School-Based Health Centers
(SBHCs) 101:
An Overview and Framework for
Building Programs
Laura C. Brey, MS
Tammy Alexander, M.Ed.
NASBHC Training of Trainers
April 21-23, 2008
Getting to Know You Activity
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
3
Objectives
Participants will be able :


Describe who uses school-based health
centers and who sponsors them
List three national school-based health care
models
4
What is a School-Based Health
Center (SBHC)?
5
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
6
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.
7
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.
8
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.
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.
11
Why School-Based Health
Centers?
12
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
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
14
“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.
15
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
16
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
17
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
18
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.
19
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
20
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
21
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.
22
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
23
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
24
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
25
Efficiencies in SBHCs

Parents time off

Follow-up less labor intensive

Identifying problems earlier

Reduction in more costly emergency
room visits
26
National Data and Trends
Census 2004-05
27
Where are SBHCs Located?
N = 1709 28
Location of Health Center (n=1234)

In school building 87%

On school property 11%

Mobile (non-fixed) 2%
29
Types of Schools with Health Centers
( n=1222)
Middle/High
7%
Elementary/
Middle
14%
K-12
14%
High
30%
Elementary
20%
Middle
15%
30
SBHCs by Community
Characteristic (N=1235)
Suburban
14%
Rural
27%
Urban
59%
31
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%
32
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%
33
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%
34
SBHC Service
Delivery Models
35
Primary Care Only Model
NP/PA/MD 1-5 days/week
 Full or part-time (FT/PT) coverage
 No Mental Health/Substance Abuse
Services

36
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

37
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

38
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
39
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
40
SBHC Staffing Models
(N=1235)
Primary Care
Mental Health
Plus
31%
Unknown
4%
Primary Care
Only
31%
Primary CareMental Health
34%
41
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
42
What Services Do SBHCs
Offer?
43
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
44
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
45
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
46
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
47
Examples of Commonly Raised
Concerns and Issues
The 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
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
49
Questions and Answers
50