School-based health centers is an idea that’s quietly gaining traction at schools across the country.
The newest catchphrase in medicine, “patient-centered care,” really boils down to one thing: making access to quality health care as streamlined and intuitive as possible. And when the goal is expanding health care to underserved young people, there’s nothing more intuitive than bringing that care to exactly where they are and where we want them to stay: school.
School-based health centers is an idea that’s quietly gaining traction at schools across the country. Straight from those on the front lines of making health care and health education available to young people, here’s a look at what school-based health centers are, how they’re funded, and why the model is taking hold in the North Bay.
The school-based health center model
School-based health centers (SBHCs) are often the result of partnerships between schools or school boards and community health organizations, such as local health centers, hospitals or county health departments. Each is designed to meet the specific needs of the community it serves. Some are just for students, while others are available to the wider community at specific times. Schools may be responsible only for providing the space for a portable building or may supply unused classroom space and cover custodial and utility costs (with the affiliated health organization covering other costs).
Because these clinics are located on school campuses, local school boards act as the ultimate decision makers on what services are provided. In California, 84 percent of SBHCs offer primary medical services like check-ups and vaccinations, 58 percent offer mental health services and 62 percent offer reproductive health screenings and education. Other services may include dental care, health education and fitness programs. This variety of resources often helps take the stigma out of going to school clinics for some students, as they can be the place to get a sports physical, take a cooking class or seek emotional support during a tough time.
The growth of SBHCs
The increase in SBHCs began in the 1980s, as cash-strapped schools increasingly had to write school nurses and counselors out of their budgets. Most often found in areas with higher poverty rates and lower rates of insured residents, SBHCs were seen as a way to deliver vital medical care to populations that would otherwise go without.
By 1995, the School-Based Health Alliance was formed to address the shared concerns and needs of these health centers nationwide. The California School-Based Health Alliance (CSBHA), formerly known as California School Health Center Association, was later created in Oakland to provide support and advocacy for SBHCs in California.
“Through our policy work in Sacramento and Washington, D.C., we try to generate resources and support for school-based health centers,” says Serena Clayton, executive director of CSBHA. “We also work at the community level to bring school and clinic staffs together to address the on-the-ground issues that need to be worked out to actually make clinics successful.”
CSBHA members can use the organization’s informational toolkits or one-on-one consulting services to start or expand their own SBHCs, learning about everything from optimal clinic layout to billing practices to how to make the most positive impact on students’ academic success.
By far, the biggest thing to happen to SBHCs in some time has been the support they’ve found in 2010’s Affordable Care Act (ACA). According to the U.S. Department of Health and Human Services, the ACA allocated $200 million in funding specifically to build, expand or remodel SBHCs nationwide. The first batch of funding, $109 million, was released in 2011 and 2012 to 323 SBHCs expected to serve more than 493,000 students. An additional 197 SBHCs received the remaining funds in 2013, allowing them to serve an additional 384,000 students.
Clayton predicts that we’ll see about 20 SBHCs opening in California in 2014, thanks to ACA funds, but that growth may then slow down until other forms of public and private funding appear.
“I expect we’ll see ongoing expansion in the next couple of years,” she says. “We’ve seen that, once a school district has one school-based health center, it tends to want more.”
“We surround them with care”
When Elsie Allen High School opened in Santa Rosa in 1995, the new campus included a student clinic, the Elsie Allen Health Center (EAHC). Originally built and funded by St. Joseph Health Foundation, the clinic has been operated by Santa Rosa Community Health Centers (SRCHC) since 2001.
The health center is open to any youth aged 12 to 19 years old and will provide taxi vouchers (for sensitive services) to bring off-campus teens to and from the site. Students can make appointments during the school day or after school, and while the clinic is closed on weekends and most school holidays, it remains open during the summer. On average, the center has 3,600 patient visits per year. SRCHC also operates teen health clinics at its Vista Health Center and Roseland Pediatrics locations. (Roseland Pediatrics used to be operated as a SBHC on the campus of Roseland Elementary School but moved into a larger space offsite last year.)
Meredith Kieschnick, M.D., is a pediatrician for SRCHC who practices at both the EAHC and Roseland Pediatrics facilities. At EAHC, students come in for everything from regular check-ups and immunizations, chronic disease management and treatment of minor injuries to what are termed “sensitive services,” such as pregnancy prevention and sexually transmitted disease counseling.
All SBHCs must conform to a strict set of state and federal guidelines regarding both parental consent and insurance billing. Students seeking nonsensitive services must have a parental consent form and any insurance information on file. SRCHC then bills the appropriate public or private insurer with costs determined on a sliding scale. No student is refused services because of inability to pay.
In keeping with state law, teens can request family planning services without parental consent. Most of the clinic’s reproductive health services are funded through California’s Family Planning, Access, Care and Treatment (Family PACT) program. Family PACT is managed by the state’s Office of Family Planning, through the Department of Health Care Services, and is charged with providing family planning education and services to low-income residents.
“It’s hard for teens to walk up to the pediatrics department at Kaiser and say, ‘I need to be checked out,’ or ‘I need condoms,’ there in front of everyone,” says Kieschnick. “But they feel they can do that in their own little clinic at their high school.”
Kieschnick says that, in the wake of the officer-involved shooting death of 13-year-old Andy Lopez in the school’s Santa Rosa neighborhood, many students have turned to her staff to help them deal with their anger, grief and depression.
“Kids are coming to school facing many issues, whether it be hunger, toothaches or stress about family finances, and they wander into the clinic with a variety of stress-related symptoms, like stomach aches and headaches,” says Kieschnick. “We can treat those and say, ‘Would you also like to speak to a counselor, or get a flu shot or a physical?’ We surround them with care they wouldn’t normally be seeking out.”
Through the ACA, the clinic was awarded a $500,000 grant to remodel its 18-year-old facility. The remodel will include expanding into a classroom that borders the current clinic, providing more room for group support and educational activities.
New clinics in Petaluma
Another recipient of ACA funding for construction of SBHCs is Petaluma Health Center (PHC). Supplemented by donations from Kaiser Permanente Northern California Region and Marin-Sonoma, as well as local donors, PHC is using these funds to expand its health care offerings for Petaluma teens, starting with a new SBHC, which opened in October at San Antonio High School in Petaluma.
PHC previously ran a teen clinic out of its facilities on Southpoint Boulevard, as well as a clinic on Santa Rosa Junior College’s Petaluma campus, but had been in contact with school administrators for years about the possibility of bringing health care directly into the schools. In 2010, when the funding became available, a nurse practitioner from PHC presented the idea to the Petaluma school board and the organization was given the go-ahead to start the planning process.
Currently, about 100 students are affiliated with the San Antonio campus, 75 of whom are students at the on-campus continuation high school and 25 of whom are part of a homeschooling program, Valley Oaks High School. Students from Petaluma High School and other local schools are also welcome, and the clinic will soon be open to the community during after-school hours.
PHC also plans to open another clinic later this year, at Petaluma’s Casa Grande High School, with construction hopefully being completed this summer, just in time to open for the 2014-15 school year. The two clinics will offer a range of primary health care and mental health services, provided on a sliding scale for those without insurance.
“We’re bringing health care services to a group of young people who don’t normally access services for themselves,” says Kathryn Powell, PHC’s CEO. “A lot of students just go without certain health care because they don’t want to talk to their parents about it or can’t get access to it.”
She points out studies that show that, after age 10 or 11, children are less likely to visit the doctor for even routine concerns like a sore throat. The hope is that, by making the process of getting care as easy as possible, and by fostering relationships between students and health care providers, students will be more likely to step inside the clinic doors.
“We have people there who are accessible to the students,” she says. “Our providers can teach them about healthy lifestyles and have a great influence on these kids just by interacting with them on a daily basis.”
School-linked health centers
Some schools don’t have the funding, space or need for a full-time, school-based health center and have found different models to best deliver care to their students. In Novato, a collaboration between school officials, health care providers and community members has made certain medical services available to local teens through Novato Youth Center’s school-linked health programs.
School-linked programs, as opposed to school-based, don’t maintain permanent medical facilities on school grounds, but they do work closely with schools to coordinate services and foster a presence on campuses.
The Novato Youth Center (NYC), in partnership with Marin Community Clinic, operates a weekly teen clinic at the Novato Wellness Center in downtown Novato, centrally located between the city’s two main public high schools. While Marin Community Clinic provides the physical care, NYC provides the facilities, health educators and behavioral and mental health care services.
The teen clinic, which began in 2006 as part of a group called the Novato Youth Wellness Collaborative, doesn’t offer primary care services like EAHC and PHC’s school-based clinics, but rather focuses on integrated reproductive, mental and behavioral health. Youth aged 12 to 21 can access the free and confidential services, offered only on Monday afternoons.
“Youth come in on their own, usually for reproductive health services,” says Kara Vernor, director of operations planning at NYC. “They’re coming in for the services they can’t talk to their parents about, or can talk to their parents about but feel so much more comfortable going somewhere where they feel like people ‘get them.’”
If a mental health or substance abuse concern comes up, there’s a bilingual counselor onsite who can meet with teens immediately. “It takes away any barriers to accessing services and doesn’t rely on youth to identify their own mental health needs, which a lot of teens—and adults—can’t do,” says Vernor.
A cornerstone of the clinic’s community outreach is its peer educator program. Each year, a group of eight high school students go through an initial training program, followed by monthly training sessions, to act as ambassadors for the clinic in the local high schools. These teens, many of whom aspire to careers in health care, give presentations in health education classes each semester about what services are offered and what to expect during a visit to the clinic. They also staff the waiting room, making sure teens are comfortable and providing real-time health education.
“The peer educators put themselves out there as resources for youth who have questions they don’t want to ask in front of everybody,” says Vernor. “They’ve had people drop them notes in their lockers or send them texts. Peer educators have even accompanied people into the clinic who might be shy about visiting.”
NYC employs a health educator who goes out into the middle schools and high schools to teach teens about not only birth control and reproductive health, but also about healthy relationships, boundaries and refusal skills. NYC also provides 13 counseling interns on K-12 campuses throughout Novato, who provide mental health services as needed.
On a national level, Clayton says that other communities have found it helpful to locate their health services in mobile vans that go out to the schools or in centrally located youth centers for multiple schools to access.
“We really want to get people to see the potential here and cultivate their thinking about new solutions, because school-based health centers are one solution—and a great one—but there are probably other ways to deliver health services in schools that we haven’t even conceptualized yet,” she says.
Making the grade
CSBHA tracks data coming from studies around the country trying to measure the effects of SBHCs on children’s health and well being and is eager for word to get out on the findings.
“When we talk about the health benefits, we see that kids who have a health center at school have more access to mental health care and preventive care, the kids with asthma are less likely to miss school or use emergency rooms, and kids are more likely to get an annual physical,” reports Clayton. “There’s a whole range of things [a health care provider] can do better when [they’re] there every day.”
In one 2003 study, children with asthma who attended New York City schools with SBHCs had more than 50 percent fewer emergency room visits than students whose schools didn’t have such clinics. When children can be treated quickly for routine illnesses, sick days are decreased and schools are less likely to miss out on much-needed funding. Clinic staffs can also act as important resources for teachers and administrators trying to help students with physical, emotional or behavioral issues. “When the link between school and clinic is working well, teachers will say, ‘I can’t imagine working at a school that doesn’t have this,’” says Clayton.
The big picture
“We can talk about the benefits of SBHCs in two ways,” continues Clayton. “One is at the broad population level, where more kids get access to health care and the population’s overall health is improved. On the other end of spectrum, for a few kids in those schools, this has changed their lives. They would have dropped out by now. They may have gone through some trauma and really needed to be [at the clinic] every day with people who support them. I hear those stories every day.”
Kieschnick believes that making preventive primary care available to young people gives health care providers a chance to address the root problems that may be causing the chronic absences or underperformance in school that lead some students to drop out, as well as address health issues, like obesity and risky behaviors, that may lead to disease in the future.
“This is really our opportunity, because this is where they are every day,” she says. “We can be at the right place at the right time, not just to talk about family planning but to address the whole teen: exercising, eating right, staying clean and sober, even wearing their seatbelts.”
“This is really the model of ‘patient-centered care,’” concludes Clayton. “You’re basically saying, ‘We’re going to come to you, not wait for you to navigate the transportation and bureaucracy. We have an open door for you right where you are.’”
