Laura C. Brey, MS Tammy Alexander, M.Ed. NASBHC Training of Trainers April 21-23, 2008 School-Based Health Centers (SBHCs) 101: An Overview and Framework for An Overview and Framework for Building Programs

Getting to Know You Activity

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

4 Objectives Participants will be able : Describe who uses school-based health centers and who sponsors them Describe who uses school-based health centers and who sponsors them List three national school-based health care models List three national school-based health care models

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

6 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 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 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

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

8 School-Based Health Center National Definition SBHCs have a policy on parental consent. 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. 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.

9 School-Based Health Center National Definition SBHCs make provisions for care beyond the centers’ operating hours or scope of service 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. 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.

10 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. 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. 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.

11 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. 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.

12 Why School-Based Health Centers?

Group Activity Why School-Based Health Centers? –Think of yourself as a school aged child, pick your age, or –Think of your own child or adolescent, or –Think of family members, neighbors as a school aged child –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

14 Why School-Based Health Centers? Uninsurance among children, especially adolescents Uninsurance among children, especially adolescents Geographic and financial barriers to health, mental health and dental access Geographic and financial barriers to health, mental health and dental access Dangerous health outcomes associated with adolescents Dangerous health outcomes associated with adolescents Nonexistent/fragmented/singular discipline systems of care Nonexistent/fragmented/singular discipline systems of care Decreased educational attainment Decreased educational attainment

15 “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.

16 The Evidence Base for School- Based Health Care Research Published in Professional Literature Research Published in Professional Literature National and State Data National and State Data –National State Initiative Survey –NASBHC Biennial census –White papers Training and technical assistance in the field 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 Pre and post assessments, chart reviews, progress reports, storyboards, consultation calls

17 What Does the Literature Tell Us About Emergency Room Use and SBHCs? Reduced inappropriate emergency room use, Reduced inappropriate emergency room use, Increased use of primary care, and Increased use of primary care, and Fewer hospitalizations Fewer hospitalizations Santelli J, Kouzis A, et al. Journal of Adolescent Health 1996; 19: Prevention-oriented care in SBHCs results in decreased utilization of emergency departments Prevention-oriented care in SBHCs results in decreased utilization of emergency departments Key JD, Washington EC, and Hulsey TC, Journal of Adolescent Health 2002: 30;273

18 What Does the Literature Tell Us About Asthma and SBHCs? > 50% reduction in asthma related emergency room visits for students enrolled in SBHCs in New York City > 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: $3 million savings in asthma-related hospitalization costs for students enrolled in SBHCs in New York City $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

19 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 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 times more likely to come to a SBHC for mental health services than a community health center network or HMO Adolescents were 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; 32S: Kaplan D, et al. Archives of Pediatric and Adolescent Medicine Jan;152(1):25-33.

What Does Science Tell Us About Education and SBHCs Health has both direct and indirect effects on school failure Health has both direct and indirect effects on school failure Good education predicts good health 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 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 Public health and education are linked toward a common cause: school success 20

What Do We Know Intuitively? Healthy students make better learners Healthy students make better learners You can’t teach a child who is not healthy You can’t teach a child who is not healthy A child who succeeds in school is more likely to enjoy lifelong health A child who succeeds in school is more likely to enjoy lifelong health 21

What Science Tells Us About Education Academic performance is negatively affected by: 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: Academic performance is positively affected by: –High levels of resiliency, developmental assets, and school connectedness. 22

SBHCs Health Risk Behaviors EducationalOutcomes EducationalBehaviors Substance use Mental health Mental health Poor diet Poor diet Intentional injuries Physical illness Physical illness Self-esteem Self-esteem Sexual behaviors Sexual behaviors Attendance Attendance Dropout Rates Dropout Rates Behavioral Problems Graduation GPA GPA Standardized test scores 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. The Health-Academic Outcomes Connection 23

SBHC Outcomes and Tactics Reduce barriers to learning Increase attendance Improve student health Meet government regulations Identify students at-risk for health and behavioral problemsIdentify students at-risk for health and behavioral problems Assist in IEP developmentAssist in IEP development Provide mental health servicesProvide mental health services Treat acute conditionsTreat acute conditions Manage chronic conditionsManage chronic conditions Provide preventive health servicesProvide preventive health services Treat acute conditionsTreat acute conditions Administer medication to students with chronic conditionsAdminister medication to students with chronic conditions Enroll students in health insuranceEnroll students in health insurance Provide mental health servicesProvide mental health services Refer students to services not provided in the SBHCRefer students to services not provided in the SBHC Provide preventive health servicesProvide preventive health services Treat acute conditionsTreat acute conditions Manage chronic conditionsManage chronic conditions Conduct sports physicalsConduct sports physicals Provide mental health servicesProvide mental health services Immunize studentsImmunize students Participate in community initiatives on public health such as obesity and emergency planningParticipate in community initiatives on public health such as obesity and emergency planning Maintain health records for migratory studentsMaintain health records for migratory students 24

25 The Medical Home Half of SBHCs estimate > 30% of their enrollees use the center as their medical home Half of SBHCs estimate > 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 40% estimate 50% or more of enrollees use the center as their medical home

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

27 National Data and Trends Census

28 N = 1709 Where are SBHCs Located?

29 Location of Health Center (n=1234) In school building 87% In school building 87% On school property 11% On school property 11% Mobile (non-fixed) 2% Mobile (non-fixed) 2%

30 Types of Schools with Health Centers ( n=1222)

31 SBHCs by Community Characteristic (N=1235)

32 Who Uses SBHCs? Ethnic/Racial Profile of Student Population in Schools with SBHCs (n=1235)

33 Other Populations Served by SBHCs (n=1227 )

34 Who Sponsors SBHCs (n=1233)

35 SBHC Service Delivery Models

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

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

38 Staffing for Primary Care-Mental Health Model Medical provider (NP/PA/MD) Medical provider (NP/PA/MD) School nurse (if present) School nurse (if present) Mental Health provider (e.g.) Mental Health provider (e.g.) –Clinical Social Worker, –Psychologist/Psychiatrist, May include Substance Abuse Counselor if appropriate May include Substance Abuse Counselor if appropriate

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

40 Staffing for Primary Care-Mental Health PLUS Model School Nurse School Nurse Medical provider (NP/PA/MD) Medical provider (NP/PA/MD) Mental Health provider Mental Health provider Dentist/Dental Hygienist Dentist/Dental Hygienist Addictions Counselor Addictions Counselor Nutritionist Nutritionist Health Educator Health Educator Social Worker Social Worker

41 SBHC Staffing Models (N=1235)

42 Alternative Models Services and Staffing School-Linked Health Centers School-Linked Health Centers Can mirror the service and staffing patterns of primary care only,Can mirror the service and staffing patterns of primary care only, primary care-mental health, and primary care-mental health PLUS models primary care-mental health, and primary care-mental health PLUS models Mobile Health Centers Mobile Health Centers Can mirror the service and staffing patterns of primary care only, primary care-mental health, and primary care- mental health PLUS modelsCan mirror the service and staffing patterns of primary care only, primary care-mental health, and primary care- mental health PLUS models

43 What Services Do SBHCs Offer?

44 Primary Care Services Provided by SBHCs (N= )

45 Reproductive Health Services Offered to Adolescents on Site (n= ) community type

46 Contraception Prohibition (N=853) Who Prohibits Dispensing Contraceptives in SBHCs Other Don’t know State Policy School Policy State Law Health Center School District

47 Mental Health Services in SBHCs With (n=805) and Without (n=388) Mental Health Providers * P<.01 * P<.01

Examples of Commonly Raised Concerns and Issues The following are issues that typically arise when discussing SBHCs and being prepared to answer adequately is the best strategy. –Reproductive Health –Parental Consent –Cost –Why in a school setting – resources concern

49 National Tools and Resources for Getting Started NASBHC website NASBHC website –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 National Association of Community Health Centers’ (NACHC) CD-Rom, How to Start a Successful School-Based Health Center $25

50 Questions and Answers