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New funds spawning more SBHCs across the US
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When local school officials in Pinellas County, Fla., heard they may be eligible to receive as much as $500,000 in federal grant monies to establish a separate health care facility on their campus to tend to their students’ health needs, it was an easy decision to apply, according to the school district’s spokeswoman.
Melanie Marquez told Infectious Diseases in Children that the district already has three established school-based health centers (SBHCs) and is looking to add one more because the centers have been successful. She said SBHCs are a great fit for the district, where there are a number of medically underserved children. So the school board recently authorized a resolution to apply for the funds and is waiting to hear about the status of its application.
Allison Kempe, MD, MPH, of the University of Colorado School of Medicine, said that SBHCs are particularly helpful for adolescents.
Source: Kempe A
From Pinellas County, Fla., to Washington County, Ore., school administrators across the country have been busy this summer applying for federal grant monies to establish SBHCs on their sites. The funds became available in 2010 under the Affordable Care Act. The first grants — totaling $95 million for 278 centers — were announced last year, and another $1 million is scheduled to follow.
Many federal health officials have said they hope the funds will change children’s access to care. Currently, only about 2,000 SBHCs exist, according to data from the most recent National Assembly on School-Based Health Care (NASBHC) census, but the funds are expected to dramatically boost this number. Although the funding has been heralded by some, some pediatricians, such as
Infectious Diseases in Children Editorial Board member Stan L. Block, MD, have expressed concern that more school treatment could possible disrupt their ability to see children.
“The medical home, vaccine compliance and tracking, and patient rapport would likely suffer as more centers become established. These school-based approaches often skim off the ‘bread-and-butter’ easy cases for pediatricians, leaving us to manage only the complicated, very time-consuming, and costlier (to us) cases,” Block said in an interview. “Conversely, many of these complex adolescent issues and diagnoses, which we see frequently, will also be missed. Economic survival could be in jeopardy for many practices.”
However, the AAP recently released a policy statement on these centers and the pediatric medical home practice. The statement reviewed the opportunities, challenges and recommendations for the integration of SBHCs and some of their documented benefits; addressed the issue of potential conflict with the medical home; and provided recommendations to support the integration and coordination of SBHCs and the pediatric medical home practice.
According to the AAP policy statement, “as SBHCs become more prevalent, pediatricians and other health care providers should be familiar with the role of SBHCs in providing primary care and preventive services to school-aged youth. In addition, it is critical that health care providers working in SBHCs are aware of the importance of supporting the medical home and coordinating care with other primary care providers in the community.”
An overview of SBHCs
SBHCs are exactly what the name implies: the center of health in the schools where they are based. An estimated 33% of SBHCs are located in high schools, 24% are located in elementary or middle schools and 43% are located in alternative schools or schools with a combination of grade levels, according to data from the NASBHC Census Survey.
Students and their families rely on SBHCs to meet their needs for a full range of age-appropriate health care services, typically including:
- primary medical care;
- mental/behavioral health care;
- dental/oral health care;
- health education and promotion;
- substance abuse counseling;
- case management; and
- nutrition education.
Students can receive treatment for acute illnesses, such as influenza, and chronic conditions, including asthma and diabetes. They can also be screened for dental, vision and hearing problems. With an emphasis on prevention, early intervention and risk reduction, SBHC staff are supposed to counsel students on healthy habits and how to prevent injury, violence and other threats.
“[SBHCs] in schools aren’t a natural fit for everybody, but they can be particularly useful and helpful when you have a situation where there are populations of children who aren’t able to access primary care, because of no insurance, to the case of teenagers who don’t want to go to a physician,” said Stephen E. Barnett, MD, who is one of the primary authors on the AAP’s statement about SBHCs.
Stephen E. Barnett
Barnett said there are a number of settings, including inner-city and rural settings, where SBHCs have been established because of a need for health care in vulnerable populations.
“The best way to do it is in conjunction with people who are already providing primary care, like family physicians or pediatricians. When you’ve got a community where being able to access primary care is a problem, often times you may be able to meet that need by setting up SBHCs,” Barnett said. “It is documented that they improve access to care, even among those children who already have a primary care physician.”
Increased access to federal funding
US Department of Health and Human Services Secretary Kathleen Sebelius and US Secretary of Education Arne Duncan last year announced awards of $95 million to 278 SBHCs. Eligible applicants were defined as a SBHC or a sponsoring facility of a SBHC as outlined in the Social Security Act. An objective review committee used the review criteria established in the grant guidance to assess and rank applications. Each reviewer on the objective review committee is screened to avoid conflicts of interest and is responsible for providing an objective, unbiased evaluation based on the review criteria.
“These new investments will help [SBHCs] establish new sites or upgrade their current facilities to keep our children healthy,” Sebelius said in a press release about the grants. “These new or improved sites will help ensure effective, efficient and high-quality care.”
“We know that if kids aren’t healthy, then kids can’t learn,” Duncan said. “These grants will make it a lot easier for working moms and dads to help get their children the health care they need and deserve. This unprecedented investment in school-based health care will bring communities closer together and help children succeed in the classroom.”
Since the announcement last summer, hundreds of districts across the country have applied for funding to establish SBHCs in their towns.
Implementation of programs
Six new SBHC planning sites are currently under way in Oregon, and if approved, will join the 63 SBHCs already established there, according to Robert J. Nystrom, MA, manager of the Adolescent, Genetics and Reproductive Health Section in the Oregon Public Health Division.
Robert J. Nystrom
“Being able to develop these centers is a challenge, but a larger challenge is figuring out an operational budget that is sustainable,” Nystrom told Infectious Diseases in Children. “We have received about $4.8 million in federal monies, and it did spur interest in establishing centers in locations that we’ve never seen interest before, so this money has been successful in that regard.”
Nystrom also said many centers in Oregon are using the funds to establish electronic medical records for the SBHCs.
In Oregon, one of the top visits to SBHCs has been for the mental health component. “Anxiety, conduct problems, attention-deficit/hyperactivity disorder and depression make up a significant part of our care,” he said. “What will typically happen is our kids will present with a stomachache or malaise, and then you dig down deeper, and they’ll tell you, ‘I’m worried about being pregnant,’ or they are in an abusive relationship, experiencing some other circumstances at school or home.”
Nystrom said SBHCs in Oregon commonly give immunizations, injury or acute illness treatment, provide health supervision and screening of other medical issues, including asthma and diabetes. The model emphasizes establishing SBHCs as access points to primary care, so children who may not have been seen previously by a regular doctor, regardless of insurance status can start accessing health care.
Barnett said the most important part of getting an SBHC started is identifying which students are not being served. “It’s usually obvious, so you have to figure out if you are in a rural community or if there are a whole bunch of teenagers in your community who aren’t coming in to have things taken care of.”
The next step is for the school health representative to work with local clinicians to establish a School Health Advisory Council, which should include superintendents, principals and local clinicians and nurses. This council should also include parents and students, and together this committee should look at census numbers and establish which needs should be met, according to Barnett, including dental services or infectious diseases and immunizations.
Success stories
Barnett said identifying which communities are most in need of SBHCs is a good starting point to improve the overall health of a student population. Besides delivery of dental services and addressing immunizations and infectious diseases, SBHCs appear to be cost-effective.
A study published earlier this year by Allison Kempe, MD, MPH, director of the Children’s Outcomes Research Program at the University of Colorado School of Medicine, looked only at a school-based immunization recall system and showed that school-based immunization programs can be cost-effective.
Kempe and colleagues conducted a demonstration study of 265 girls who were due for one or more adolescent vaccinations and a randomized controlled study of 264 boys who also were due for vaccines. Half of the populations received recall and half received standard care. The researchers assessed immunization rates 6 months after recall, and costs of the first doses were evaluated by direct observation and examining invoices.
Kempe and colleagues reported that recall was effective and economical: 77% of girls received one or more vaccines and 45% received all required vaccines, whereas 66% of boys received one or more vaccines and 59% received all vaccines. These results were significant compared with 45% and 36% in the control group. For girls, immunizations among those who needed each of the vaccines were 68% for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, 57% for quadrivalent meningococcal conjugate (Menactra, Sanofi-Pasteur) vaccine, and 59% for the first dose of HPV vaccine. The researchers reported the range of cost to be $1.12 to $6.87 per recalled child who was immunized.
In an interview with Infectious Diseases in Children, Kempe said “SBHCs are very successful” at delivering immunizations in a safe and cost-effective manner.
“SBHCs are fabulous because they attract primarily adolescents, which is important because there are a lot of adolescents not being served elsewhere,” Kempe said. “These SBHCs are generally located in schools with a high percentage of students who are lower income, as demonstrated by a high percentage who qualify for the free and reduced lunch program, and these children may not be being seen elsewhere.”
In both scenarios, both immunization clinics and SBHCs, students are a “captive audience,” which facilitates delivery of necessary vaccines in a comprehensive fashion, Kempe said, adding that she believes the primary strength of SBHCs is an ability to work collaboratively with others for the health of students.
“We have to start collaborating across sectors, private health practitioners, munity health practitioners and schools to accomplish what’s best for the child,” she said. – by Colleen Zacharyczuk
References:
AAP Council on School Health. Pediatrics. 2012; 129:387-393.
www.nasbhc.org/schoolpersonnelhandbook.
Disclosures:
Drs. Barnett, Block and Kempe report no relevant financial disclosures. Mr. Nystrom and Ms. Sebelius report no relevant financial disclosures.
Do you think having a school-based health center in your community would hurt your access to patients, and the practice’s bottom line?
Praful Bhatt
There are many more plusses than minuses for school-based health centers. The No. 1 advantage is immunization. Research has shown that immunization rates improve when a school-based clinician or nurse practitioner works with a child to get their vaccines. Specifically this is true with influenza. It has been shown that despite our best efforts, influenza vaccination rates are still not up to par. Data from our group showed that influenza rates lag even in children up to age 2 years, even in those children who pediatricians are seeing on a regular schedule. Therefore, SBHCs can only be of assistance regarding influenza immunization.
Another way that SBHCs are helpful is in areas like nutrition and sports. Addressing the epidemic of obesity in this country is key, and considering the fact that school-based clinicians are on site, working with the physical education programs, etc, they can be a big help.
Finally, if the child is sick, the school-based clinician has to make a call and send that child home. So in those cases, the child may be referred back to their primary care physician, which is also an asset.
Praful Bhatt, MD, is a pediatrician and clinical assistant professor in the department of pediatrics at The Commonwealth Medical College in Scranton, Pa. He is also clinical associate professor in the physician assistant program at Lock Haven University of Pennsylvania in Lock Haven, Pa. Disclosure: Dr. Bhatt reports no relevant financial disclosures.
Richard Lander
School-based health centers do not interfere with most clinicians in suburbia. They really serve a need in the inner cities and in rural areas.
Children must attend school and having a medical/mental health facility on the premises greatly increases the children’s access to care.
Richard Lander, MD, is a pediatrician in private practice in northern New Jersey and is a member of the Infectious Diseases in Children Editorial Board. He is co-chair of the Pediatric Initiative at the Atlantic Health Care System and clinical assistant professor of pediatrics at the University of Medicine and Dentistry of New Jersey in Newark, N.J.