Introduction
Imagine enthusiastic, innovative, highly qualified teachers nimble with a rich, comprehensive curriculum embracing cutting-edge technology and focused on critical thinking and analysis; teachers at ease and empowered with multiple instructional strategies and styles capable of captivating the facile young minds of their students. Imagine sophisticated administrators armed with the tools of a robust budget, academic expertise, financial savvy, and an abundance of resources, time, dollars and staff, strong, accountable chief executive and academic officers.
Imagine high standards and rigorous assessments providing data, collected both for individual students to monitor progress, and in the aggregate to inform and support the continuing development of excellent curriculum and instruction.
Imagine clean, bright halls and classrooms or smooth cyber pathways and an inclusive, welcoming school environment where parents actively participate in school governance as respected members of a school community that shares a sense of purpose and a culture which expects and believes that all students will have access to higher education or job training in order to succeed in the 21st century workforce.
Imagine that all schools in Philadelphia, public, charter and private, reach this level of excellence and that every family is able to choose the school most appropriate for their children. Do we have education reform in Philadelphia? We do not.
Poor attendance rates, abysmal graduation rates, acute and chronic health problems especially among medically underserved populations, complex behavioral health issues, attention deficit disorders with and without hyperactivity, poor lifestyle choices, substance abuse, violence in the community and at home, bullying at school and persistent barriers to family involvement in schools, are all factors that continue to compromise educational excellence. Across the country, educators and policy makers are acknowledging that physical health and mental health impact educational outcomes and, as a result, are bringing health care to schools for student success. Unless and until all students are healthy, in school and ready to learn and to capitalize on innovative educational opportunities, educational outcomes will not change.
School-Based Health Care: Meeting Students Where They Are
The National Assembly on School-Based Health Care (NASBHC) reports that a quiet and high-impact movement is beginning to bridge the education and health-care worlds. NASBHC reported in 2010 that over 1,900 School-Based Health Centers (SBHCs) across the country provided access to high-quality, comprehensive medical care, mental health services, preventive care, social services, and youth development to nearly two million children and adolescents in 44 states and the District of Columbia. These services are provided without concern for the students’ ability to pay in a location that meetschildren and adolescents where they are: at school.
School-based health care is provided in schools or on school grounds by a multidisciplinary team of providers, primarily nurse practitioners and registered nurses but also physician assistants, social workers, school psychologists, alcohol and drug counselors, physicians and other health professionals. A comprehensive range of services that meet the specific physical and behavioral health needs of the young people in the community is provided. SBHC personnel conduct all screenings as required and then provide the requisite follow-up, facilitating the provision of dental, vision, hearing and mental health services to students.
What do SBHCs do?
- Assess immunization and tuberculin test compliance and then provide immunizations as necessary to keep students in school.
- Provide comprehensive health assessments, treatment of acute illness, and treatment and management of chronic health concerns such as asthma and diabetes.
- Provide prescriptions for medication and oversee the administration of medication in school.
- Perform lab tests and provide appropriate treatment, offer nutritional counseling, provide standardized behavior risk assessments and conduct sports physicals.
- Consult with teachers and administrators to build and deliver health education and health promotion programs and collaborate on plans for emergency preparedness.
- Participate on SAP (Student Assistance Program) and IEP (Individualized Education Program) teams during the evaluation and planning process and then provide physical health and behavioral health care, as necessary.
- Provide support to teachers and administrators and often provide specific health care to staff such as flu shots and acute care.
- Provide behavioral health/mental health services including mental health assessments, crisis intervention, individual therapy, consultation to teachers and case management.
Parents are required to sign written consents for their children to receive the full scope of services provided at the SBHC, and an advisory board consisting of school and community representatives, parents and youth provide planning and oversight for each center.
Documented Benefits
The benefits of SBHCs are documented in an ever-expanding body of research (see the NASBHC website). Among the benefits reported are a significant increase in attendance for both the average and the chronically absent student populations, a decrease in tardiness, a decrease in school discipline referral rates and subsequent suspensions, and a significant increase in persistence rates. Additionally, it has been demonstrated that the presence and use of SBHCs reduced inappropriate emergency room use; reduced use of costly urgent, emergent and after-hours care; reduced inpatient hospital days with a subsequent reduction in Medicaid expenditures; and significantly increased access to medical health care services, mental health services and substance abuse services.
Current national health policy (the 2010 Patient Protection and Affordable Care Act) stresses the fundamental importance of prevention as our country looks to make health care more affordable, accessible and equitable. SBHCs are uniquely positioned to provide comprehensive disease prevention and health promotion education. A national census conducted by NASBHC identified a wide range of topics concerning health promotion and education currently being addressed in SBHCs, including these:
- Living with chronic diseases such as asthma and diabetes
- Open airway programs
- Nutrition, fitness and weight management
- Mental health promotion
- Resiliency
- Social skill building
- Identifying and dealing with depression
- Injury and violence prevention
- Tobacco, alcohol and drug prevention
- Pregnancy prevention (both comprehensive and abstinence only)
- Parenting
Using individual, small group, classroom and parent instruction, and local decision-making concerning content, SBHCs address the specific needs of the particular school community. Because many students lack access to basic primary care and acute illness or chronic care can tap the limited resources of families, SBHCs across the country are providing primary care so often missing in medically underserved rural and urban communities.
The Pennsylvania Public School Code of 1949 addresses school health services for students in Pennsylvania. Certified school nurses have historically been responsible for maintaining student health records; assessing immunization and tuberculin test compliance; conducting growth, vision, hearing and scoliosis screenings; and supervising first aid services and specialized care for medically fragile students. Some school nurses serve on SAP teams and participate on IEP teams, make medical referrals and help children enroll in public health insurance programs.
But while the Pennsylvania Department of Health regulations list 16 immunizations that each child must receive in order to enroll in or attend school, none are provided by certified school nurses. Though screenings identify vision and hearing difficulties, follow-up is not guaranteed. This is not surprising when you consider that the Pennsylvania School Code of 1949 provides that the number of pupils under the care of each school nurse shall not exceed 1,500. Health services in Pennsylvania schools were designed to provide public health data and oversight, not access to health care.
Funding Models
Funding models for SBHCs vary, but generally a sponsoring organization—a hospital or health department, for example—provides fiscal oversight. Funding sources include state appropriations, Title V Maternal and Child Health grants, and Medicaid fee for service and managed care organizations. Two-thirds of the nation’s SBHCs reside in 19 states, of which all but one have a school-based health care program office, most within the state public health agency, dedicated to administering and overseeing the grants. Expanding the availability and ensuring the sustainability of SBHCs requires a commitment from the state.
In 2008, Pennsylvania received over $24 million in Maternal and Child Health Block Grant funding. Priorities for the use of this funding include increasing mental health screening, decreasing teen pregnancy, and expanding access to health services and injury prevention activities. All of these priorities are cost-effectively supported by school-based health care. It’s not clear how grants like Maternal and Child Health will be affected going forward by health-care reform, but it is clear that school-based health care achieves the goals of access, equity and affordability. And it is equally clear that all Pennsylvania students deserve a state with the vision to recognize that physical and mental health care services must be delivered where the students are: in school.
School-based health care increases access to quality care to all students, improves educational outcomes and enhances workforce development. School-based health care is central to the reform of both education and health care. Imagine…the support that students need to succeed delivered where they need to be: school-based health care, education reform actualized.