School-based health centers (SBHCs) and school-linked health centers (SLHCs) represent a relatively new model of health care service. Former US Surgeon General C. Everrett Koop, MD, advocated for family-centered, community-based, coordinated health care for all children.[1] He stated that care must be accessible. To be accessible, health care services must meet four criteria. The services must be available, community-based, affordable, and culturally acceptable to the population served. Do SBHCs/SLHCs meet these four criteria of accessibility?
This paper addresses this question. First, a literature review is presented on development of SBHCs/SLHCs from a historical perspective, and accessibility of these centers. Second, development and accessibility of one SBHC, serving young children in a rural community, are described.
DEVELOPMENT OF SBHCS
Although traditional school health services have been in place since the 1800s, the first national school health program did not begin until the late 1970s.[2] Serving children in kindergarten through 12th grade, this program was supported by the Robert Wood Johnson Foundation and was '...stimulated by the apparent need for better health services for school-age children in the United States.'[3] Twenty-three public schools at five sites in four states received support to '...determine the feasibility of providing primary health care and health education in the school setting.'[3]
The experience of this first national program supports the role of the school nurse, school nurse practitioner, and school-based primary health services in helping the nation meet its health care goals.[4,5] DeAngelis, Berman, Oda, and Meeker conclude: 'The integration of physical examinations and screenings in a school setting, staffed by nurse practitioners supported by physicians, can maximize the identification and resolution of health problems.'[6] These authors also report that immunization rates increase in schools with SBHCs.[7] Oda, DeAngelis, Berman, and Meeker show that: 'More than 95% of the problems [health problems identified in school-age children] were resolved or in the process of resolution at the end of the school year.'[8]
In 1986, the SBHC movement again was supported by the Robert Wood Johnson Foundation through creation of the School-Based Adolescent Health Program.[9] The focus of this program was on use of primary health services in secondary schools to meet health care needs of adolescents. Each of 18 grantees received financial support for two years to initiate one or more school-based health centers. Twenty-four sites were developed. Through process evaluation, Marks and Marzke identify positive outcomes for adolescents and parents involved and they conclude: 'The sites in this initiative provide a model for an effective way to reach and serve vulnerable adolescents -- one that provides not only health care, but also healthy caring.'[9]
The Support Center for School-Based and School-Linked Health Care, Center for Population Options (CPO), a nonprofit organization, '...provides information, technical assistance, training, policy analysis and advocacy to assist in establishing school-based and school-linked health centers and in enhancing their operation.'[10] Through this organization, McKinney and Peak reported on survey results from 202 of 418 SBHCs and SLHCs in operation during the 1991-1992 school year. Most of these centers were located in urban areas and served adolescent youth attending secondary schools.
In addition to the Robert Wood Johnson Foundation and the CPO, many other groups support the growth of the SBHC movement.[11-13] The American Academy of Pediatrics states: 'The Academy...supports the selective implementation of school-based health clinic programs in areas where the health care needs of the school age population are not being met.'[14] The National Association of School Nurses '...encourages the establishment of integrated school health programs and school based clinics to provide comprehensive health services...'[15] The American School Health Association (ASHA) supports '...the development and implementation of school-based and school-linked health care programs, including medical, social work, and personal counseling (mental health and substance abuse), in areas where children and adolescents lack access to primary health care and comprehensive services.'[16]
Individual leaders in health care also have supported SBHCs. Current US Surgeon General Joycelyn Elders, MD, writes about planning and designing school-based health services. She, states: 'Arkansas has demonstrated that the health care needs of many children can be met effectively through a school-based program of health services.'[17] Nurse leader Judith B. Igoe recommends expanding SBHCs/SLHCs to serve the entire family. She explains: 'The plan sponsored by nursing for school-based and school-linked family health care centers meets all the important criteria for health care reform; moreover, it assists two of the most significant institutions in American society -- the neighborhood and the family.'[18]
In contrast to this support, Rienzo and Button report on four SBHCs which experienced opposition to the planning and implementation of services.[19] They describe opposition to SBHCs from national conservative associations, some local religious organizations, and individual parents and citizens. Most opposition dealt with sexuality issues and parental rights. Other arguments were 1) services not needed, 2) services too costly, 3) services not effective, 4) not the school's responsibility, and 5) too much liability for the school. Rienzo and Button conclude that although organized opposition did affect the health care delivery of some SBHCs, development of key strategies in response to this opposition strengthened the SBHC movement as a whole.
The School-Based Adolescent Health Care Program of the Robert Wood Johnson Foundation describes the SBHC movement as 'an idea whose time has come' and 'the wave of the future.'[11] Support for the movement overcomes opposition to the movement in most communities. SBHCs/SLHCs will continue to proliferate according to a report completed from the US Dept. of Health and Human Services' Inspector General's office in Chicago.[13]
ACCESSIBILITY OF SBHCS
In regard to accessibility, the US Dept. of Health and Human Services' Office of the Inspector General (OIG) conducted 88 structured interviews with SBHC staff and concluded that 'school-based health centers increase access to health care for adolescents.'[13] The OIG study also described the difficulty of studying SBHCs since '...the literature on school-based health centers rarely gives a national perspective and provides little information about health outcomes for adolescents.'[13] McKinlay, Stone, and Zucker also describe the difficulties of school-based research and encourage the researcher '...to make optimal use of a wide variety of experimental designs and observation strategies.'[20]
Despite these difficulties, numerous articles describe SBHCs/SLHCs. This literature is summarized here, to provide an understanding of 'accessibility' as defined as available, community-based, affordable, and culturally acceptable health care.
Available. Recommended available services were identified in August 1993 by the School Health Policy Initiative of the Center for Population and Family Health. This group compiled a comprehensive list of essential, optional preferred, and optional as needed services for SBHCs in elementary, middle, and high schools (unpublished material, August 1993). Although contraceptive services were included in this list, Klein, Starnes, and Kotelchuck et al found that other types of health care centers are more likely than SBHCs/SLHCs to provide these services.[21] The Council on Scientific Affairs(22) and McKinney and Peak[10] reported this same finding.
When looking at services besides contraception, McKinney and Peak demonstrated that comprehensive medical services, counseling or mental health services, and health education services were provided in most SBHCs/SLHCs.[10] McHarney-Brown and Kaufman compared a SBHC with a hospital-based pediatric clinic and discovered '...that the school-based clinic received significantly more visits for counseling and health maintenance while the pediatric clinic received more visits for acute and chronic illness.'[23]
All SBHCs and 75% of SLHCs are located in schools where school-age children spend much of their day.[10] Generally, the site provides convenient access to health care for these children. This location may be threatening, however, to children and families with a negative experience at school. As a result, one SBHC plans to open a branch office in a nearby mall.[24]
Most SBHCs/SLHCs are open during school hours.[10] Ruminski and Klink describe a system for making appointments and meeting urgent health care needs while, at the same time, minimizing disruption of the educational environment. They say, 'Appointments are preferably scheduled for before school, during lunch, during study hall, or after school.'[25] Fifty-three percent of SBHCs/SLHCs are open in the summer; some provide evening and weekend hours while some refer to other sources of care during these time periods.[10]
Although SBHCs/SLHCs appear to have available services, locations, and hours, these services are not available to all children. In 1991, McGinnis and DeGraw reported some 46 million students in 100,000 schools in 15,000 school districts in the US.[26] During this same time period, 418 SBHCs/SLHCs served 1,086 schools.[10] Therefore, 98,914 schools and millions of children are without these comprehensive primary health care services.
Community-Based. Public schools and, therefore, SBHCs/SLHCs are located in the community. In addition, ongoing community involvement is an important part of the SBHC. Local planning groups and community advisory boards include parents, students, health professionals, academic and administrative school staff, and other members of the community.[17] All four SBHCs, studied by Rienzo and Button, identified involvement of these different groups as an important strategy for operating successful SBHCs.[19]
Affordable. In general, children and their families are not billed directly. Revenue sources include support from grants; agencies at the local, state, or federal levels; in-kind contributions; and third party reimbursements.[10,23,24,27] Bocchino states that the cost per pupil is estimated at more than $100 per year.[27] Marks and Marzke looked at three sites and found the cost per enrolled student to be $98.18, $193.12, and $194.06.[9] They attribute this range to labor market differences, cost-of living differences, number of staff at each site, a minimum threshold of costs for services, and economies of scale with larger enrollment sizes. These authors encourage ongoing contributions from medical sponsors as grant funding is predicted to decrease in the future. The US Dept. of Health and Human Services Office of the Inspector General encourages a cooperative relationship between SBHCs and managed care systems.[13]
In the article 'Adolescent Health: A Report to the US Congress,' three findings were presented: one of seven adolescents has no health insurance coverage; one of four adolescents is poor or near poor; and one of three poor adolescents does not receive Medicaid services.[28] Twenty-eight percent of students were covered by Medicaid insurance in the McKinney and Peak study.[10] Others have found the rate of uninsured children to be between 31% and 58%.[7,17,20] For students with private health care coverage, many preventive health services are not reimbursed. Direct billing of the students and families would limit the accessibility of health care.
Culturally acceptable. Enrollment in all SBHCs/SLHCs was voluntary and, in most SBHCs, parental consent was required before students can receive services. Enrollment rates of 50% to 71% are described.[6,10,16,21] In the Baltimore SBHCs, the enrollment rate grew from 12% in year one to 60% by year five.[24] In general, most parents chose to enroll their children in a SBHC when one was available.
McKinney and Peak report that 72% of enrolled students use SBHC services.[10] Ruminski and Klink surveyed students enrolled at one SBHC; 50% had used the service at least once. Ninety percent felt the service increased health care accessibility, while 60% believed that their health was improved because of the service.[25] Concern about reproductive issues, parental rights, and lack of awareness of services have been suggested as barriers for students who do not enroll or use SBHC services.[23,29]
Generally, SBHCs are accessible; they are available, community-based, affordable, and culturally acceptable to most students and families they serve. Many schools are without SBHCs, and therefore, many students are without access to SBHCs. More SBHCs are needed to meet the needs of these students.
DEVELOPING A RURAL SBHC
Background
The following information provides a case study on establishing an SBHC. This SBHC is located in a community of 10,000 persons in a rural area of Pennsylvania. County percentages exceeded the state percentages for the following statistics: children younger than age five years living at or below the poverty level, single-parent families headed by females, low birth weight infants, youth with drug and alcohol dependency, adolescent pregnancies, and adolescent deaths. In addition, the community has limited access to health services because of lack of public transportation and limited hours of some and long waiting hours of other health services (D. Paul, EdD, unpublished data, August 1992). This school district covers more than 160 square miles and enrolls 2,200 students each year. The school board has a history of supporting the physical and emotional needs of children as well as addressing academic concerns. Many innovative programs already are in place in the district: a breakfast program, a full-day kindergarten, a before and after school day care, a summer child care program, a special education service for the county, and a mandatory community service program for all high school students (D. Paul, EdD, unpublished data, August 1992).
Despite these school achievements, other problems exist in the school. In 1991, 28% percent of the district's kindergarten children did not have the academic skills necessary to enter first grade; 74% of these children were predicted to continue to have difficulties in third grade. Forty-five percent of children starting school in 1991-1992 were eligible for free or reduced lunches. In addition, the speech disability rate for the district was 38% higher than the state average (D. Paul, EdD, unpublished data, August 1992, July 1993).
In response to these needs, a kindergarten program for four-year-old children (K-4) began in fall 1992 with an enrollment of 113 children. This program was the second full-day program to be opened in the state. It was the first universal program offered to all four-year-old children in the district, regardless of financial or academic need. This program sought to accomplish Novello's first goal for education which states: 'By the year 2000, all American children will start school ready to learn.'[30] Academic knowledge, physical health, self-confidence, and social competence were encouraged through the program.
In fall 1992, the superintendent also organized a committee of experts to plan a SBHC. Members of the committee included individuals from the area's health planning and community service agencies, health department, and a medical clinic. A three-year grant under the governor's initiative for health care was awarded to the district in January 1993.[31] In the first six months of 1993, personnel were hired, offices and examination rooms were constructed, equipment and supplies were obtained, protocols and collaborative agreements were developed, Medicaid and private insurance provider numbers were secured, and children were enrolled.
The initial staff consisted of a full-time pediatric nurse practitioner, half-time secretary, part-time social worker, and a school nurse who spent one day a week in the building. These staff members were employed by the school district. The collaborating physician, a family medicine specialist, was available by telephone contact. He was employed by a large medical clinic located in the area and also was a community resident and school board member.
During the last two months of the school year, 65 children were seen by the nurse practitioner in the SBHC for state-mandated physical examinations. At the same time, children registering for 1993-1994 K-4 program were offered enrollment in the SBHC.
By the end of the 1992-1993 school year, several strengths of the SBHC model were identified. Location seemed to be one of the most important factors for success of the service. Another strength was a school health software program that made record keeping, tracking, and data collection accurate and efficient. Working relationships between the SBHC, school, medical community, and other community agencies were positive; no opposition occurred to development of the center. In addition, many health problems and health education needs were identified to assist in planning for the 1993-1994 school year.
Three main barriers were revealed, however. Immunization vaccines were not available in the SBHC. Dental services for children with Medicaid health insurance were difficult, if not impossible, to obtain. Finally, many services provided by the nurse practitioner were not reimbursable under private insurance plans.
During summer 1993, children who had attended the K-4 program were promoted to the district's kindergarten program for five-year-old children (K-5). Although these children now attend school in other school buildings, they continue to be served by this SBHC. In addition, 110 new children entered the K-4 program in fall 1993; 99% of these children are White and 99% live within the school district boundaries. One child with special needs is transported to the school from another district.
For this paper, only the charts of the children in the K-4 program during the 1993-1994 school year were reviewed. Data regarding visits made to the center during the first six months of the 1993-1994 school year were examined from the computer record. In the next section of the paper, this information is summarized and examined for evaluation of accessibility.
Accessibility
Available. Services provided in the SBHC were compared to the list of elementary school services identified as essential by the School Health Policy Initiative Project (Center for Population and Family Health, unpublished data, August 1993). All essential services were available except for dispensing of medications and on-site treatment for children who were sexually abused. Medications were prescribed but had to be purchased at one of the community pharmacies. Cost of the medicine was a problem for some families. One child and her mother were referred to the child's primary care provider for a diagnosis of possible sexual abuse.
The SBHC was located in the K-4 building and most services were provided on-site. A few students, needing medical services beyond the scope of the center, were referred to their own primary care provider or to the office of the collaborating physician. The social worker facilitated referrals to community agencies for the students with mental health and social needs that exceeded the scope of the SBHC.
The SBHC was open from 8:30 am to 5 pm, five days a week, and from 5-8 pm, one day a week, for well-child and sick-child visits. The SBHC social worker provided on-site services two days a week. A health education program was developed by the SBHC staff, and a topic was presented weekly to children in their classrooms. In addition, parents were invited to a monthly health talk held during the evening; refreshments and child care were available.
Community-Based. The health center was located in the K-4 building, at the edge of the community. All children were transported to the K-4 program by bus. Some parents received assistance with transportation to the school to be present for their child's well-child examination. At least one parent or guardian was present for every child. Also, parents were involved through a parent advisory board, which met every two months.
SBHC staff worked closely with school personnel. Communication with teachers occurred daily as needed, in addition to scheduled meetings held each month. The nurse practitioner and superintendent met monthly. The SBHC social worker and school counseling staff communicated as needed. The SBHC staff met weekly, while other school staff, including the principal, psychologist, school nurses, speech therapist, and guidance counselor attended these meetings monthly.
The nurse practitioner acted as the liaison between the SBHC and the medical community. The social worker collaborated with community social service agencies. Newsworthy events appeared regularly in the community newspaper and area newsletters.
Affordable. Forty-nine percent of the K-4 children received free or reduced breakfast and lunch. Thirty-nine percent had health coverage through Medicaid. Another 14% of the children were covered under a managed care program. Forty-four percent, however, had no coverage for preventive health care services other than immunizations.
The center began billing medicaid and other third insurance companies in December 1993. In addition to services not reimbursed by the private fee-for-service health insurance plans, the SBHC was not approved as a managed care provider and, therefore, was unable to bill for students with managed care insurance coverage. Families were not billed directly, however, as grant funding was available during this time period.
Table 1Status of Completion of Well-Child Examinations Occurrence(*)Status %Completed in SBHC 88.0Scheduled in SBHC next month 4.6Referred to SBHC social worker for assistance 3.7Completed in another health facility 3.7* Percentages were roundedTable 2Problems Identified During Well-Child Visits Occurrence(*)Status %Dental caries 42.6Hearing loss 17.6Otitis media 15.7Speech difficuIties 12.0Anemia 10.2Asthma 9.3Overweight 8.3Vision problems 2.8* Percentages were roundedTable 3Common Problems Identified During Sick-Child Visits Occurrence(*)Status %Otitis media 34.7Upper respiratory infections 11.2Injuries 9.8Gastroenteritis 8.6Asthma 5.0Skin disorders 4.6Conjunctivitis 3.2Toothache 2.1Suspicion of abuse 0.8* Percentages were rounded
Culturally acceptable. Ninety-eight percent (n = 108) of children were enrolled in the SBHC. Of the children enrolled, 99% (n = 107) used the SBHC for either well-child or sick-child care or both. Table 1 shows that 88% (n = 95) of children received well-child examinations in the SBHC. Table 2 lists common health problems discovered during well-child care. Ninety-four percent (n = 102) of children visited the SBHC at least once for sick-child care. The total number of sick-visits made to the SBHC during this time period was 487, an average of 4.5 visits per enrolled student. Children were referred for these visits by parents, teachers, and health staff. Common problems identified during sick-child visits are presented in Table 3. The SBHC social worker saw 39.8% (n = 43) of enrolled students. Family problems were identified for 38% of these children, developmental or behavioral problems for 31%, and medical access problems for 31%.
During the last week of the study period, surveys were given to 20 parents who visited the SBHC. This survey asked parents to describe benefits and problems associated with having SBHC services in the school. Most parents identified convenience as the greatest benefit. Some parents also reported feeling more comfortable sending their four-year-old child to school knowing that health care needs would be addressed. These parents did not identify any problems.
Impact
Overall, health care services were accessible to children in the K-4 program through this rural SBHC. Comprehensive services were available and location and hours were convenient for students attending the K-4 school. Parents were actively involved. Communication was encouraged among the SBHC, school, and community. No cost accrued to the families of children enrolled in the SBHC. Enrollment and usage rates were outstanding, much higher than those described in the literature. Parents saw the service as beneficial. The community was supportive; no opposition occurred to opening the center. Strategies that contributed to accessibility of this center are summarized in Figure 1.
Some barriers continue to be a problem, however. This site is not as available to the children who have moved to the schools housing the K-5 classes. Reimbursement of services will be a major issue when grant funding ends in two years. In addition, cost of medications and limited access to dental services continue to be a problem. Dental caries, hearing loss, and speech difficulties may have been prevented if children had access to SBHC services at a younger age. Finally, some teachers are concerned that more sick children come to school and that more people, in general, are in the school. Both factors could be disruptive to the educational environment.
In spring 1994, the SBHC enrolled children ages zero to three years through a new family center program to address prevention at an earlier age. Enrollment and usage rates for children attending the K-5 program still need to be analyzed. Also, the effect of a SBHC on the educational environment needs to be studied. Is the school safe with the increase of traffic to the SBHC office? What are the absentee rates? How well are children learning in this setting?
References
1. Koop CE. Closing Session/Shaping the Future of Children's Health Care, audiotape. Denver, Colo: National Nursing Network, Inc; 1990.
2. Mastrangelo R. From sore throats to STD's, NPs make a difference in school-based clinics. Advance for Nurse Practitioners. 1993;1 (9):8-10,28.
3. DeAngelis C. The Robert Wood Johnson Foundation National School Health Program. Clin Pediatr. 1981;20(5):344-348.
4. Oda DS, DeAngelis C, Meeker R, Berman B. Nurse practitioners and primary care in schools. Am J Mat Child Nursing. 1985;10(2):127-131.
5. Oda DS. The invisible nursing practice. Nursing Outlook. 1991;39(1):26-29.
6. DeAngelis C, Berman B, Oda D, Meeker R. Comparative values of school physical examinations and mass screening tests. J Pediatr. 1983;102(3):477-481.
7. DeAngelis C, Berman B, Oda D, Meeker R. Achieving optimal immunization levels in school-age children. J Pediatr. 1983;103(5):811-814.
8. Oda DS, DeAngelis C, Berman B, Meeker R. The resolution of health problems in school children. J Sch Health. 1985;55(3):96-98.
9. Marks E, Marzke CH. Health Caring: Process Evaluation. Princeton, NJ: Mathtech; 1993.
10. McKinney DH, Peak GR. School-based and School-linked Health Centers: Update 1993. Washington, DC: The Center for Population Options; 1994.
11. The Answer is at School: Bringing Health Care to Our Students. Washington, DC: The School-Based Adolescent Program; 1993.
12. School-based and School-linked Health Centers. Washington, DC: The Center for Population Options; 1994.
13. Office of the Inspector General. School-based Health Centers and Managed Care. Chicago, Ill: US Dept of Health and Human Services; 1993. Publication no OEI-05-92-00680.
14. American Academy of Pediatrics. AAP guidelines:School-based health clinics (RE 7090). AAP News. 1987;April:683.
15. Resolutions and Policy Committee. Resolutions and Policy Statements. Scarborough, Maine: National Association of School Nurses, Inc; 1989.
16. American School Health Association. ASHA Compendium of Resolutions, Section II, Position Papers and Policy Statements: School-Based Primary Health Care. Kent, Ohio: American School Health Association; 1993.
17. Elders MJ. Schools and health: A natural partnership. J Sch Health. 1993;63(7):312-315.
18. Igoe JB. School-linked family health centers in health care reform. Pediatr Nursing. 1993; 19(1):67-68.
19. Rienzo BA, Button JW. The politics of school-based clinics: A community-level analysis. J Sch Health. 1993;63(6):266-272.
20. McKinlay SM, Stone EJ, Zucker DM. Research design and analysis issues. Health Educ Q. 1989;16(2):307-313.
21. Klein JD, Starnes SH, Kotelchuck M, et al. Current trends: Availability of comprehensive adolescent health services--United States, 1990. MMWR. 1993;42(26):507,513-515.
22. Council on Scientific Affairs. Providing medical services through school-based health programs. JAMA. 1989;261(13):1939-1942.
23. McHarney-Brown C, Kaufman A. Comparison of adolescent health care provided at a school-based clinic and at a hospital-based pediatric clinic. South Med J. 1991;84(11): 1340-1342.
24. Feroli KL, Hobson SK, Miola ES, et al. School-based clinics: The Baltimore experience. J Pediatr Health Care. 1992;6(3):127-131.
25. Ruminski D, Klink H. School-based health centers: A model for delivery of adolescent health care in Portland, Oregon. J Ambulatory Care Management. 1993;16(1):29-41.
26. McGinnis JM, DeGraw C. Healthy Schools 2000: Creating partnerships for the decade. J Sch Health. 1991;61(7):292-297.
27. Bocchino C. School-based clinics: Ensuring access to the health care for adolescent America. Pediatr Nursing. 1991;17(4):398,418.
28. Dougherty D, Eden J, Kemp KB, et al. Adolescent health: A report to the US Congress. J Sch Health. 1992;62(5):167-174.
29. Gonzales C, Mulligan D, Kaufman A, et al. Adolescent health care: Improving access by school-based service. J Fam Pract. 1985;21(4):263-270.
30. Novello AC. The Surgeon General's Initiative for Children. J Sch Health. 1991;61(8):359-360.
31. Investing in Our Children & Families: Governor Robert P Casey's 1993-1994 Budget Initiatives. Harrisburg, Pa: Office of the Governor; February 1993.
Figure 1
Ten Strategies for a Successful SBHC
* Assess the unique health care needs of the community
* Involve parents, students, and school and community health care staff
* Choose a site in the school
* Obtain a computer system for data collection
* Employ staff familiar with the community
* Start with a small population but plan to expand rapidly
* Enroll students during registration for school or when physical examinations are required by the school
* Provide comprehensive services on site
* Evaluate the program every six months
* Network with other SBHCs
Susan H. Terwilliger MS, RNCS, PNP, Director: Primary Health Care Services, Towanda Area School District, K-4 Complex, RR 2, Box 82-A1, Towanda, PA 18848.
