Veda Johnson, MDDirector, Partners for Equity in Child and

Adolescent Health Emory University School of Medicine

School Based Health Centers

Health and Education

Why are school health programs important?

Health and Education

Association between health and academic successStudents learn best when they are healthyStudents learn best when they are presentStudents learn best when they are connected

to the school emotionally and sociallyStudents learn best when there is hope

Health…

GeorgiaGeorgia ranks 40th in the nation overall

for child well-being (Kid’s Count 2015). 43rd - Child economic well-being (% in poverty)37th – Overall child health (child & teen

deaths)40th - Overall education (preschool,

proficiencies)40th – Family and Community (single parent,

parents w/ HS diploma)

Health…

GeorgiaWe have the 17th highest childhood

obesity rate in the country (37% OW/OB)29% of our adolescents had significant

episodes of depression during the past 12 months.

26% of our children live in poverty and approx. 240,000 children are uninsured.

Approx. 320,000 children miss more than 10 days of school each year due to illness.

Education…GA Reading

4th graders (2013)34% read at proficient or

better 21% of Low income and

minority students 53% of Higher income

students

8th graders (2013)32% are proficient

GA Math4th graders (2013)

39% are proficient8th graders (2013)

29% are proficient

Education…

In GeorgiaEducational underachievement is

pervasive. GA ranks in the bottom 5 percentage for

high school drop out rates in the country. Approx. 72.5% of our students graduate on

time9.7% of children are absent 15 or

more days from school

Health and Education…

Poor school performance is linked to health-related issues such as hunger, physical and emotional abuse, and chronic illness.

Poor academic outcomes are linked to risky health behaviors such as substance use, violence, and physical inactivity which in turn affect students' school attendance, grades, test scores, and ability to pay attention in class.

Health and Education…

Education is a direct predictor of healthEducation and income are

markers of socioeconomic position. Academic underachievement

contributes significantly to the health disparities observed in children from lower socioeconomic positions

People with lower socioeconomic position are more likely to have worse access to healthcare

Health and Education…

What we know… School health programs and policies can be

an efficient way to prevent or reduce risky health behaviors and avoid serious health problems among students.

They may also help close the educational achievement gap between disparate socioeconomic groups of students.

School Based Health Centers

5 Key DescriptivesPatient and Community-

FocusedAccessible and AffordableComprehensive & Quality

CareMulti-& Inter-disciplinary Outcomes Oriented

SBHCs… ‘School based health centers (SBHCs) represent the

most effective system of health care for the underserved in this country. It is a system of care that essentially eliminates every barrier to healthcare (i.e. cost, hours of operation, transportation, easy access) and the holistic, multidisciplinary approach to providing healthcare is very effective in addressing health disparities in the context of the social determinants of health. In addition, SBHCs provide services in a coordinated, integrated manner where all providers are operating under the same roof and in constant communication with one another. It embodies the quintessential ‘team approach’ to providing health care. This efficient method of service delivery impacts not only the health outcomes of patients but improves student attendance/achievement and significantly reduces the cost of healthcare to the state.’

SBHCs…

Definition:Comprehensive school based health clinics are medical centers that blend medical care with preventive and psychosocial services as well as organize broader school-based and community-based health promotion efforts and includes the following essential components: location within a school building or in close proximity to a school building; provision of comprehensive primary and mental health care; and interrelation of family, school, and community

SBHC’S…

Common Features of School-Based Health Centers:

They are located in schools or in close proximity (school-linked).

The health center works cooperatively within the school to become an integral part of the school.

The health center provides a comprehensive range of services that meet the specific physical and behavioral health needs of the young people in the community as well as providing for the more traditional medical care needs.

A multidisciplinary team of providers care for the students:  nurse practitioners, registered nurses, physician assistants, social workers, physicians, alcohol and drug counselors, and other health professionals.

SBHC’s…

Common Features…

The clinical services within the health center are provided through a qualified health provider such as a hospital, health department, or medical practice.

Parents sign written consents for their children to enroll in the health center.

The health center has an advisory board consisting of community representatives, parents, youth and family organizations, to provide planning and oversight.

SBHC’s…

Seven Basic Principles:

Supports the school Responds to the community Focuses on the student Delivers comprehensive care Advances health promotion Implements effective

systems Provides leadership in

adolescent and child health

SBHCs…

Health Services:The scope of health care services provided by a SBHC is determined at the community level. They may include but are not limited to:

primary care for acute and chronic health conditions mental health services substance abuse services case management services dental health services nutrition education health education and promotion

The services are determined through a collaborative effort between the umbrella health organization, the school, and the community.

SBHCs…

Health Services:The services reflects the health care needs of the children in that specific community and supports the values and regulations of the community and school system.

Services should be provided according to the basic principles of the Patient-Centered Medical Home.

Suggested staffing Medical Provider (nurse practitioner, physician asst., MD) Medical Assistant Licensed Clinical Social Worker Options

Community Outreach Worker Dentist Dental Assistant Dental Hygienist Health Educator

SBHCs…

Research demonstrates that SBHCs effectively address the needs of students:Increased access to quality

healthcareImproved health outcomesDecreased healthcare costsImproved school

attendance and academic performance

Decreased health care costs – Whitefoord Elementary School - Based

Health Clinic

Adams EK, Johnson V. An elementary school-based health clinic: can it reduce Medicaid costs? Pediatrics. 2000;105(4 pt 1):780–788 Compared Medicaid costs to children enrolled in a

SBHC to those not enrolled in a SBHCSummary of findings:

Decrease in total Medicaid costs per child over 2 year period w/SBHC

Significant decrease in In-Patient costs Significant decrease in prescription drug use costs Significant decrease in emergency room costs Decrease more significant across all categories if child used

SBHC as medical home For children with asthma, decrease in Medicaid cost for total

yearly expenditures with significant decreases in inpatient and drug costs.

SBHC’s…

Nationally (National Census – 2010/11)Over 2000 SBHCs

54% in urban settings28% in rural settings18% in suburbs

GeorgiaOnly 2 SBHCs from 1994 – 2009

Partners for Equity in Childand Adolescent Health

Expansion of comprehensive school based health center programs in Georgia…Only 2 SBHCs in GA from 1994-2009

Whitefoord Elementary and Coan Middle School

Goal of the program is to increase the number of SBHCs to 10 over a 5 year period.

School Based Health Center Project

The development and expansion of SBHCs has four basic elements.

Recognized community need and support

SustainabilityEvidence of health and cost impactFidelity to model programs

Our efforts to expand SBHCs in Georgia capture these four elements within 3 phases – planning, implementation, and sustainability.

School Based Health Center Project

Planning PhaseSolicited applications and provided 12

month planning grants to counties/communities interested in establishing a SBHC

Grantees participated in developing community advisory group, conducting needs assessment, defining strategies to address needs, identifying specific school for clinic services, and developing a business plan for establishing SBHC

School Based Health Center Project

Awarded School Based Health Centers (SBHCs) planning grants to 29 counties representing 34 communities throughout the state of Georgia.Yellow- year 1Green – year 2Orange – year 3Blue – year 4

Scheduled to fund 4 additional sites this year.

School Based Health Center Project

Implementation PhaseIn October of 2012, Healthcare Georgia

Foundation (HCGF) provided funding to support the start-up of three SBHCs in Georgia. Lake Forest Elementary SBHC located in Sandy

Springs GA (Family Health Centers of Georgia FQHC)

Turner Elementary SBHC located in Albany GA (Albany Area Primary Health Care FQHC) Tiger Creek Elementary SBHC located in Tunnel Hill

GA (Primary Care Health Centers of Dade FQHC)

Implementation Phase

The process included:District and School engagement along with

School Board approvalIdentification of Space for SBHC and

renovation of spaceSBHC Sponsoring organization: Staff hiring,

‘Change of Scope’ approval from HRSA, Medicaid certification and staff credentialing

Student Recruitment, enrollment, and utilization

Advisory Council Input

Implementation/Planning Phase

As a result of the implementation/planning phases:Six (6) new SBHCs were established. Three were

established through a grant provided by Healthcare Georgia Foundation (Catoosa County, Fulton County, and Dougherty County)

Several School Telemedicine programs were established40+

Mental Health Services are provided in 2 schools 

5 new sites are slated to become operational during the 2015-2016 school year.

Sustainability Phase

In 2014, 2nd round of funding from HCGFSBHCs developed a sustainability plan that

included:developing strong partnerships, clinic outreach and marketing, establishing quality benchmarks and creating a strong business model

SBHC budgets developedBenchmarks for clinic utilization and

patient revenue were established

Sustainability Phase

Why FQHCs as SBHC sponsoring organizations?Aligns with the mission of caring for the underservedIncreased capacity to sustain the efforts

Increased Medicaid ReimbursementsAccess to Federal Grants

o New Access Pointso Expanded Service Grants

Nationally, 40% of SBHCs sponsored by FQHCs

Turner Elementary School-Based Health Center (Albany, GA)

March, 2013

Lake Forest Elementary School-Based Health Center (Atlanta, GA)

May, 2013

Tiger Creek Elementary School-Based Health Center (Tunnel Hill, GA), May 2013

North Clayton High School-Based Health Center (Atlanta, GA), January 12, 2015

Evaluation of SBHCs in GA

Questions included:How do SBHCs increase access to health care?What is the impact of SBHCs on the management of

asthma and obesity for identified patients?What is the impact of SBHCs on students receiving on

schedule health checks and immunizations?What is the impact of enrollment and utilization in

SBHCs on school attendance and seat time?What actions are taken by SBHCs to ensure long-term

sustainability?What is the impact of utilization of SBHCs on cost to

the state’s Medicaid system?

Evaluation…

How do SBHCs increase access to health care?High enrollment of students in SBHCs over

1st 2 years72% - 87% enrolled over the first 2 years

Increasing patient encounters from year 1-2Two-fold increase in patient encounters – Tiger Creek1/3rd increase in patient encounters for Turner and Lake

Forest

Utilization

Evaluation…

What is the impact of SBHCs on the management of asthma and obesity for identified patients?increase in the percentage of asthma patients with flu shots at 2

sites.> 80% of students with asthma action plan

Benchmark – 80% of students. > 90% of students had the severity level documented for 2 sites.

Benchmark – 90% of students Very few ER and hospitalizations for asthma

no emergency room visits or hospitalizations for Tiger Creek asthma patients

Turner Elementary asthma patients had 3 ER visits and 3 hospitalizations in year 1; 6 ER visits and 2 hospitalizations in year 2.

Evaluation…

What is the impact of SBHCs on students receiving on schedule health checks and immunizations?Increase in number of health checks for all 3 sites

from year 1 to 2100% of students w/ Psychosocial screenings at Turner and

Lake Forest; >95% at T. Creek during health check visit. Immunizations up-to-date for all patients 0-6 years of

age at Turner and Lake Forest>98% of adolescents (186) fully immunized for

Menactra, HPV#1, and Tdap at TurnerIncreased flu vaccines at Turner and Lake Forest

Evaluation

What is the impact of enrollment and utilization in SBHCs on school attendance and seat time?Only one site, Lake Forest, collected data on seat time and absenteeism44% and 38% increase in seat time from

pre-SBHC to post – SBHC, years 1 & 2 respectively

Decrease in numbers of days missed due to illness between years 1 & 2

Evaluation…

What actions are taken by SBHCs to ensure long-term sustainability?Start-up cost for Year 1:  $200,000 -

$250,000 75% in personnel costs (Full-time Nurse Practitioner or Physician’s Assistant; full

time Licensed Clinical Social Worker; full time Medical Assistant) 12% in medical equipment 7% in medical and office supplies 6% in office equipment/furniture

In-Kind for Year 1:  $170,000 22% for pediatrician/family practitioner oversight provided by medical sponsor

organization 38% for school nurse provided by school system (if a school nurse is present in

the school) 40% for space and utilities provided by school system (fluctuates based on

square footage of space provided)

Evaluation…

What actions are taken by SBHCs to ensure long-term sustainability?Year 2/ Sustainability costs: $150,000 -

$200,000.00 (Direct)o Dependent on productivity and billing capacity of

organizationso Advantage of FQHCs

Year 2 In-kind costso Same as year 1

State Investment in SBHCs2011 Census

18 states investing in SBHCs$89.6 million annually in total investments875 SBHCs supported by state fundingInvestments from state increased by 122% since

1996Funding sources:

General State Funding - $60 millionTobacco Settlement - $9.2 millionTitle V MCH Block Grant - $5.6 millionOther - $14.8 million

Potential Return on Investment

Increased access to quality healthcare

Improved health outcomes

Decreased healthcare costs

Improved school attendance and academic performance It is easier to build strong children than to repair

broken men.”

Frederick Douglass (1817–1895)