WASHINGTON, D.C. - Many school-based health centers are struggling to survive, but not because of lack of interest by students and parents.
"They like the convenience of it," said Paul Melinkovich, MD, director of Denver School-Based Health Centers. "They like the staff that's tuned in to dealing with adolescents. It's a comfortable place to go. They like the confidentiality. And at the elementary school level, the parents like it. In the communities we're in, there's a high percentage of families that don't have insurance. Many of them are undocumented residents of the United States, and they're not eligible for public insurance programs. We see a lot of kids who really have had no prior health care."
School-based health centers provide "more than just medical services," said John Schlitt, MSW, executive director of the National Assembly on School-Based Care here. "They tend to deal a lot with social and emotional needs of kids. It's a different kind of care. It's very family-oriented, very child-centered, and it requires a lot of nonmedical services."
These services include individual and group mental health counseling. In addition, they handle issues, such as classroom behavior, sexual abuse, substance abuse, grief management, gang intervention, peer-to-peer mediation and conflict resolution. Health center staff also provide students with guidance on nutrition, physical fitness, smoking, substance abuse and sexuality. "It's a really great opportunity to get kids at the most developmentally appropriate and probably most at-risk age and begin to talk about the kinds of behaviors they're engaging in and what they can do to avoid them," Schlitt said.
Financing has always been a problem. School-based health centers do not "fit in the paradigm of health care financing that Medicaid and managed care organizations have set up," Schlitt said.
"Reimbursement is difficult," Melinkovich said. "We've had little reimbursement for services. We are unable to get any money from the HMOs."
While Denver's school-based health centers are supported by local, state and federal grants, many are not. "That's largely why [school-based health centers] are closing," Schlitt said.
Lack of administrative support can also be devastating. For example, the sponsor of the Adolescent Health Clinic at Snyder High School, Jersey City, N.J. pulled all primary care services out of the clinic in 1995. As a result, patient visits dropped from 5,000 to fewer than 1,000 visits per year.
Once a school health center is in place, students come to depend on it. "They expect to be able to come back to school and get sports physicals," Melinkovich said. "They expect to be able to go in and get pregnancy tests and exams for sexually transmitted diseases, and they expect to be able to get their sore throat taken care of."
As a result, students are adversely affected when a school health center closes or cuts back on services. When services were cut at the Adolescent Health Clinic, many teens were left completely without medical care.
"We still took referrals from the school nurse for kids with colds and sore throats," said Leslie Morris, MSW, MPH, former director of the Adolescent Health Clinic and current project manager for the Adolescent and School Health Initiative at the National Association of Community Health Centers here. "We were back to square one, because we were referring those kids out, but they weren't keeping their appointments. We were referring those kids to their primary care physician, and half of the time those kids didn't know who that was. The services were not accessible." Instead, teens relied on the emergency department when they needed care.
For a school-based health center to work, several things need to be in place, including support from the sponsor organization.
"If you have an administration in place that's committed to providing services to kids through school-based health centers, then that administration will make certain that all avenues are pursued in order to keep services going," Morris said.
A solid commitment from the community is also important. "Sometimes that foundation isn't always laid," Schlitt said. "Somebody gets an idea for a grant and plots a health center in a school without laying an adequate foundation. Does the school really want them there? Is the school board on board?"
School-based health centers also need the support of the health care community.
"It's not just one health provider and one school," Schlitt said. "It's all health providers in the community coming together and plotting a district-wide scenario for primary care services for kids."
Government funding is important as well. "Public grants have to be in place," Schlitt said. "The communities that don't have state support are going to be in a tougher position if their community health providers continue to experience the kinds of fiscal austerity that they are experiencing right now."
One program that has good community and government support is the School-Based Health Center Program in Multnomah County, Ore. Out of a budget of approximately $3.5 million, $2.5 million comes from county general funds. The program has 13 school-based health centers and serves nearly 7,000 students.
"The school-based health centers began in the health department," said Valerie Whittlesey, MA, program director for the School-Based Health Center Program. "Because we have so many interventions designed for at-risk kids, it's a perfect public health program, although it's expensive."
"We have a lot of in-kind contribution of staff from the public providers of health and mental health care in the community," Melinkovich said.
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