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How School-Based Health Care Can Contribute to Closing the Achievement Gap

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Some strategies to close the achievement gap are widely discussed -- lowering class sizes and paying educators a bonus to work in a low-income environment, for example. Others are not. For instance, you rarely hear about efforts to close the gap by providing school-based healthcare. But in Colorado's Montrose County School District RE-1J, that's what they're trying.

After the district took on Richard Rothstein's Class and Schools (which considers the influence of out-of-school factors such as health, safety, and more on student achievement) for their book club, staff realized that there were gaps in access to healthcare for low-income and Hispanic students in their community that corresponded to gaps in academic outcomes. In examining the healthcare challenges that low-income families faced, including a limited number of primary care facilities in the area that took new Medicaid patients, they came up with an idea: Bring healthcare to school.

What is a School-Based Health Center?

While all school-based health centers (SBHCs) look different, they share some common characteristics. They are located on school grounds, working with the school to become an integral part of it. They provide a comprehensive range of services that meet the physical and mental health needs of young people in the community, working with a qualified health provider (such as a hospital, health department or medical practice) and employing a multidisciplinary team of providers (such as nurse practitioners, physicians, social workers and/or other health professionals) to provide care to students with the written consent of parents.

SBHCs benefit not only a school and its students, but the surrounding community. For example, they reduce inappropriate emergency room use and Medicaid expenditures related to inpatient, drug and emergency department use. Adolescents are significantly more likely to go to a SBHC for mental health services than a community health center or HMO, and SBHCs decrease absenteeism and tardiness among adolescents who receive counseling services in them. They have also been shown to reduce hospitalization and increase school attendance in children with asthma.

The Montrose Clinic

In Montrose, staff chose an elementary school with a high free and reduced-price lunch population located in the center of the community as a potential site for the district's first SBHC. They surveyed parents at the school, finding that 41 percent of respondents had no medical home and 49 percent had no medical insurance. They also surveyed teachers, finding that 100 percent regularly saw students who could benefit from a primary care facility. Teachers particularly saw need for mental health services, to help kids deal with issues ranging from anger management to incarcerated parents.

After proving the need for an SBHC, the district found community partners and grants from private foundations willing to support its operation. And today Montrose boosts a school-based health clinic staffed with a pediatric nurse practitioner, mental health therapist, promotora (a family outreach staffer) and school health tech. It provides a wide range of services, including individual, group and family counseling; sick visits; well visits; sports physicals; ADD management; and depression management. It gives flu shots and does splinting, wraps and some wound care. Staff works with children on nutrition and physical activity. A dental hygienist comes in regularly to do cleanings and fluoride and sealant applications. Partner institutions have taught parenting classes.

The clinic is located on an elementary school campus but open all aged 0 to 18. Children are served regardless of whether their family can pay, though there is a sliding fee scale based on family size and income for those who are uninsured and the promotora works to get eligible families enrolled in Medicaid or CHP+ [a Colorado public health insurance plan]. A partnership with a local pharmacy helps reduce the cost of medicine for uninsured children.

The Impact

Since opening in October 2007, the clinic has grown significantly. It initially served 30 patients a month. Now, it can serve 30 a week. County commissioners (initially opposed to the idea of a SBHC) are very supportive now that they have seen the clinic's impact on the Medicaid costs they are charged with. The community as a whole has been so pleased that it opened a second school-based clinic -- this one able to serve adults as well as children -- in another town.

While it is difficult to measure the impact of the clinic on student achievement given the indirect nature of its work and the fact that the clinics are just one part of a broad strategy to improve outcomes, the district is tracking standardized test score and other academic outcomes (like dropout rates). Time will tell if their comprehensive approach to closing the gap really works.

February 2011 is National School-Based Health Care Awareness Month. You can learn more about it by visiting this Web site.

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Wendy Doremus's picture

Since student health is obviously a priority and this district seems to understand the connection between health and learning, I am wondering why the district does not employ Registered Nurses as School Nurses in each one of the school buildings, rather than health technicians with one supervising RN. School nurses provide essential services such as medication administration, emergency care and chronic disease management among other things to ALL children and staff at a rate far greater than 30 individuals per week, the number reportedly seen in this School Based Health Center. Most individual school nurses see at least 30+ students a day. School nurses also address mental health concerns, organize immunization clinics and provide levels of health assessment and interventions that health technicians are neither trained to nor legally able to provide. There certainly is a place for School Based Health Centers but School Nurses can manage many of the same services at a fraction of the cost and they do screen and refer students to the SBHS. Seems like this district is missing an essential link in student health services.

Amanda Dunn's picture

I'm guessing that these SBHCs receive federal funds through partnerships with local community clinics and other donors, which might actually make them less expensive than hiring an RN for every school in the district. Many districts have worked around the lack of funds to hire nurses by billing Medi-cal to supplement the district's budget and subsidize RN salaries. Perhaps there needs to be a larger federal effort (like allowing the use of Title I funds for health needs) to help subsidize the cost of hiring RNs for every school, given the immeasurable savings from prevention of chronic disease, future medi-care hospital bills, etc.? (Or would that be a government take-over of health care, or too much "big government"?)

In addition, as a school nurse (RN) I find that I'm often referring parents to services that they cannot afford to access either because they lack insurance or cannot take the time from work or family obligations to bring a child to the doctor. There are often situations where I cannot provide the care a student needs in my limited facility and having the ability to immediately refer students to see a doctor or nurse practitioner for further care would greatly benefit the children in our community.

Amy Harris's picture

Until I read this blog, I was not familiar with School Based Health Care Centers. What a stupendous idea! My school community would most definitely benefit from these services. Each day I probably have at least eight students request to see the nurse, the majority of which stem from true need or injury. One nurse, no matter how quality or competent, cannot address the extensive amount of physical (not to mention mental) needs in the Prek-8 building. There is mounting frustration when I am told that students in my 3rd grade room have failed vision screenings since kindergarten, but no one has taken them to get glasses. I have had four students this year complain of toothaches, and the nurse has said that they have a cavity, but they are not taken to the dentist and forced to "concentrate" while in continual pain. In addition to the physical needs, I can't imagine the positive impact the counseling services would have in my building. I feel incapable, due to time and training, to address the serious needs of students who have witnessed a shooting of a family member, or who have such anger management issues that they are stabbing classmates with scissors. Although the direct link to increased student achievement may be difficult to measure, it seems obvious that students whose physical and mental health needs are being addressed will be able to focus on learning and most assuredly improve. I hope that the idea of School Based Health Care Centers becomes much more common.

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