1. School-Based Health Centers in the Delivery of Immunizations to Adolescents Allison Kempe, MD, MPH

2. SchooI-based health care delivery School budgets and health priorities are set at the local level and vary widely Virtually no health services or education Limited nursing services Comprehensive health care center staffed by physicians, nurse or nurse practitioners

3. Aims Background regarding SBHCs nationally Background regarding SBHCs nationally New data regarding adolescent immunization delivery in SBHCs New data regarding adolescent immunization delivery in SBHCs Overview of adolescent immunization delivery at Denver SBHCs as an example Overview of adolescent immunization delivery at Denver SBHCs as an example Summarize Pros and Cons of SBHCs as sites for adolescent immunization delivery Summarize Pros and Cons of SBHCs as sites for adolescent immunization delivery

4. School-based Health Centers (SBHCs) SBHC model SBHC model Provision of comprehensive health care services on school campus--can include mobile units Provision of comprehensive health care services on school campus--can include mobile units Usually provided by multidisciplinary team including nurses, nurse practitioners, PAs, behavioral health specialists and physicians Usually provided by multidisciplinary team including nurses, nurse practitioners, PAs, behavioral health specialists and physicians Usually located in schools with high percentages of low-income, medically underserved children Usually located in schools with high percentages of low-income, medically underserved children In 2004-05, over 1,700 SBHCs nationwide In 2004-05, over 1,700 SBHCs nationwide Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

5. Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

6. Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

7. Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

8. SBHCs in the United States Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008 and The Center for Health and Health Care in Schools report: website www.healthinschools.org accessed February 4, 2008. www.nasbhc.org www.healthinschools.org

9. SBHCs in the US by Type of School Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

10. SBHCs in the US by Type of School Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

11. SBHCs in the US by Type of School Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

12. Health Services in SBHCs Comprehensive primary care Comprehensive primary care Acute and chronic illness care Acute and chronic illness care Immunizations Immunizations Substance abuse counseling Substance abuse counseling Mental health care Mental health care Dental care Dental care Limited pharmacy and laboratory services Limited pharmacy and laboratory services

13. National Survey of SBHCs Providing Care to Adolescents University of Colorado at Denver Matthew F. Daley, MD (PI) Matthew F. Daley, MD (PI) Jennifer Pyrzanowski Jennifer Pyrzanowski Allison Kempe, MD MPH Allison Kempe, MD MPH Jennifer Barrow, MSPH Jennifer Barrow, MSPH Lori Crane, PhD Lori Crane, PhD Katie Benton, MSPH Katie Benton, MSPH Denver Health and Hospitals Paul Melinkovich, MD Paul Melinkovich, MD Lisa Abrams, MS, PNP Lisa Abrams, MS, PNP National Assembly on School-Based Health Care Linda Juszczak, DNSc, MPH, CPNP Linda Juszczak, DNSc, MPH, CPNP Centers for Disease Control and Prevention C. Robinette Curtis, MD, MPH C. Robinette Curtis, MD, MPH

14. Objectives To assess in a national sample of school-based health centers that serve adolescents: Current vaccination practices Current vaccination practices Barriers to providing immunizations in this setting Barriers to providing immunizations in this setting

15. Methods The National Assembly on School-Based Health Care has most comprehensive listing of SBHCs nationally The National Assembly on School-Based Health Care has most comprehensive listing of SBHCs nationally Randomly selected 1,000 of 1,725 schools with SBHCs to participate Randomly selected 1,000 of 1,725 schools with SBHCs to participate Eligibility criteria for inclusion: Eligibility criteria for inclusion: Serve adolescents 11-18 year olds Serve adolescents 11-18 year olds Provide preventive or sick care Provide preventive or sick care Health center is on school grounds or mobile Health center is on school grounds or mobile

16. 1,725 School Health Centers 1,000 Randomly Selected for Participation 172 Excluded: -Don’t serve 11-18 -Don’t provide well/ sick care -Center not in school/ on school property -Closed 828 Survey-Eligible 483 Responders 345 Non- Responders 85% Provide Immunizations 15% Don’t Provide Immunizations Survey Outcomes 58% RR

17. SBHCs Providing Care to Adolescents Type of school Public traditional Public traditional Public magnet Public magnet Public alternative Public alternative Public charter Public charter Public vocational Public vocational Parochial/religious Parochial/religious Private non-parochial/religious Private non-parochial/religious Other Other88%3%2%1%<1%<1%<1%5%

18. SBHCs Providing Care to Adolescents Funding sources Bill insurance Bill insurance State government State government Non-profit or philanthropic foundations Non-profit or philanthropic foundations School district School district Federal government Federal government City/county government City/county government Corporations or businesses Corporations or businesses64%58%47%34%32%25%17%

19. Current Vaccination Practices 409 of 483 (85%) currently provide vaccines to adolescents 409 of 483 (85%) currently provide vaccines to adolescents Vaccines offered include: Vaccines offered include: Hepatitis B (95%) Hepatitis B (95%) Tdap (93%) Tdap (93%) MMR/MMRV (89%) MMR/MMRV (89%) Influenza (84%) Influenza (84%) MCV4 (79%) MCV4 (79%) HPV (79%) HPV (79%)

20. Payment for Vaccines Among SBHCs Providing Immunizations to Adolescents Currently vaccinate patients with: No health insurance No health insurance Medicaid Medicaid SCHIP SCHIP Private Private97%94%87%82% Bill private insurance for vaccines 38% Participate in VFC program 92%

21. Consent Issues Adolescents always/frequently seen w/o parent 86% Means for obtaining consent for immunizations Consent forms sent home with student Consent forms sent home with student Obtained when visit health center Obtained when visit health center Obtained at school registration Obtained at school registration Obtained by mail or fax Obtained by mail or fax Verbal consent obtained by telephone Verbal consent obtained by telephone76%65%45%27%14%

22. Use of Vaccine Information Statements (VIS) VIS forms use Given to parents at time of visit Given to parents at time of visit Sent home with student before vaccination Sent home with student before vaccination Sent home with student after vaccination Sent home with student after vaccination Mailed to parents before vaccination Mailed to parents before vaccination Given out at school registration Given out at school registration Mailed to parents after vaccination Mailed to parents after vaccination67%63%42%25%14%8%

23. SBHCs Providing Immunizations to Adolescents 45% report that ≥50% students have PCP outside SBHC 45% report that ≥50% students have PCP outside SBHC Methods used to notify outside PCP Methods used to notify outside PCP Ask parents/patients to notify PCP66% Ask parents/patients to notify PCP66% Rely on registry or IIS58% Rely on registry or IIS58% Send letters, fax, telephone50% Send letters, fax, telephone50%

24. Reminder/Recall for Immunizations Method to send reminders Messages sent to student at school Mail sent to home Telephone to home Email sent to parent Email sent to student 62%55%53%3%2%

25. Perceived Barriers to Vaccinating: SBHCs that Immunize Difficulty obtaining vaccination records Difficulty obtaining vaccination records Requirements for parental consent Requirements for parental consent Inability to vaccinate non-VFC Inability to vaccinate non-VFC Difficulty billing private insurance Difficulty billing private insurance Adolescents too busy Adolescents too busy51%37%31%29%28%

26. Perceived Barriers to Vaccinating: SBHCs that DO NOT Immunize Difficulty billing private insurance Difficulty billing private insurance Inability to vaccinate non-VFC Inability to vaccinate non-VFC Requirements for parental consent Requirements for parental consent Other health issues take priority Other health issues take priority Difficulty obtaining records Difficulty obtaining records49%36%30%27%23%

27. HPV Vaccination Among SBHCs that vaccinate adolescents, 79% currently offer HPV vaccine Among SBHCs that vaccinate adolescents, 79% currently offer HPV vaccine “Has school district been resistant to offering HPV?” “Has school district been resistant to offering HPV?” Not discussed with school district: 34% Not discussed with school district: 34% Not resistant: 58% Not resistant: 58% Mildly/moderately resistant: 6% Mildly/moderately resistant: 6% Definitely resistant: 1.5% Definitely resistant: 1.5%

28. Denver School Based Health Centers 20 th Year of Providing Services April 1988 - Present

29. The People Behind the Denver SBHCs and Immunization Delivery SBHC Key Personnel SBHC Key Personnel Paul Melinkovich, MD—Director Denver Community Health Services and founder of Denver SBHCs Paul Melinkovich, MD—Director Denver Community Health Services and founder of Denver SBHCs Simon Hambidge, MD, PhD—Director of Pediatrics Simon Hambidge, MD, PhD—Director of Pediatrics Steven Federico, MD—Director of SBHCs Steven Federico, MD—Director of SBHCs Lisa Abrams, PNP, MS—PNP Program Manager Lisa Abrams, PNP, MS—PNP Program Manager Audrey Gil—Clerical Supervisor Audrey Gil—Clerical Supervisor Stephanie Wasserman—Administrator Stephanie Wasserman—Administrator Denver Health Immunization Program Denver Health Immunization Program Anne Hammer, RN—Director Anne Hammer, RN—Director Denise Turner—Coordinator Denise Turner—Coordinator

30. Denver SBHCs Operated by: Operated by: Denver Health, a vertically-integrated safety-net health organization Denver Health, a vertically-integrated safety-net health organization In collaboration with Denver Public Schools, Mental Health Organizations and School of Nursing In collaboration with Denver Public Schools, Mental Health Organizations and School of Nursing 12 SBHCs 12 SBHCs 6 high schools 6 high schools 6 middle schools plus feeder elementary school 6 middle schools plus feeder elementary school High rates of free and reduced lunch and medically underserved population High rates of free and reduced lunch and medically underserved population 6,800 students received services in 2006-2007 school year for a total of 32,799 visits 6,800 students received services in 2006-2007 school year for a total of 32,799 visits

31. Data from Denver Health Administration, 2007. Patient Demographics

32. SBHC Clinic Room

33. Immunization Delivery in Denver SBHCs Students using Denver’s SBHCs more likely than those using Community Health Center alone to: Students using Denver’s SBHCs more likely than those using Community Health Center alone to: Receive influenza vaccine, tetanus booster and Hepatitis B vaccine Receive influenza vaccine, tetanus booster and Hepatitis B vaccine Immunization cost per dose at SBHCs shown to be significantly less than an HMO-based program Immunization cost per dose at SBHCs shown to be significantly less than an HMO-based program Government-purchased vaccine available at lower cost Government-purchased vaccine available at lower cost Parents did not incur work-loss costs Parents did not incur work-loss costs Allison, MA et al. Pediatrics. 2007; 120;e886-e894 Deuson, RR et al. Am J Public Health. 1999; 89; 1722-27

34. Sources of funding for vaccines at Denver SBHCs Approximately 77% of vaccines provided are to population eligible for VFC Approximately 77% of vaccines provided are to population eligible for VFC Because State Health Department recognizes SBHCs as public health outlet 317 funding used to pay for 23% with CHP+ or commercial insurance Because State Health Department recognizes SBHCs as public health outlet 317 funding used to pay for 23% with CHP+ or commercial insurance Attempts at billing for small percentage of patients with commercial insurance have not been fruitful Attempts at billing for small percentage of patients with commercial insurance have not been fruitful Problems with accurately identifying insurance carriers Problems with accurately identifying insurance carriers Not cost-effective Not cost-effective

35. Enrollment of Adolescents in Denver SBHCs Pre-registration mailings to parents Pre-registration mailings to parents Instructed to bring in current Iz record Instructed to bring in current Iz record Consent to be enrolled in SBHC included Consent to be enrolled in SBHC included Consents for SBHC enrollment collected at registration Consents for SBHC enrollment collected at registration Students also enrolled on rolling basis throughout school year Students also enrolled on rolling basis throughout school year

36. Consent for Vaccines at School Registration At registration hand-held records, Colorado State Immunization Information System (CIIS) and the DPS data base checked to verify immunization status At registration hand-held records, Colorado State Immunization Information System (CIIS) and the DPS data base checked to verify immunization status If not UTD, parent is given VIS form regarding the vaccine If not UTD, parent is given VIS form regarding the vaccine Vaccine-specific consent form collected for individual vaccines needed Vaccine-specific consent form collected for individual vaccines needed Vaccine consents also obtained t/o school year Vaccine consents also obtained t/o school year

37. SBHC-based Reminder/Recall for Vaccines Vaccine consent forms entered into data base, which functions as a tickler for reminder-recall Vaccine consent forms entered into data base, which functions as a tickler for reminder-recall On a weekly basis, reminders generated for students with consents for vaccines On a weekly basis, reminders generated for students with consents for vaccines Students are called to the clinic during their off- time or during class to receive vaccines Students are called to the clinic during their off- time or during class to receive vaccines When students receive an immunization, the Colorado State Immunization Information System registry is updated When students receive an immunization, the Colorado State Immunization Information System registry is updated

38. Denver SBHC Enrollment and Users 06-07 school year as of 12/31/06 07-08 school year as of 12/31/07 % Students enrolled that used SBHC 29%44% Data from Denver Health Administration, 2007.

39. Denver SBHC Users UTD rates as of 12/31 each year *At least 1 dose for female users only. Data from Denver Health Administration, 2007.

40. Pros and Cons of SBHCs in Immunization Delivery for Adolescents

41. Obstacles to Immunization Delivery in SBHCs Limited distribution of SBHCs across the country Limited distribution of SBHCs across the country Difficulty financing SBHCs and billing commercial insurers for vaccines Difficulty financing SBHCs and billing commercial insurers for vaccines Difficulty determining UTD status of students Difficulty determining UTD status of students Challenges in obtaining consent for vaccines Challenges in obtaining consent for vaccines Possible promotion of record scatter Possible promotion of record scatter

42. Assets of SBHCS in Adolescent Immunization Delivery Most SBHCs are in high schools and middle schools with adolescents in most need Most SBHCs are in high schools and middle schools with adolescents in most need When there IS a SBHC When there IS a SBHC Immunization delivery is augmented for students with other sources of care Immunization delivery is augmented for students with other sources of care SBHCs are the only source of care for many SBHCs are the only source of care for many School-based immunization delivery can save money School-based immunization delivery can save money Quick adopters of new vaccines Quick adopters of new vaccines “Captive audience”--SBHCs have enormous capacity to ensure immunization “Captive audience”--SBHCs have enormous capacity to ensure immunization

43. SBHC-Medical Home Partnership SBHCs, in partnership with the medical home, serve an important role in increasing immunization coverage for hard-to-reach adolescents

44. www.healthinschools.org www.healthinschools.org www.healthinschools.org www.nasbhc.org www.nasbhc.org www.nasbhc.org Pulse/Internal/CHS/School-based Pulse/Internal/CHS/School-based

45. Acknowledgments Portions of this work were funded by the Centers for Disease Control and Prevention

46. Immunizers vs. Non-immunizers SBHCs that provide immunizations SBHCs that provide immunizations higher percentage of the total student population eligible for free lunch higher percentage of the total student population eligible for free lunch more likely to also provide gyn. exams, Pap smears, diagnosis/ treatment of STIs, pregnancy tests and birth control on site more likely to also provide gyn. exams, Pap smears, diagnosis/ treatment of STIs, pregnancy tests and birth control on site SBHCs that do not provide immunizations reported a higher percentage of students with a PCP elsewhere SBHCs that do not provide immunizations reported a higher percentage of students with a PCP elsewhere

47. SBHCs in the US by Rural/Urban Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

48. SBHCs in US by Region Data from School-Based Health Centers National Census School Year 2004-05 report: NASBHC website: www.nasbhc.org accessed February 27, 2008. www.nasbhc.org

49. Sources of Funding Data from Denver Health SBHC Report Card, 2006.

50. Most Frequent Reasons for Health Visits Data from Denver Health SBHC Report Card, 2006.

51. Insurance Type Based on Patient Charges Data from Denver Health SBHC Report Card, 2006.

52. Methods Self-administered 10-minute survey containing primarily closed-ended responses Self-administered 10-minute survey containing primarily closed-ended responses Survey period: November 2007 – March 2008 Survey period: November 2007 – March 2008 Via internet or mail depending on the preference Via internet or mail depending on the preference Pilot tested with 25 randomly selected centers Pilot tested with 25 randomly selected centers

53. SBHCs Providing Care to Adolescents

54. Successes of Denver SBHCs Students using Denver’s SBHCs more likely than those using other sources of care w/o SBHC access to: Students using Denver’s SBHCs more likely than those using other sources of care w/o SBHC access to: Receive health maintenance visits Receive health maintenance visits Receive mental health care Receive mental health care Students using Denver’s SBHCs less likely than those using other sources of care w/o SBHC access only to: Students using Denver’s SBHCs less likely than those using other sources of care w/o SBHC access only to: use emergency care use emergency care Allison, MA et al. Pediatrics. 2007; 120; e886-e894 Juszczak, L et al. J Adol. Health. 2003; 32; 108-18 Kaplan, DW et al. Arch Pediatr Adolesc Med. 1999; 153; 235-43

55. How Have Schools Been Involved in the Delivery of Immunizations? Point of access only for delivery of immunizations during immunization initiatives Point of access only for delivery of immunizations during immunization initiatives Delivery of immunizations as part of sustained health care delivery efforts Delivery of immunizations as part of sustained health care delivery efforts