School-Based Health Centers in an Era of Health Care Reform: Building on History

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School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs' impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths' academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation's youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.

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Historical Background

The origins of school-based health can actually be traced back to the early 1900s with the public health nursing movement.1, 11 At that time, student absenteeism rates because of communicable disease, such as measles, scarlet fever, whooping cough, and tuberculosis, were high.11 In an attempt to contain contagious illnesses, the Board of Health in New York City instituted a “rule of exclusion” in schools, sending home any child with a contagious disease—but without any treatment or plan of

Meeting the Needs of Underserved Populations

SBHCs are well positioned to address the unmet physical and mental health needs of underserved youth populations by increasing accessibility and continuity of health care directly on the school campus.

SBHCs and Health and Social Outcomes

SBHCs have been found to impact a variety of health and social outcomes. A summary of the literature demonstrating these impacts is provided in the following text.

Supporting the Larger School Environment

The scope of SBHC services expands beyond the provision of individual client health-related services to reach the broader school community. For example, SBHC staff deliver health education curricula in classrooms; conduct health fairs for students, staff, and parents; serve on educational committees; and provide consultations to teachers and other school staff to support and address students' needs in their classrooms.

The relationship between emotional or behavioral dysfunction and poor

Providing Meaningful Opportunities for Youth Participation

In addition to their health and academic impacts, SBHCs provide opportunities to expose youth to projects that promote healthy development and empowerment. The concept of youth development has been defined as “the ongoing growth process in which all youth are engaged in attempting to: (1) meet their basic personal and social needs to be safe, feel cared for, be valued, be useful, and be spiritually grounded, and(2) to build skills and competencies that allow them to function and contribute in

Serving Students' Families, School Staff, and Community Members

More than two-thirds of SBHCs nationwide reported providing services to individuals beyond the student population at the schools in which they are located.3 These individuals include students from other schools in the community (58%); out-of-school youth (34%); faculty and school personnel (42%); family members of students (42%), and other community members (24%).3 Recently, the number of SBHCs that serve nonstudent populations nationwide has increased. Contributing factors may include

Evaluation and Quality Improvement

SBHC evaluation and quality improvement efforts have helped to refine and advance this model of care, although these areas can benefit from further attention as the model expands.

SBHC Financing and Sustainability

To consider how the SBHC model could be brought to “scale” and potentially play a more important role in schools across the country, 2 important factors must be acknowledged: costs associated with establishing and operating the model and fiscal sustainability.

Policy/Advocacy and Health Care Reform

Historically, most advocacy efforts for SBHCs have materialized on the state level. Over the past 20 years, the number of state SBHC initiatives has increased from 5 to 19.22 These initiatives are often characterized by state health departments establishing SBHC programs within their departments, as well as allocating funding to and authorizing legislation for SBHCs. As mentioned previously, state initiatives played a significant role in the expansion of SBHCs by securing state funding,

Implications and Future Directions

This article has provided an overview of the documented role of SBHCs in improving health and social outcomes and their promise in making a contribution to reducing health inequities. Throughout the country, SBHCs are a key strategic partner in providing critical access to health care for youth. In summary, there are several implications for the future of SBHCs in the current era of health care reform, as well as implications for health care providers who may be delivering care in communities

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      Obstacles to sustainability include lower third-party payer reimbursement, inconsistent government support, and changing grant revenues. State and federal grants are the mainstays of SBHC funding, but to remain sustainable, successful SBHCs combine funding from local foundations, schools, private and state insurance, and Chapter 1, Title X, and Title XX funding (Keeton et al., 2012; Love et al., 2019; Soto Mas & Sussman, 2016; Ran et al., 2016). SBHCs overcome barriers and provide an entry point for care to those facing health disparities, such as homeless, minority, or immigrant youth (Keeton et al., 2012).

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    This research was supported in part by grants from the Maternal and Child Health Bureau, Health Resources and Services Administration, and the United States Department of Health and Human Services (U45MC00002 and U45MC 00023). The authors would like to also acknowledge Serena Clayton, PhD, Executive director, California School Health Centers Association; Sara Geierstanger, MPH, Senior researcher, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco; and Linda Juszczak, DNSc, MPH, MS, CPN, Executive director, National Assembly on School-Based Health Care, for their contributions and support.

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