1. Sustainability of School-based Health Centers
HARVARD BUSINESS SCHOOL
ASSOCIATION OF OREGON
COMMUNITY PARTNERS
Sustainability of School-based Health Centers
A study conducted by administrative and medical staff of the Virginia Garcia School-Based Health Centers and a pro-bono consulting team of the Harvard Business School Association of Oregon, June – November, 2015

2. Project Focus
Virginia Garcia Memorial Health Center (VG) operates six School-Based Health Centers (SBHCs).
Beginning with the first center in 2008, the SBHCs launched with financial support of Virginia Garcia Foundation grants, state funding, and school districts that provide facilities.
VG is concerned that patient-generated revenues do not yet cover patient-related expenses.

3. Project Objective:
Identify elements of a financially sustainable program that can be implemented at SBHCs.

4. Project Approach Interviews: Analysis: Research: Executive leaders
Functional leaders
SBHC staff
Analysis:
Financial reports
Patient encounter reports
Research:
Publications on SBHC experience nationwide
Discussions with Oregon School-Based Health Alliance

5. Project Report Utilization Financial performance
Findings and Recommendations in the areas of:
Utilization
Financial performance
Coordination with VG Clinics
Stakeholder Relations

6. Finding: Common Diagnoses are Typical of SBHCs
1. Utilization
Finding: Common Diagnoses are Typical of SBHCs

7. Finding: Patient volume is growing and has pronounced fluctuations
1. Utilization
Finding: Patient volume is growing and has pronounced fluctuations
Current Utilization,
2,331 patients served (Primary Care and Mental Health)
5,282 patient visits (PC and MH)
Average visits per clinic day:
Primary Care Mental Health
Forest Grove
Tigard
Beaverton
Century
Willamina

8. 1. Utilization Finding: SBHC Staffing …
Has appropriate skill sets for most common diagnoses
Varies in total headcount from 3 to 5
Is adjusted through sharing among SBHCs

9. 1. Utilization Finding: In General …
VG SBHCs have launched operations with a minimum number of staff
VG SBHCs have room to grow

10. 1. Utilization
Recommendation: Continue efforts to reach a target staffing profile at every SBHC
1 medical provider (P.A. or N.P.)
1 mental health provider
2 office health assistants
1 dental hygienist

11. 1. Utilization
Recommendation: Build patient volumes to match the target staffing profile
10-12 Medical (Primary Care) visits per day
7-8 Mental Health visits per day
1-3 Auxiliary visits per day (no provider involved, e.g. vaccine only or lab draw)
A full day of dental care at each SBHC (hygiene, sealants, screenings, etc.)

12. 1. Utilization Recommendations to build patient volumes
Expand marketing strategy
Address seasonal opportunities
Expand concept of medical home to include SBHCs
Develop work flows to maximize use of mental health and primary care co-visits
Develop protocols with VG call center and membership office to utilize SBHCs when unexpected rescheduling occurs at VG Clinics (underway in Hillsboro)

13. 1. Utilization Recommendations for Marketing Strategy
Prepare new, professional print materials with branding separate from schools (In process)
Distribute materials to schools and VG Primary Care sites (In process)
Coordinate communication through school districts; increase online presence
Improve location signage within regulatory constraints
Reach out to elementary and middle schools
Continue to develop Youth Advisory Committees

14. 1. Utilization Recommendations for Managing Seasonality
Schedule and promote school-wide clinics for:
Vaccines (in process)
Sports physical clinics prior to each sports season
Seasonal issues (allergies, colds, flu, etc.)
Dental screenings

15. 2. Financial Performance – Findings (a)
SBHC patient related expenses exceed patient revenues
Analysis of operations for indicated that:
Medical Services show a deficit of $1,390,000
Mental Health Services show a contribution of $264,000
Dental Services have insufficient experience for analysis
Operating losses are offset by grants, donations, and transfers from the Virginia Garcia Foundation
Dependence of grants and government programs presents a long term revenue risk
Statewide and nationwide, SBHCs are subsidized

16. 2. Financial Performance – Findings (b)
Mission vs. Margin – write-offs are substantial; variations exist in applying policy to practice
Managing Fee-For-Service vs. APM appointments presents challenge and opportunity (balancing act)
Allocation of APM monthly payments for youth under 18 is a substantial revenue factor
Current allocations from VG to its SBHCs is out of proportion to the number of APM patients established at SBHCs (too large)
Mix of services drives revenue
SBHCs offer to VG a network of low cost primary care “satellite” locations – a potentially high value resource

17. 2. Financial Performance – Recommendations (a)
APM Revenue
“Establish” new school age children at SBHCs and direct them to SBHCs rather than VG Clinics
Develop allocation method to attribute revenue to treatment location (or team)
Increase volume of “established” patients with an outreach program
Fee-for-Service Revenue
Identify services at VG clinics that could be directed to SBHCs
(Lower cost for VG; additional revenue for SBHCs)
Consider adding higher fee services
Review policies and practices for write-offs. Develop tracking system to better enable VG to quantify charitable care
Increase percentage & volume of Fee-for-Service visits

18. 2. Financial Performance – Recommendations (b)
Continue support of APM analysis sponsored by Oregon School-Based Health Alliance
Continue to monitor developments in government funding (e.g., Safety Net Capacity Grant)
Continue focus on revenue growth rather than expense reduction (current cost structure is nominal)

19. 3. Coordination with VG Clinics - Findings
SBHCs operate independently from VG Clinics
Integration between VG Clinics and SBHCs provides an opportunity to improve:
Resource utilization across the system
Revenue allocation between Clinics and SBHCs
Efficiency in the delivery of patient services
SBHC staff job satisfaction 

20. 3. Coordination with VG Clinics - Recommendations
Consider including SBHC medical staff as part of a home panel (provider team) at the nearest VG Clinic.
Consider emphasizing the VG branding of the SBHCs and their connection to nearby VG Clinics.
Raise the visibility of SBHC activities throughout VG through regular internal communications.
Coordinate scheduling between VG Clinics and SBHCs to optimize utilization of both.
Develop protocols for call center and membership services to appropriately schedule SBHCs for medical, mental, and dental health services
Provide mutual overflow support and after-hours coverage

21. 4. Stakeholder Relations - Findings
The SBHCs manage 12+ stakeholder groups:
School principals and counselors, school districts, staff, parents, students, patients and multiple city and state government departments
Stakeholders want more communication, tailored to their service areas
Stakeholders would like to know about goals and future plans for SBHCs
Stakeholder expectations for SBHC administrative support exceeds staff capacity resulting in reactive rather than proactive planning.

22. 4. Stakeholder Relations - Recommendations
Establish internal roles, responsibilities, accountabilities, and decision levels to present a coordinated, united front to all stakeholders
Consider SBHC representation at VG executive level
Consider allocating additional staff to Stakeholder relations
Develop a three year business plan and gain acceptance from Stakeholders
Establish external communication tools and practices (e.g, SBHC website linked to school websites with frequent updates, joint marketing efforts)
Support the Stakeholder coordinating committee

23. Summary Observations VG SBHCs are similar to others in terms of:
Services needed and offered
Size and staffing
Subsidizing patient revenue to meet expenses
Developing cooperation with medical sponsors
Managing multiple stakeholder relationships
VG is uniquely positioned to:
Leverage its brand
Grow SBHC utilization through increased outreach
Integrate SBHCs with VG primary care programs

24. Bottom Line SBHCs have room to grow
With increased integration SBHCs can become an important complement to the Virginia Garcia clinics to the benefit of both.