The Answer Is At School: Bringing Health Care to Our Students

In 1987, The Robert Wood Johnson Foundation awarded grants to 18 community institutions around the country to establish school-based health centers. The grantees launched health centers in 24 schools that provided (and all but one continues to provide) on-site, comprehensive physical and mental health care for adolescents at risk--everything from physical exams and lab tests to prescriptions and counseling. While this program focused on adolescents, school-based health centers have proved effective for younger students as well. Indeed, there are many models of school-based health care that serve many different populations. Because the experience of The Robert Wood Johnson grantees has been well developed in a variety of communities and has achieved a high level of acceptance, this report concentrates primarily on that model. The following article is excerpted from a 38-page report produced by the School-Based Adolescent Health Care Program in 1993.

Rarely does an idea come along that solves several long-standing health problems at once, inspires broad support among diverse groups and creates a successful model with wide applicability. Comprehensive school-based health care does all of this and more. By bringing medical and mental health services to underserved students, school-based health centers provide a direct response to the health needs of young people.

From AIDS to violence, young people today face more dangerous health risks than have recent generations. The dangers are greatest for those disadvantaged by poverty, who grow up in communities with poor schools, high unemployment and limited health services.

In poor communities, rural and urban, even the most concerned parents cannot afford to miss work to take their children to the doctor. In rural communities, lack of transportation can render health care particularly inaccessible. Red tape and waiting lists make it difficult for poor families everywhere to obtain even the basic health services that most of us take for granted.

Access is not the only obstacle. The health care system is ill-suited to deliver the multidisciplinary, preventive and often time-intensive care required to address today's adolescent health problems. Most publicly funded services for low-income youth are packaged in categories: one for immunization, another for health education, a third for substance abuse. But children's needs do not come in neatly packaged categories; young people need a comprehensive approach to health care--one which views them as whole people with multiple, interrelated problems.

Delivering health services in schools is not a new idea. School-based health centers are new because they treat students for a broad range of physical and mental health problems. Critics contend that schools should not be burdened with students' non-academic needs. And yet schools are burdened with students who cannot learn well because of physical and mental health problems. Proponents of school-based health centers do not expect schools to provide health care resources or expertise. Schools, instead, serve as a central location where care can be delivered by health professionals. Centers receive funding from a variety of sources, including state health departments. Though school-based health centers look different from community to community, they share features:

School-based health centers are located in the schools. Rather than expecting students to make their way to local health providers, why not bring the providers to the students? Make it possible for a variety of health professionals to begin delivering services at school, and the problem of connecting students with services is solved. Placing health services in schools assures students access to immediate care and guarantees that services fit students' needs.

"Health services need to be where students can trip over them," said Philip J. Porter, M.D., early architect of the school-based health center movement. "Adolescents do not carry appointment books, and school is the only place where they are required to spend time."

School-based health centers make getting health care easy. Students don't have to travel off campus. They don't need to have insurance. The centers give students a medical home.

School-based health centers are operated by health professionals. Students receive care from multidisciplinary teams of professionals of primary care professionals, each of whom can address a broad range of problems. A medical assistant supports a nurse practitioner or physician assistant. Mental health services are typically provided by a master's level social worker. A part-time pediatrician or family practitioner rounds out the core staff. Centers also may have a part-time nutritionist, dental hygienist, substance abuse counselor, conflict resolution counselor and health educator.

"The adolescent health problems of the '90s are no longer solvable by a nurse practitioner or doctor working in isolation," said Martin Fisher, M.D., chief of adolescent medicine at New York's North Shore University Hospital. "They require multidisciplinary attention. When medical and mental health providers work alongside teachers, you get a comprehensive approach to complex issues. You encourage common purpose."

The team of school-based health professionals is typically led by a sponsoring community health-care institution to ensure comprehensive health services, including lab work, X-rays and consultation with specialists. Three of four school-based health centers are administered by a community health center, health department, hospital or medical school.

School-based health centers provide comprehensive services. From diagnosis and treatment of diseases to counseling for students and families, school-based health centers address a broad spectrum of health problems. In contrast to some people's image of what services students seek, national surveys suggest that reproductive health care prompts only 15 percent of student visits to school-based centers. The other 85 percent of visits illustrate how comprehensive the services are:

School-based health centers build cooperative linkages with parents. As a rule, most school-based health centers require written parental consent prior to accepting students as patients. Fewer than 1 in 10 parents that sign consent forms choose to limit services their children can receive. School-based health centers also strive to get parents involved through parent newsletters, family communication seminars and satisfaction surveys.

Center staff seek to communicate with parents without compromising the confidential patient-provider relationship that teens desire and expect. Parents are immediately informed about their children's condition and treatment in life-threatening situations. While protecting teens' privacy, staff also strongly encourage family communication. "In over 80 percent of cases, confidentiality is simply not a problem," said Steven Tames, M.D., project director of New York Medical College's Morris High School Adolescent Medicine Program. "Most kids we see, with some encouragement, are willing to discuss even very private problems with their family. Often, they just don't know how to talk about the issues, so we help them do that. Sometimes we tell their parents together."

School-based health centers build cooperative linkages with the school. Health centers host open houses, attend faculty conferences, conduct school-wide immunizations, teach staff workshops on adolescent health, organize health fairs and find many ways to participate in their schools. Health-center staff participate in health education programs, organize sports clinics and health fairs, serve on crisis-response committees, work with guidance counselors on dropout prevention and offer clinical backup to schools' day-care centers.

"The whole school is the patient, not just the individual students," said Harriet Smiley, health educator for two school-based health centers in Detroit. "The health center can be part of an effort to transform the entire school environment."

To better integrate into the school system, most health-center staff meet with principals, assistant principals, teachers, coaches, guidance personnel and front-office staff. Health center personnel, who are not school district employees, team up with the school's own health staff and with the academic and administrative staff. One key reason is that teachers and administrators can account for more than half of patient referrals.

School-based health centers build cooperative linkages with the community. "The health centers are only as successful as the people behind them," said Jane M. Foy, M.D., medical director of the Student Health Project in Guilford County, N.C. "With a network of parents and community leaders in your corner, a lot can be accomplished."

To organize community support, health centers establish advisory councils of parents, students, health-care providers, legislators, clergy and community leaders. The councils advise on local needs, help form policies and educate the community about adolescent health.

"The partnership we've developed with community groups has been one of the health center's strongest points," said Holley Galland, M.D., who directs two school-based heath centers in Baton Rouge, La.

Paying for school-based health care. More state and local leaders are recognizing the value and potential of school-based health centers. In 1994, over 600 centers were in operation in 41 states across the country. School-based health centers are funded through a variety of federal, state and local dollars, including grants from state health departments, private foundations and the federal Maternal and Child Health Block Grant program. Last year state governments contributed nearly $40 million to school-based health centers. Despite the rapid expansion of and financial support for the primary-care-in-schools model, school-based health centers face an uncertain future. In light of national fiscal belt-tightening, decreasing federal and state public-health dollars and greater competition for those dollars school-based health centers will need to emphasize collecting patient revenues, including Medicaid and private insurance, and rely less on private and public grant dollars. How programs fare will depend greatly on state efforts to protect the role of school-based health centers in delivering primary care services to children and adolescents.

School-based health centers clearly work. Whether you count the number of students who visit them, the number of parents, educators and health providers who support them, the number of problems they address or the number of dollars they save, the tally is success.

"School-based health centers provide more than just health care," said Laura Secord, R.N., F.N.P., former manager of the Ensley High School health center in Birmingham, Ala. "We provide healthy caring--an on-going relationship that builds self-esteem, builds relationships and builds students' ability to care for themselves. That is the difference that school-based health centers make. It gives us a chance to develop a daily relationship with the young people we serve. And that relationship builds a bridge to help them finish school and become contributing members of society."