School-Based Health Centers: An Overview

By Mara Minguez MD, MSc.

School-based health centers (SBHCs) can play a critical role in decreasing health care disparities among those who are medically underserved and are often located strategically in locations of high-need, where barriers to care are prominent. This mechanism for providing health care has been widely adopted both nationally in the United States and increasingly internationally as a means of achieving the goal of attaining health equity. SBHCs services are an expansion of the traditional school nurse care model, and the health services provided in this content are identified as traditional medical encounters. Decreasing the barrier of access can maximize student learning time as a consequence of eliminating transportation and parental availability to seek health care.

The range of services provided by SBHCs varies and may include primary care services, immunizations, reproductive health (e.g., STI/HIV screening, Pregnancy tests, contraceptive and pregnancy counseling), mental health, acute and chronic disease management, and screenings for vision, oral health, weight management, and depression.  Mental or behavioral health services are a crucial component of SBHCs, including screening and treatment for a range of conditions such as depression, suicide ideation and attempts, anxiety, trauma, grief/loss, and substance abuse. Addressing the stigma around mental health services, can be an essential initiative in the quest to decrease rates of suicidality.

SBHCs can serve as the first stop for comprehensive health services for immigrant children who are uninsured and are going through the lengthy application process to receive health insurance.  Additionally, SBHCs can provide care to a vulnerable population of young adult, uninsured immigrants, ages 18 to 22 years, who are completing their high school studies. These students may rely on SBHCs as their sole access to health care.

Substantial research evidence supports SBHCs functionality in improved access to quality health care for the school-aged children, including increased access and utilization of primary care services, increased use of reproductive health care, decreased emergency department visits and hospitalizations, and increased access to mental health (1-6). Within the educational space, lower absenteeism and higher academic achievements are additional benefits of SBHCs (7). Improvement in academic achievements can indirectly result in higher graduation rates.

Adolescence is a transformative, crucial stage with a great need for health guidance. Unfortunately, a recent study showed that many adolescents are not receiving health screens and anticipatory guidance as recommended by professional entities such as the American Academy for Pediatrics(8).  Conversely, a study comparing an urban high school with a SBHC and one without a SBHC found that students with access to a SBHC are more likely to report exposure to higher quality of care, and greater health care provider discussion of topics such as sexual activity, birth control, emotions, future plans, diet, and exercise (1).

SBHCs can have a significant impact on access to reproductive health care; adolescents attending schools with a SBHCs report greater use of hormonal contraception and greater exposure to reproductive health and counseling compared to adolescents attending schools without a SBHC(2).  Using the evidence about improved adolescent health in schools with a SBHCs, we may infer that SBHCs can provide adolescents with, a nurturing, adolescent-friendly, safe space to receive developmentally appropriate, high quality, evidence-based, comprehensive care.

A National census of SBHCs

Every three years the US-based School-based Health Alliance conducts a census in which they collect information as it pertains to the current status and functioning of SBHCs across the United States.  Multiple parameters are described including; the range of services offered, patient demographics, staffing, and financing.  The last published census reports on data collected from the 2013-2014 academic year (9).

Since the inception in the 1970s, the number of centers has substantially increased to approximately 2300 operating centers nationally, which provides access to a large school-aged population estimated at 2.3 million in the US (9).  The geographic locations of these centers can vary from suburban to rural to urban areas, and there is a representation of all grade levels, from pre-kindergarten to 12th grade(9). The student body served by SBHCs is racially/ethnically and financially diverse with most serving majority-minority schools (71.1%), and schools where approximately 2/3 of the student body qualifies for free school lunch (76.5%)(9).  Some schools may extend services to family members, school personnel, and students from other schools in the district. Some even provide services to members of their community at large.

Per the last census, New York State had the most extensive school-based health care program in the country (9). In 2019, an updated data source has reported a  total of 262 centers which serve over a quarter of a million children and adolescents in New York State (10). In the five boroughs of NYC, there were 164 school-based health centers, and these mostly service underserved student communities that span all education levels(10).

Not all SBHCs are created equal, from the physical space in which they are located to the range of services offered. Institutional/public policies and resource availability drive the needle on how each center will function. Ongoing collaboration among communities, schools, parents, and healthcare stakeholders is imperative for optimal, comprehensive care delivery.

Several staffing models exist, and the most common, representing over 60% of  SBHCs, consist of primary care providers including physicians, nurse practitioners, or physicians assistants and behavioral health providers. Additional providers that may be a part of the SBHC team include health educators, dentists, dental assistants, dental hygienists, medical assistants, and registration clerical staff(9).

An updated version of the census report with data collected during the 2017-2018 academic year is scheduled to be published by May 2019.

Funding 

Funding and reimbursement mechanisms for SBHCs vary state by state.   Nationally, funding sources include federal and state government grants, school and school district support, academic institutions and hospitals sponsorship, as well as independent foundation support.  Most SBHCs rely on revenue generated by third-party payers including private insurance, Medicaid and Medicaid Managed Care Plans with differences based upon State regulations and upon contractual arrangements.  In New York State, SBHCs services have received a carve-out from the Medicaid Managed Care benefit package and sponsoring institutions have billed NYS Medicaid directly fee for service (11).

Looking Ahead

The future of health care is complicated with numerous intricacies. Nonetheless, to truly improve the health of our children and adolescents, we need a shared vision for the health of our community.

 

* Mara Minguez, MD, MSc.

Assistant Chief Medical Officer for Community Affairs &

Medical Director, Lang Youth Medical Program

New York- Presbyterian Hospital

Assistant Professor of Pediatrics and Population & Family Health

Columbia University Irving Medical Center

Acknowledgements:

Melanie A. Gold, DO, DABMA, DMQ, FAAP; John Santelli, MD, MPH; Janet Garth, MPH; Andres Nieto, MPA

BOX1: MYTH Clarification

  •   All students MUST have parental consent to be seen for primary care services in a SBHC.
  • Signing a parental consent DOES NOT lead to changes in health insurance.
  • Collaboration between SBHC’s and existing Primary Care provider is the current standard of care.

 

Resources

1.Measuring school health center impact on access to and quality of primary care.

Gibson EJ, Santelli JS, Minguez M, Lord A, Schuyler AC.

J Adolesc Health. 2013 Dec;53(6):699-705.

2.Reproductive health impact of a school health center.

Minguez M, Santelli JS, Gibson E, Orr M, Samant S.

J Adolesc Health. 2015 Mar;56(3):338-44.

  1. Key JD, Washington EC, Hulsey TC. Reduced Emergency Department Utilization Associated with School-Based Clinic Enrollment. Journal of Adolescent Health. Apr 2002;30(4):273-278.
  2. Santelli J, Kouzis A, Newcomer S. School- Based Health Centers and Adolescent Use of Primary Care and Hospital Care. Journal of Adolescent Health. 1996;19:267-275.
  3. Juszczak L, Melinkovich P, Kaplan D. Use of Health and Mental Health Services by Adolescents Across Multiple Delivery Sites. Journal of Adolescent Health. Jun 2003;32(6 Suppl):108-118.
  4. Gall G, Pagano ME, Desmond MS, Perrin JM, Murphy JM. Utility of Psychosocial Screening at a School- Based Health Center. Journal of School Health. Sep 2000;70(7):292- 298.
  5. Walker SC, Kerns SE, Lyon AR, Bruns EJ, Cosgrove TJ. Impact of School-Based Health Center Use on Academic Outcomes. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. Mar 2010;46(3):251-257.

8.Discussion of Potentially Sensitive Topics With Young People.

Santelli JSKlein JD, Song XHeitel JGrilo SWang MYan HKaseeska KGorzkowski JSchneider MDereix AECatallozzi M.Pediatrics. 2019 Feb;143(2).

  1. US National Census Data

Love HL, Schelar E, Taylor K et al. 2013-2014 Census of School-Based Health Centers Report. Washington, D.C.: School-Based Health Alliance, 2015.

10.New York State, Department of Health

https://www.health.ny.gov/statistics/school/skfacts.htm

https://www.health.ny.gov/facilities/school_based_health_centers

11.New York State Senate Bill S. 6012 (Seward) :

https://legislation.nysenate.gov/pdf/bills/2017/S6012

 

Additional Resources

1.School-Based Health Alliance

https://www.sbh4all.org/

4.New York State Departmen of Education

https://www.schools.nyc.gov/school-life/health-and-wellness/school-based-health-centers

4.Policy Statement. School-Based Health Centers and Pediatric Practice.Pediatrics. 2012; 129 (2): 387-393.

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