Healthcare Operations Change Initiative Proposal

MENTAL HEALTH IN SCHOOL BASED HEALTH CENTERS

Expanding Mental Health Care Access through School Based Health Centers

Leah M. Schreder

Saint Mary's University of Minnesota

Schools of Graduate & Professional Programs

HP 652 Health Policy

Susan Doherty

December 20, 2015

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Introduction

Access to mental health care for children and teens is an area of need when addressing

healthcare operations. An effective way to address these needs is through School Based

Healthcare Centers (SBHCs). SBHCs are not a new idea and were first introduced in the 1900’s,

initially based on contagious illness containment (Keeton, Soleimanpour, & Brindis, 2012).

According to Keeton, Soleimanpour, and Brindis (2012), the first school nurse was hired and

began treating children using a variety of methods, which decreased the rates of absenteeism by

90%. Since then, SBHCs have evolved to cover projects helping teenage mothers, increasing

access to overall care and immunizations, and to meet the mental health needs of the underserved

population. SBHCs offer a convenient way for those children who are underserved to have

access to mental health treatment plans through proximity. The stigma of mental health care is

decreased since services can be provided without having to go offsite while attending school.

Even with the advancements in mental health care access, much more is needed to fill in

gaps in access. One specific change in policy is to induce an increase in predictable, steady

funding for SBHCs. Besides making funding more predictable and expanding it, more outreach

programs are needed within the school setting based on increasing knowledge of cultural needs

and disparities. Lastly, the evaluation of SBHCs and quality of service should be improved and

specific outcomes and models need to be defined as the number of centers increase.

Justification for Change

Since the Affordable Care Act (ACA) was passed, many cultural groups suffering

disparities in health care access have seen a decrease in inequality, however, children have not

gained additional access to insurance through eligibility levels within Medicaid or Children’s

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Health Insurance Program (CHIP) (Estes, Chapman, Dodd, Hollister, & Harrington, 2013).

Approximately 20% of adolescents meet diagnostic criteria for a mental disorder with severe

impairment, however, only about one-third of identified adolescents obtain treatment (Keeton,

Soleimanpour, & Brindis, 2012).

Children’s mental health affects many social and economic areas, in a cyclical

relationship, creating a need for additional change. The American Public Health Association’s

(APHA) Center for School, Health, and Education (2011) reported the strongest predictor of high

school dropout status is mental/emotional dysfunction and substance use. In addition,

educational disparities, or adults with a low level of education, are more likely to develop

cardiovascular disease, cancer, infections, lung disease, and diabetes (APHA Center for School,

Health, and Education, 2011). To infer that the levels of academic achievement and health status

are strongly correlated to good mental health would be deemed appropriate. Therefore,

addressing mental health needs in children will reduce future economic and societal problems.

Overview of Professional Organization, Regulation, and Laws

The most closely linked professional organization related to SBHCs and children’s

mental health is the APHA’s Center for School, Health, and Education. The center is organized

around the premise of preventing school dropouts and improving graduation rates by addressing

learning barriers such as bullying, hunger, and distress (APHA Center for School, Health, and

Education, 2015). APHA’s Center for School, Health, and Education focuses on increasing the

number of SBHCs to meet health care needs in children and adolescents. The Substance Abuse

and Mental Health Services Administration (SAMHSA) (2015, October 13) is also supportive of

the promotion of mental health wellness in schools in order to provide a safe learning

environment for students. SAMHSA (2015, October 13) reported that over the last two decades,

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the amount of mental health conditions have continued to increase, which is one reason why

SAMHSA offers grants programs and other resources that promote mental and emotional health

in schools and on campuses.

In 2004, the W.K. Kellogg Foundation developed the School-Based Health Care Policy

Program (SBHCPP), which focused efforts on making SBHCs financially stable, increasing

access to children and families, and supported consumer-centered care (APHA Center for

School, Health, and Education, 2015). At this time, 1709 school-connected programs that had a

difficult time maintaining adequate reliable sources of revenue were identified, serving the most

vulnerable populations, which included uninsured and underinsured children (APHA Center for

School, Health, and Education, 2015). SBHCPP’s design was based on developing infrastructure

needed for SBHCs, strengthening the capacity of the National Assembly of School-Based Health

Care to advocate for policy change to increase sustainability of SBHCs (APHA Center for

School, Health, and Education, 2015). Eventually, the federal recognition of SBHCs as

providers able to obtain reimbursement through Children’s Health Insurance Program

Reauthorization Act (CHIPRA) was accomplished (APHA Center for School, Health, and

Education, 2015).

The National Conference of State Legislatures (October 2011) provided information on

federal provisions, information and conditions for grant money, including states’ roles in

implementing health reform within the area of SBHCs. The ACA set aside $50 million for

grants in each fiscal year between 2010 and 2013 (National Conference of State Legislatures,

October 2011). The money was for basic construction and to support operations of SBHCs.

Some of the federal provisions under section 4101 (a) described eligibility for grants wherein

SBHCs needed to be primarily described as “a health clinic in or near a school, is organized

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through school, community, and health provider relationships, is administered by a sponsoring

facility, and provides primary health services to children in accordance with state and local law

through health professionals” (National Conference of State Legislatures, 2011). Additionally,

preferences for grants were made to SBHCs that served higher proportions of children eligible

for Medicaid or CHIP (National Conference of State Legislatures, 2011). The states’ roles in

SBHC regulation have been to provide oversight of SBHCs as well as stand as the primary

funding source.

Stakeholders

Adolescents are especially in need of mental health care due to the fact that they engage

in risky behaviors that can affect their present health and health status in the future (Keeton,

Soleimanpour, & Brindis, 2012). They require additional guidance when it comes to sensitive

needs such as mental health care. SBHCs provide care that is connected to high levels of

satisfaction and studies have shown that students are much more likely to keep appointments

through SBHCs (Keeton, Soleimanpour, & Brindis, 2012). It would be beneficial to provide a

service that is both highly satisfying and increases maintenance of services. Patients are more

likely to continue care and treatment when relationships and services are meeting their personal

needs.

SBHC providers are constantly challenged with the task of providing evidence or data

that their work is improving health and educational outcomes for its patients. There is a

correlation between evaluations and production of increases in access, improved outcomes, and

achieved, high levels of satisfaction. The issue remains that financial resources are limited along

with the narrow range of services while restrictions based on privacy keeps monitoring

challenging, or at the very least extremely laborious. SBHC providers also have a difficult time

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finding a steady source of income from year to year. Relying on private donations is difficult to

predict and is problematic when SBHCs provide services to all students with or without

insurance.

Payers for SBHCs are diverse and school based centers finance their operations based on

the types of financial revenue they acquire. Keeton, Soleimanpour, and Brindis (2012) reported

NASBHC’s 2008 national census of SBHCs reported the use of non-patient billing revenue. The

sources used were: state government (76% of SBHCs), private foundations (50%), sponsoring

organizations (49%), school districts (46%), and federal government (39%) (Keeton,

Soleimanpour, & Brindis, 2012). The study also concluded that most SBHCs bill public

insurance programs (Keeton, Soleimanpour, & Brindis, 2012). The sustainability of SBHCs will

be the passage of legislation providing more funding through the state and federal government.

SBHCs survival will also be based on the amount of community support and resources that are

available, which can be difficult, specifically because most SBHCs are already serving a

majority of uninsured or underinsured population where resources are already limited.

Procedure and Practices

SBHCs are health providers that provide services to every student in need. Within their

practice and procedures should be an outreach to patients. Such activities could begin with

surveys or screenings for the intended population. Because services are provided within or near

schools, school personnel should have a clear understanding on procedures of intake in order to

become primary sources of referrals. Providers working within SBHCs should have knowledge

of best practices and be provided trainings on how to interact with the population of students,

including cultural trainings and trainings on the sensitive nature of mental health needs. SBHCs

integrate within the school community, building educational opportunities and healthy

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relationships with staff, parents, and students. SBHCs should develop programs to introduce

healthy activities that promote mental health and a sense of community, with positive programs

defining mental health initiatives such as preventing bullying, understanding depression, and

breaking down stereotypes of mental health diagnoses. Case management should be used to

follow and provide services to those with chronic mental health needs, especially monitoring of

medication and frequent documentation based on teacher observations within school. SBHCs

should set regular meetings to discuss changing health needs within the school setting as well as

provide assistance to school staff as to managing their own stress and wellness within the

workplace. Besides day-to-day procedures and practices, SBHCs should be financially stable

putting effort into budget management and expense reimbursement. If needed, depending on the

amount of expenditures and the state in which the center resides, fiscal audits should be included

in the SBHCs practices and procedures also.

Ethical Considerations

Children and teens with mental health care needs have several types of ethical issues

worth considering when discussing a change initiative. Cultural disparities have been discovered

in access to general healthcare itself, although within SBHCs, studies have found that disparities

are very slight with few significant discrepancies. When discussing general health care services,

SBHCs delivered equitable access regardless of demographics or socioeconomic status

(Parasuraman & Shi, 2015). Parasuraman and Shi (2015) also concluded that very few

significant discrepancies were found when considering gender, race/ethnicity, and insurance

status. In contrast, when focusing on adolescents with serious emotional concerns and female

adolescents, differences in unmet needs were found in mental health care (Parasuraman & Shi,

2015). Unmet mental health needs for female and underserved adolescents were observed the

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most while these groups were at the highest risk of being undiagnosed or developing mental

health disorders (Parasuraman & Shi, 2015). Ethically, SBHCs will need to address the

inequality of female and adolescents with serious emotional concerns to ensure mental health

care is provided in the most equitable way possible across the board. Other ethical issues that

need to be addressed are use of active consent to provide services versus passive consent.

Passive consent may be helpful to students who desperately need care and parental supervision is

not consistent where consent may be delayed. It would allow some cases to begin treatment

immediately; where as active consent would hinder the immediate response to needed care.

However, passive consent may put organizations at risk for legal issues, depending on the

satisfaction of results or outcomes.

Proposed Changes in Policy, Procedures, and Practices

In order to provide students in need of mental health care the care they need, SBHC

providers need change their procedures to increase the use of quality measures that will identify

areas of organization weakness and areas that need improvement. Those measures should

generally focus on qualities of a strong SBHC operation such as capacity, efficiency, and

sustainability (California School-Based Health Alliance, 2014). The quality of care should also

be measured in terms of access and timelines, as well as, coordination and continuity. Areas

such as general preventive behaviors and management of chronic disease, in terms of mental

health, could be measured to assess areas in need of improvement (California School- Based

Health Alliance, 2014).

Improvements in SBHCs, and changes in practice, include increasing outreach programs.

Likewise, SBHCs need to maintain and build stronger relationships with students, as well as,

parents and guardians. Review of the outreach measures should be set on a regular schedule to

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be discussed with a sample group including providers and SBHCs employees, along with school

administration, the school board, and other school staff members. Brochures should be produced

to clearly outline services provided and the unique benefits to having them provided within the

SBHC. SBHCs need to continue open communication with parents by offering “open houses” so

that parents may be able to visit the organization physically and ask questions face-to-face.

Outreach could additionally include activities that are not specifically based on showing the

community what is offered at the care center, but may simply build relationships that would

increase trust, such as hosting family sporting events or partnering with local businesses to

fundraise through banquets or other events such as silent auctions. SBHC employees could

further consider volunteering to improve the community as whole, such as gathering groups to

clean up local parks, beaches, or picking up on a main street in town spreading information about

the center by word of mouth (Mackie, 2014).

Based on funding numbers previously provided, a stabilization and eventual increase of

federal and state funding for SBHCs must be part of a change in policy. Without more federal

and state funding, it’s difficult to predict the expansion of much needed SBHCs. Healthcare

reform focuses on increasing accountability for all healthcare organizations, including SBHCs.

Increasing measures of quality should provide validation of the important role SBHCs have in

providing mental health care, especially to youth. Due to mental health care’s sensitive nature

and the need for immediate care, it should be easy to provide numbers using outcome measures

and data proving the importance of providing increased access for this vulnerable population

within schools.

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Impacts of Change

Making changes within the SBHCs mental health funding process will create many

benefits to society as a whole. Keeton, Soleimanpour, and Brindis (2012) report that uninsured

and underinsured children and adolescents are at a high risk for not having healthcare needs met,

such as mental health services. That risk would be decreased and children and adolescents

would have a predictable, sustained follow up on mental health care with more access to

healthcare. When children are not well, either physically or emotionally, parents need to stay

home with them, creating economic hardship for the family. In the research done by Keeton,

Soleimanpour, and Brindis (2012), “adolescents were 10 to 21 times more likely to prefer

visiting an SBHC over CHC for mental health care, and enhanced availability of care was cited

as one of the likely reasons for this preference”. Based on the information, it would be probable

that more children and teens would be reached to provide much needed services.

Because mental health is linked to other health risks such as cardiovascular disease,

diabetes, and other chronic ailments outlined previously, these rate would decrease and affect

that amount of money spent on treating these diseases. In addition, providing more services

would increase the need for more healthcare providers creating more jobs in the healthcare field,

including medical equipment. Creating clinics within schools would increase jobs in other

industries as well, such as construction.

Influencing, Advocating, and Lobbying for Change

Advocating and lobbying for change should be centered mainly on outcome based

measurements. It’s difficult to argue with statistics and actual numbers based on measurements

defining the unique characteristics of SBHCs. Information should be presented in an informative

way focusing on benefits in healthcare but also benefits to society. Specific community numbers

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should be included in preparing for advocating SBHCs. Lobbying would include the same types

of information while adding quality measures into the information, toward pushing for an

increase in federal and state funding. Selling SBHCs should be the focus, so that SBHCs can

work on increasing accountability and quality without the worry of extreme financial shortages.

Conclusion

In closing, the amount of access to mental health care and accountability within SBHCs

cannot be duplicated in another setting. The population that is served by these centers, children

and teens, are dependent on others to take necessary steps to provide mental health care.

Outreach for these programs simply need to be where the population maintains their daily routine

to increase access to the care they need provided. SBHCs reduce the amount of transportation

needed to receive services, the time associated with parents needing work leave to provide

services, and increase the likelihood of follow-up services after care. SBHCs should be

recognized as an essential need for children and teens to provide mental health care in the most

sensible, appropriate setting possible and programs for increased revenue should be expanded.

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References

American Public Health Association’s Center for School, Health, and Education. (2015).

Retrieved from http://www.schoolbasedhealthcare.org/

American Public Health Association’s Center for School, Health, and Education. (2011). The

dropout crisis: A public health problem and the role of school-based health care.

Retrieved from

http://www.schoolbasedhealthcare.org/wp-content/uploads/2011/09/APHA4_article_Dro

pOut_0914_FINAL3.pdf

California School- Based Health Alliance. (2014). Key performance measures for school-based

health centers. Retrieved from

http://www.schoolhealthcenters.org/wp-content/uploads/2014/10/CSHA-Key-

Performance-Measures-for-SBHCs.pdf

Department of Health & Human Services, USA. (2010). Connecting kids to coverage:

Continuing the progress the 2010 CHIPRA annual report. Retrieved from

http://www.insurekidsnow.gov/professionals/reports/chipra/2010_annual.pdf

Estes, C., L., Chapman, S., A., Dodd, C., Hollister, B., & Harrington, C. (2013). Health policy:

Crisis and reform. Burlington, MA: Jones & Bartlett Learning.

Keeton, V., Soleimanpour, S., & Brindis, C. D. (2012). School-Based Health Centers in an Era

of Health Care Reform: Building on History. Current Problems in Pediatric and

Adolescent Health Care, 42(6), 132–158. http://doi.org/10.1016/j.cppeds.2012.03.002

Mackie, D. (2014, September, 30). Why marketing your small business through community

outreach really works. Retrieved from http://blog.fundinggates.com/2014/09/small-

business-marketing-ideas-community-outreach/

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http://www.insurekidsnow.gov/professionals/reports/chipra/2010_annual.pdf

http://www.schoolbasedhealthcare.org/wp-content/uploads/2011/09/APHA4_article_DropOut_0914_FINAL3.pdf

http://www.schoolbasedhealthcare.org/wp-content/uploads/2011/09/APHA4_article_DropOut_0914_FINAL3.pdf


Parasuraman, S. R., & Shi, L. (2015). Differences in Access to Care Among Students Using

School-Based Health Centers. The Journal Of School Nursing: The Official Publication

Of The National Association Of School Nurses, 31(4), 291-299.

doi:10.1177/1059840514556180

SBHC Best Practices Checklist. Reteived from

http://thelatrust.org/wp-content/uploads/2012/12/SBHC-Principles-Checklist-July-

2014.pdf

Substance Abuse and Mental Health Services Administration. (2015, October, 13). School and

campus health. Retrieved from http://www.samhsa.gov/school-campus-health

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http://www.samhsa.gov/school-campus-health

http://thelatrust.org/wp-content/uploads/2012/12/SBHC-Principles-Checklist-July-2014.pdf

http://thelatrust.org/wp-content/uploads/2012/12/SBHC-Principles-Checklist-July-2014.pdf



Mental health care services can be provided to children and teens by increasing the

quality and number of School Based Health Centers (SBHCs). Evidence has shown the need for

mental health care for children and teen continues to increase. In addition, research has shown

that students are highly satisfied with services provided by SBHCs and more likely to keep

appointments. After care and follow up care of SBHC providers is easily attained, being in close

proximity of patients. Although the need is increasing, funding for SBHCs continues to be

unstable and unpredictable.

Approximately 20% of adolescents meet diagnostic criteria for a mental disorder with

severe impairment, however, only about one-third of identified adolescents obtain

treatment (Keeton, Soleimanpour, & Brindis, 2012).

NASBHC’s 2008 national census of SBHCs reported the use of non-patient billing

revenue. The sources used were: state government (76% of SBHCs), private foundations

(50%), sponsoring organizations (49%), school districts (46%), and federal government

(39%) (Keeton, Soleimanpour, & Brindis, 2012).

Adolescents were 10 to 21 times more likely to prefer visiting an SBHC over CHC for

mental health care, and enhanced availability of care was cited as one of the likely

reasons for this preference (Keeton, Soleimanpour, and Brindis, 2012).

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A 50% decrease in absenteeism and a 25% decrease in tardiness two months after

receiving school-based mental health counseling (American Public Health

Association’s Center for School, Health, and Education, 2011).

Recommendations for Change:

1.) Increase outreach programs 2.) Increase federal and state funding 3.) Increase quality

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Healthcare Operations Change Initiative Proposal

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