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SBHCs can serve as entry point, extension of primary care
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School-based health centers have a unique opportunity to address common and emerging health issues among the pediatric population.
According to the 2010-2011 census on school-based health centers (SBHCs) from the School-Based Health Alliance, there are more than 1,900 SBHCs in the United States. Of these, approximately 54% are in urban areas, 28% in rural areas and 19% in suburban areas.
SBHCs typically follow one of three models: 1) primary care, which is composed of a primary care provider such as a nurse practitioner or physician's assistant; 2) primary care and mental health, in which the PCP works with a mental health professional such as a licensed clinical social worker or psychologist; and 3) primary care and mental health plus, which is the most comprehensive model and includes a PCP, mental health professional and other providers such as an oral health provider or nutritionist.
Approximately 38% of SBHCs follow the primary care and mental health plus model, 33% follow the primary care and mental health model, and 29% follow the primary care model, according to the 2010-2011 census on SBHCs.
Overall, most SBHCs provide comprehensive health assessments, vision, hearing and other screening services and immunizations, according to a literature review by Victoria Keeton, RN, MS, CPNP, CNS, an associate professor at the School of Nursing, of the University of California, San Francisco, and colleagues.
Victoria Keeton, RN, MS, CPNP, CNS, of the University of California, San Francisco, said that SBHCs can offer a range of services for students without access to routine care.
Photo courtesy of Merrell S/UCSF
The most obvious benefit of SBHCs is access to some of the most underserved populations in regard to health care services.
"The fact that SBHCs are located inside the school, where children spend a good portion of the day, allows SBHCs to bring care directly to the child, care that many of these children would struggle to receive otherwise," Elliott Attisha, DO, FAAP, a pediatrician at the Henry Ford Health System in Detroit, told Infectious Diseases in Children.
SBHCs house a myriad of health services in an easily accessible location. This benefit mitigates certain barriers to health care experienced by the pediatric population.
Diverse benefits for a diverse population
Adolescents have a tendency to engage in behaviors that increase their risk for the leading causes of morbidity and mortality. SBHCs are well positioned to mitigate these risky behaviors by providing supervision and services in a familiar and compassionate setting, according to Keeton and colleagues.
According to an AAP policy statement, SBHCs increase adolescent health care use, particularly for sexual health, substance abuse and mental health services. These services can improve students' health as well as their academic performance.
Beth Mattey, MSN, RN, NCSN, president-elect of the National Association of School Nurses, said SBHCs have a significant role in ensuring adolescents have the appropriate tools to be sexually healthy.
"Of course, the ideal is for children to remain abstinent until they are in a committed, long-term relationship. But if they choose to be sexually active, we want to have services available to them so they can access the help they need," she told Infectious Diseases in Children.
More than 80% of SBHCs that serve middle and high school populations offer abstinence counseling; 69% provide on-site diagnosis and treatment of STDs; and 81% offer other diagnostic services, such as pregnancy testing, according to the 2010-2011 census on SBHCs.
By offering sexual health services, SBHCs can promote healthy sexual behaviors through education and treatment. In this way, SBHCs increase adolescents' ability to play an active role in promoting their own health.
The integration of medical health and mental health screening and services benefit school performance, according to the AAP. Results from a study conducted in 2007 found users of SBHC mental health services increased their grade point averages over time more than nonusers, according to the School-Based Health Alliance (SBHA).
Seventy-eight percent of SBHCs provide crisis intervention; 73% provide comprehensive individual evaluation and treatment; 69% offer case management; 62% offer classroom behavior and learning support; 43.4% offer peer mediation; and 39% prescribe and manage behavioral health medications, according to the 2010-2011 census on SBHCs.
Mental health services provided by SBHCs are beneficial to younger children in addition to adolescents. Services integrated within elementary schools assist with early identification, referral, and treatment of children with emotional and behavioral issues, according to Keeton and colleagues.
Beth A. Mattey
Besides mental and reproductive health, SBHCs also have a significant effect on children with chronic illnesses, most notably children with asthma.
"Asthma contributes to over 10 million missed school days each year," Attisha told Infectious Diseases in Children.
"An SBHC that can help a child manage their asthma has a significant impact on the child by creating a healthier learning environment for them and increasing their chances of attending school," he said.
Almost 60% of school-aged children with asthma reported school absences related to asthma, according to Keeton and colleagues.
A study cited in the AAP's policy statement reported a decrease in hospitalization rates and an increase of 3 days of school attendance among children with asthma who had access to SBHCs.
Researchers have estimated a potential cost-savings of $970 per child with asthma related to SBHCs' ability to decrease hospital utilization, according to Keeton and colleagues.
These urgent care needs are another benefit of SBHCs, according to Mattey. "If a student has not been diagnosed with asthma or it is not well managed, they may come to the school nurse with breathing issues. We can refer them to the SBHC's nurse practitioner so they can be treated immediately, as the nurse practitioner can prescribe the necessary medication," she told Infectious Diseases in Children.
Accessibility to children and adolescents has allowed SBHCs to improve immunization rates.
Elliot Attisha
More than 70% of SBHCs provide a host of immunizations, including Tdap, influenza, hepatitis B, meningococcal, HPV, hepatitis A and varicella, according to the 2010-2011 census on SBHCs.
Keeton and colleagues cited one study that found SBHC users, aged 14 to 17 years, were more likely to have received influenza vaccine (45% vs. 18%); a tetanus booster (33% vs. 21%); and a hepatitis B vaccine (46% vs. 20%) compared with community clinic users.
Recall notification systems that remind students of necessary vaccines are often used in SBHCs, according to Keeton and colleagues, and may contribute to high immunization rates.
Further, if a child is new to a school with an SBHC and is not up-to-date with his immunizations, the SBHC can provide necessary services, according to Mattey.
Besides immunizations and asthma services, SBHCs commonly offer oral health services, obesity programs and substance abuse counseling and services.
According to the AAP, students who use SBHCs have higher satisfaction with their health status and have healthier behaviors, including more physical activity and greater consumption of healthier foods.
Overall, children who used SBHCs had a 50% decrease in absenteeism and a 25% decrease in tardiness after receiving SBHC services for 2 months, according to the AAP and SBHA.
Comprehensive care for all students
Adolescents from minority or disadvantaged backgrounds have the highest risk for not having regular health maintenance visits, according to Keeton and colleagues.
These children may benefit from SBHCs more than any other population, because they do not have the same opportunities as their peers from higher-income households.
Because SBHCs are located where children spend a significant amount of time, scheduling and transportation barriers are minimized, according to the AAP.
Transportation and scheduling issues may be more common among families from low socioeconomic groups due to their location or financial situation. If a child can receive proper care at school, parents do not have to miss work to take them to an appointment nor coordinate with the public transportation system.
Children in racial minority groups used SBHCs more frequently than other available community health delivery options, according to Keeton and colleagues, which suggests that SBHCs are an ideal provider setting for these children and families.
According to the SBHA, black males who accessed SBHCs were three times more likely to stay in school compared with their peers who did not use SBHCs.
"SBHCs are well positioned to overcome cultural barriers because they are centered in the community. Some immigrant families may not be familiar with the American health care system and the practice-based model. If their child is attending a school with an SBHC, families can access medical and educational resources that may increase their comfort with the health care system," Mandy Allison, MD, MSPH, an assistant professor of pediatrics at the University of Colorado in Denver, told Infectious Diseases in Children.
Further, if a school has a significant number of children from a particular immigrant group, the school frequently provides outreach to the community, such as having materials available in different languages, Allison said.
SBHCs interact with all children regardless of parents' insurance type.
"SBHCs do not turn away children who do not have proof of insurance at the moment. If a child does not have proof of insurance, the SBHC oftentimes research whether the child is eligible for Medicaid and will even sign the child up for Medicaid," Allison told Infectious Diseases in Children.
Location not only mitigates transportation and scheduling barriers, but puts SBHCs in touch with the needs of patients and their community.
'A safety-net system'
SBHCs can provide an entry point and source of primary care for children who do not otherwise have access to consistent care and can provide additional care to those who already have PCPs.
"Because SBHCs do not turn children away, SBHCs are what I consider a safety net system. If a child has a private practice medical home, that's the ideal. But truthfully, a lot of children do not have that, particularly children on Medicaid or without insurance," Allison said.
The AAP defines the medical home "as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective to all children and youth."
SBHCs often serve as an extension of a child or adolescent's primary medical home, according to the SBHA. If the child needs to manage a chronic illness that requires care during school hours, such as diabetes, they will be treated in the SBHC. If the child requires urgent care, such as an injury or strep throat, an SBHC can provide that.
There are some concerns about SBHCs serving as the medical home. Some pediatricians expressed concern that SBHCs might fragment children’s health care because of their hours, according to the AAP.
One solution is for the SBHC to provide a link to medical services in the community. Local hospitals often provide after-hours and school vacation coverage for SBHCs, according to the AAP. This arrangement is mutually beneficial, as SBHCs are proven to reduce hospital costs by preventing unnecessary ED visits.
Coordinated communication is another concern. SBHCs may provide duplicative services to children outside their medical homes without communicating with the medical home, according to the AAP.
Fragmented care can be avoided by coordinating or collaborating with local health care providers to address community needs, the AAP said in a policy statement. Telemedicine can also promote communication between SBHCs and PCPs.
Mismatched priorities, financial instability
Health and education systems do not always share the same priorities, which contributes to difficulties SBHCs have in providing certain services and remaining financially stable.
Of the 49% of SBHCs that are prohibited from providing contraceptives, 76% are prohibited by school district policy; 54% are prohibited by school policy; and 27% are prohibited by state law or regulation, according to the 2010-2011 census on SBHCs. Further, a little more than half of SBHCs provide HIV testing, as some policies prohibit testing.
These data show the differences between medical, educational and legal priorities, which can hinder SBHC services.
"The most significant challenge is financial sustainability. Many SBHCs provide supplemental or collaborative care. It can be difficult for insurance companies to recognize SBHCs in the same way they recognize PCPs, and provide the same type of reimbursement," Keeton told Infectious Diseases in Children.
Due to these billing challenges, SBHCs rely on external funding, which is continuously challenging to obtain, Keeton said.
One solution to funding difficulties is for SBHCs to be recognized as reimbursable PCPs.
Approximately 48% of SBHCs reported being recognized as PCPs or preferred providers, according to the 2010-2011 census on SBHCs.
Furthermore, because the largest population served by SBHCs are either uninsured or receive Medicaid, reimbursement can be low, Allison told Infectious Diseases in Children.
Oftentimes, Medicaid does not reimburse as well as private insurers, Allison said. Only 35% of managed care organizations recognize SBHCs as reimbursable primary care providers, according to the AAP.
Despite proven increases of access to care, improved health and education outcomes, and increase satisfaction, SBHCs consistently face challenges in securing adequate funding for the services they provide.
SBHCs are keeping pace with the evolving health care system, which requires new business practices, greater value and improved coordination across providers, according to the SBHA.
The potential of different reimbursement models and greater accountability for patients, promoted by the Affordable Care Act, may create new care delivery sites, according to Keeton and colleagues.
"One thing we'd like to see moving forward, and I believe there is a lot of recent progress toward this, is SBHCs serving as a patient-centered medical home or a component of a medical home, and being properly reimbursed for the care they deliver. SBHCs are known to improve health outcomes. If we can increase recognition of SBHCs as a patient-centered medical home, we'll only be able to advance what we do," Attisha said. — by Amanda Oldt
Should SBHCs serve as the medical home?
Yes, SBHCs are uniquely positioned to be medical homes.
SBHCs have been shown in multiple studies to provide high-quality care as measured by decreased ED utilization, enhanced immunization rates and improved access to care for underserved populations.
In some instances SBHCs may the only source of care for a patient. In other cases, care may be provided in conjunction with other providers. In either case, SBHCs are well positioned to evaluate patients for ongoing chronic care, the provision of preventive care and follow-up care.
Most SBHCs are strategically placed to serve underserved populations in a manner that fulfills the elements of a medical home as defined by the AAP. SBHCs provide enhanced access to students where they spend a majority of their day. Students can make future appointments, same-day appointments or may be actively sought by clinic staff for needed services such as immunizations or medication refills.
SBHCs are inherently family- and patient-centered as they minimize the amount of time children spend away from class as well as minimizing parents’ time away from work. Mature SBHCs communicate regularly with parents to include them even when they are not present for visits. Most SBHCs operate with a limited number of staff, often one or two providers, which enables them to provide continuity to their patients.
There is no uniformly accepted model for SBHCs, so there is significant variation in type of services offered beyond physical health needs not dissimilar from other practice settings. Similar to other medical homes, a growing number of SBHCs provide comprehensive and coordinated services, including referrals to specialist, behavioral health counseling, oral health, immunizations, medications, health education and insurance outreach.
Successful SBHCs are well integrated into their schools and surrounding communities. These unique relationships provide additional insight into factors that impact the health of children such as housing, violence, and resource availability. This knowledge and team-based approach greatly enhances SBHCs ability to provide compassionate and cultural effective care. Similar to other clinic settings, SBHCs must work as part of a team to provide an optimal medical home. This can be done in the context of an integrated delivery system or in partnership with pediatric practices, and the school setting is ideal to optimize child health.
Steve Federico, MD, is associate director of School and Community Programs at Denver Health, and an associate professor of pediatrics at the University of Colorado; email: steve.federico@dhha.org. Disclosure: Federico reports no relevant financial disclosures.
No, SBHCs should not serve as a child’s medical home.
Many studies have demonstrated the medical effectiveness of SBHCs in dealing with follow-up care for problems such as asthma or improving vaccine rates, which I do not refute. However, I think there are two main drawbacks to utilizing SBHCs as a child’s medical home.
The first drawback is the lack of continuity of care when the child moves from grammar school to middle school and then to high school. Each move involves a new set of medical providers. There is a distinct advantage when seeing a teenager who is entering high school and presents with certain symptoms and the physician is familiar with the patient having the same symptoms in the past.
The other concern is availability of after school hours or on the weekends. With no primary care provider, where does the child receive health care during non-school hours? Do they go to the local ED, an urgent care center or a retail-based clinic where care is rarely given by a pediatrician? This is the antithesis of a medical home. Seeing patients after hours, on Sundays and holidays emphasizes continuity of care.
Richard Lander, MD, is a pediatrician in private practice in northern New Jersey and clinical assistant professor of pediatrics at the University of Medicine and Dentistry of New Jersey in Newark, N.J. He is immediate past chair of the AAP Section on Administration and Practice Management and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Lander reports no relevant financial disclosures.