School-Based Health Centers: A Model for the Provision of Adolescent Primary Care
Case study
Annie (identity disguised) is a student at one of the public high schools where a school-based health clinic (SBHC) is located in the building. Annie is called to the clinic during school to receive her second human papilloma virus (HPV4) vaccination. The medical assistant checking her into the clinic noticed that she has lost quite a bit of weight. When questioned further, Annie stated that she was not trying to lose weight. The medical assistant had her see the primary care provider in the clinic instead of only vaccinating her and sending her back to class. After a history and physical examination were obtained, the clinician notes that Annie has experienced polyuria and polydipsia. A urinalysis in the clinic displays glucosuria and ketonuria. Fortunately, she was not severely acidotic at this time. Ultimately, Annie was referred to endocrinology and diagnosed as having Type I diabetes.
Health care of adolescents can be challenging for a primary health care provider in a typical clinic or office setting. Adolescents are the least likely group of patients to seek health care in traditional clinic settings [1]. Many of the health needs of this age group are unique in nature related to risky health behaviors, such as unprotected sex, substance abuse, and violence. Traditional health care settings are often not adequate and primary health care providers in these settings do not have the time to delve into the risky behaviors of this patient population. Although this case study does not highlight one of these risky behaviors, it does illustrate an advantage of having a clinic in a setting that is convenient for at-risk youth. It is likely that because of barriers faced by this teenager, her presentation as a new diabetic would have been more severe had it not been for the clinic located in her school.
It is difficult for children to attend school and learn if they are sick. Illness for the adolescent may come in the form of either physical health or mental health. These illnesses may commonly be chronic and need follow-up care. Learning is affected by high absenteeism rates associated with chronic illness and disciplinary actions related to behavior and mental health issues. Delay or failure of high school graduation is also affected by teen pregnancy rates [2].
The major focus of Healthy People 2010 was access to quality health care for every person [1]. Access to care for adolescents remains an issue despite improvements in health care access for the general United States population. Adolescents have an average of 2 visits to a health care provider each year, fewer than any other age group with the exception of young adults [3]. Lack of health insurance, convenience, confidentiality, and cost are all factors that may affect teenagers’ ability to access health care.
The objective of this article is to describe the evolving models of SBHCs in the United States. To date, peer-reviewed studies have documented the success of SBHCs in decreasing emergency room use and improving access to preventive services, such as immunizations. The authors highlight the long-standing comprehensive model located in Denver.
School-based health centers
School-based health centers present a solution to some of the barriers by adolescents related to access to care, school absenteeism, and their unique health care needs. Comprehensive services offered in the place where adolescents spend their days has become an alternative to traditional primary health care for this age group. Although this model has existed for decades, generally knowledge of SBHCs among health care workers remains limited.
History
School-based health centers originated to provide health care to underserved children in urban areas. With the support of the Community Access to Child Health program, a part of the American Academy of Pediatrics, the first school-based health centers opened in the late 1960s and early 1970s. The first centers opened in Cambridge, Massachusetts and were organized by Philip J. Porter, a local pediatrician. More centers followed in Minneapolis and Dallas. The Robert Wood Johnson Foundation supplied funding for several new centers in 1978. State level funding assisted the further growth of school-based health centers throughout the country. In 1995, federal funding came from the Health Resource and Service Administration in the form of Healthy Schools-Healthy Communities grants to build more school-based health centers [1].
As of November, 2009, more than 1900 school-based health centers existed across the United States, including those centers that are school linked and mobile. The majority of the centers are based in high schools (33.3%) but with the increase in centers, more are found in middle schools, elementary schools, and combination schools. More than half of the school-based health centers have been open for at least 10 years. The concentration of school-based health centers remains in urban areas, having more than 50%, but there has been an increase in rural centers. A variety of ethnic backgrounds are found in the student populations served with 36.8% Hispanic, 29.5% white, and 26.2% African American [4].
The growing popularity of this model has lead to the creation of a national organization representing school-based health centers. The National Assembly of School-Based Health Care (NASBHC) located in Washington, DC states that its mission is to improve the health status of children and youth by advancing and advocating for school-based health care. NASBHC reported 16 different state affiliates in 2010. In its 2009 annual report, NASBHC reported that the number of SBHCs had doubled from 1000 to more than 2000 since 1995 [5]. Aside from growth and organizational structure, SBHCs have also received recent validation through federal language in both the Children’s Health Plan reauthorization and the Patient Protection and Affordability Act. Both acts of Congress establish SBHCs as sites for comprehensive primary care, which enhance opportunities for billing and federal funding.
Models of care
The majority of school-based health centers are built based on a primary care model with the primary care provided by a nurse practitioner, a physician’s assistant, or physician. There are 3 variations of this model: primary care, primary care and mental health, or primary care and mental health plus. The primary care model may have medical assistants, registered nurses, or licensed practical nurses that complement and support the services offered by the primary care provider. This model does not include mental health services. The primary care and mental health model combines the services of a primary care provider with the those of a mental health provider who is either a licensed clinical social worker, psychologist, or substance abuse counselor. The primary care and mental health plus model have expanded services that may be dental, health education, or case management services [4].
Services
There are a variety of services that may be offered at any of the school-based health centers. The most common services include comprehensive health assessments, acute minor illness care, health screenings, chronic illness care (eg, asthma), immunizations, and anticipatory guidance. Many centers provide medications for treatment of acute minor illnesses and chronic care. These medications are dispensed on-site and taken home. Laboratory testing and referral to specialty services are also included in the care [4].
