Reprinted with permission from American School Board Journal, August 2000. Copyright 2000, National School Boards Association. All rights reserved.

The school-based health center in Evanston Township High School's sprawling complex north of Chicago is just around the corner from a row of classrooms. But once students step inside the attractive reception area, they enter a world that is more like a modern doctor's office than a suburban school room. In state-of-the-art examination rooms, a medical and mental health team, backed by a support system from Evanston Northwestern Healthcare, is providing student-friendly medical care and counseling to kids who otherwise might go without it. "This is a safe place to talk about whatever you have on your mind," a poster proclaims.

Evanston Township's school-based health center -- designated a national model by the National Assembly on School-Based Health Care -- is one of more than 1,300 such centers nationwide. School-based health centers treat a wide variety of ailments, from asthma -- the No. 1 cause of school absence for chronic illness -- to the common cold, from child abuse to drug abuse, from depression to sexually transmitted diseases.

A key to the centers' effectiveness is the opportunity, rarely afforded by other health care providers, to uncover and address emotional and psychological issues that are often masked by routine medical complaints. "For most kids the schools are the default mental health system," says John Schlitt, executive director of the National Assembly, a Washington, D.C.-based advocacy group. Indeed, the need for mental health care -- the service most often provided by school-based health centers -- is growing. A survey covering more than 21,000 youngsters ages 4 to 15, published in the June issue of Pediatrics, finds that emotional and behavioral problems have more than doubled from 1979 to 1996.

The typical school-based health center is sponsored and operated by an established hospital, health department, or community health center in a facility provided by the school district. Day-to-day management is shared in various combinations by an off-site medical director or administrator from the sponsoring medical institution and an on-site center coordinator. Most centers offer primary health care, mental health services, health education, and preventive care, along with physical exams and immunizations. These services are usually administered by a nurse practitioner or physician assistant and a clinical social worker, aided by administrative personnel. Outside medical and psychiatric specialists are also available for referrals and visitations.

School-based health centers are located in 45 states and the District of Columbia. High schools and middle schools house more than half of them; elementary schools account for a third. The large majority of the centers are located in poor urban and rural areas, where primary health care, psychological services, and preventive care are scarce and children are likely to be uninsured or underinsured.

Convenience gives school-based health centers a clear advantage over the traditional doctor's office. "Adolescents do not carry appointment books," says Dr. Philip J. Porter, a pediatrician and one of the earliest supporters of school-based health centers. "Health services need to be where students can trip over them."

Ideally, the decision to establish a school-based health center follows a rigorous community assessment of student health needs and available resources. In communities where prevention and early intervention are the top priorities, citizens might choose to invest in an elementary rather than a high school health center. Where space is an issue, communities might have to make do with barely converted classrooms, provided such facilities can deliver high-quality care.

School boards are essential participants in the decision-making process. Although boards do not ordinarily provide financial assistance, they must approve the decision to start a health center, and they usually supply in-kind support in the form of space, renovation, security, and janitorial services. To ensure that the center complies with board policies, the school and the health care partners sign a contract or "memorandum of understanding" that spells out issues of responsibility, liability, and levels of service.

"A fundamental school board responsibility is communicating to the community -- including parents, staff, students, and the media -- the benefits the health center will offer students and the school," says Brenda Z. Greene, director of school health programs for the National School Boards Association in Alexandria, Va. "And it's up to the board to make sure that its established decision-making process is followed to maintain trust with the community and avoid controversy."

A community concern

School-based health centers were first established in the early 1970s. Organized opposition to birth control counseling and the dispensing of contraceptives slowed their progress in the1980s, but since then, efforts to raise public awareness, use of parental consent forms, and fear of AIDS and other sexually transmitted diseases have counteracted most concerns.

In the 1990s the growth of school-based health centers resumed. But despite a recent surge in their numbers -- from only 600 six years ago to the present 1,300-plus -- future expansion is uncertain. With median operating costs running at more than $200,000 per center annually, the overriding question is whether the centers can secure dependable long-term support. For now, they must rely on a chaotic and bureaucratic funding system that means centers must piece together the necessary funding from a variety of sources.

Constrained by limited resources and complex regulations, the management of school-based health centers has become increasingly onerous. State accreditation standards require consultation with medical specialists, adherence to strict medical protocols, and meticulous record-keeping. The need for constant communication with school and community interest groups competes with the health center's primary mission: to deliver care to students.

To strengthen public acceptance, health centers have found it useful to form community advisory boards that participate in policy and planning and give support and feedback. Representing a cross-section of community interests, these advisory boards often include medical and social service providers, school board members, parents, civic leaders, clergy, and financial supporters.

Evanston school board president Elizabeth Tisdahl believes the extensive community outreach of Evanston's 30-member advisory board was crucial in achieving victory in a divisive year-long battle over including reproductive health among the center's services. "I don't believe the board would have voted for it if the advisory group had not recommended it," she says.

In a poor urban setting, school-based health centers face a different set of priorities. George Washington High School's school-based health center, a joint venture of New York Presbyterian Hospital and the Columbia University School of Public Health, serves students from an impoverished Hispanic neighborhood in upper Manhattan that was until recently a hotbed of drugs and violent crime. Stressing HIV prevention and avoidance of other high-risk behaviors, the center is a life-saving force in the delivery of health care, psychological services, and preventive care to the school's underserved and often uninsured population.

The largely immigrant community surrounding the school lobbied to establish the health center, but, in contrast to Evanston's activist population, it now provides relatively little advice on policy or programs; rather, the health center's bilingual staff relies primarily on its medical partners.

As for distribution of contraceptives, the health center is guided strictly by New York State law. "We explain to parents who want to opt out [of birth control counseling] that under state law, adolescents would have access to reproductive health services, even without their parents' permission," says clinic director Pamela Haller, an ordained minister with a degree in public health. But most do give permission: "Our enrollment speaks for itself -- our parents want their kids to have access to those services," she maintains. Haller estimates that nearly 90 percent of the school's 1,500 students are enrolled with parental consent for all services, including reproductive health.

A compelling need

School-based health centers represent a departure from the pattern of the school nurse or visiting public health nurse as the sole dispenser of health care in the schools. Faced with a growing incidence of emotional problems among their students, communities are recognizing that comprehensive school-based health centers, linked to mainstream medical institutions, might be the best and perhaps the only checkpoint for identifying and treating potentially serious dysfunctions.

What's more, school-based health centers reduce barriers to learning and help keep students in school. They allow teachers to concentrate on their students' academic performance, and help parents who can't afford to miss work for their children's doctors' appointments. They also reduce the number of hospital emergency room visits and 911 calls.

As statistics from the Centers for Disease Control and Prevention and other sources show, the case for adolescent school-based health centers is especially compelling:

• Adolescents (ages 10-19) have the lowest use of health care services of any age group and are the least likely to seek care at a doctor's office or hospital.

• Seventy percent of adolescent health problems are due to violence, substance abuse, tobacco use, inadequate physical activity, poor dietary habits, and risky sexual behavior. Four in 10 girls become pregnant at least once before age 20.

• The leading causes of adolescent deaths have changed from illness and birth defects to injuries, both intentional and unintentional. For young people 15 to 24, suicide is the third leading cause of death, after unintentional injury and homicide.

• During puberty, in particular, physical and mental health issues are interconnected. By offering physical and mental health services in the same location, school-based health centers can respond to students who are more likely to reveal emotional problems during a medical visit in a comfortable setting.

The case is also compelling for children from poor families, who suffer disproportionately from ill health. School-based health centers are uniquely positioned to target children in economic distress and supply easy-to-reach medical, mental health, and preventive services of high quality. Yet, the centers represent a remarkably small proportion of the estimated 10,000 urban and rural schools that serve predominantly low-income children.

An uncertain future

Why have school-based health centers failed to reach a critical mass? One explanation is that the public's preoccupation with upgrading academic standards has obscured the fact that sick or troubled kids have difficulty learning. For politicians, moreover, raising test scores seems simpler than creating new institutions with funding sources that cross jurisdictional lines.

A second and more fundamental explanation is that the patchwork of federal, state, local, and private funding sources is a nearly insuperable barrier to the centers' long-term expansion and growth -- to moving "from demonstration to scale," as Julia Graham Lear, head of The Robert Wood Johnson Foundation's Making the Grade program, puts it.

Currently, the federal Healthy Schools/Healthy Communities program supplies $14.4 million to support 62 school-based health centers across the country. The federal government also makes funds available to the states through the Maternal and Child Health Block Grant program ($9.3 million was allocated to centers by the states in 1997-98) and from the federal Centers for Disease Control and Prevention for education programs such as those to reduce tobacco use and the spread of HIV and other sexually transmitted diseases.

Although there are huge disparities among the states, state dollars in aggregate remain the largest funding source. In addition to administering federal block grants, 21 states allocated $29.6 million in general funds in 1997-98, with New York, Connecticut, Delaware, and Louisiana leading the way. Texas, though, will discontinue funding for school-based health centers starting next month. In Illinois, Massachusetts, and Louisiana, funds from settlements of tobacco suits have been earmarked specifically for school-based health centers.

Increasingly, state funding has been supplemented by city and county funds. In 1995, the last year for which figures are available, local dollars provided 46 percent of the total budgets of school-based health centers in 11 cities. In 1996-97, four communities -- Dallas, Denver, Seattle, and Portland, Ore. -- reported receiving well over 50 percent from local funding.

Mindful that combined direct government support remains insufficient, health centers are being forced to take the market approach of chasing revenues from managed care plans. These plans now provide reimbursement for services for students eligible for Medicaid or for the new federally supported State Children's Health Insurance Program (SCHIP). Seeking reimbursement, however, has entangled the centers in a web of negotiation, enrollment, documentation, and record-keeping that has been time-consuming and only partially successful. In Illinois the enrollment process has proven so frustrating that the state awards a $50 bonus to the sponsoring agency for each completed application to KidCare, the state's version of SCHIP.

Reimbursement usually entails a struggle to be recognized by Medicaid managed care plans. (In New York City, for example, this has involved the negotiation of more than 2,000 contracts.) Even then, many plans fail to recognize nurse practitioners as health care providers and refuse to reimburse such core activities as mental health counseling and preventive services. Others require centers to maintain coverage 24 hours a day, seven days a week.

Among private funders, The Robert Wood Johnson Foundation, a pioneer in the school-based health center movement, was instrumental in developing a national model for good care. The foundation has supported both the establishment of school-based health centers and the search for new funding partners. Now, through its Making the Grade program, the foundation is encouraging the reorganization of state and local funding policies. The Carnegie Corporation, the W.K. Kellogg Foundation, regional and community foundations, private corporations, hospitals, and health organizations have also supported school-based health centers.

Advocates of school-based health centers see no way out of the maze of multiple funding sources. Rather, centers will need all the political skill they can muster to maneuver through difficult bureaucratic terrain. The emergence of independent state coalitions of school-based health centers should aid this endeavor. The coalitions, which now operate in 15 states, are proving successful in organizing networks of child health advocates to explore funding opportunities, share information and strategies, and develop standards for school-based health centers.

Making health centers work

While advocates worry whether school-based health centers can be sustained financially, employees of the centers must sort out day-to-day relationships with the teachers, administrators, and health personnel in their school -- relationships that are often complicated by clashes in mission and culture between the disparate worlds of education and health care.

Teachers and administrators are concerned with academic standards and want their students to remain in class. They might regard a visit to the health center as an excuse to avoid class work. Health center personnel are more attuned to the students' physical and emotional concerns and tend to regard repeated visits to the center as symptoms of deeper problems that need to be addressed by a skilled professional.

School administrators, teachers, school social workers, and guidance counselors expect reciprocity in sharing information about students. But health center personnel need to follow medical standards of confidentiality regarding student problems and their treatment, and that can lead to frustrations on both sides. However, they are required by law to warn parents and appropriate school staff if students pose a danger to themselves or others.

In most schools, the health center occupies renovated quarters. Teachers might resent the loss of space and envy such amenities as telephones, beepers, computers, and adequate filing space, which are ordinary tools-of-the-trade for school-based health centers.

Establishing cooperative relationships is the joint responsibility of school principals and health center directors, though school board policies can set useful guidelines. Practitioners nationwide have found the following strategies successful in encouraging staffs from the two different worlds to work collaboratively:

• Principals introduce health center personnel and explain their mission at the opening-of-school orientation meeting. They describe jointly developed policies regarding the health center's hours of operation and procedures to promote proper use of the center by students. They encourage teachers, guidance counselors, and other school personnel to make appropriate referrals. They inform the school staff of procedures developed with the health center staff for schoolwide crisis intervention.
  
  
• Health center directors and their staff use school registration days to introduce services to parents, obtain parental consent for use of the center, and provide information on health insurance plans. They organize open houses to familiarize school staff, parents, and students with the center's services. They make presentations at parent-teacher meetings and send home informational flyers and newsletters with students. They provide for health coverage when the school is closed.
  
  
• Health center personnel reach out to the school staff (especially school social workers, guidance counselors, health teachers, and physical education instructors) to exchange information and plan joint activities. They provide faculty training and make classroom presentations. They explain the need for medical confidentiality, and, with student and parental permission, share information regarding students' problems and treatment when appropriate.

As school-based health centers face an uncertain future, they are finding that expansion and growth will depend not only on the availability of dependable funding but also on how well they manage their resources and answer to their constituencies. Medicaid managed care, for all its complications, is forcing business-driven efficiencies and information collecting. Funders are demanding research and evaluation of outcomes. These are challenging tasks for school-based health centers, which often operate using part-time personnel and without a full-time director on site.

Despite the obstacles, advocates are convinced that school-based health centers meet a pressing need. "Look, we read every other week about some new tragedy involving kids, where we think a mental health intervention or health intervention -- or prevention -- might be useful," says Julia Graham Lear. "And we know that school-based health centers, with well-trained professionals who are connected to established medical providers, have a pretty good record in this regard."

Nina Hurwitz and Sol Hurwitz are freelance education writers in Rye, N.Y. Their article "Tests That Count" appeared in the January 2000 issue of American School Board Journal.

A coalition builder in Illinois

AS A FORMER DIRECTOR of a school-based health center, Ann Marchetti believes deeply in their effectiveness. Marchetti, staff director of the Illinois Coalition of School-Based/Linked Centers, has used her prodigious personal and political skills to create coalitions of advocates, persuade Illinois officials to improve funding for school health-care centers, and identify new sources of financing. Her efforts have led to the inclusion of school-based health centers as a line-item in the state budget and an improvement in the state grant formula.

The Illinois Coalition's 300 members, Marchetti says, provide "strength in numbers" and new opportunities to "learn from one another." But much of the credit goes to Marchetti herself: She has organized students to lobby the state legislature; persuaded Paul Vallas, chief executive officer of the Chicago Public Schools, to renovate existing health centers and designate space for centers in new schools; and enticed foundations and private organizations to support the coalition -- in one case without submitting a formal proposal.

Describing her lobbying technique with one state legislator, she recalls: "I argued the case, and he ended up asking, 'How much do you want?' I threw out a figure, and he said, 'Done!'" -- N.H. and S.H.

Adolescent and School Health Division, Centers for Disease Control and Prevention

Center for School Mental Health Assistance, University of Maryland

Healthy Schools/Healthy Communities, U.S. Department of Health and Human Services

Making the Grade: State and Local Partnerships to Establish School-Based Health Centers, Robert Wood Johnson Foundation

National Assembly on School-Based Health Care

National Governors' Association, State Children's Health Insurance Program

National School Boards Association School Health Programs

UCLA School Mental Health Project