1. Julia Graham Lear, PhD Research Professor, Department of Prevention and Community Health Director, Center for Health & Health Care in Schools GWU School of Public Health & Health Services The Center for Health and Health Care in Schools School-Based Health Centers: Policy and Practice

2. SBHCs: Policy & Practice Some thoughts on state policies & SBHCs Recent lessons on expanding children’s mental health and dental health services through SBHCs

3. Some Background: How SBHCs Came to Be Emerged in late 70s and 80s, result of growing recognition of unmet needs among children and adolescents Built on newly-available NPs who were able to diagnose and treat patients at a lower cost than physicians With exception of a few city-county governments, state governments led expansion of SBHCs. State government role described by professor Jim Morone in 1/2001 Health Affairs article http://content.healthaffairs.org/cgi/reprint/20/1/122.pdf

4. Policy Lessons from Past Decade Multiple funding sources, carve-outs of mental health and dental health services from state and 3rd party contract provisions, and low reimbursement rates challenge SBHC stability. State policies differ. Each state’s licensure, certification and public health insurance payment practices affect way states reimburse SBHCs Medicaid managed care & SCHIP are significant forces with impact on SBHCs financial future

5. Policy Context: State Health Regulatory Functions and SBHCs Licensure -- State regs establish which health providers can practice in state Certification -- State regs determine which providers are eligible to receive payment for providing health care services. Certification required for providers to receive state funds for Medicaid & SCHIP services. Insurance Commissioner determines which providers are eligible for reimbursement by private payers. Payment - State regs determine eligibility, payment structures, rates for Medicaid & SCHIP payments

6. Two Ways of Thinking about Revenue Sources for SBHCs Monies directed towards SBHCs or the services they provide, eg. Public or private grants;in-kind contributions Monies tied to individuals served by SBHCs -- eg. Fees for primary care services (EPSDT), fees for services for special needs children (‘related services’ for students covered by IDEA)

7. How do SBHCs fit within larger health care system? Different states/ different strategies -- it all depends on how a state chooses to configure its SBHC policy Three targeting strategies or models for SBHCs Safety net provider Adolescent focus Public health & health promotion for children & adolescents

8. Why Define a Model or Select a Targeting Strategy? Defining a model gives policymakers a clearer sense of where the moneys should come from to support the centers Long-term prospects for SBHC development and expansion depend on states' ability to articulate why and how the centers are useful in the larger health care delivery system.

9. Strategy #1: Safety Net Provider or Medical Home Model Public dollars targeted on low-income kids with limited access to care, eg. uninsured kids, rural kids, underserved urban areas Funding the centers is viewed as mechanism for expanding the child health care delivery system Significant funds to support program should come from patient care revenues Examples: New York State, Connecticut

10. Elected official on SBHCs as safety net Sen. Jay Dardenne (R-LA Former Senate Majority Leader) “Even conservative legislators looking to save money in Medicaid budgets and public health budgets recognize that if we can deliver more targeted primary services at a school-based clinic, that’s a better use of tax dollars.”

11. Strategy #2: SBHCs as Service for Adolescents Public dollars targeted on teens, eg. teen friendly providers; services targeted to teen developmental issues & reproductive health issues Funding stream a mix of payments for patient care and public support to sustain poorly- reimbursed or unreimbursed services Examples : Delaware, 2 county programs (Seattle-King County, Multnomah County (Portland, OR)

12. Elected Officials on SBHCs & Adolescents Former Governor Tom Carper (D-DE) “This (SBHCs) was an idea that just made sense. When I ran for governor, the focus of my campaign was on strengthening families. Promoting school-based health centers tied in well with that theme.” State rep Nancy Wagner (R-DE) “These things transcend governors. We support them and we want them. When you see something that’s making a difference and it’s working, you want to copy it.”

13. Strategy #3: Public Health and Health Promotion for Kids and Teens Under a public health model (also referred to as an access model), a school-based health center is responsible for identifying and responding to the major health problems within the school community. A state strategy to support a public health vision of SBHCs would understand that only portion of these activities will be supported through third party payments and would identify other sources of funding to support the public health mission. Example: North Carolina

14. Expanding Dental Health & Mental Health Services through SBHCs Caring for Kids grant initiative –$3.4 million grant initiative funded by RWJF –Grants awarded February 2002; 3-year grants –15 funded sites: 8 mental health; 7 dental health –Goal: to develop sustainable models; increase available dental & mental health services, and connect services to relevant public and private programs & policies

15. Dental Health Services: Lessons Learned Patient care revenues were surprisingly robust -- some states paid an institutional rate for services; others increased individual provider payments to get more dental services for publicly-insured kids Dental hygienists play key role; limited dentist time focuses on restorations The services were popular with parents & kids Medical staff & dental staff within SBHCs did not partner naturally; integrated teamwork is a work in progress With more than 50% of students’ health insurance status not reported, the number of uninsured students is underreported.

16. Mental Health Services: Lessons Learned Mental health services were in demand ; in the middle schools, 57% of visits were made by young men. The services were accessed by a diverse population of students. Student enrollment at participating schools included 9,044 (41%) Latinos; 5,595 (25%) whites; 3,685(17%) African Americans; 2,677 (12%) Asians; 959 (4%) American Indians, and 231 (1%) Other. Staffing was not a problem; and one site demonstrated the impact of strengthening clinical leadership on overall staff productivity time with teachers that may not be reimburseable.

17. Mental Health Services: Lessons Learned continued All sites emphasized the importance of solidifying relationships with teachers and administrative staff. A consequence is that high quality mental health programs spend time with teachers that may not be billable. To improve opportunities for patient care revenue, most projects needed to achieve some modifications in state policy. For example, NY removed barrier to billing for services provided by LCSWs. Mental health projects had insurance information on less than 50% of students enrolled in health center. Complete data are essential to program development.

18. Contact Information The Center for Health and Health Care in Schools GWU School of Public Health & Health Services 2121 K Street, NW, Suite 250 Washington, DC 20037 202-466-3396 fax 202-466-3467 jgl@gwu.edu www.healthinschools.org