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Assessing Community Needs
F. SCHOOL-BASED OR SCHOOL-LINKED HEALTH SERVICES
School-based and school-linked health services are becoming some of the most efficient methods for solving student health care access problems for many communities. Development of a school-based program, however, requires substantial resources and often creates controversy in the community. The following overview of such services will help pediatricians work with community members to achieve the best results for children and for schools.
1. Background
Once considered extremely controversial, school-based health centers are now viewed as one of the ways communities can address the unmet needs of young people. According to the National Assembly on School-based Health Care, more than 1000 school-based health centers were operating in the United States in 1998. School-dates in the history of school-based health centers are 3 decades old.
- The first clinics appeared in schools around 1970 when schools in Dallas, Texas, and St Paul, Minnesota, established school-based health programs.
- By the early 1980s, nearly 50 school-based health centers had been established.
- Innovative programs such as an initiative supported by the Robert Wood Johnson Foundation in the early 1980s helped establish models.
- State support of school-based health centers began in the mid- 1990s and has fueled much of the recent growth in this area. By the late 1990s, more than 50% of school-based health centers were supported by state funding.
- During the last decade, major national resources such as the Making the Grade Program at George Washington University and the National Assembly on School Based Health Care were established to provide support and resources to professionals working in or with school-based health centers.
2. The Need
Although most children in the United States are in excellent health and receive quality care, too many neither see physicians at recommended intervals nor receive treatment for episodic or chronic problems. The establishment of school-based health centers has helped address the barriers to care that are faced by these children.
- The primary barrier is financial. Many children are in low-income families and do not have health insurance. The difficulties confronting these children are made worse by the higher rates of health problems associated with poverty.
- Although universal health insurance is an essential step toward universal access for children, insurance alone is not enough. Unequal distribution of physicians and other health professionals across the United States, inadequate transportation, cultural barriers, and institutional practices all impede access to care.
- Even when physicians are present in a community, they may refuse to see children enrolled in Medicaid because of its many rules, low reimbursement rates, and restrictions on coverage. For example, nearly half the state Medicaid programs do not pay for care by psychologists or clinical social workers, even when they are supervised by psychiatrists.
- Adolescents face additional barriers to care and are more likely than any other age group to be uninsured. Many adolescents, despite legal protections, are also unable to secure confidential services related to substance abuse, sexuality, or emotional problems. All adolescents confront a shortage of physicians or other health professionals trained in adolescent health care.
3. The State of School-Based Health Services
During the past 25 years, parents, school officials, health care professionals, and public agencies have tested the effectiveness of school-based health centers in providing care to school-aged children. The rapid growth in the number of such centers reflects the enthusiasm that schools and communities have developed for this model of service.
The centers blend medical care with preventive and psychosocial services and organize broader school-based and community-based health promotion efforts. Data from a variety of school-based health centers confirm that the centers:
- Are popular with parents-more than 70% of parents' consent to having their children use the centers.
- Are popular with students-on average, about half of the students enrolled in the school will use the center, and they average 4 visits per year.
- Have increased access to care for young people who do not have access to regular providers, who have not seen a physician recently, and who do not have health insurance.
- Provide a range of physical and mental health services. Treatment of psychosocial problems is an increasingly important service component of school-based health centers.
- Are beginning to participate in managed care networks as the managed care plans see the centers as opportunities to expand their capacity to provide primary care to their enrolled school-aged children.
4. School-Based Health Centers and Managed Care
Why is the managed care community interested in school-based health services?
- School-based services can be cost-effective.
Under managed care arrangements, increased attention is given to the cost-effectiveness of patient management. If it actually costs less and is more convenient for students to receive services at schools than at physicians' offices, managed care organizations may support such services. Even if schools deliver some health services for health maintenance organizations (HMOs), those services should be provided at school only if the loss of capitation to physicians was less than the cost of providing the service itself.
- School-based services can help increase health care quality and patient satisfaction.
Collaboration with schools can improve immunization rates, reduce hospital admissions for asthma, increase well-child checkups, and improve statistics related to other gauges of quality health care. Quality assurance for health insurance plans is far more characteristic of HMOs than it is of indemnity plans. Therefore, there is additional impetus for collaboration among managed care, schools, physicians, and the health care consumers (students and their families).
When school districts and HMOs collaborate to provide health care for students, the following principles must be adhered to:
- Each partner must recognize and respect the other's institutional goals and understand how they differ and where they overlap. The educational community's goal in keeping students healthy concerns their attendance at school and their ability to learn. For health plans and primary care professionals, members need to be kept healthy by the provision of care in a cost-effective, coordinated, and accessible manner.
- Collaborative activities need to maintain principles of confidentiality, parent involvement, preventive care, and continuity of care.
- A student's health care plan-or more appropriately the designated health care provider-must be regarded by all partners as that student's optimal medical home, not the school.
- Collaborative agreements have to be replicable to student populations with varying demographic and cultural characteristics and applicable to each school in any one district.
- Financially, each individual agreement needs to be sound and viable for the managed care organization, the health care professionals, and the school.
