into Special
Education programs.
 Increased parental involvement
 Witnessed several challenged families assume proper
responsibility for their children

School Based-Health Centers -
Health and academic
achievements
 Increases access to
quality healthcare
 Improves health
outcomes
 Decreases
healthcare costs
 Improves school
attendance and
academic
performance

Contact Information
 Veda Johnson, MD
Associate Professor of Pediatrics
Emory University School of Medicine
49 Jesse Hill Jr Dr
Atlanta, GA 30303
Phone: 404-778-1419
Email: vjohn01@emory.edu

Urban Health Program
 Urban Health Program
at the Department of
Pediatrics, Emory
University School of
Medicine
 Vision:
 To reduce health
disparities ensuring that
all Georgia children are
more likely to be happy,
healthy and productive
members of society.

Urban Health Program…
 Goals of UHP:
 Increase access to healthcare for
underserved children through expansion of
School Based Health Centers (SBHCs)
throughout the state
 Improve the delivery of health care for at-
risk children and adolescents
 Improve academic outcomes for
underserved children
 Train future pediatricians to address the

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