School-Based Health Care: Models & Services

1. School-Based Health Care:Models & Services Colin Walker WA School-Based Health Alliance info@wasbha.org

2. Objectives Define a school-based health center (SBHC). Describe school-based health care and SBHC sponsorship, staffing, operations and service models. Be able to describe alternative health care in school service models. Understand the landscape of SBHCs and school-based health care locations in Washington state:  history and growth, healthcare sponsors, delivery models. Session Description: School-Based Health Center.  Wellness Center.  Adolescent Clinic.  Mobile Clinic.  School-based health centers (SBHCs) may have different names, use different models, and provide different services depending on the community, but all have this in common:  they provide youth with meaningful access to health care where they already spend much of their time—at school.  SBHCs collaborate with schools and school staff to provide medical, mental health, and other healthcare services to students, improving both student health and academic outcomes. This session focuses on the operations, services and models of school-based health and is applicable for those new to the concept as well as experienced sponsors looking to learn more.

3. School-Based Health Care and SBHCs. Definitions and history.

4. Delivery Models Typical school-based health care program – sponsor providing health care services in a school building while integrating into school system Mental health only programs School-linked clinics Mobile dental, medical or other health outreach services School-based health centers

5. Common Characteristics Located in schools or on school grounds Work cooperatively within the school Provide clinical services through a qualified health provider such as a hospital, health department, or medical practice. Require parents to sign written consents for their children to receive the full scope of services.

6. Key Principles • Supports the school • Focuses on the student and school community • Provides complete care • Advances health promotion activities • Implements effective systems of service delivery • Provides leadership in adolescent and child health http://www.nasbhc.org/site/c.jsJPKWPFJrH/b.2743459/k.9519/NASBHC_Principles_and_Goals_for_SBHCs.htm

7. History • School-Based Health Centers emerged in the 1970s to address the unmet health needs of children and families. • During the 1990s there was a rapid and significant rise in the number of centers. • Significant increase in the last 8 years. 2010 Affordable Care Act recognized school-based health centers and provided capital funding. • 2,600 estimated total SBHCs in the US (2016-17 school year). • SBHCs are found in nearly every state plus the District of Columbia, the U.S. Virgin Islands, and Puerto Rico. • SBHCs serve children in all grade levels in urban, suburban, and rural settings.

8. Advantages of School-Based Care Students have direct access to health care providers. Serve all students Students do not have to miss as much class time to receive basic health care. Parents do not have to miss work to take their child to a provider. Transportation challenges in seeking health care are reduced. Risky behaviors are identified and addressed. Students learn how to be effective consumers of health care. Referrals are made to appropriate community providers for services not provided at the site.

9. Outcomes of School-Based Care • SBHCs improve school attendance. • SBHCs improve rates of graduation. • SBHCs decrease emergency room and urgent care visits. • SBHCs decrease hospitalizations for children with asthma. • SBHCs improve access to and use of mental health services. • SBHCs improve access to and use of preventive services and improve vaccination rates. • SBHCs reduce Medicaid expenditures related to inpatient, drug, and emergency department use. • Reference: http://www.casbhc.org/publications/index.asp

10. Operations and Service Models

11. Sponsoring Agency • The sponsoring health care agency has the overall responsibility for: Administration, operations, and oversight Staffing Data management and quality improvement

12. *Courtesy of the School-based Health Alliance 2013-2014 Census

13. Delivery Models Typical school-based health care program – sponsor providing health care services in a school building while integrating into school system Mental health only programs School-linked clinics Mobile dental, medical or other health outreach services School-based health centers

14. Mental Health Only Programs Mental health counselor/therapist based in a school Serves as referral source to school staff, counselors Group, individual and family therapy • Benefits Mental health often seen as greatest need (20 to 38% of students in need of support). Limited expenses outside salary cost • Challenges Reimbursement – prior authorizations sometimes needed Limited coordination and scope of care. Health care issues are not typically isolated to one area of need.

15. Outreach Based Programs Mobile based programs (i.e. dental vans) Health education outreach (nutrition presentations, classes, group therapy) • Benefits Limited cost and risk Community benefit May facilitate better access to care • Challenges Not comprehensive, limited scope Difficult to integrate into the school environment

16. School-linked Clinics Clinic, often a community health center, located near a school Some level of established relationship with the school May have specific hours for just students Sometimes clinic staff integrate into school systems Often serve more than one school Benefits Limited financial risk, infrastructure established Ability to serve multiple schools without needing to manage logistics of students from multiple facilities. Challenges Utilization drops drastically when clinic not on school site Integration and focus on building, school’s academic/support plan limited

17. School-based Health Center ACA Definition Federal definition of SBHC in Affordable Care Act (section 2110(c)(9) IN GENERAL.—The term ‘school-based health center’ means a health clinic that— (i) is located in or near a school facility of a school district or board or of an Indian tribe or tribal organization; (ii) is organized through school, community, and health provider relationships; (iii) is administered by a sponsoring facility; (iv) provides through health professionals primary health services to children in accordance with State and local law, including laws relating to licensure and certification; and (v) satisfies such other requirements as a State may establish for the operation of such a clinic.

18. School-based Health Center Delivery Models • Wide range of SBHC staffing models and services (three broad categories): Primary medical care only Primary medical and mental health care 3) Primary medical and mental health with enhanced services

19. School-based Health Center Delivery Models • Primary medical care only • Immunizations • Sports physicals • Exams • Illness • Injury • Chronic care management • Reproductive health care • Primary and acute health care assessment, diagnosis, treatment and referral

20. School-based Health Center Delivery Models • Primary medical and mental health care • Individual, group and family mental health screening, counseling, case management, and referral • Crisis intervention • Addressing issues of: Depression, anger, stress, relationship issues, grief & loss, trauma recovery, problem-solving, working on goals • Health education and health promotion • Care coordination and referral for drug/alcohol services and dental care

21. School-based Health Center Delivery Models • Primary medical and mental health care with enhanced services: • Oral health care. Often through mobile vans or mobile equipment. • Services range from screenings to comprehensive • Medical providers – oral health assessments/education/varnish. • Health educators • Nutrition counselors • Care coordinators or social workers • Eligibility/insurance support or other basic need services

22. SBHC Model Ranges 12% dental, 13% nutrition services Ave hrs per week, medical - 26, mental health – 33 Models range from one medical provider a few hours a week to 6+ exam rooms, dental operatories, health educators and nutrition programs 2009 data *Courtesy of the School-based Health Alliance 2009 Census

23. *Images Courtesy of Neighborcare Health, Mercer Middle School SBHC

24. SBHC Floor Plan – Expanded Model

25. School-Based Health Center Staffing Typical: 1.0 FTE Mid-Level Practitioner (NP/PA) 1.0 - 2.0 FTE MH Counselor 1.0 FTE Administrative/Coordination Support .30 FTE Management Support Directly for SBHC (high range) Middle schools may have a .5 FTE medical providerMedical assistants typically used in high volume clinics that often see the community as well or in a SBHC with +12 visit a day volumes.

26. SBHC Staffing Models N = 1096 NASBHC SBHC Census 2009 *Courtesy of the School-based Health Alliance 2009 Census

27. *Courtesy of the School-based Health Alliance 2013-2014 Census

28. SBHC Staffing ModelsWestern States

29. Summary Service Models • Programs other than comprehensive school-based health center • May be the best fit for the community/school • School board, families, leasing of facilities/space present too great of a barrier • Key factors to success for all school-based health care programs • Partnership, collaboration and planning with school nurse • Collaboration with other on-site/community providers • Support of school administration, formal contracts in place for more established relationships • Participation in outreach to students and families (family nights, PTSA presentations, open houses) • Follow up and coordination of care essential component

30. National and Regional Landscape, SBHCs

31. Nationally 2,300 Total SBHCs. 2013-14 Census *Courtesy of the School-based Health Alliance 2013-2014 Census

32. *Courtesy of the School-based Health Alliance 2013-2014 Census

33. Distribution of SBHCs. Urban, Rural, Suburban. *Courtesy of the School-based Health Alliance 2013-2014 Census

34. School-Based Health Centers in Washington 46 School-Based Health Centers (medical+ services, open to all students in school) 16+ mental health only sites 10 schools with health centers serving military families Cities with SBHCs Madigan’s Military Families School Sites (10) Dupont, Lacey, Lakewood, Puyallup, Steilacoom, Spanaway

35. Oregon State

36. Populations Served • Of those sites responding to 2013-2014 SBHA national census (typically SBHCs are those that respond) • 94.1% are on school property • 3% are mobile • 2.7% school-linked • 7.3% use telehealth services, more likely in rural areas (12.7%). *Courtesy of the School-based Health Alliance 2013-2014 Census

37. *Courtesy of the School-based Health Alliance 2013-2014 Census

38. Funding and Implementation Planning

39. SBHC Funding • Operational cost estimates (annual) 5k – 75k for non-SBHC school-based program 250-400k est. average for an SBHC (1 FTE medical and mental health provider, admin support, overhead) Upper range 500k Overhead (typically 20 – 30%) • Start up costs 25 to 60k est. average equipment/supply cost Construction and renovation cost vary widely (380k for 1,400 sq foot is one example in 2010).

40. Funding History Many started with foundation support (Ford, Kellogg, Kresge) Developed into state association or advocacy efforts to create state SBHC department and associated funding Many able to bill for at least Medicaid Built a diverse funding stream and have larger organization sponsorship

41. Financing SBHCs • Third party reimbursement 89% of SBHCs bill payers (public and private). Revenue on average covers 34% of program costs.* Average patient revenue, as a % of total operating expenses, from billing*: • FQHCs: 50% • Hospitals: 29% • Health departments: 21% • Schools: 10% Other revenue sources. % = SBHCs that receive this type of funding (2011 data). State governments (75%), federal government (53%), private foundations (40%), hospitals (33%), city/county governments (32%), corporations/business (18%), state network/associations (5%), tribal governments (1%). • Billing challenges (short list) Maintenance of confidentiality Referral or prior authorization from PCP needed in advance of bill Number of preventative or outreach services non-reimbursable Patient deductibles, scope of benefits Diversity of payers *Courtesy of the School-based Health Alliance 2013-2014 Census

42. *Courtesy of the School-based Health Alliance 2013-2014 Census

44. Common Path to Sustainability: Diverse Funding and Highlighting the Impact Combination of foundation or sponsor contribution, governmental support, patient revenue State, county, regional or city funding is common component. Many start with foundation support. Return on investment: 6 Seattle SBHCs: 14,000 visits with 1.4 million of funding Youth focused Link to academic success - UW study found over 5 semesters relative increase in attendance and grades amongst SBHC users SBHCs recognized as health entity in Affordable Care Act

45. SBHC Outcomes. Specific Examples. • The use of SBHCs by students with asthma saved the state Medicaid program $3 million in hospital inpatient costs in one year in New York • Students enrolled in Seattle SBHCs have better attendance rates and grade point averages than their matched peers. • A study by Johns Hopkins University found that school-based health centers reduced inappropriate emergency room use among regular users of school-based health centers. • In 2002, a SBHC in CT had 2044 student visits with a primary diagnosis of asthma. SBHC site interventions saved $1,684,164 in additional health costs.

46. SBHC Start Up and Planning • Visit Planning and Start-Up and Effective Collaborations Sessions at todays conference • Brief overview: Community Planning/Stakeholder Development (sponsors, community/school leaders, advisory/youth committee). Business Planning (needs assessment, management structure, pro forma, program/quality evaluation) Operations Planning (facility, standards and processes, billing, health records and confidentiality, staffing, scope of services including lab and pharmacy) Marketing/Communication (informing families and staff, community outreach – provider community – who typically get more referrals with an SBHC than without). Advocacy (advocacy plan with strategies – city council, leg, etc)

47. Navigating Challenges • Education, outreach, and screenings may not need specific contracts. Oral health can be a key contribution early. • Focus on high priority items to school (i.e trauma informed care and behavioral health). • Form systems, communication pathways, management structures in advance. • Education is key and perception makes a difference. Early engagement with principal, superintendent, school board is essential. Academic impact is key. • Sexual health services or confidentiality challenges that are perceived to be a barrier within the community, may not be. Get community input early and develop champions.

48. Opportunity to Grow the Model • Many high need schools throughout WA state • Recognition of SBHCs at federal level • WA does not have any laws preventing SBHCs from billing for services (unlike other states) – that we know about. • Schools focus on behavioral health, trauma informed care, social/emotional interventions, is increasing. • Accountable care organizations, payers, health care providers are looking for ways to promote preventative activities. • Support and awareness for the model growing with general support at legislative level.

49. SBHC ExpandedRole *From the American Public Health Association

50. Community Health Centers in WA