Transcript Preventive Services Improvement Initiative

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 schoolbased health centers are there in the US and
where are they located
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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
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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
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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 works
in collaboration with school nurses and
other service providers in the school and
community.
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School-Based Health Center
National Definition

SBHCs have a policy on parental
consent.

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 provide
comprehensive medical, mental health
and health education services.
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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 and
access to students, the health center
team is able to reach out to students to
emphasize prevention and early
intervention.
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, school districts, and
individual and agency health care
providers.
9
School-Based Health Center
National Definition


Services typically offered in SBHCs are age
appropriate and address the most
important health needs of children and
youth.
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, nutrition
education, health education and health
promotion.
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.
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Why School-Based Health Centers?
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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
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“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.
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The Evidence Base for SchoolBased 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
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What Does the Literature Tell Us
About Emergency Room Use and
SBHCs?


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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
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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 SchoolBased Primary Care, 2005
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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.
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What Does Science Tell Us About
Education and SBHCs

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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
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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
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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.
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The Health-Academic Outcomes Connection
Health Risk
Behaviors
Graduation
GPA
Standardized test scores
Substance use
Mental health
Poor diet
Intentional injuries
Physical illness
Self-esteem
SBHCs
Attendance
Dropout Rates
Behavioral Problems
Sexual behaviors
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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
• Identify students
at-risk for health
and behavioral
problems
• Assist in IEP
development
• Provide mental
health services
• Treat acute
conditions
• Manage chronic
conditions
Increase
attendance
• 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
Meet
government
regulations
• Refer students • Immunize
to services not
students
provided in the • Participate in
SBHC
community
• Provide
initiatives on
preventive
public health
health services
such as
obesity and
• Treat acute
emergency
conditions
planning
• Manage
• Maintain
chronic
health
conditions
records for
• Conduct sports
migratory
physicals
students
• Provide mental
health services
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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
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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%

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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)
Suburban
14%
Rural
27%
Urban
59%
30
Who Uses SBHCs?
Ethnic/Racial Profile of Student Population in Schools
with SBHCs (n=1235)
Asian
4%
Hispanic
34%
Native
American
1%
Other
1%
White
30%
Black
30%
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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%
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50%
Who Sponsors SBHCs (n=1233)
Private Other, 3%
Nonprofit
Organization,
University
12%
(Medical,
Nursing, Public
Health), 4%
Hospital/
Medical Center
29%
Local Health
Department
18%
Community
Health Center
22%
School
System
14%
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SBHC Service
Delivery Models
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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

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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
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Staffing for Primary Care-Mental
Health PLUS Model
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
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

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 CareMental 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 caremental health PLUS models
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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
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0
10
20
30
40
50
60
70
80
90
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
community type
Pregnancy testing
0
10
20
30
40
50
60
70
80
90
44
Contraception Prohibition
(N=853)
NO
30%
YES
70%
Other
Don’t know
Who Prohibits Dispensing
Contraceptives in SBHCs
State Policy
School Policy
State Law
Health Center
School District
0
10
20
30
40
50
60
70
45
Mental Health Services in SBHCs With (n=805) and
Without (n=388) Mental Health Providers
*Medication Mngt/Admin
With MH Staff
*Long Term Therapy
Without MH Provider
*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
10
20
30
40
50
60
70
80
90
100
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SBHC Fundamental
Principles
http://www.nasbhc.org/site/c.jsJPKWPFJrH/b.274345
9/k.9519/NASBHC_Principles_and_Goals_for_SBHC
s.htm
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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
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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.
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1. Supports the School
Principles/ Goals
Structures
Processes
Outcomes
 Understands and respects
accountability within the
educational system
Mutually agreed upon
vision statement for
the SBHC
Works with the school
administration to develop and
achieve a shared vision
Mutually agreed upon
roles and
responsibilities of
each party
Communication with
School Administration,
School Nurse, Guidance
Counselor, Social Worker,
School Psychologist and
Faculty
Recognition by school
personnel of the value the
SBHC provides in meeting
educational mission
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
Mutually agreed upon
policies regarding
appointment
scheduling during
school hours and
information sharing
Delineated role within
the school’s crisis
intervention plan
Attendance of SBHC
personnel at school staff
meetings
Presence of SBHC
personnel at appropriate
school functions
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
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.
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2. Responds to the Community
Principles/ Goals
Structures
Processes
Outcomes
Assesses child and
adolescent health care
needs and available
resources in the community
through formal evaluation
methods
Definition of geographic
service area
Program
development based
on periodic review of
data
Improved access to
primary care as
measured by increased
utilization of SBHC
services
Informs the community of
student health needs and
trends
Solicits community input
to address unmet health
needs and support the
operations of the program
Identification of population to
be served including
demographic and
socioeconomic characteristics
Advisory Committee
meetings
Identification of key health
indicators
Stakeholder
meetings
Continuous needs
assessment
Periodic
communication with
the general public
System for gathering data on
key indicators
Resource manual
Advisory Committee with
appropriate community
representation
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 interprogram collaboration
Communications plan
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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
Parental consent and
parental notification policies
Provision of services in a
manner consistent with
established policies
Increased
enrollment for and
utilization of SBHC
services
Involves the parents or other
adult caregivers as
supportive participants in the
student’s health care
whenever appropriate and
possible
Emancipated minor policy
Ensures confidentiality of
information whether
transmitted through
conversation, billing activity,
telemedicine, or release of
medical records
Patient rights and
responsibilities
Provides services and
materials that are culturally
sensitive and respectful of
family values and diversity
Methodology for identifying
children with special health
care needs
Confidentiality and minor
consent policy
Child abuse and neglect
policy
Non-discrimination policy
Patient education materials
in languages other than
English, where appropriate
Methodology for identifying
non-users
Treatment of students
with acute illness or injury
Counseling of students
with behavioral issues
Management of students
with chronic conditions
Provision of culturally
sensitive anticipatory
guidance and health and
safety education
Student-centered risk
assessment and follow-up
Family assessment and
follow-up
Outreach to non-users
High user and
parent awareness of
SBHC policy
regarding access to
confidential services
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.
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Delivers Comprehensive Care
An interdisciplinary team provides
access to high quality
comprehensive physical and
mental health services
emphasizing prevention and early
intervention.
55
Principles/Goals
Structures
Processes
Outcomes
Provides a scope of
services that is consistent
with identified health care
needs
Defined scope of services
to be provided
Population-based Screening
Patient perception
that well-being has
improved
Promotes availability of onsite services whenever the
school is open and facilitates
after-hours care 24-hour-aday, seven-days-a-week
Adopts generally accepted
guidelines for clinical practice
Promotes the
interdisciplinary role and
functions of the school-based
health care team
Coordinates and integrates
efforts with existing systems
to optimize complementary
programs, improve continuity
of care, reduce
fragmentation, prevent
duplication, and maintain
affordable services
Multidisciplinary team of
caregivers
Posted hours of operation
Effective 24/7 on-call
system
Staffing guidelines
Clinical protocols or
practice guidelines
consistent with nationally
recognized best practices
Referral relationships with
other providers in the
community (including lab,
radiology and pharmacy)
Standards for medical
record keeping
Release of information
policy
Early identification and
treatment
Delivery of care consistent
with best practices
Patient assessment
Patient education
Patient treatment
Patient referral
Management of chronic
conditions
Anticipatory guidance,
health promotion and
prevention activities
Continuity of care
Quality assurance
Chart review
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
Structures
Processes
Outcomes
Serves as a resource to
school administration on
the selection,
development and delivery
of health education
curricula
Partnership
between the
school’s health
education faculty
and SBHC staff
Delivery of
classroom health
education
segments
Increased student awareness of health
threats and risk factors
Participates in
classroom-based and
school-wide health
promotion activities
responsive to the risk
factors that are prevalent
among students
Promotes parent and
community involvement
in health promotion
activities
Coordinated risk
assessment and
health promotion
plan
Age appropriate
health education
materials
Display and
distribution of
multilingual health
education materials
in SBHC
(pamphlets,
posters, models,
videos, etc.)
School-wide
health and safety
promotional events
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 persona
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
Structures
Processes
Outcomes
Ensures compliance with all
relevant laws and regulations
Organizational chart
Develops and measures annual
program goals and objectives
Goals and objectives
Licensing,
Certification
and/or
Accreditation
Staff knowledge of
current laws and
regulations affecting
delivery of services
CLIA compliance
Treatment for high
volume, high risk
problems consistent
with current
professional
knowledge
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
Mission statement
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
Medicaid
EPSDT
compliance
Medical record
keeping
according to
accepted
standards and
demonstrating
collaboration and
communication
among providers
Collects, evaluates and reports
health outcomes and utilization
data
Staff credentialing
Establishes quality improvement
practices including but not limited
to assessment of patient and
community satisfaction
Personnel evaluation and
salary review
Formal quality
assurance
monitoring of
clinical and
administrative
functions
Facility maintenance
Financial audits
Develops strategies and systems
to support long-term financial
stability
Strategic business/
marketing/financial plan
Staff training
Billing and collection system
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
60
third-parties
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
Structures
Processes
Outcomes
Participates in national and local
organizations that focus on adolescent
and child health
Local
Conferences
Precepting
students in the
health professions
Increased public awareness
of the health care needs of
children and adolescents
Research
Greater number of children
and adolescents with a
medical home
Contributes to the body of knowledge
on the health care needs of adolescents
and children
Promotes the School-Based Health
Center as a training site for health care
professionals
Advocates for the resources necessary
to increase access to physical, mental
and dental health services for
adolescents and children
Informs elected officials, policymakers, 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
National
Conferences
Journal Articles
Annual
Reports\
Videotapes
Web sites
Vehicles to
communicate
with state and
local health
authorities
Outcome
evaluation
Process
evaluation
Clinical trials
Medical
professional
training
Curriculum
development
Public education
and advocacy
Use of student
volunteers
Improved access to primary
care
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
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Questions and Answers
64