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School Based Health Centers Veda Johnson, MD Director, Partners for Equity in Child and School Based Health Centers Veda Johnson, MD Director, Partners for Equity in Child and Adolescent Health Emory University School of Medicine

Health and Education Why are school health programs important? Health and Education Why are school health programs important?

Health and Education Association between health and academic success Students learn best when they Health and Education Association between health and academic success Students learn best when they are healthy Students learn best when they are present Students learn best when they are connected to the school emotionally and socially Students learn best when there is hope

Health… Georgia ranks 40 th in the nation overall for child wellbeing (Kid’s Count Health… Georgia ranks 40 th in the nation overall for child wellbeing (Kid’s Count 2015). 43 rd - Child economic well-being (% in poverty) 37 th – Overall child health (child & teen deaths) 40 th - Overall education (preschool, proficiencies) 40 th – Family and Community (single parent, parents w/ HS diploma)

Health… Georgia We have the 17 th highest childhood obesity rate in the country Health… Georgia We have the 17 th highest childhood obesity rate in the country (37% OW/OB) 29% of our adolescents had significant episodes of depression during the past 12 months. 26% of our children live in poverty and approx. 240, 000 children are uninsured. Approx. 320, 000 children miss more than 10 days of school each year due to illness.

Education… GA Reading 4 th graders (2013) 34% read at proficient or better 21% Education… GA Reading 4 th graders (2013) 34% read at proficient or better 21% of Low income and minority students 53% of Higher income students 8 th graders (2013) 32% are proficient GA Math 4 th graders (2013) 39% are proficient 8 th graders (2013) 29% are proficient

Education… In Georgia Educational underachievement is pervasive. GA ranks in the bottom 5 percentage Education… In Georgia Educational underachievement is pervasive. GA ranks in the bottom 5 percentage for high school drop out rates in the country. Approx. 72. 5% of our students graduate on time 9. 7% of children are absent 15 or more days from school

Health and Education… Poor school performance is linked to health-related issues such as hunger, Health and Education… Poor school performance is linked to health-related issues such as hunger, physical and emotional abuse, and chronic illness. Poor academic outcomes are linked to risky health behaviors such as substance use, violence, and physical inactivity which in turn affect students' school attendance, grades, test scores, and ability to pay attention in class.

Health and Education… Education is a direct predictor of health Education and income are Health and Education… Education is a direct predictor of health Education and income are markers of socioeconomic position. Academic underachievement contributes significantly to the health disparities observed in children from lower socioeconomic positions People with lower socioeconomic position are more likely to have worse access to healthcare

Health and Education… What we know… School health programs and policies can be an Health and Education… What we know… School health programs and policies can be an efficient way to prevent or reduce risky health behaviors and avoid serious health problems among students. They may also help close the educational achievement gap between disparate socioeconomic groups of students.

School Based Health Centers 5 Key Descriptives Patient and Community- Focused Accessible and Affordable School Based Health Centers 5 Key Descriptives Patient and Community- Focused Accessible and Affordable Comprehensive & Quality Care Multi-& Inter-disciplinary Outcomes Oriented

SBHCs… ‘School based health centers (SBHCs) represent the most effective system of health care SBHCs… ‘School based health centers (SBHCs) represent the most effective system of health care for the underserved in this country. It is a system of care that essentially eliminates every barrier to healthcare (i. e. cost, hours of operation, transportation, easy access) and the holistic, multidisciplinary approach to providing healthcare is very effective in addressing health disparities in the context of the social determinants of health. In addition, SBHCs provide services in a coordinated, integrated manner where all providers are operating under the same roof and in constant communication with one another. It embodies the quintessential ‘team approach’ to providing health care. This efficient method of service delivery impacts not only the health outcomes of patients but improves student attendance/achievement and significantly reduces the cost of healthcare to the state. ’

SBHCs… Definition: Comprehensive school based health clinics are medical centers that blend medical care SBHCs… Definition: Comprehensive school based health clinics are medical centers that blend medical care with preventive and psychosocial services as well as organize broader schoolbased and community-based health promotion efforts and includes the following essential components: location within a school building or in close proximity to a school building; provision of comprehensive primary and mental health care; and interrelation of family, school, and community

SBHC’S… Common Features of School-Based Health Centers: They are located in schools or in SBHC’S… Common Features of School-Based Health Centers: They are located in schools or in close proximity (school-linked). The health center works cooperatively within the school to become an integral part of the school. The health center provides a comprehensive range of services that meet the specific physical and behavioral health needs of the young people in the community as well as providing for the more traditional medical care needs. A multidisciplinary team of providers care for the students: nurse practitioners, registered nurses, physician assistants, social workers, physicians, alcohol and drug counselors, and other health professionals.

SBHC’s… Common Features… The clinical services within the health center are provided through a SBHC’s… Common Features… The clinical services within the health center are provided through a qualified health provider such as a hospital, health department, or medical practice. Parents sign written consents for their children to enroll in the health center. The health center has an advisory board consisting of community representatives, parents, youth and family organizations, to provide planning and oversight.

SBHC’s… Seven Basic Principles: Supports the school Responds to the community Focuses on the SBHC’s… Seven Basic Principles: Supports the school Responds to the community Focuses on the student Delivers comprehensive care Advances health promotion Implements effective systems Provides leadership in adolescent and child health

SBHCs… Health Services: The scope of health care services provided by a SBHC is SBHCs… Health Services: The scope of health care services provided by a SBHC is determined at the community level. They may include but are not limited to: primary care for acute and chronic health conditions mental health services substance abuse services case management services dental health services nutrition education health education and promotion The services are determined through a collaborative effort between the umbrella health organization, the school, and the community.

SBHCs… Health Services: The services reflects the health care needs of the children in SBHCs… Health Services: The services reflects the health care needs of the children in that specific community and supports the values and regulations of the community and school system. Services should be provided according to the basic principles of the Patient-Centered Medical Home. Suggested staffing Medical Provider (nurse practitioner, physician asst. , MD) Medical Assistant Licensed Clinical Social Worker Options Community Outreach Worker Dentist Dental Assistant Dental Hygienist Health Educator

SBHCs… Research demonstrates that SBHCs effectively address the needs of students: Increased access to SBHCs… Research demonstrates that SBHCs effectively address the needs of students: Increased access to quality healthcare Improved health outcomes Decreased healthcare costs Improved school attendance and academic performance

Decreased health care costs – Whitefoord Elementary School - Based Health Clinic Adams EK, Decreased health care costs – Whitefoord Elementary School - Based Health Clinic Adams EK, Johnson V. An elementary school-based health clinic: can it reduce Medicaid costs? Pediatrics. 2000; 105(4 pt 1): 780– 788 Compared Medicaid costs to children enrolled in a SBHC to those not enrolled in a SBHC Summary of findings: Decrease in total Medicaid costs per child over 2 year period w/SBHC Significant decrease in In-Patient costs Significant decrease in prescription drug use costs Significant decrease in emergency room costs Decrease more significant across all categories if child used SBHC as medical home For children with asthma, decrease in Medicaid cost for total yearly expenditures with significant decreases in inpatient and drug costs.

SBHC’s… Nationally (National Census – 2010/11) Over 2000 SBHCs 54% in urban settings 28% SBHC’s… Nationally (National Census – 2010/11) Over 2000 SBHCs 54% in urban settings 28% in rural settings 18% in suburbs Georgia Only 2 SBHCs from 1994 – 2009

Partners for Equity in Child and Adolescent Health Expansion of comprehensive school based health Partners for Equity in Child and Adolescent Health Expansion of comprehensive school based health center programs in Georgia… Only 2 SBHCs in GA from 1994 -2009 Whitefoord Elementary and Coan Middle School Goal of the program is to increase the number of SBHCs to 10 over a 5 year period.

School Based Health Center Project The development and expansion of SBHCs has four basic School Based Health Center Project The development and expansion of SBHCs has four basic elements. Recognized community need and support Sustainability Evidence of health and cost impact Fidelity to model programs Our efforts to expand SBHCs in Georgia capture these four elements within 3 phases – planning, implementation, and sustainability.

School Based Health Center Project Planning Phase Solicited applications and provided 12 month planning School Based Health Center Project Planning Phase Solicited applications and provided 12 month planning grants to counties/communities interested in establishing a SBHC Grantees participated in developing community advisory group, conducting needs assessment, defining strategies to address needs, identifying specific school for clinic services, and developing a business plan for establishing SBHC

School Based Health Center Project Awarded School Based Health Centers (SBHCs) planning grants to School Based Health Center Project Awarded School Based Health Centers (SBHCs) planning grants to 29 counties representing 34 communities throughout the state of Georgia. Yellow- year 1 Green – year 2 Orange – year 3 Blue – year 4 Scheduled to fund 4 additional sites this year.

School Based Health Center Project Implementation Phase In October of 2012, Healthcare Georgia Foundation School Based Health Center Project Implementation Phase In October of 2012, Healthcare Georgia Foundation (HCGF) provided funding to support the start-up of three SBHCs in Georgia. Lake Forest Elementary SBHC located in Sandy Springs GA (Family Health Centers of Georgia FQHC) Turner Elementary SBHC located in Albany GA (Albany Area Primary Health Care FQHC) Tiger Creek Elementary SBHC located in Tunnel Hill GA (Primary Care Health Centers of Dade FQHC)

Implementation Phase The process included: District and School engagement along with School Board approval Implementation Phase The process included: District and School engagement along with School Board approval Identification of Space for SBHC and renovation of space SBHC Sponsoring organization: Staff hiring, ‘Change of Scope’ approval from HRSA, Medicaid certification and staff credentialing Student Recruitment, enrollment, and utilization Advisory Council Input

Implementation/Planning Phase As a result of the implementation/planning phases: Six (6) new SBHCs were Implementation/Planning Phase As a result of the implementation/planning phases: Six (6) new SBHCs were established. Three were established through a grant provided by Healthcare Georgia Foundation (Catoosa County, Fulton County, and Dougherty County) Several School Telemedicine programs were established 40+ Mental Health Services are provided in 2 schools 5 new sites are slated to become operational during the 2015 -2016 school year.

Sustainability Phase In 2014, 2 nd round of funding from HCGF SBHCs developed a Sustainability Phase In 2014, 2 nd round of funding from HCGF SBHCs developed a sustainability plan that included: developing strong partnerships, clinic outreach and marketing, establishing quality benchmarks and creating a strong business model SBHC budgets developed Benchmarks for clinic utilization and patient revenue were established

Sustainability Phase Why FQHCs as SBHC sponsoring organizations? Aligns with the mission of caring Sustainability Phase Why FQHCs as SBHC sponsoring organizations? Aligns with the mission of caring for the underserved Increased capacity to sustain the efforts Increased Medicaid Reimbursements Access to Federal Grants o New Access Points o Expanded Service Grants Nationally, 40% of SBHCs sponsored by FQHCs

Turner Elementary School-Based Health Center (Albany, GA) March, 2013 Turner Elementary School-Based Health Center (Albany, GA) March, 2013

Lake Forest Elementary School-Based Health Center (Atlanta, GA) May, 2013 Lake Forest Elementary School-Based Health Center (Atlanta, GA) May, 2013

Tiger Creek Elementary School-Based Health Center (Tunnel Hill, GA), May 2013 Tiger Creek Elementary School-Based Health Center (Tunnel Hill, GA), May 2013

North Clayton High School-Based Health Center (Atlanta, GA), January 12, 2015 North Clayton High School-Based Health Center (Atlanta, GA), January 12, 2015

Evaluation of SBHCs in GA Questions included: How do SBHCs increase access to health Evaluation of SBHCs in GA Questions included: How do SBHCs increase access to health care? What is the impact of SBHCs on the management of asthma and obesity for identified patients? What is the impact of SBHCs on students receiving on schedule health checks and immunizations? What is the impact of enrollment and utilization in SBHCs on school attendance and seat time? What actions are taken by SBHCs to ensure long-term sustainability? What is the impact of utilization of SBHCs on cost to the state’s Medicaid system?

Evaluation… How do SBHCs increase access to health care? High enrollment of students in Evaluation… How do SBHCs increase access to health care? High enrollment of students in SBHCs over 1 st 2 years 72% - 87% enrolled over the first 2 years Increasing patient encounters from year 1 -2 Two-fold increase in patient encounters – Tiger Creek 1/3 rd increase in patient encounters for Turner and Lake Forest

Utilization Utilization

Evaluation… What is the impact of SBHCs on the management of asthma and obesity Evaluation… What is the impact of SBHCs on the management of asthma and obesity for identified patients? increase in the percentage of asthma patients with flu shots at 2 sites. > 80% of students with asthma action plan Benchmark – 80% of students. > 90% of students had the severity level documented for 2 sites. Benchmark – 90% of students Very few ER and hospitalizations for asthma no emergency room visits or hospitalizations for Tiger Creek asthma patients Turner Elementary asthma patients had 3 ER visits and 3 hospitalizations in year 1; 6 ER visits and 2 hospitalizations in year 2.

Evaluation… What is the impact of SBHCs on students receiving on schedule health checks Evaluation… What is the impact of SBHCs on students receiving on schedule health checks and immunizations? Increase in number of health checks for all 3 sites from year 1 to 2 100% of students w/ Psychosocial screenings at Turner and Lake Forest; >95% at T. Creek during health check visit. Immunizations up-to-date for all patients 0 -6 years of age at Turner and Lake Forest >98% of adolescents (186) fully immunized for Menactra, HPV#1, and Tdap at Turner Increased flu vaccines at Turner and Lake Forest

Evaluation What is the impact of enrollment and utilization in SBHCs on school attendance Evaluation What is the impact of enrollment and utilization in SBHCs on school attendance and seat time? Only one site, Lake Forest, collected data on seat time and absenteeism 44% and 38% increase in seat time from pre-SBHC to post – SBHC, years 1 & 2 respectively Decrease in numbers of days missed due to illness between years 1 & 2

Number of Students Sent Home by Lake Forest Clinic 500 450 400 350 300 Number of Students Sent Home by Lake Forest Clinic 500 450 400 350 300 2012 250 2013 2014 200 150 100 50 0 Number of Students Sent Home by Clinic

Number of Missed Days from School After Visiting the Health Center 100% 90% 80% Number of Missed Days from School After Visiting the Health Center 100% 90% 80% 70% 60% 2014 50% 2015 40% 30% 20% 10% 0% 0 days 1 day 2 days 3 days

Evaluation… What actions are taken by SBHCs to ensure long-term sustainability? Start-up cost for Evaluation… What actions are taken by SBHCs to ensure long-term sustainability? Start-up cost for Year 1: $200, 000 - $250, 000 75% in personnel costs (Full-time Nurse Practitioner or Physician’s Assistant; full time Licensed Clinical Social Worker; full time Medical Assistant) 12% in medical equipment 7% in medical and office supplies 6% in office equipment/furniture In-Kind for Year 1: $170, 000 22% for pediatrician/family practitioner oversight provided by medical sponsor organization 38% for school nurse provided by school system (if a school nurse is present in the school) 40% for space and utilities provided by school system (fluctuates based on square footage of space provided)

Evaluation… What actions are taken by SBHCs to ensure long-term sustainability? Year 2/ Sustainability Evaluation… What actions are taken by SBHCs to ensure long-term sustainability? Year 2/ Sustainability costs: $150, 000 - $200, 000. 00 (Direct) o Dependent on productivity and billing capacity of organizations o Advantage of FQHCs Year 2 In-kind costs o Same as year 1

State Investment in SBHCs 2011 Census 18 states investing in SBHCs $89. 6 million State Investment in SBHCs 2011 Census 18 states investing in SBHCs $89. 6 million annually in total investments 875 SBHCs supported by state funding Investments from state increased by 122% since 1996 Funding sources: General State Funding - $60 million Tobacco Settlement - $9. 2 million Title V MCH Block Grant - $5. 6 million Other - $14. 8 million

Potential Return on Investment Increased access to quality healthcare Improved health outcomes Decreased healthcare Potential Return on Investment Increased access to quality healthcare Improved health outcomes Decreased healthcare costs Improved school attendance and academic performance It is easier to build strong children than to repair broken men. ” Frederick Douglass (1817– 1895)