School-Based Health Centers (SBHCs) 101: An Overview and Framework for Building Programs

Objectives

Participants will be able :   

Define

the term school-based health center

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 I 2

Objectives

Participants will be able : 

Describe

who uses school-based health centers and who sponsors them  

List

three national school-based health care models

List

seven principles describing how to plan and implement a school-based health centers 3 I

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

4

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 

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

5

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.

 The school-based health care team

other service providers works in collaboration with school nurses and

in the school and community.

6

School-Based Health Center National Definition

 SBHCs have a

policy consent

.

on

parental

 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

and health education services

.

provide comprehensive medical, mental health

7

School-Based Health Center National Definition

 SBHCs make

provisions for care beyond

the centers’

operating hours

or

scope of service



Because of

the

unique vantage point access to students

, the health center team is able to reach out to students to

emphasize prevention

and

early intervention.

and 8

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 providers.

,

school districts

, and

individual and agency health care

9

School-Based Health Center National Definition

 

Services

typically offered in SBHCs

are age appropriate youth

. and

address

t

he

most important health needs of children and

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 promotion

. ,

nutrition education, health education and health

10

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

.

11

Why School-Based Health Centers?

12

Why School-Based Health Centers?

 Uninsurance among children, especially adolescents  Geographic and financial barriers to health, mental health and dental access  Dangerous health outcomes associated with adolescents  Nonexistent/fragmented/singular discipline systems of care  Decreased educational attainment 13

“

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.

14

The Evidence Base for School Based Health Care

   Research Published in Professional Literature National and State Data – National State Initiative Survey – NASBHC Biennial census – White papers 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 15

What Does the Literature Tell Us About

Emergency Room Use

and SBHCs?

   Reduced inappropriate emergency room use, Increased use of primary care, and Fewer hospitalizations

Santelli J, Kouzis A, et al. Journal of Adolescent Health 1996; 19:267-275

 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

16

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

Webber MP et al. Archives of Pediatric and Adolescent Medicine. 2003; 157: 125-129

 $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

17

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  Adolescents were 10-21 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:108-118.

Kaplan D, et al. Archives of Pediatric and Adolescent Medicine. 1998 Jan;152(1):25-33.

18

What Does Science Tell Us About

Education

and SBHCs

 Health has both direct and indirect effects on school failure  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  Public health and education are linked toward a common cause: school success 19

What Do We Know Intuitively?

 Healthy students make better learners  You can’t teach a child who is not healthy  A child who succeeds in school is more likely to enjoy lifelong health 20

What Science Tells Us About Education

 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: – High levels of resiliency, developmental assets, and school connectedness.

21

The Health-Academic Outcomes Connection

Health Risk Behaviors Substance use Mental health Poor diet Intentional injuries Physical illness Self-esteem Sexual behaviors Graduation GPA Standardized test scores

SBHCs

Attendance Dropout Rates Behavioral Problems

22 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.

SBHC Outcomes and Tactics

Reduce barriers to learning Increase attendance

• • • • •

Identify students at-risk for health and behavioral problems Assist in IEP development Provide mental health services Treat acute conditions Manage chronic conditions

• • • • •

Provide preventive health services Treat acute conditions Administer medication to students with chronic conditions Enroll students in health insurance Provide mental health services

• • • • • •

Improve student health Refer students to services not provided in the SBHC Provide preventive health services Treat acute conditions Manage chronic conditions Conduct sports physicals Provide mental health services

• • •

Meet government regulations Immunize students Participate in community initiatives on public health such as obesity and emergency planning Maintain health records for migratory students

23

The 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 24

Efficiencies in SBHCs

 Parents time off  Follow-up less labor intensive  Identifying problems earlier  Reduction in more costly emergency room visits 25

National Data and Trends

Census 2004-05

26

Where are SBHCs Located?

N = 1709

27

Location of Health Center (n=1234)

 In school building 87%  On school property 11%  Mobile (non-fixed) 2% 28

Types of Schools with Health Centers

( n=1222)

Middle/High 7% Elementary/ Middle 14% K-12 14% High 30% Elementary 20% Middle 15%

29

SBHCs by Community Characteristic

(N=1235)

Rural 27% Suburban 14% Urban 59%

30

Who Uses SBHCs?

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

Asian 4% Native American 1% Other 1% Hispanic 34 % Black 30% White 30%

31

Other Populations Served by SBHCs

(n=1227 )

Other people from the community, 12% Out-of-school youth, 16% Faculty/school Peronnel, 19% Family of student users, 29% Students from other schools, 33% Only children in the school, 45%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Who Sponsors SBHCs

(n=1233)

Private Other, 3% Nonprofit Organization, University 12% (Medical, Nursing, Public Health), 4% Local Health Department 18% Hospital/ Medical Center 29%

Community Health Center

School System 14%

22%

33

SBHC Service Delivery Models

34

Primary Care Only Model

 NP/PA/MD 1-5 days/week  Full or part-time (FT/PT) coverage  No Mental Health/Substance Abuse Services 35

Primary Care-Mental Health Model

 PT or FT coverage  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  Provision for after-hours care 36

Staffing for Primary Care-Mental Health Model

 Medical provider (NP/PA/MD)  School nurse (if present)  Mental Health provider (e.g.) – Clinical Social Worker, – Psychologist/Psychiatrist,  May include Substance Abuse Counselor if appropriate 37

Primary Care-Mental Health PLUS Model

 FT coverage if possible 

Primary care and mental health plus

: (one or more of the following) – Dental Services – Reproductive Health Services that include contraception dispensing/prescribing – Nutrition Counseling – On-site Substance Abuse Treatment 38

Staffing for Primary Care-Mental Health PLUS Model

 School Nurse  Medical provider (NP/PA/MD)  Mental Health provider  Dentist/Dental Hygienist  Addictions Counselor  Nutritionist  Health Educator  Social Worker 39

SBHC Staffing Models

(N=1235)

Primary Care Mental Health Plus 31% Unknown 4% Primary Care Only 31% Primary Care Mental Health 34%

40

Alternative Models Services and Staffing

 School-Linked Health Centers • Can mirror the service and staffing patterns of primary care only, primary care-mental health, and primary care-mental health PLUS models  Mobile Health Centers • Can mirror the service and staffing patterns of primary care only, primary care-mental health, and primary care mental health PLUS models 41

What Services Do SBHCs Offer?

42

Primary Care Services Provided by SBHCs

(N= 1176-1259) Dental Comprehensive Care Dental Preventive Care Dental Screenings/Diagnostics Care for Infants of Students Medications Dispensed to be Taken at Home Assessment of Psycholigical Development Standardized Behavioral Risk Assessment Lab Tests Immunizations Treatment of Chronic Illness Medications Administed in the Center Nutrition Counselling Sports Physicals Asthma Treatment Anticipatory Guidance Prescriptions for Medicines Screenings Comprehensive Health Assessments Treatment of Acute Illness 0 10 20 30 40 50 60 70 80 90 43 100

Reproductive Health Services Offered to Adolescents on Site (n= 897-931 ) Prenatal Care Pap Smears HIV testing Follow- up of Contraceptive Users Urine Based Chlamydia Screening Sexual Orientation Counseling Gyn Exams Chlamydia Screening STD Diagnosis and Treatment Counseling for Birth Control HIV AIDS Counseling Abstinence Counseling Pregnancy testing

community type

0 10 20 30 40 50 60 70 80 90 44

Contraception Prohibition

(N=853)

NO 30% YES 70% Other Don’t know State Policy School Policy State Law Health Center School District 0 10 20 Who Prohibits Dispensing Contraceptives in SBHCs 30 40 50 60 70

45

Mental Health Services in SBHCs With (n=805) and Without (n=388) Mental Health Providers

*Medication Mngt/Admin *Long Term Therapy *Psycho-education *Case Management *Substance Use Counseling *Brief Therapy *Tobacco Use Counseling *Conflict Res/Mediation *Skill-Building *Screening *Referrals *Assessment *Crisis Intervention *Grief and Loss Therapy *Mental Health Diagnosis 0 * P<.01

With MH Staff Without MH Provider 10 20 30 40 50 60 70 80 90 100

46

SBHC Fundamental Principles

http://www.nasbhc.org/site/c.jsJPKWPFJrH/b.274345

9/k.9519/NASBHC_Principles_and_Goals_for_SBHC s.htm

47

The School-Based Health Center:

1.

2.

3.

4.

5.

6.

7.

Supports the school Focuses on the community Focuses on the student Provides comprehensive care Advances health promotion activities Implements effective systems Provides leadership in adolescent and child health 48

Supports the School

The school-based health center is built upon mutual respect and collaboration between the school and the health provider to promote the health and educational success of school-aged children.

49

1. Supports the School Principles/ Goals

 Understands and respects accountability within the educational system  Works with the school administration to develop and achieve a shared vision  Communicates the vision to all school constituencies including teachers, support staff, students and parents  Builds collaborative and mutually respectful relationships with school personnel  Identifies community resources that provide support to students and promote successful learning  Serves as a resource in times of school crises and community disasters

Structures Processes

 Mutually agreed upon vision statement for the SBHC  Mutually agreed upon roles and responsibilities of each party  Mutually agreed upon policies regarding appointment scheduling during school hours and information sharing  Communication with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty  Attendance of SBHC personnel at school staff meetings  Presence of SBHC personnel at appropriate school functions  Delineated role within the school’s crisis intervention plan  Partnership in identifying students with issues influencing educational performance  Training of SBHC staff on the school’s crisis intervention plan and community’s emergency preparedness plan and the SBHCs expected response

Outcomes

 Recognition by school personnel of the value the SBHC provides in meeting educational mission  High satisfaction of school personnel with SBHC services  Increased number of appropriate referrals by school personnel  Reduced number of students who leave school during the day due to illness  In the event of a school crisis or community disaster, SBHC performs effectively according to plan 50

Responds to the Community

The school-based health center is developed and operates based on continual assessment of local assets and needs .

51

2. Responds to the Community Principles/ Goals

 Assesses child and adolescent health care needs and available resources in the community through formal evaluation methods

Structures

 Definition of geographic service area  Identification of population to be served including demographic and socioeconomic characteristics  Informs the community of student health needs and trends  Identification of key health indicators  Solicits community input to address unmet health needs and support the operations of the program  Continuous needs assessment  System for gathering data on key indicators  Resource manual  Advisory Committee with appropriate community representation  Communications plan

Processes

 Program development based on periodic review of data

Outcomes

 Improved access to primary care as measured by increased utilization of SBHC services  Advisory Committee meetings  Stakeholder meetings  Periodic communication with the general public  Recognition by community of the value of SBHC services in meeting the needs of students and responding to community values  High parent satisfaction  Improved utilization of other community resources through referrals and/or inter program collaboration 52

Focuses on the Student

Services involve students as responsible participants in their health care, encourage the role of parents and other family members, and are accessible, confidential, culturally sensitive, and developmentally appropriate.

53

3. Focuses on the Student Principles/Goals Structures Processes Outcomes

 Encourages the student’s active, age appropriate participation in decisions regarding health care and prevention activities  Involves the parents or other adult caregivers as supportive participants in the student’s health care whenever appropriate and possible   Ensures confidentiality of information whether transmitted through conversation, billing activity, telemedicine, or release of medical records Provides services and materials that are culturally sensitive and respectful of family values and diversity  parental notification policies  consent policy  Parental consent and Confidentiality and minor Emancipated minor policy  Child abuse and neglect policy    Non-discrimination policy Patient rights and responsibilities  Patient education materials in languages other than English, where appropriate  Methodology for identifying children with special health care needs Methodology for identifying non-users  Provision of services in a manner consistent with established policies  Increased enrollment for and utilization of SBHC services  Treatment of students with acute illness or injury  Counseling of students with behavioral issues  High user and parent awareness of SBHC policy regarding access to confidential services  Management of students with chronic conditions  sensitive anticipatory guidance and health and safety education  Student-centered risk assessment and follow-up  follow-up  Provision of culturally Family assessment and Outreach to non-users  Improved user knowledge of how and when to utilize the health care system  Students with chronic disease or behavioral issues can demonstrate self-care skills  High satisfaction among users.

54

Delivers Comprehensive Care

An interdisciplinary team provides access to high quality comprehensive physical and mental health services emphasizing prevention and early intervention .

55

4. Delivers Comprehensive Care Principles/Goals

 Provides a scope of services that is consistent with identified health care needs

Structures

 Defined scope of services to be provided

Processes

 Population-based Screening  Multidisciplinary team of caregivers  Early identification and treatment  Promotes availability of on site services whenever the school is open and facilitates after-hours care 24-hour-a day, seven-days-a-week  Posted hours of operation  Effective 24/7 on-call system   Delivery of care consistent with best practices Patient assessment  Adopts generally accepted guidelines for clinical practice  Promotes the interdisciplinary role and functions of the school-based health care team  Clinical protocols or practice guidelines consistent with nationally recognized best practices  Coordinates and integrates efforts with existing systems to optimize complementary programs, improve continuity of care, reduce fragmentation, prevent duplication, and maintain affordable services   Referral relationships with other providers in the community (including lab, radiology and pharmacy)   Staffing guidelines Standards for medical record keeping Release of information policy  Patient education  Patient treatment  Patient referral  Management of chronic conditions  Anticipatory guidance, health promotion and prevention activities  Continuity of care  Quality assurance  Chart review

Outcomes

 Patient perception that well-being has improved  Increasing number of students receiving comprehensive well exam including risk assessment  Increasing compliance rates as measured by follow-up visits completed, prescriptions filled, therapy attended, referrals completed.  Reduced number of students with disruptive behavior or discipline problems 56

Advances Health Promotion Activities

The school-based health center takes advantage of its location to advance effective health promotion activities to students and community.

57

5. Advances Health Promotion Activities Principles/Goals

 Serves as a resource to school administration on the selection, development and delivery of health education curricula  Participates in classroom-based and school-wide health promotion activities responsive to the risk factors that are prevalent among students

Structures

 Partnership between the school’s health education faculty and SBHC staff  Coordinated risk assessment and health promotion plan  Age appropriate health education materials  Promotes parent and community involvement in health promotion activities

Processes

 Delivery of classroom health education segments  Display and distribution of multilingual health education materials in SBHC (pamphlets, posters, models, videos, etc.)  School-wide health and safety promotional events

Outcomes

 Increased student awareness of health threats and risk factors  Reduced high risk behaviors among students  Increased positive health and safety behaviors among students  Increased student understanding of important health and psychosocial issues  Increased student ability to access valid health information and health promoting products and services  Increased student knowledge of health care rights and responsibilities  Increased student ability to communicate about and advocate for improved personal health  Increased participation of parents in heath promotion activities 58

Implements Effective Systems

Administrative and clinical systems are designed to support effective delivery of services incorporating accountability mechanisms and performance improvement practices .

59

6. Implements Effective Systems Principles/Goals

 Ensures compliance with all relevant laws and regulations  Develops and measures annual program goals and objectives  Maintains a physical plant which is adequate to deliver high quality services and assure patient comfort and privacy  Develops all necessary policies and procedures, training manuals, and memoranda of agreement or understanding  Develops a human resources system for hiring, credentialing, training and retaining high quality, competent staff  Collects, evaluates and reports health outcomes and utilization data  Establishes quality improvement practices including but not limited to assessment of patient and community satisfaction  Develops strategies and systems to support long-term financial stability

Structures

 Organizational chart  Mission statement  Goals and objectives  Administrative policy and procedure manual  Clinical policy and procedure manual  Appointment system and scheduling standards  Tracking system for missed appointments, follow-up appointments and lab reports  Incident reports  Staff credentialing  Staff training  Personnel evaluation and salary review  Facility maintenance  Strategic business/ marketing/financial plan  Billing and collection system

Processes

 Licensing, Certification and/or Accreditation  CLIA compliance  Medicaid EPSDT compliance  Medical record keeping according to accepted standards and demonstrating collaboration and communication among providers  Formal quality assurance monitoring of clinical and administrative functions  Financial audits

Outcomes

 Staff knowledge of current laws and regulations affecting delivery of services  Treatment for high volume, high risk problems consistent with current professional knowledge  High SBHC provider and staff satisfaction  Low SBHC provider and staff turnover  Increased provider productivity  High patient and parent satisfaction with ease of appointment-making and waiting time  Operations within budget  Eligibility for reimbursement from public and private third-parties 60

Provides Leadership in Adolescent and Child Health

The school-based health center model provides unique opportunities to increase expertise in adolescent and child health, and to inform and influence policy and practice.

61

7. Provides Leadership in Adolescent and Child Health Principles/Goals

 Participates in national and local organizations that focus on adolescent and child health  Contributes to the body of knowledge on the health care needs of adolescents and children

Structures

 Local Conferences  National Conferences  Journal Articles

Processes

 Precepting students in the health professions  Research  Outcome evaluation  Promotes the School-Based Health Center as a training site for health care professionals  Annual Reports\  Videotapes  Process evaluation

Outcomes

 Increased public awareness of the health care needs of children and adolescents  Greater number of children and adolescents with a medical home  Improved access to primary care  Advocates for the resources necessary to increase access to physical, mental and dental health services for adolescents and children  Informs elected officials, policy makers, health professionals, educators, and the community-at-large regarding the unique value, acceptability, efficiency and convenience of the school-based health center model of health care delivery  Forms partnerships to develop stable, sustainable funding mechanisms for expanded services  Web sites  Vehicles to communicate with state and local health authorities  Clinical trials  Medical professional training  Curriculum development  Public education and advocacy  Use of student volunteers  Increased exposure of health professionals to the SBHC model  Legislation and regulation supportive of the SBHC model  Increased investment in SBHCs by federal, state, local and private funding sources  Increased participation of SBHCs in Medicaid and Child Health Insurance Plans  Appropriate contracts with 62 managed care organizations

National Tools and Resources for Getting Started



NASBHC website

www.nasbhc.org

–

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 www.nachc.org

63

Questions and Answers

64