SBHC 101: Nuts and Bolts of Starting a
Successful School-Based Health Center
in a Community School
Laura Brey, MS, NASBHC Training Director
Lisa Handwerker, MD, FAAP, Medical Director, The Children’s Aid Society
Coalition for Community Schools, 2010 National Forum
April 7, 2010
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Objectives
Define the term school-based health center.
Describe three national school-based health care models
List the five nuts and bolts for planning and implementing a successful school-based health center
Our Vision
All children and adolescents are healthy and
achieving at their fullest potential.
Our Mission
To improve the health status of children and youth
by advancing and advocating for school-based
health care
Adopted by Board of Directors, January 2009
Adopted by Board of Directors, January 2009
Our Core Values
NASBHC believes that:• Children and adolescents need high quality, accessible, culturally competent,
comprehensive health care.
• The school setting is a sensible and appropriate place to deliver health care
because that is where the students are.
• Ideally, the full scope of services is provided directly in a SBHC; alternative models
may be dictated by resources and the needs of the community.
• SBHCs reduce health inequities and improve health outcomes for underserved youth.
• SBHCs should be fairly reimbursed for the high-quality health services they provide.
NASBHC Membership
Individual $75 ($25 student)
A national voice advocating for SBHCs at the Federal level
Quarterly newsletter
Events calendar
Online renewal
Free access to NASBHC publications
Access to members-only space on NASBHC.org
– Searchable member directory
– Archived issues of the newsletter
– Special member updates
– Archived NASBHC Web
conferences
Free access to NASBHC toolkits
Organizational $500
All of the benefits of an individual membership, AND
Two individual memberships
Access to job board with ability to post positions
50 customizable postcards promoting the SBHC model
E-mail updates and action alerts for the entire staff (requires submission of a staff e-mail roster)
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What is a School-Based Health
Center (SBHC)?
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SBHC: 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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SBHC: 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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SBHC: 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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SBHC: 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.
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SBHC: 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.
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SBHC: 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?
Group Activity
Why School-Based Health Centers?
– Think of yourself as a school aged child, pick
your age, or
– Think of your own child or adolescent, or
– Think of family members, neighbors as a school
aged child
– Using the first letter of your first or last name, or
draw an alphabet card, come up with a reason
for having a SBHC in your community
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Why SBHCs?
Uninsurance among children, especially adolescents
Geographic and financial barriers to health, mental health, and oral health
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 SBHC movement
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The Evidence Base for SBHCs
Research published in professional literature
National and state data
– National State Initiative Survey
– NASBHC Triennial 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 the Literature Tell Us About
Emergency Room Use and SBHCs
Reduced inappropriate emergency room use,
Increased use of primary care, and
Fewer hospitalizationsSantelli 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 the Literature Tell Us About
Asthma and SBHCs
Greater than 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
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What the Literature Tell Us About
Mental Health and SBHCs
SBHCs attract harder-to-reach populations, especially minorities and males and 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.
What 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: student success
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What We Know Intuitively
Healthy students make better learners
You cannot 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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SBHCs
Health Risk
BehaviorsSubstance use
Mental health
Poor diet
Intentional injuries
Physical illness
Self-esteem
Sexual behaviors
Attendance
Dropout Rates
Behavioral Problems
Graduation
GPA
Standardized test scores
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.
The Health-Academic Outcomes Connection
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SBHC Outcomes and Tactics
Reduce barriers to learning
Increase attendance
Improve student health
Meet government regulations
• 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
• 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
• Immunize students
• Participate in community initiatives on public health such as obesity and emergency planning
• Maintain health records for migratory students
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The Medical Home
Half of SBHCs estimate more than 30% of their enrollees use the center as their medical home
40% of SBHCs estimate 50% or more of their enrollees use the center as their medical home
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Efficiencies in SBHCs
Parents do not need to take time off
Follow-up is less labor intensive
Ability to identifying problems earlier
Costly emergency room visits reduced
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National Data and Trends
Census 2007-08
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2007-08 National SBHC Census
Total number of SBHCs = 1910
Total number of respondents = 1226
Response rate 64% (1226/1910)
Completed by person most knowledgeable about clinical care
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SBHCs by State (n=1910)
State Total # of Open SBHCs State Total # of Open SBHCs
Alabama 5 Nebraska 1
Alaska 3 Nevada 6
Arizona 81 New Hampshire 1
Arkansas 2 New Jersey 40
California 160 New Mexico 79
Colorado 45 New York 206
Connecticut 79 North Carolina 49
Delaware 28 Ohio 20
District of Columbia 4 Oklahoma 11
Florida 245 Oregon 51
Georgia 3 Pennsylvania 28
Illinois 60 Puerto Rico 2
Indiana 87 Rhode Island 2
Iowa 16 Saskatchewan 1
Kansas 2 South Carolina 7
Kentucky 20 South Dakota 6
Louisiana 64 Tennessee 21
Maine 26 Texas 70
Maryland 71 Utah 5
Massachusetts 59 Vermont 5
Michigan 90 Virginia 19
Minnesota 16 Washington 20
Mississippi 31 West Virginia 50
Missouri 3 Wisconsin 8
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SBHCs by Location (n=1226)
In school building 95.7 percent
On school property 2.9 percent
Mobile 1.4 percent
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SBHCs by types of School (n=1096)
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SBHCs by Community Characteristic (n=1235)
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SBHCs by Population Served (n=1096)
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SBHCs by Sponsoring Agency (n=1096)
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SBHC Service
Delivery Models
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Primary Care Only Model
Medical provider (NP/PA/MD) 1-5 days/week
Full or part-time (FT/PT) coverage
No mental health or substance abuse services
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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 and 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
– Clinical Social Worker
– Psychologist/Psychiatrist
May include substance abuse counselor
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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
School nurse
Medical provider (NP/PA/MD)
Mental health provider
Dentist/Dental hygienist
Addictions counselor
Nutritionist
Health educator
Social worker
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SBHCs by Staffing Model (N=1017)
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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
Examples of Commonly Raised
Concerns and IssuesThe following are issues that typically
arise when discussing SBHCs and being prepared to answer adequately is the best strategy.
– Reproductive Health
– Parental Consent
– Cost
– Why in a school setting – resources
concern
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Participant Expectations
Complete the index card and hand it in.
NASBHC
Roadmap
NASBHC
Roadmap
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Collaboration and Partnerships
Nut and Bolt #1
Collaborative Partnerships
A mutually beneficial and well-defined relationship among two or more organizations to JOINTLY develop structure
• Responsibility
• Resources
• Authority
• Accountability
• Rewards
Why have a Collaboration?
To accomplish a common goal that none of the units can attain alone
To help agencies share information, resources, staff, and equipment
To create and share an awareness of needs, challenges, and opportunities
Characteristics of a Successful
Collaboration
Concrete, achievable work plan and goals
Well-defined leadership
Clear roles and responsibilities
Mutually respectful environment that facilitates commitment and sharing of ideas
Cooperative teams
Characteristics of a Successful
Collaboration Established core team
Transparent processes
Exchange and respect knowledge and talent
Shared decision making
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Establish a Planning Group
Composition Considerations
• Local health department
• Community or rural health center
• Community and/or teaching hospital(s)
• Mental health, substance abuse, and social service agencies
• Private physicians
• University faculty
• Elected Officials
• Business and community leaders
• Faith community
• School superintendent, board, or designee
• School administration and Faculty (school nurse, teachers, principals, guidance counselors, physical education, nutrition/food services)
• Students
• Parents
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Conduct the Needs Assessment
Nut and Bolt #2
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What is a Community Needs
Assessment?
A process for:
identifying needs and resources in a community
determining gaps between what a situation is and what it should be
establishing priorities
An opportunity to paint a picture of the conditions in a community and sharpen your perceptions of the critical issues children and families face.
Why conduct a needs assessment?
An accurate appraisal of the current situation (strengths, concerns, and general conditions) of a community’s population
An opportunity to paint a picture of the conditions and sharpen your perceptions of the critical issues children and families face
Outcome of a needs assessment
Better understanding of your community
Document need to rally supporters and
funders
Increased awareness of strengths and
needs
Identify hidden strengths or
underutilized resources
Outcome of a needs assessment
Alignment of actions with identified needs
Garner greater support and involve more
people in subsequent action
Give voice to individuals in the community
who have not traditionally been solicited for
comment
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Nut and Bolt #3
Funding for SBHCs
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Maslow’s Hierarchy of Need
It’s hard to focus on
best practice standards
when your needs are
rooted in basic survival.
School health clinics
fight for lives
Karina BlandThe Arizona RepublicMarch 12, 2001
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Foundations
Federal Public
Grants
Local
Funding/
Community
Partners
State Public
Grants
SCHIP
Medicaid
Private insurance
Patient fees
Federal entitlement programs
administered at the state level
MCHB/Title V
CDC HIV/AIDS Prevention
SAMHSA/Title XIX (substance abuse
and mental health screening and early
intervention)
Title XX/ Soc Services Block Grant
(TANF, daycare, child neglect and
abuse)
State Funding
State General Revenue
Tobacco Tax/Settlement
Education
NCLB /ESEA (Title I improving
academic achievement of the
disadvantaged and Title IV safe and
drug free schools)
IDEA (health-related special
education services)
BPHC/FQHC (Section 330 of
the Public Health Service Act)
Title X of the Public Health
Service Act: Family Planning
Figure 1 School-Based Health Center Funding Models
Patient revenue
Foundations that commonly
supports school-based health
care
Robert Wood Johnson
Foundation
KB Reynolds Charitable Trust
WKKF Kellogg Foundation
Welborn Foundation
McKesson Foundation
Duke Endowment
Health Foundation of Greater
Cincinnati
Visit the Grantsmanship Center
at http://www.tgci.com/ and the
Foundation Center at
http://fdncenter.org for other
foundation funding
opportunities
Local Funding
Public and private grants (e.g.,
universities, United Way)
City/county funds
Local businesses (e.g., banks,
insurance companies)
Community Partners
In-Kind Contributions from schools,
hospitals, health departments,
community health departments, and
community agencies (e.g., staff,
facilities, supplies)
Examples of Partners
Parents’ employers
Parents’ health insurance agencies
Local businesses
School districts
Universities
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Nut and Bolt #4Developing a Case Statement for a
School-Based Health Center
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Case Statement Content
Purpose
– What you propose to do / what are you
seeking funding for
– Summary of needs assessment findings
– Partners/collaborators and their
contributors
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Case Statement Content
Service design
– Model
– Services
– Staffing
– Hours of operation
– Parent, student, and school staff
involvement
– Community, collaborator/partner
involvement
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Case Statement Content
Current project support /infrastructure
– Sponsoring organizations
– Health center planning group activities
– In-kind contributions of
partners/collaborators
– Implementation grant possibilities
Proposed Budget
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Nut and Bolt #5
Communications and the Media
Communications
Discipline that studies the principles of transmitting information and the methods by which it is delivered
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Media Methods
Print media
Broadcast media
Social Media
Access to the media is access to the public
Know the types of stories publication(s) or station(s)
cover and how they report the news
Be an available information resource
Don’t be afraid to approach them with an issue or a
story idea
Keep relationships friendly and honest
Remember, they are doing their job—try to make it
easier for them
Communicating with the Media
Strategic communications strategies
News releases, Letters to the Editor, Op Eds
Blogs
E-newsletters and e-blasts
Referral network
Online resources
The Children’s Aid Society
Community Schools
School–Based Health Centers
Lisa Handwerker, MD, FAAP
Medical Director
The Children’s Aid Society
The Children’s Aid Society
Community Schools
The first school was Salomé Ureña de Henriquez Middle Academies, opened in March of 1992, followed by PS 5 which opened in 1993
The Children’s Aid Society
Community Schools Both schools started
as full-service schools– before and after
school programs
– parent involvement programs
– adult education
– health
dental
medical
mental health
CAS Developmental Triangle
services that remove barriers to learning
• physical health• dental health
• mental health• social services
Key Program Components
After-School and Summer Enrichment
Parent Involvement
Adult Education
Medical, Dental, Mental Health and Social Services
Early Childhood
Community and Economic Development
The Children’s Aid Society
Community Schools Model17 Community Schools in New York City 100% have Out of School Time
– 100% after school programs
– 65% (11/17) Summer programs
– 47% (8/17) Saturday and/or Holiday programs
76% (13/17) have Youth Development programs
47% (8/17) offer Family Support Services 82% (14/17) offer Adult Programs
CAS Community Schools
Health Services
71% (12/17) have Health Services
Medical
– 6 on-site
– 6 school linked
Dental
– 4 on-site
– 7 school linked
Mental Health
– 12 on-site
CAS Community Schools
School-Based Health Services
5 full service SBHC’s
In 2008/2009 school year
– Total School enrollment: 4544
– Total clinic enrollment: 4026
(89% of school population)
CAS Community Schools
School-Based Health ServicesTotal number of visits: 37,533 >55% of visits were to a
health care provider– 46% to a medical practitioner
– 23% to a dental practitioner
– 31% to a mental health practitioner
Benefits of a SBHC within a
Community School
Communication with principal and school staff
Integration of services
Parent communication
FERPA
Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education.
Generally, schools must have written permission from the parent or eligible student in order to release any information from a student's education record.
FERPA
FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions:
– School officials with legitimate educational
interests
– Appropriate officials in cases of health
and safety emergencies
HIPAA
HIPAA (the Federal Health Insurance Portability and Accountability Act) is federal legislation that protects patient health information. It pertains to individuals receiving care from health professionals. Other than doctors, nurses, mental health counselors or dentists, this may include, for example, pharmacists, clinical health educators, physical therapists, and all health related office staff.
Anyone who has indirect or direct patient contact or access to health information must abide by HIPAA.
HIPAA
WHAT HEALTH INFORMATION IS PROTECTED
Information regarding an individual’s health condition (such as any disease the patient may have);
Information about healthcare services individuals have received or potentially may receive in the future.
Challenges of a SBHC within a
community school Expectations for
information sharing
Boundaries
Expectations for SBHC center staff to be involved in all community schools activities
A great place to work!