Preventive Services Improvement Initiative

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School-Based Health Centers (SBHCs) 101 An
Overview and Framework for Building Programs

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Objectives

• Participants will be able
• Define the term school-based health center
• Explain why school-based health centers are an
  effective health care delivery system for
  children and adolescents
• Answer the question, how many school-based health
  centers are there in the US and where are they
  located
• I

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Objectives

• Participants will be able
• Describe who uses school-based health centers and
  who sponsors them
• List three national school-based health care
  models
• List seven principles describing how to plan and
  implement a school-based health centers
• I

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What is a School-Based Health Center (SBHC)?
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School-Based Health Center National Definition

• 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
• 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

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School-Based Health Center National Definition

• 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.
• The school-based health care team works in
  collaboration with school nurses and other
  service providers in the school and community.

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School-Based Health Center National Definition

• SBHCs have a policy on parental consent.
• 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.

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School-Based Health Center National Definition

• SBHCs make provisions for care beyond the
  centers operating hours or scope of service
• 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.

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School-Based Health Center National Definition

• 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.

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School-Based Health Center National Definition

• Services typically offered in SBHCs are age
  appropriate and address the most important health
  needs of children and youth.
• These services may include but are not limited
  to primary care for acute and chronic health
  conditions, mental health services, substance
  abuse services, case management, dental health
  services, reproductive health care, nutrition
  education, health education and health promotion.
  

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School-Based Health Center National Definition

• 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.

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Why School-Based Health Centers?
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Why School-Based Health Centers?

• Uninsurance among children, especially
  adolescents
• Geographic and financial barriers to health,
  mental health and dental access
• Dangerous health outcomes associated with
  adolescents
• Nonexistent/fragmented/singular discipline
  systems of care
• Decreased educational attainment

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• 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.
• - Philip J. Porter, M.D., early architect of the
  school-based health center movement.

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The Evidence Base for School-Based Health Care

• Research Published in Professional Literature
• National and State Data
• National State Initiative Survey
• NASBHC Biennial census
• White papers
• Training and technical assistance in the field
• Results of beta testing tools and resources
• Collaboratives
• Pre and post assessments, chart reviews, progress
  reports, storyboards, consultation calls

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What Does the Literature Tell Us About Emergency
Room Use and SBHCs?

• Reduced inappropriate emergency room use,
• Increased use of primary care, and
• Fewer hospitalizations
• Santelli J, Kouzis A, et al. Journal of
  Adolescent Health 1996 19267-275
• Prevention-oriented care in SBHCs results in
  decreased utilization of emergency departments
• Key JD, Washington EC, and Hulsey TC, Journal of
  Adolescent Health 2002 30273

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What Does the Literature Tell Us About Asthma and
SBHCs?

• gt 50 reduction in asthma related emergency room
  visits for students enrolled in SBHCs in New York
  City
• Webber MP et al. Archives of Pediatric and
  Adolescent Medicine. 2003 157 125-129
• 3 million savings in asthma-related
  hospitalization costs for students enrolled in
  SBHCs in New York City
• Analysis by the Empire Health Group for the NY
  Coalition of School-Based Primary Care, 2005

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What Does the Literature Tell Us About Mental
Health and SBHCs?

• Attract harder-to-reach populations, especially
  minorities and males, do a better job at getting
  them crucial services such as mental health care
  and high risk screens
• Adolescents were 10-21 times more likely to come
  to a SBHC for mental health services than a
  community health center network or HMO
• Juszczak L, Melinkovich P, Kaplan D. Journal of
  Adolescent Health 2003
• 32S108-118.
• Kaplan D, et al. Archives of Pediatric and
  Adolescent Medicine. 1998
• Jan152(1)25-33.

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What Does Science Tell Us About Education and
SBHCs

• Health has both direct and indirect effects on
  school failure
• Good education predicts good health
• Inequities in health and education are closely
  linked young people who experience inequities in
  educational achievement also experience
  inequities in health care access
• Public health and education are linked toward a
  common cause school success

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What Do We Know Intuitively?

• Healthy students make better learners
• You cant teach a child who is not healthy
• A child who succeeds in school is more likely to
  enjoy lifelong health

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What Science Tells Us About Education

• Academic performance is negatively affected by
• Alcohol, tobacco, and other drug use
• Emotional problems
• Poor diet
• Intentional injuries
• Physical illness
• Low self-esteem
• Risky sexual behavior
• Lack of access to health care
• Unstable home environment
• Academic performance is positively affected by
• High levels of resiliency, developmental assets,
  and school connectedness.

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The Health-Academic Outcomes Connection
Graduation GPA Standardized test scores
Health Risk Behaviors
Educational Outcomes
SBHCs
Substance use Mental health Poor diet
Intentional injuries Physical illness
Self-esteem Sexual behaviors
Attendance Dropout Rates Behavioral
Problems
Educational Behaviors
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.
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SBHC Outcomes and Tactics
Reduce barriers to learning Increase attendance Improve student health Meet government regulations
Identify students at-risk for health and behavioral problems Assist in IEP development Provide mental health services Treat acute conditions Manage chronic conditions Provide preventive health services Treat acute conditions Administer medication to students with chronic conditions Enroll students in health insurance Provide mental health services Refer students to services not provided in the SBHC Provide preventive health services Treat acute conditions Manage chronic conditions Conduct sports physicals Provide mental health services Immunize students Participate in community initiatives on public health such as obesity and emergency planning Maintain health records for migratory students
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The Medical Home

• Half of SBHCs estimate gt 30 of their enrollees
  use the center as their medical home
• 40 estimate 50 or more of enrollees use the
  center as their medical home

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Efficiencies in SBHCs

• Parents time off
• Follow-up less labor intensive
• Identifying problems earlier
• Reduction in more costly emergency room visits

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National Data and Trends

• Census 2004-05

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Where are SBHCs Located?
N 1709
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Location of Health Center (n1234)

• In school building 87
• On school property 11
• Mobile (non-fixed) 2

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Types of Schools with Health Centers ( n1222)
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SBHCs by Community Characteristic (N1235)
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Who Uses SBHCs?Ethnic/Racial Profile of Student
Population in Schools with SBHCs (n1235)
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Other Populations Served by SBHCs (n1227)
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Who Sponsors SBHCs (n1233)
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SBHC Service Delivery Models
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Primary Care Only Model

• NP/PA/MD 1-5 days/week
• Full or part-time (FT/PT) coverage
• No Mental Health/Substance Abuse Services

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Primary Care-Mental Health Model

• PT or FT coverage
• Full Range of Prevention/Early Intervention
  Physical and Behavioral Health Services (age and
  developmentally appropriate, e.g. reproductive
  health)
• Diagnosis, Treatment and Management of Minor
  Acute/Chronic Illnesses
• Provision for after-hours care

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Staffing for Primary Care-Mental Health Model

• Medical provider (NP/PA/MD)
• School nurse (if present)
• Mental Health provider (e.g.)
• Clinical Social Worker,
• Psychologist/Psychiatrist,
• May include Substance Abuse Counselor if
  appropriate

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Primary Care-Mental Health PLUS Model

• FT coverage if possible
• Primary care and mental health plus
• (one or more of the following)
• Dental Services
• Reproductive Health Services that include
  contraception dispensing/prescribing
• Nutrition Counseling
• On-site Substance Abuse Treatment

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Staffing for Primary Care-Mental Health PLUS Model

• School Nurse
• Medical provider (NP/PA/MD)
• Mental Health provider
• Dentist/Dental Hygienist
• Addictions Counselor
• Nutritionist
• Health Educator
• Social Worker

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SBHC Staffing Models(N1235)
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Alternative ModelsServices and Staffing

• School-Linked Health Centers
• Can mirror the service and staffing patterns of
  primary care only,
• primary care-mental health, and primary
  care-mental health PLUS models
• Mobile Health Centers
• Can mirror the service and staffing patterns of
  primary care only, primary care-mental health,
  and primary care-mental health PLUS models

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What Services Do SBHCs Offer?
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Primary Care Services Provided by SBHCs (N
1176-1259)
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Reproductive Health Services Offered to
Adolescents on Site (n 897-931 )
community type
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Contraception Prohibition(N853)
Other Dont know State Policy School Policy State
Law Health Center School District
Who Prohibits Dispensing Contraceptives in SBHCs
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Mental Health Services in SBHCs With (n805) and
Without (n388) Mental Health Providers
Plt.01
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SBHC Fundamental Principles
http//www.nasbhc.org/site/c.jsJPKWPFJrH/b.27434
59/k.9519/NASBHC_Principles_and_Goals_for_SBHCs.ht
m
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The School-Based Health Center

1. Supports the school
2. Focuses on the community
3. Focuses on the student
4. Provides comprehensive care
5. Advances health promotion activities
6. Implements effective systems
7. Provides leadership in adolescent and child health

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Supports the School
The school-based health center is built upon
mutual respect and collaboration between the
school and the health provider to promote the
health and educational success of school-aged
children.
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1. Supports the School 1. Supports the School 1. Supports the School 1. Supports the School
Principles/ Goals Structures Processes Outcomes
Understands and respects accountability within the educational system Works with the school administration to develop and achieve a shared vision Communicates the vision to all school constituencies including teachers, support staff, students and parents Builds collaborative and mutually respectful relationships with school personnel Identifies community resources that provide support to students and promote successful learning Serves as a resource in times of school crises and community disasters Mutually agreed upon vision statement for the SBHC Mutually agreed upon roles and responsibilities of each party Mutually agreed upon policies regarding appointment scheduling during school hours and information sharing Delineated role within the schools crisis intervention plan Communication with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty Attendance of SBHC personnel at school staff meetings Presence of SBHC personnel at appropriate school functions Partnership in identifying students with issues influencing educational performance Training of SBHC staff on the schools crisis intervention plan and communitys emergency preparedness plan and the SBHCs expected response Recognition by school personnel of the value the SBHC provides in meeting educational mission High satisfaction of school personnel with SBHC services Increased number of appropriate referrals by school personnel Reduced number of students who leave school during the day due to illness In the event of a school crisis or community disaster, SBHC performs effectively according to plan
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Responds to the Community
The school-based health center is developed and
operates based on continual assessment of local
assets and needs.
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2. Responds to the Community 2. Responds to the Community 2. Responds to the Community 2. Responds to the Community
Principles/ Goals Structures Processes Outcomes
Assesses child and adolescent health care needs and available resources in the community through formal evaluation methods Informs the community of student health needs and trends Solicits community input to address unmet health needs and support the operations of the program Definition of geographic service area Identification of population to be served including demographic and socioeconomic characteristics Identification of key health indicators Continuous needs assessment System for gathering data on key indicators Resource manual Advisory Committee with appropriate community representation Communications plan Program development based on periodic review of data Advisory Committee meetings Stakeholder meetings Periodic communication with the general public Improved access to primary care as measured by increased utilization of SBHC services Recognition by community of the value of SBHC services in meeting the needs of students and responding to community values High parent satisfaction Improved utilization of other community resources through referrals and/or inter-program collaboration
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Focuses on the Student
Services involve students as responsible
participants in their health care, encourage the
role of parents and other family members, and are
accessible, confidential, culturally sensitive,
and developmentally appropriate.
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3. Focuses on the Student 3. Focuses on the Student 3. Focuses on the Student 3. Focuses on the Student
Principles/Goals Structures Processes Outcomes  
Encourages the students active, age appropriate participation in decisions regarding health care and prevention activities Involves the parents or other adult caregivers as supportive participants in the students health care whenever appropriate and possible Ensures confidentiality of information whether transmitted through conversation, billing activity, telemedicine, or release of medical records Provides services and materials that are culturally sensitive and respectful of family values and diversity Parental consent and parental notification policies Confidentiality and minor consent policy Emancipated minor policy Child abuse and neglect policy Non-discrimination policy Patient rights and responsibilities Patient education materials in languages other than English, where appropriate Methodology for identifying children with special health care needs Methodology for identifying non-users Provision of services in a manner consistent with established policies Treatment of students with acute illness or injury Counseling of students with behavioral issues Management of students with chronic conditions Provision of culturally sensitive anticipatory guidance and health and safety education Student-centered risk assessment and follow-up Family assessment and follow-up Outreach to non-users Increased enrollment for and utilization of SBHC services High user and parent awareness of SBHC policy regarding access to confidential services Improved user knowledge of how and when to utilize the health care system Students with chronic disease or behavioral issues can demonstrate self-care skills High satisfaction among users.
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Delivers Comprehensive Care
An interdisciplinary team provides access to high
quality comprehensive physical and mental health
services emphasizing prevention and early
intervention.
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4. Delivers Comprehensive Care 4. Delivers Comprehensive Care 4. Delivers Comprehensive Care 4. Delivers Comprehensive Care
Principles/Goals Structures Processes Outcomes
Provides a scope of services that is consistent with identified health care needs Promotes availability of on-site services whenever the school is open and facilitates after-hours care 24-hour-a-day, seven-days-a-week Adopts generally accepted guidelines for clinical practice Promotes the interdisciplinary role and functions of the school-based health care team Coordinates and integrates efforts with existing systems to optimize complementary programs, improve continuity of care, reduce fragmentation, prevent duplication, and maintain affordable services Defined scope of services to be provided Multidisciplinary team of caregivers Posted hours of operation Effective 24/7 on-call system Staffing guidelines Clinical protocols or practice guidelines consistent with nationally recognized best practices Referral relationships with other providers in the community (including lab, radiology and pharmacy) Standards for medical record keeping Release of information policy Population-based Screening Early identification and treatment Delivery of care consistent with best practices Patient assessment Patient education Patient treatment Patient referral Management of chronic conditions Anticipatory guidance, health promotion and prevention activities Continuity of care Quality assurance Chart review Patient perception that well-being has improved Increasing number of students receiving comprehensive well exam including risk assessment Increasing compliance rates as measured by follow-up visits completed, prescriptions filled, therapy attended, referrals completed. Reduced number of students with disruptive behavior or discipline problems
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Advances Health Promotion Activities
The school-based health center takes advantage of
its location to advance effective health
promotion activities to students and community.
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5. Advances Health Promotion Activities 5. Advances Health Promotion Activities 5. Advances Health Promotion Activities 5. Advances Health Promotion Activities
Principles/Goals Structures Processes Outcomes
Serves as a resource to school administration on the selection, development and delivery of health education curricula Participates in classroom-based and school-wide health promotion activities responsive to the risk factors that are prevalent among students Promotes parent and community involvement in health promotion activities Partnership between the schools health education faculty and SBHC staff Coordinated risk assessment and health promotion plan Age appropriate health education materials Delivery of classroom health education segments Display and distribution of multilingual health education materials in SBHC (pamphlets, posters, models, videos, etc.) School-wide health and safety promotional events Increased student awareness of health threats and risk factors Reduced high risk behaviors among students Increased positive health and safety behaviors among students Increased student understanding of important health and psychosocial issues Increased student ability to access valid health information and health promoting products and services Increased student knowledge of health care rights and responsibilities Increased student ability to communicate about and advocate for improved personal health Increased participation of parents in heath promotion activities
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Implements Effective Systems
Administrative and clinical systems are designed
to support effective delivery of services
incorporating accountability mechanisms and
performance improvement practices.
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6. Implements Effective Systems 6. Implements Effective Systems 6. Implements Effective Systems 6. Implements Effective Systems
Principles/Goals Structures Processes Outcomes
Ensures compliance with all relevant laws and regulations Develops and measures annual program goals and objectives Maintains a physical plant which is adequate to deliver high quality services and assure patient comfort and privacy Develops all necessary policies and procedures, training manuals, and memoranda of agreement or understanding Develops a human resources system for hiring, credentialing, training and retaining high quality, competent staff Collects, evaluates and reports health outcomes and utilization data Establishes quality improvement practices including but not limited to assessment of patient and community satisfaction Develops strategies and systems to support long-term financial stability Organizational chart Mission statement Goals and objectives Administrative policy and procedure manual Clinical policy and procedure manual Appointment system and scheduling standards Tracking system for missed appointments, follow-up appointments and lab reports Incident reports Staff credentialing Staff training Personnel evaluation and salary review Facility maintenance Strategic business/ marketing/financial plan Billing and collection system Licensing, Certification and/or Accreditation CLIA compliance Medicaid EPSDT compliance Medical record keeping according to accepted standards and demonstrating collaboration and communication among providers Formal quality assurance monitoring of clinical and administrative functions Financial audits Staff knowledge of current laws and regulations affecting delivery of services Treatment for high volume, high risk problems consistent with current professional knowledge High SBHC provider and staff satisfaction Low SBHC provider and staff turnover Increased provider productivity High patient and parent satisfaction with ease of appointment-making and waiting time Operations within budget Eligibility for reimbursement from public and private third-parties
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Provides Leadership in Adolescent and Child Health
The school-based health center model provides
unique opportunities to increase expertise in
adolescent and child health, and to inform and
influence policy and practice.
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7. Provides Leadership in Adolescent and Child Health 7. Provides Leadership in Adolescent and Child Health 7. Provides Leadership in Adolescent and Child Health 7. Provides Leadership in Adolescent and Child Health
Principles/Goals Structures Processes Outcomes
Participates in national and local organizations that focus on adolescent and child health Contributes to the body of knowledge on the health care needs of adolescents and children Promotes the School-Based Health Center as a training site for health care professionals Advocates for the resources necessary to increase access to physical, mental and dental health services for adolescents and children Informs elected officials, policy-makers, health professionals, educators, and the community-at-large regarding the unique value, acceptability, efficiency and convenience of the school-based health center model of health care delivery Forms partnerships to develop stable, sustainable funding mechanisms for expanded services Local Conferences National Conferences Journal Articles Annual Reports\ Videotapes Web sites Vehicles to communicate with state and local health authorities Precepting students in the health professions Research Outcome evaluation Process evaluation Clinical trials Medical professional training Curriculum development Public education and advocacy Use of student volunteers Increased public awareness of the health care needs of children and adolescents Greater number of children and adolescents with a medical home Improved access to primary care Increased exposure of health professionals to the SBHC model Legislation and regulation supportive of the SBHC model Increased investment in SBHCs by federal, state, local and private funding sources Increased participation of SBHCs in Medicaid and Child Health Insurance Plans Appropriate contracts with managed care organizations
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National Tools and Resources for Getting Started

• NASBHC website www.nasbhc.org
• Basics,
• Training and Assistance,
• Publications, and
• Members Only Sections
• National Association of Community Health Centers
  (NACHC) CD-Rom, How to Start a Successful
  School-Based Health Center 25 www.nachc.org

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Questions and Answers