1. High School Reunion: Implementing a residency curriculum for school-based health centers Sarah Cole, DO, FAAFP Mercy Family Medicine, St. Louis

2. School-based health centers: the intersection of health and education Located in schools or on school grounds as an integral part of the school Provide services for the specific physical & behavioral health needs of young people in the community Employ a multidisciplinary team of providers –nurse practitioners, registered nurses, physician assistants, social workers, physicians, alcohol and drug counselors, and other health professionals Require parents to sign consent for their children to receive the full scope of services provided at the SBHC

3. Location of SBHCs Data from NASBHC 2007-08 Census ■ Urban ■ Rural ■ Suburban

4. Models of SBHCs 36% percent of SBHCs serve only students who attend the school(s) they serve. Other patient populations seen by SBHCs include: –students from other community schools –faculty & school personnel –family members of students –out-of-school youth –other community members 25% employ the primary care model. –APN or PA in collaboration with a physician 75% incorporate behavioral health or other ancillary services such as –Social worker –Nutritionist –Health educator

5. Services Provided by SBHCs Data from NASBHC 2007-08 Census

6. Benefits of SBHCs Decreased absenteeism Increased graduation rate Reduced hospitalization Reduced ER/UCC visits Reduced Medicaid costs Parental perception of higher academic expectations & school engagement

7. School-based Health Centers Data from NASBHC, 2007-08 Census

8. Mercy Clinic Roosevelt High School St. Louis, MO Established in August 2012 to improve access to health care and reduce health care disparities within an urban adolescent population. Expanded in February 2013 to include neighboring middle school.

9. Using the primary care model, the SBHC is open to students, faculty & staff and children of students enrolled in the campus child care center. While the clinic is a partnership between the local school district and a local teaching hospital, it operates as an extension of the family medicine residency.

10. Educational Need FM residents should be able to: –Adapt health delivery to the culture and needs of the patients & community being served Practice-based Learning & Improvement, Systems-Based Practice –Develop patient-centered treatment plans for adolescents based on comprehensive risk-based assessments that account for cultural, linguistic & socioeconomic background Medical Knowledge, Patient Care, Interpersonal Skills & Communication –Optimize treatment plans for adolescents utilizing local, state & federal resources Systems-Based Practice, Patient Care

11. PGY-2s said…

12. PGY2-s said…

13. Goals & Objectives: Medical Knowledge Demonstrate knowledge of normal growth & development of adolescents Demonstrate knowledge of health risks adolescents face & how to address them 80% or higher on ABFM SAM on Well Child Care Knowledge Assessment Completion of ABFM Well Child Care Clinical Simulation with self assessment

14. Goals & Objectives: Patient Care Provide evidence-based care that is compassionate, appropriate & effective for adolescents & promotes health 4-5 half-day patient care sessions at RHS SBHC Sideline coverage of RHS boys’/girls’ football, soccer and basketball games, with follow-up in SBHC of injuries as indicated

15. Goals & Objectives: Systems-Based Practice Understand how SBHCs may decrease student absenteeism & increase adolescent’s opportunities for personal & academic success Assigned readings: 1) SBHCs: cost-benefit analysis and impact on health care disparities. Guo et al. Am J Public Health. Sept 2010 2) Impact of SBHC use on academic outcomes. Walker et a. J Adolesc Health. Mar 2010. 3 half-day sessions with school nurses at RHS as well as one private and one special school

16. Goals & Objectives: Interpersonal Skills & Communication Apply knowledge of the challenges facing adolescents, including attention to self-care as well as mental, sexual and reproductive health Facilitation of at least one SBHC small group student health education session –Girls Club (emotional health) –Healthy Athletes –Asthma Club –Prenatal Classes

17. Goals & Objectives: Practice Based Learning & Improvement Demonstrate the ability to continuously improve patient care based on self- evaluation and lifelong learning Assessment of health care indicators for small group health education at SBHC, such as trending –PHQ-9 for Girls Club –BMI for Healthy Athletes –Peak flows for Asthma Club

18. Summary: Curricular Strategies All residents had orientation to SBHCs in October 2012 Inserted into month-long Community Medicine rotation during PGY-2 at various points through 2012: –Patient care at SBHC –Completion of ABFM Well Child Care SAM –Assigned article readings –Discussion with nurses at 3 different schools, including school with SBHC –Athletic coverage through SBHC –Facilitation & assessment of small group student health education meetings at SBHC Continues to evolve

19. Assessment Methods Resident Performance –ABFM Well Child Care SAM feedback –Written competency-based rotation evaluation from SBHC medical director or APN –Written post-rotation self-assessment

20. SBHC Self Assessment Submitted by the PGY-2 upon completion of the rotation Asked to reflect upon –Differences between 3 school nurse offices –Future plans for community involvement as physician leader Asked to gauge knowledge of –SBHCs –Local health care disparities

21. PGY-2s said…

22. PGY2-s said…

23. Resources Required SBHC School nurse(s) willing to teach residents Evidence-based reading related to SBHCs Computer with internet access & subscription to electronic databases ABFM log-in

24. Barriers Partnering with school faculty& staff re role of SBHC & outreach endeavors. –“We already have an ambulance at the football games.” –Health teacher declined SBHC endeavors for classroom-based educational outreach. As the SBHC is not a second FMC site, residents do not have a longitudinal patient panel to follow.

25. Moving forward Assessment of health care or education indicators for purposes of QI or population management Continue to implement solutions to students’ & health care providers’ perceived health care disparities. Continue SLPS faculty/staff development. Consider methods to make the resident’s SBHC curriculum longitudinal instead of rotational.