School-Based Health Centers Toolkit

School-Based Health Centers and Other School Health Programs

A Toolkit for Pediatricians

Prepared by the School Health Committee

Georgia Chapter American Academy of Pediatrics

July 2024

Toolkit Introduction

According to 2023 Kids Count, 17% of all children nationwide (12.2 million children) are living in poverty and are at a greater risk for a variety of negative outcomes including:

  • Increased rates of health problems and mortality, and
  • Increased risk of academic underachievement and school drop-out.

Unaddressed health needs impact a student’s ability to learn. Students with chronic health conditions are more likely to miss school due to symptoms associated with their illness or seeking treatment during the school day. Students may also miss school due to oral or behavioral health issues. School nurses, in addition to their other responsibilities, can help manage a student’s health needs during the school day. School-based health centers (SBHCs) can provide comprehensive medical care and for some students serve as a medical home.

SBHCs are recognized as an effective means of delivering physical health, behavioral health, and dental services that can significantly reduce barriers to health care for those living in poor communities. The barriers of cost, transportation, and hours of operation along with the lack of knowledge around how to manage one’s health and when to access healthcare are readily addressed through SBHCs. SBHCs not only increase access to healthcare, but also improve school attendance and academic achievement for these students.

 

The scope of services for these centers includes but are not limited to:

Medical

  • Diagnosis and treatment of acute and chronic illnesses and minor injuries
  • Routine health and sports physicals
  • Health Check (EPSDT) screenings/immunizations
  • Laboratory testing
  • Referrals and coordination of outside services

Behavioral Health

  • Behavioral health screening
  • Individual, group counseling
  • Crisis intervention

Dental Services

  • Exams, cleaning, sealants, fluoride varnishes, fillings, extractions, and other restorative procedures

Vision Services

  • Screening and eye exams
  • For centers with full-service vision centers – comprehensive eye exams and prescription glasses

 Other

  • Social services support and community outreach
  • School-wide Health Education/Health Promotion and Wellness activities
  • Limited medical support for teachers and other school staff

All services may not be available in every health center. The decision rests with the community and the medical sponsor on the depth and breadth of services offered.

In 1994, the first comprehensive SBHC in Georgia was created and managed by Emory University School of Medicine’s Department of Pediatrics. For over 18 years, there were only 2 SBHCs in Georgia. Since 2013, SBHCs in Georgia have increased exponentially (i.e., 2 to117) under the guidance of PARTNERS for Equity in Child and Health within Emory’s Department of Pediatrics. In 2022, Governor Brian Kemp allocated $125 million for the expansion of school-based health centers (SBHCs) throughout the state of Georgia. The purpose of this funding is to increase access to healthcare for children and adolescents living in under resourced communities and to improve academic achievement for students enrolled in Georgia’s lowest performing schools. These SBHCs will be operated by community-based medical sponsors and each medical sponsor will receive $680,000+ over a 2-year period for start-up costs (i.e., staffing, equipment, supplies). The school district will receive $300,000+ to cover renovation costs or the purchase of a modular unit to house the SBHC. Georgia’s Department of Education is administering the program and the Georgia School-based Health Alliance (GASBHA) is providing technical support. Currently, 30 grantees are in various stages of planning and starting SBHCs throughout the state.

Pediatricians are encouraged to explore how they can collaborate with their local school districts to consider the possibility of serving as a medical sponsor for a SBHC in their respective communities.

A medical sponsor operates independently and collaboratively with the school to provide medical and mental health services for students, their siblings, and if within their capacity, the school staff. The sponsor is responsible for:

  • Providing pediatric primary care services
  • Hiring and managing staff,
  • Outfitting the health center (i.e., medical supplies and equipment, furniture, IT equipment, etc.)
  • Providing janitorial services
  • Referrals to subspecialty care
  • After hours coverage

For the pediatrician and other medical sponsors, the SBHC is an extension of their practice and often increases access to their existing patient panel but can also serve as a medical home for students who do not have access to a medical home. The sponsor coordinates care with other medical providers in the community, especially for those students who have a medical home.

The purpose of this toolkit is to provide guidance, instruction and technical assistance for those interested in participating in the expansion of these centers throughout the state. Visit www.gasbha.org for questions or additional information.

We hope you find this toolkit helpful. Please contact us vjohn01@emory.edu with suggestions or comments for future updates.

Map of School-Based Health Centers in GA

Operational School-Based
Health Centers – Georgia

Scaling School-Based Health Centers

To effectively replicate this healthcare model, four basic elements are required:

  • Recognized community needs and support
  • Evidence of health and cost impact
  • Sustainability, and
  • Fidelity to an exemplar model

Following an exemplar model (Whitefoord Elementary School-Based Health Center founded in Atlanta, Georgia in 1994) and under the direction of PARTNERS for Equity in Child and Adolescent Health of the Department of Pediatrics at Emory University, the Georgia SBHC project was created to expand SBHCs in Georgia with 3 key phases that support the four basic elements for scaling:

  1. Planning
  2. Implementation
  3. Sustainability

The planning process occurs over a minimum of one year and can be extended into 2 years or more. From implementation to sustainability, there is usually a minimum of 3 years. For some centers, it may take longer to reach sustainability.

Implementation is dependent on funding and constructing mutual agreements between school and medical sponsor on how the SBHC should operate along with defining liabilities and determining where specific liabilities reside.

Factors impacting sustainability are patient volume (number of students in a school), patient enrollment and utilization, ability to serve siblings of students in school, ability to integrate into the culture of the school, perceived value of SBHC services by school and parents, cultural or language barriers, and financial efficiency and support of medical sponsor.

Development At a Glance

Planning

  • Apply for Planning Grant
  • Develop community advisory group
  • Perform a needs assessment
  • Visit existing SBHCs to better understand operations/scope
  • Identify which schools would be best served
  • Identify a potential medical provider/sponsor
  • Develop a business plan

Implementation 

  • Engage and obtain approvals from district and school
  • Plan budget
  • Procure funding
  • Develop SBHC Advisory Council
  • Identify and renovate space
  • Hire staff
  • If FQHC-sponsored – obtain “change of scope” approval from HRSA
  • Enroll in insurance plans
  • Credential staff with insurance programs
  • Market/outreach to recruit/enroll patients

Sustainability

  • Develop strong partnerships between stakeholders
  • Develop robust marketing/outreach plan to continue enrolling sufficient patients
  • Further develop business model to maximize billing/collections

Planning Phase

It is important that the community is informed about the basic tenets of SBHCs and the value they provide to the students, parents, faculty, staff, and the community at large. Planning grants are awarded to communities for the purpose of increasing knowledge and public will around the development of SBHCs. Grantees are required to create a community advisory group consisting of stakeholders in child and adolescent health and education to guide the planning process.

Responsibilities of advisory group:

  • Provide guidance and direction and assists with the identification of resources and funding for the development of the SBHC. Educating the community on the value of SBHCS and increasing public will around the development of these centers. Members should include but are not limited to:
      • Local school system (LEA); administrators; board members; school nurse,
      • Health care providers such as Community Health Centers/Federally Qualified Health Centers (FQHCs); pediatricians; academic centers; hospital systems; faith-based organizations, health departments,
      • Community agencies and child advocacy organizations,
      • Local foundations, businesses, and other potential funders
      • Parents, etc.
  • Perform a needs assessment to define the health and academic needs of students. The needs assessment identifies specific health problems in the community, the type of services and resources available to address those needs, gaps in service delivery and current barriers to care (physical, mental, and oral health).
  • Participate in site visits of an SBHC to better understand operations and scope.
  • Identify which school(s) in the district that would be best served by a SBHC.
  • Determine the SBHC delivery model. The most common models are:
    • Onsite within the school (requires repurposing of existing space with associated costs)
    • Modular unit on school grounds (requires purchase of modular unit and outfitting of unit)
    • Mobile unit which can serve multiple school locations
  • Determine scope of services and how staffed.
  • Determine hours/days/months of operation. For example, will the SBHC be open 5 days per week or fewer; 8 hours per day or fewer; 12 months per year, or only when school is in session?
  • Develop a business plan (a collaboration between the school system, community-at-large, and the medical provider) to determine the financial needs and resources available to support the implementation and sustainability of the SBHC.
  • At the end of the planning year, it is expected that:
    • The community will have a clearer understanding of the healthcare needs of their children and adolescents.
    • A determination will be made whether a SBHC is needed.
    • A clearer understanding of the costs associated with start-up and sustainability.
    • The targeted school for the development of a SBHC will be identified.
    • A potential medical provider/sponsor for the SBHC will be identified. For Example:
      • Pediatricians or Family Physician
      • Federally Qualified Health Centers (FQHCs)
      • Local hospital systems
      • Academic medical systems
      • Health Department
    •  

Implementation

Implementation of a SBHC involves the following

  • District and School engagement along with School Board approval
  • Dentification and renovation of space for SBHC
  • Hiring of staff
  • For FQHC sponsoring organizations, obtaining a ‘Change of Scope’ approval from Health Resources & Services Administration (HRSA)
  • Enrolling SBHC site in Medicaid, PeachCare, and private insurers
  • Credentialing staff with Medicaid, PeachCare, and private insurers
  • Student recruitment and enrollment (includes marketing and outreach)
  • Establishing and monitoring enrollment, utilization, and quality metrics

Steps toward implementation involve budget planning and the procurement of start-up funds, creation of a Memorandum of Understanding, marketing strategies, and the creation of the SBHC Advisory Council. In considering costs for a SBHC start up, a sample budget has been developed. (See Sample SBHC Start Up Budget).

 

Budgets should include costs for:

  • Space renovation
    • If within the existing school building
      • This could be the responsibility of the local school system (LEA), the medical sponsor or a shared responsibility between the two. Occasionally, funds from other sources (foundations, governmental grants, etc.) are used for renovations. (See Link to Sample Floor Plan)
    • If within a modular unit located on school grounds
      • The expectation is usually a negotiation between the LEA and the medical provider on cost sharing. Other resources can be used as well.
    • If a mobile unit
      • The expectation is that this would be funded by the medical sponsor or an outside funder.
  • Clinic Staff
    • Funded by and employees of the medical sponsor
    • Core staff include – Physician (part-time to provide oversight), Advanced Practice Practitioner (nurse practitioner or physician assistant), Medical Assistant, Licensed Clinical Social Worker, and front office support.
      • Add additional staff as funds become available (i.e., dentist, dental hygienist, optometrist, health educator, community outreach worker, etc.)
      • Some members of core staff, i.e., behavioral health and dental, can be provided and funded by organizations outside of the medical sponsor.
  • Start-up supplies and equipment
    • Major medical equipment (exam beds, medical devices, etc.)
    • Major office equipment (copiers, scanners, computers, etc.) and furniture
    • Start-up medical and office supplies (See Start-up Equipment List)
  • Janitorial services
    • The school janitorial services are not aligned with what is required to clean and disinfect a medical clinic (SBHC). The SBHC should hire an entity licensed and trained to provide this service
  •  IT and Translational Services (for some sites).

Marketing

  • Marketing is a key component to implementation as it is critical in the enrollment and utilization of the SBHC services as well as educating the public (school, parents, and community) on the value of SBHCs. Strategies include but are not limited to:
    • Creation and distribution of flyers, brochures, newsletters, and other forms of written communication
    • Inclusion of SBHC on school and school district websites
    • Press releases
    • Social media (Facebook, Twitter) campaigns
    • Public service announcements
    • Presentations at school and community events (i.e., health fairs, school programs)

Note: Marketing is a continuous and ongoing activity.

Advisory Council for the SBHC

It is recommended that an advisory council be created for the purpose of providing oversight and advocacy for the SBHC. Many members of the advisory group from the planning phase can continue in this capacity; however, it is recommended that other members from the community and school district be added to provide broader oversight and advocacy. Staff from the SBHC should be included. This will ensure quality and alignment of services with school and community needs and to provide guidance and feedback as needed. At a minimum, Council members should consist of school administrators, medical sponsor, school nurse and other school personnel (i.e., counselors), SBHC staff, parents, and community members (school board/local politicians).

NOTE:

  • SBHC staff do not replace school personnel, but rather complement services already provided by school nurses, counselors, and family liaison workers.
  • SBHCs adhere to HIPAA (Health Insurance Portability and Accountability Act) protocols to ensure confidentiality of medical information and acknowledge FERPA (Family Educational Rights and Privacy Act) protocols to ensure confidentiality of student educational information. Sharing of information is only accomplished through parental consent.

Sustainability/Conclusion

From historical data, most SBHCs require at least three years of extramural funding to become sustainable. It takes that amount of time to recruit and enroll a sufficient patient base that will utilize the services for whom the SBHC can bill. Sustainability depends not only upon patient utilization but also on insurance status and patient satisfaction which is a reflection of the patients’ perception of the quality of care they receive. Finally, sustainability involves strong business practices and community collaboration.

The School-Based Health Alliance has developed a sustainability model.

Sustainability plans should include the following key components:

  • Develop strong partnerships between the school district, the medical sponsor, school administration, school nursing staff, parents, and the community at large.
  • Robust program marketing outreach and promotion to recruit a sufficient number of patients to utilize the services of the SBHC.
  • Establish quality benchmarks to promote healthy outcomes and patient satisfaction, and
  • A strong business model to maximize billings and collections from Medicaid and private payers while ensuring that all patients are seen regardless of their ability to pay.

Conclusion

School-Based Health Centers are a proven model of healthcare for children and Adolescents living in under-resourced communities. They provide care in the context of all factors that impact the health and well-being of students (i.e., home, community, and school) and eliminate most barriers to healthcare (i.e., cost, transportation, hours of operation, lack of parental leave from work, etc.). Research has demonstrated that these centers not only improve access to health care, but they also improve health outcomes (i.e., asthma, mental health), increase school attendance and performance, and reduce the cost of healthcare.

School-Based Mental Health

Behavioral Health services are a significant component of all SBHCs. According to the CDC’s Youth Risk Behavior Surveillance Data Summary & Trends Report, in 2021, 42% of students felt persistently sad or hopeless, 22% of students seriously considered attempting suicide and 10% attempted suicide. These rates are disproportionately higher for some groups, including students of color, LGBTQ+ students, and girls.

Common conditions seen in school-age children include:

  • Anxiety
  • Depression
  • ADHD
  • Trauma, including physical and psychological abuse
  • Aggression and Bullying
  • Eating disorders
  • Gender identity issues
  • Substance use

In addition to affecting students’ overall well-being, these conditions can negatively affect school attendance and performance as well as relationships with peers and family members. They can also increase the likelihood of suspensions/expulsions as well as high-risk behaviors. Schools have increasingly become the major source of mental health care for students as the shortage of community mental health providers has worsened.

In Georgia, many have linked with mental health organizations in their community to provide mental health services to students directly in the schools. The Georgia Apex program, funded by the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD), is working with schools in every county in the state to facilitate these collaborations and is an important supplement to the mental health services also offered at SBHCs.

 

Mental health services at SBHCs are delivered differently from most school-based mental health programs. These services are integrated into the primary care system of care which is viewed as the ‘whole child’ approach. All aspects of a child’s well-being (physical, emotional, and social) are considered in assessing and treating their mental health problems. It has been demonstrated that students who receive mental health services at SBHCs are 10 times more likely to have a mental health or substance abuse visit than a student without access to a SBHC. This integrated model increases parental buy-in and participation and reduces the stigma of receiving these services.

Pediatricians can support the delivery of mental health services in schools by:

  • Serving as a referral source
  • Providing relevant physical health information/background to assist mental health provider(s) in providing care through the ‘whole child’ approach.
  • Prescribing medications for common mental health conditions
  • Encouraging families to participate in treatment plans
  • Providing in-classroom instruction to students on behavioral health topics
  • Participating in IEP staffing for children requiring additional specialized services

FAQs

What is the value of SBHCs?

SBHCs are an effective means of delivering physical health, behavioral health, and dental services that can significantly reduce barriers to healthcare and increase access to quality healthcare. The barriers of cost, transportation, and hours of operation along with the lack of knowledge around how to manage one’s health and when to access healthcare are readily addressed through SBHCs. SBHCs also help improve school attendance and academic achievement of students.

Do I need to quit my job to get involved with a SBHC? How much time will it involve?

Most SBHCs are staffed by Nurse Practitioners who are supervised by Physicians and would not require you to be present in-person full-time. A SBHC can be an extension of your practice to allow closer monitoring of your current patients who may have complex medical needs. If you are planning to work with a school to start a SBHC, collaborating with existing school health/wellness advisory groups and community groups can help with the planning process. Creating an advisory board consisting of community representatives, parents, youth, and family organizations to provide planning and oversight support of the SBHC is also an important first step in starting a SBHC. Planning grants and training workshops to develop new SBHCs are available through the PARTNERS for Child and Adolescent Equity Program of Emory University’s Department of Pediatrics and the Georgia Department of Education. Technical assistance is also available from the Georgia School-Based Health Alliance and the National School-Based Health Alliance.

Is there a source of income for the physician involved in a SBHC?

The majority of patients seen at SBHCs have Medicaid coverage or are eligible for Medicaid coverage. SBHC can be trained to assist families to apply for it if needed. All care provided at a SBHC can be billed to Medicaid if the patient has coverage. This applies even when patients have an outside PCP. In addition, approximately 10-15% of students have private insurance which can serve as a source of income. Finally, for students who are not uninsured and do not qualify for Medicaid, a sliding fee scale can be applied to their visit.

Do SBHCs compete with private practices in the community?

No. It is important for SBHCs to work together with other medical providers in the community to coordinate the care of mutual patients. Many SBHCs are in communities where there is a lack of access to quality health care and many students do not regularly see a pediatrician. For students who have a pediatrician or other primary care provider, the pediatrician can collaborate with the SBHC to help manage children with acute illnesses or chronic health problems (i.e. asthma, diabetes, sickle cell, etc.). Students who have complex medical conditions but have not had regular care can also be referred to pediatricians and specialists in the community.

Who decides where SBHCs are located? How do I get linked to a specific school?

The school district and medical sponsors collaborate with the community and stakeholders to determine the needs and possible locations for a new SBHC. Often, an enthusiastic school superintendent or principal familiar with the effectiveness of SBHCs will support and advocate for a SBHC at a specific school early in the process. Most SBHCs are located in Title 1 schools. Become familiar with schools where your patients attend or are in the neighborhood where you practice/live. Meeting principals and other school staff there or contacting district superintendents can help pinpoint more specific needs of students. Contact information for superintendents in Georgia school districts can be found here. Identifying a champion at an individual school may also be helpful in gaining support from the superintendent.

Does the SBHC need to be open every day?

Ideally, the SBHC should be open every day that school is in session and can also be open before and after school. A SBHC that is just starting may start with fewer days or part of the day every day and work up to 5 days a week. Since a SBHC will be a medical home for many students, we recommend being open for at least some days during school breaks as well. After-hours coverage is provided in accordance with your current policy.

What are my liabilities?

The medical liabilities in the SBHC are no different from those covered by your medical practice.

How else can I become involved in school health?
  • Educate school staff, students, and families on pertinent health topics (PTO meetings, staff meetings, STEM/career day events)
  •  Serve as a consultant for schools and districts to develop health-related policies.
  • Serve on wellness/school climate committees o Become familiar with resources available in the community and advise schools on accessing services.
  • Advocate for students and their families at IEP meetings.

Resources

Committees

Prepared by

The School Health Committee Georgia Chapter

American Academy of Pediatrics

Special thanks to Summer Gilmer-Hughes, Georgia AAP

Committee Chair
Veda Johnson, MD

Vice-Chair
Yuri Okuizumi-Wu, MD

Members

  • Jay Berkelhamer, MD
  • Reshma Chugani, MD
  • Seema Csukas, MD
  • Bill Edwards, MD
  • Belise Livingston-Burns, MD
  • Barbara Menchan, MD
  • Datta Munshi, MD
  • Karyl C. Patten, DDS, MPH, JM
  • Barbara Pettitt, MD
  • Leslie Rubin, MD
  • Lynette Wilson-Phillips, MD