National Assembly on School-Based Health Care. New Orleans Charter Science and Math High ... The School Health Connectio
are Making a Difference
An Evaluation Study of School-Based Health Centers In Orleans Parish Schools
A Program of the Louisiana Public Health Institute
January 2010
Evaluation Summary
ACKNOWLEDGEMENTS: Students of Orleans Parish Schools Algiers Schools Charter Association LSU Interim Public Hospital LSUHSC School of Medicine, Department of Pediatrics Louisiana Office of Public Health, Adolescent School Health Program Orleans Parish School Board Recovery School District Metropolitan Human Services District National Assembly on School-Based Health Care New Orleans Charter Science and Math High School School Health Connection Steering Committee Tulane University School of Medicine Tulane School of Public Health and Tropical Medicine Warren Easton Charter Foundation W.K. Kellogg Foundation
SUMMARY OF EVALUATION FINDINGS Our story… The School Health Connection (SHC) program was established in 2006 by a group of committed school-based health center (SBHC) providers and school leaders who were organized as the School Health Initiatives Network (SHINe). All five of the SBHCs in Orleans Parish had been closed or destroyed by Hurricane Katrina. The Louisiana Public Health Institute assisted SHINe in securing a grant from the W.K. Kellogg Foundation to recover and expand the network of SBHCs in the New Orleans metropolitan area and to improve access to care and health status of youth by providing high quality physical and behavioral health in SBHCs. The resulting program was named School Health Connection.
What makes school-based health centers unique? zz
SBHCs are doctor’s offices or health clinics located on a school campus. The
health care services provided in SBHCs far exceed what is possible in the
typical school nurse program and includes preventive care, comprehensive
primary care including acute diagnosis and behavioral health care services.
zz
SBHCs are holistic in their approach, integrating primary care and behavioral
health services. The service model and staff understand that prevention
and illness processes are integrally related to both physical and
emotional wellbeing.
zz
SBHC services are tailored to youth and provide age-appropriate care and thus
there is a high level of acceptance and satisfaction among students which
contributes to the effectiveness of the services.
Our study… Given the new beginning for SBHCs in the Metro area, this was an opportune time to assess the impact of SBHC services. In spring 2009 (2008/2009 school year), 1,924 students from six public high schools (3 with a SBHC and 3 without) in Orleans Parish participated in a survey to assess students’ perceptions regarding their health, healthcare seeking behaviors and other aspects of their lives including their mental and physical well-being. This target population is similar to the general population of public high school students of Orleans Parish. The principal goal of the study was to ascertain the effectiveness of SBHCs in increasing access to and utilization of essential health services (e.g., annual physicals, acute care, reproductive health counseling, behavioral health counseling and treatment), as well as a promoter of healthy lifestyles and good decision-making. Profile of Survey Participants: SBHC (n=980) Non-SBHC (n=944)
Total (n=1924)
Pct
Pct
Pct
Female
61.3
58.2
59.5
African American
87.0
94.3
90.0
Principal source of income is welfare, social security or unemployment benefits
17.8
20.3
19.0
Free lunch eligible
65.6
66.3
66.0
Hunger in last 30 days
10.9
12.2
11.6
Key Findings… School-based health center (SBHC) utilization patterns indicated that SBHCs are filling a gap for students who might otherwise have inadequate access to quality, ageappropriate, health care services. More than half of the overall students surveyed (66%) were eligible for free lunch; nearly 11.6% indicated that they were sometimes or often hungry because there was insufficient food in their homes; and nearly 30% reported general symptoms of clinical depression. Students with no regular source of care were more likely to report SBHCs as their regular source of care, and SBHC users reported a high level of satisfaction with the services. Given that the majority of public school students are from low socio-economic backgrounds, our study strongly supports that SBHCs are addressing health needs that might otherwise go unattended because of low access to care.1 SBHCs have an essential role in addressing early detection, primary and secondary prevention of chronic diseases. SBHCs offer preventive services to students, such as physical exams, nutrition and weight loss counseling, and sexual health counseling. SBHC users more frequently reported having discussed their dietary and physical activity habits and their sexual health with their SBHC provider, compared to students seeing a non-SBHC medical provider. Obesity, a primary risk factor for chronic disease, is already being observed among Orleans Parish students. Despite their youth, 3.5 % of students reported that they have been diagnosed with diabetes and 12 % with high blood pressure.
Use of behavioral health services was positively associated with the reporting of reduced mental and behavioral health related conditions and reduction in high risk behaviors, some at statistically significant levels. Depressive symtomatology was present in 30% of all students, and students with access to a SBHC were significantly more likely to have sought treatment (29.8%) than students without SBHCs (23%, p = .001) and more likely to receive medications for mental health issues when needed, however this association was not significant, suggesting that early prevention and intervention services might be having an effect. This association may be attributable to the avoidance of the need for medications when youth have access to preventive and early intervention mental health services. It is especially important that male students took advantage of SBHC counseling services. African American males living in poverty are among the least likely children and adolescents to be referred to mental health agencies for services.2 SBHCs offer an effective means of serving this group which is especially critical given their high risk for suspension and poor graduation rates.3 Orleans SBHCs provided substance abuse treatment at all three campuses. Under aged drinking and marijuana use were reported at alarmingly high levels among all students surveyed; however students from schools with SBHCs reported lower use of these substances at statistically significant levels (p=0.000).
Although SBHCs are not a panacea, they are definitely an important resource for students seeking counseling when they are troubled by interactions with peers or family members that involve abuse or violence. Our data indicated that students in SBHC schools were significantly less likely to report fighting or to carry a weapon to school compared to non-SBHC schools. These results are very promising and validate the importance of investing in skilled mental health workers that are accessible to students in schools with SBHCs. Yes, there may be other factors involved in these outcomes, for example schools with SBHCs may select students with fewer problems, but these issues can only be clarified over time with additional data. SBHCs can interrupt the negative relationship between violence, depressive symptoms and dropping out of school. The relationship between violence, mental health and school achievement is stark. Students who had been the victims of threats had nearly double the likelihood of episodes of depressive symptoms, and they were nearly three times more likely to have seriously considered suicide in the last 12 months. Girls who reported having been physically forced to have sex were nearly
A student was close to failing out of school because of excessive absences. After counseling the student the school determined that he was missing school because he was caring for his mother who was dying of cancer. The student was set up with home schooling by the psychiatrist and social worker, and also came to the health center weekly for counseling and medication checks. He ended up graduating. Without the coordinated effort of the school and the health center he would have surely dropped out in 11th grade due to absences.
three times as likely to have considered suicide. Students attending schools with SBHCs were more likely to be tested for STDs. 57% of the students sampled indicated being sexually active, but only 22.7% indicated ever being tested for HIV, 26% tested for STDs, and just over half indicated using contraception. These results clearly justify the need for additional education on risky sexual behaviors emphasizing prevention of pregnancy and sexually transmitted diseases which can result in long term problems including: infertility, ectopic pregnancy and cancer. SBHCs complement sexual health programs as they are ready and available with testing and counseling services.
Evaluation Findings at a Glance: 2008-2009 School Year 1,924 students from 6 Orleans Parish Schools responded, 3 with and 3 without SBHCs. With Regards to:
Students with access to a SBHC were:
Explanation
Use of preventive health and primary health services.
More likely to report SBHCs as their source of care, if available.
22% of all students reported that they do not have a source for routine health care.
More likely to be diagnosed for diabetes.
SBHCs provide routine preventive care. SBHCs require that every enrollee receives a comprehensive physical bi-annually. Physical exams are required for participation in sports and extracurricular activities. SBHC sports physicals are usually comprehensive physicals, not just the cursory check that is more typical of sports physicals.
Were more likely to have discussed healthy eating and exercise with a medical provider.
Change in personal health behaviors 34% of students are overweight or obese.
Sexual health 26% of all students reported that they have been tested for a sexually transmitted infection (STI).
More likely to have exercised in the past 30 days to lose weight. More likely to attempt to lose weight if obese
More likely to have discussed sexual health with a medical provider. More likely to have been tested for an STI. Less likely to report having sexual intercourse.
Use of behavioral health services for substance abuse
Less likely to have smoked in the past 30 days.
Depressive symtomatology was present Less likely to have ever consumed in 30% of all students. alcohol.
SBHCs record the Body Mass Index of students at every visit. Overweight and obese students receive counseling regarding weight loss strategies.
SBHCs do not provide contraceptive care, however students do take advantage of testing and treatment for STIs, which if unchecked, can cause long term health problems. SBHC services appear to be making a positive impact on reducing sexual risktaking behaviors.
SBHCs require a full-time behavioral health specialist and provide on-site services including individual and group therapy to address and prevent substance abuse.
Less likely to smoke marijuana. Use of behavioral health services Alarmingly, 21% of males and 33% of females reported depressive symptoms, and 11.6% of all students surveyed considered suicide.
Were more likely to have talked to a behavioral health specialist in the past year.
SBHCs require a full-time behavioral health services professional on site. Students utilize these services and report a high level of satisfaction with behavioral health services provided at SBHCs. During the past three years, the SHC program has funded psychiatry services in SBHCs, due to the need.
Violence 10% of students reported missing school because they felt unsafe and 34% reporting being in a physical fight within the last year.
Less likely to carry a weapon in the past 30 days. Less likely to report fighting.
Behavioral health services provided in SBHCs can assist students in managing potentially violent situations and teach them alternative coping skills.
Recommendations: 1.
Every high school student in Orleans Parish public schools should have access to
a school-based health center.
2.
SBHCs should be organized to serve neighboring elementary schools where
feasible. This would increase the impact of SBHCs and expand the benefits to
elementary school students.
3.
The state Medicaid program should begin reimbursement of behavioral health
services in SBHCs immediately. The evidence abounds that these services
can have a profound effect upon children’s educational success and their lives.
4.
SBHCs should be fully reimbursed for their services, including critical preventive
care such as counseling. Currently SBHCs reimbursements do not adequately
cover costs, causing reluctance of schools and medical providers to
offer these services to students.
5.
More outreach through curriculum based sexual health educational programs
and afterschool programs are needed to bring students into the SBHCs for testing
and counseling.
6.
Study results point to the need to provide contraceptive education and services
for students that request these services. This would require advocacy to change
the current law prohibiting contraception dispensing in schools, but it could be left
up to school districts and parents to determine if such policy is in the best
interest of students and their academic goals. Pregnancy is one of
the main reasons why teenagers drop out of school.
View the full report online at: www.schoolhealthconnection.org
Overall, these results are very convincing regarding the benefits of SBHCS. Preliminary findings are cause for optimism regarding the benefits of accessible quality services for youth, offered in the most accessible venue, schools.
Conclusions SBHCs address social determinants of health. The contextual factors that characterize the lives and experiences of public school students in New Orleans are stark. Given the environmental threats described in this report, students in Orleans Parish public schools face incredible odds, and it’s incumbent upon us to provide the tools to help them succeed. SBHCs are one of those tools and should be available to every public high school student in Orleans Parish. SBHCs can reduce health disparities through improving access to quality care and providing age appropriate health and behavioral health care to a population that might otherwise go without these services. SBHCs have been an especially efficient way to serve youth in a post-disaster setting where the need for services was exacerbated by the lack of community providers. The need for mental health services was especially acute post-Katrina and remains acute even after four years.4, 5 SBHC services help students stay in school. SBHCs intervene at a critical time in adolescents’ development providing preventive and primary clinical, behavioral health services that assist with their health issues and support critical decision making. Education is directly related to income and the more educated the individual, the more likely they are to succeed in life.6 Students most Through a routine sports physical conducted by a school-based health center, a 14 year old male was found to have a previously undiagnosed often miss school or congenital heart condition. The center staff immediately coordinated drop out due to personal an urgent cardiology appointment with a full workup EKG and stress health problems or testing. The cardiologist and center staff now work together to make sure he is followed up on a regular basis. Equally as important, with health problems of a the cardiologist’s help, the school was able to determine which physical close family member. activities he could safely participate in and still have a fulfilling high Behavioral health issues, school career. Without the services at this clinic this patient might which contribute to high have remained undiagnosed and would have been high risk for a sudden cardiac incident or death. risk behaviors, may often lead to school suspension and dropout.7 These health events are exacerbated by poverty, as vulnerable families have fewer resources to address health problems or advocate for their students when they are in trouble. Behavioral health services are especially critical for African American males, who are at greater risk of leaving school before graduation. Education is one of the greatest predictors of good health and the greatest remedy for poverty.
SBHCs are where health and education policy intersect. SBHCs provide unique preventive services and by definition, are inseparable from schools. Thus, education and health institutions must work hand in hand at all governmental levels to ensure that vulnerable students succeed and that due to their track record, SBHC services are available to support their students. In New Orleans, SBHCs are supported through a partnership between the state, local health care agencies and school districts. These partners require effective state and national school health policy that complements their local efforts to ensure that SBHCs can be sustained. The State of Louisiana is to be congratulated on having one of the largest networks of SBHCs programs nationwide that is supported by the Adolescent School Health Program, a dedicated state office which provides SBHC operational assistance through competitive grants and promotes quality services through technical assistance. SBHCs are included in health reform. This is an opportune time for showing such positive results for SBHCs. Due to the untiring efforts of the National Assembly on School-Based Health Care and its members, SBHCs were designated in both the House and Senate versions of health care reform at the time this was written. The House language provides for cost-based reimbursement for those SBHCs funded in the newly authorized program, and stipulates that State Medicaid and CHIPPRA programs reimburse school-based health centers for covered services. In addition to authorizing a SBHC program, the Senate version provides emergency appropriation for SBHCs. The provisions in both bills are the beginning of strong federal support for this model of care. Louisiana’s SBHCs continue to struggle with funding challenges, and if national health reform passes, SBHCs will still have the challenge of aligning state SBHC funding policy with these new opportunities for long term sustainability. Issues surrounding SBHC reimbursement are critical to enabling local medical providers to “When I first started working in SBHCs more than 30 continue sponsoring SBHCs. In years ago I quickly realized their value and strength as a source of health care, but also as a safe space addition to SBHC reimbursement reform where students can address the broader issues and for SBHCs, policy makers can ensure concerns in their lives. In many cases, their impact that Medicaid funding for SBHCs is reaches far beyond an individual’s physical health to violence, family strength, community health, expanded to cover more services. academic achievement, school wellness and more.” For example, in Louisiana, social work services and patient counseling Linda Juszczak, Executive Director of the National Assembly on School-Based Health Care services are not covered, and these are the two hallmarks of preventive care.
The bottom line is that SBHCs are an effective method of providing preventive and primary care services to an underserved and deserving population. This report certainly supports that the long term benefits of this investment are worthy and represent smart public policy.
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