Impact of school-based health centers on children with asthma

Impact of Rural School-Based Health Centers on Asthma Management

OBJECTIVE

To test the hypothesis that students with asthma who have access to school-based health centers (SBHCs) receive more recommended preventive care and use less emergency care, we compared patterns of health care utilization among rural students with asthma by SBHC access.

STUDY DESIGN

Using a cross-sectional design, we analyzed encounters for all patients ages 4 through 19 living in 4 counties covered by a health care system that sponsors a network of SBHCs in rural upstate New York. Patient addresses for each encounter were geocoded to school districts, allowing us to determine whether students lived in districts with (n = 15) or without (n = 23) a SBHC. We measured utilization among students with asthma in 2016 and 2017, comparing measures by SBHC access. Students with asthma were identified using International Classification of Diseases diagnosis codes from visits in the 2 calendar years prior to each analysis year.

RESULTS

Students in districts with SBHCs had greater odds of 2 or more asthma-related office visits (odds ratio [OR] = 2.23; 95% CI: 1.66-2.99) and 1 or more well-child visits (OR = 1.24; 95% CI: 1.03-1.50) than their peers in districts without SBHCs. Students in districts with SBHCs had lower odds of a respiratory-related convenient care or emergency department visit (OR = 0.45; 95% CI: 0.30-0.67). Across outcomes, differences were greatest when comparing students who utilized the SBHC in their district with students in districts who did not have access to a SBHC.

CONCLUSIONS

Rural students with asthma who have access to SBHCs have greater opportunities for preventive asthma care per national guidelines and use emergency departments and convenient care less.

Putting Health care Where the Kids Are: US Public Attitudes About School-Based Health Centers

BACKGROUND

School-based health centers (SBHCs) have been shown to offer substantial benefits to students but we know little about how the public thinks about them. We sought to assess US public attitudes about SBHCs and the provision of 7 health service lines-primary care, preventive care, vaccinations, preventive dental care, preventive vision care, mental health care, and nutrition counseling.

METHODS

We administered a national online survey (N = 4196) of US adults using Lucid, a large, internet-based, opt-in panel to assess public attitudes about SBHCs as well as 7 commonly offered health services in SBHCs. We then used t-tests and weighted linear regression models to carry out our study objectives.

RESULTS

Unadjusted analysis revealed that more than 2 in 3 respondents supported SBHCs in general as well as the provision of all health services in SBHCs. Regression analysis indicated that ideology, partisanship, and trust in public school principals served as consistent predictors of attitudes when controlling for demographic and health characteristics. The provision of vaccinations stood out as particularly controversial. Subanalysis of parents found even higher levels of support as well as a more subdued role of ideology and partisanship.

CONCLUSIONS

The US public broadly supports the provision of health services in SBHCs. Our results should inform policymakers, advocates, and providers seeking to improve access to health care among school-aged children, particularly for underserved populations. Increasing knowledge about SBHCs and providing stable funding should be a priority. In the immediate future, SBHCs may offer an important buffer against ongoing Medicaid disenrollments.

Effectiveness and Cost-Benefit of an Elementary School-Based Telehealth Program

Utilization of telehealth in school-based health centers (SBHCs) is increasing rapidly during the COVID-19 pandemic. This study used a quasi-experimental design to evaluate the effect on school absences and cost-benefit of telehealth-exclusive SBHCs at 6 elementary schools from 2015-2017. The effect of telehealth on absences was estimated compared to students without telehealth using negative binomial regression controlling for absences and health suite visits in 2014 and sociodemographic characteristics. The sample included 7,164 observations from 4,203 students. Telehealth was associated with a 7.7% (p = 0.025; 95% CI: 1.0%, 14%) reduction in absences (0.60 days/year). The program cost $189,000/yr and an estimated total benefit of $384,995 (95% CI: $60,416; $687,479) and an annual net benefit of $195,873 (95% CI: -$128,706; $498,357). While this cost-benefit analysis is limited by a lack of data on total healthcare utilization, the use of telehealth-exclusive SBHCs can improve student health and attendance while delivering cost savings to society.

Improving Health Equity and Outcomes for Children and Adolescents: The Role of School-Based Health Centers (SBHCs)

School-based health centers (SBHCs) provide a critical point of access to youth in low-resource communities. By providing a combination of primary care, reproductive health, mental health, vision, dental, and nutrition services, SBHCs improve the health, wellbeing, and academic achievement of the students they serve. SBHCs operate in collaboration with schools and community primary care providers to optimize the management of chronic health conditions and other health concerns that may result in suboptimal scholastic achievement and other quality of life measures. Conveniently located in or near school buildings and providing affordable, child- and adolescent-focused care, SBHCs reduce barriers to youth accessing high quality health care. SBHCs provide essential preventive care services such as comprehensive physical examinations and immunizations to students without a primary care provider, assist in the management of chronic health conditions such as asthma, and provide reproductive and sexual health services such as the provision of contraceptives, screening and treatment for sexually transmitted infections (STIs), and management of pregnancy. Additionally, some SBHCs provide vision screenings, dental care, and nutrition counseling to students who may not otherwise access these services. SBHCs have been demonstrated to be a cost-effective model of health care delivery, reducing both health care and societal costs related to illness, disability, and lost productivity.

School-based health care: improving academic outcomes for inner-city children-a prospective cohort quasi-experimental study

BACKGROUND

We examined whether a school-based health center model improved academic achievement compared to usual care.

METHODS

This was a quasi-experimental prospective cohort study. The primary outcome was an academic achievement. In addition, we analyzed sociodemographic characteristics and their relationship to academic achievement, and the wait time for a developmental assessment.

RESULTS

The differences in change of grades over time (from 2016/2017 to 2018/2019) were small for reading (-0.83, 95% CI -3.48, 1.82, p = 0.51), writing (-1.11, 95% CI -3.25, 1.03, p = 0.28), and math (0.06, 95% CI -3.08, 2.94, p = 0.98). The experimental arm's average wait time for developmental assessment was 3.4 months.

CONCLUSION

In this small, quasi-experimental prospective cohort study, we did not find evidence that our SBHC model improved academic achievement; however, the wait time at the SBHCs was considerably less than the provincial wait time for a developmental assessment.

TRIAL REGISTRATION

NCT04540003.

IMPACT

This study describes a unique and innovative school-based health center model. Our findings support the benefits of school-based health centers in diagnosing and treating children with developmental and mental health disorders for disadvantaged communities. This study did not find an improvement in academic achievement for school-based health center users. This study found that the wait time to developmental assessment was shorter for school-based health center users compared to the wait time reported in the community. Pandemic-associated school disruptions have highlighted the importance of accessible school-based health services for children requiring mental health and developmental assessments and care.

Student and Teacher Perspectives of Service Utilization at Their School-based Health Center

School-based health centers (SBHCs) positively influence student health. However, the extent to which these benefits are actualized varies across sites. We conducted focus groups with high school students and teachers at an underperforming SBHC to identify facilitators and barriers to student access to SBHC services. Our qualitative analysis revealed four main emergent categories: (1) students' knowledge of SBHC services; (2) teachers' perceptions of, and experiences with, the SBHC; (3) accessing and utilizing SBHC services; and (4) student and teacher suggestions to improve the school-SBHC relationship. Our findings suggest that the relationships between health center staff and teachers are crucial and can be damaged with poor implementation. Additionally, there was a general lack of knowledge about the procedures for accessing services at the SBHC. Participants provided recommendations, including strategies for better outreach and engagement with teachers and students, as well as operational strategies to enhance communication systems and the physical environment.

School-Based Health Centers, Access to Care, and Income-Based Disparities

Importance

School-based health centers (SBHCs) are primary care clinics colocated at schools. SBHCs have the potential to improve health care access and reduce disparities, but there is limited rigorous evidence on their effectiveness at the national level.

Objective

To determine whether county-level adoption of SBHCs was associated with access, utilization, and health among children from low-income families and to measure reductions in income-based disparities.

Design, Setting, and Participants

This survey study used a difference-in-differences design and data from a nationally representative sample of children in the US merged with SBHC indicators from the National Census of School-Based Health Centers. The main sample included children aged 5 to 17 years with family incomes that were less than 200% of the federal poverty level observed in the National Health Interview Survey, collected between 1997 to 2018. The sample was restricted to children living in a county that adopted a center between 2003 and 2013 or that did not have a center at any time during the study period. Analyses of income-based disparities included children from higher income families (ie, 200% or higher than the federal poverty level). Data were analyzed between January 2020 and July 2023.

Exposure

County-by-year SBHC adoption.

Main Outcomes and Measures

Outcomes included access (usual source of care, insurance status, barriers), ambulatory care use (general physician, eye doctor, dental, mental health visits), and health (general health status, missed school days due to illness). P values were adjusted for multiple comparisons using the sharpened q value method.

Results

This study included 12 624 unweighted children from low-income families and 24 631 unweighted children from higher income families. The weighted percentage of children in low-income families who resided in counties with SBHC adoption included 50.0% aged 5 to 10 years. The weighted percentages of the race and ethnicity of these children included 36.7% Hispanic children, 25.2% non-Hispanic Black children, and 30.6% non-Hispanic White children. The weighted percentages of children in the counties that never adopted SBHCs included 50.1% aged 5 to 10 years. The weighted percentages of the race and ethnicity of these children included 20.7% Hispanic children, 22.4% non-Hispanic Black children, and 52.9% non-Hispanic White children. SBHC adoption was associated with a 6.4 percentage point increase in dental visits (95% CI, 3.2-9.6 percentage points; P < .001), an 8.0 percentage point increase in having a usual source of care (95% CI, 4.5-11.5 percentage points; P < .001), and a 5.2 percentage point increase in insurance (95% CI, 1.2-9.2 percentage points; P = .03). No other statistically significant associations were found with other outcomes. SBHCs were associated with relative reductions in income-based disparities to dental visits by 76% (4.9 percentage points; 95% CI, 2.0-7.7 percentage points), to insured status by 63% (3.5 percentage points; 95% CI, 1.3-5.7 percentage points), and to having a usual source of care by 98% (7.2 percentage points; 95% CI, 5.4-9.1 percentage points).

Conclusions and Relevance

In this survey study with difference-in-differences analysis of SBHC adoption, SBHCs were associated with access to care and reduced income-based disparities. These findings support additional SBHC expansion.

Defining and Promoting Pediatric Pulmonary Health: Equitable Family and Community Partnerships

Optimizing pulmonary health across the lifespan begins from the earliest stages of childhood and requires a partnership between the family, pulmonologist, and pediatrician to achieve equitable outcomes. The Community Pediatrics session of the Defining and Promoting Pediatric Pulmonary Health workshop weaved together 4 community-based pillars with 4 research principles to set an agenda for future pediatric pulmonary research in optimizing lung and sleep health for children and adolescents. To address diversity, equity, and inclusion, both research proposals and workforce must purposefully include a diverse set of participants that reflects the community served, in addition to embracing nontraditional, community-based sites of care and social determinants of health. To foster inclusive, exploratory, and innovative research, studies must be centered on community priorities, with findings applied to all members of the community, particularly those in historically marginalized and minoritized groups. Research teams should also foster meaningful partnerships with community primary care and family members from study conceptualization. To achieve these goals, implementation and dissemination science should be expanded in pediatric pulmonary research, along with the development of rapid mechanisms to disseminate best practices to community-based clinicians. To build cross-disciplinary collaboration and training, community-academic partnerships, family research partnerships, and integrated research networks are necessary. With research supported by community pillars built on authentic partnerships and guided by inclusive principles, pediatric lung and sleep health can be optimized for all children and adolescents across the full lifespan in the community in which they live and thrive.

Updates in school-based asthma management

PURPOSE OF REVIEW

School-based asthma management is an important component of pediatric asthma care that has the potential to provide more universal evidence-based asthma care to children and mitigate asthma-related health inequities. The purpose of this review is to highlight relevant developments in school-based asthma management over the past 2 years.

RECENT FINDINGS

There have been considerable recent scientific advances in school-based asthma management including robust clinical trials of environmental interventions in the classroom setting, school-nurse led interventions, stock albuterol policy changes, school-based telemedicine approaches and innovative methods to engage community stakeholders in research that have pushed the frontiers of school-based asthma care.

SUMMARY

Recent scientific work in school-based asthma management demonstrates the potential power of schools in providing access to guideline-based asthma care for all children with asthma and in improving their health outcomes. Future work should focus on the evaluation of methods to promote the adoption of school-based asthma management strategies in real-world practice and support evidence-based policy change and strategic partnerships to improve asthma health outcomes and produce meaningful public health impact for diverse children and families.

Elementary School-Based Health Centers and Access to Preventive and Asthma-Related Care Among Publicly Insured Children With Asthma in Georgia

OBJECTIVES

We assessed the effects of 3 new elementary school-based health centers (SBHCs) in disparate Georgia communities-predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural-on asthma case management among children insured by Medicaid/Children's Health Insurance Program (CHIP).

METHODS

We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child-school year.

RESULTS

We found an increase of about 19 (P = .01) to 33 (P < .001) percentage points in the probability of having ≥3 asthma-related visits per child-school year and an increase of about 22 (P = .003) to 24 (P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 (P = .01) to 29 (P < .001) percentage-point increase in receipt of asthma-control medication and a 15 (P = .03) to 30 (P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC.

CONCLUSION

Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

The Role of Access and Cost-Effectiveness in Managing Asthma: A Systematic Review

Background

Inconsistent and unequal access to medical care is an issue that predates the COVID19 pandemic, which only worsened the problem. Limited access to care from asthma specialists and other specialists treating comorbid diseases may adversely affect asthma.

Objective

The purpose of this review is to identify health disparities associated with access to care for asthma, and cost-effectiveness of therapies and interventions addressing this health disparity.

Methods

A narrative systematic review was undertaken using MeSH searches of English language articles published in CINAHL, Scopus, or PubMed.

Results

A total of 725 articles were identified. Barriers recognized from the literature included access to diagnostic spirometry, access to specialists, medication formulary restrictions, and issues leading to medical nonadherence. Telemedicine, school-based health care interventions, digital applications, and non–office-based digital spirometry could be used to address these gaps in access to asthma care while potentially being cost-effective.

Conclusion

With the widespread adoption of telemedicine because of the pandemic, and adoption of other mobile services, we now have potential tools that can increase access to asthma care, which can help address this health care inequity. Evidence is limited, but favorable, that some of these tools may be cost-effective.

Weekend Versus Weekday Asthma-Related Emergency Department Utilization

OBJECTIVE

To assess variation in asthma-related emergency department (ED) use between weekends and weekdays.

METHODS

Cross-sectional administrative claims-based analysis using California 2016 Medicaid data and Vermont 2016 and Massachusetts 2015 all-payer claims databases. We defined ED use as the rate of asthma-related ED visits per 100 child-years. A weekend visit was a visit on Saturday or Sunday, based on date of ED visit claim. We used negative binomial regression and robust standard errors to assess variation between weekend and weekday rates, overall and by age group.

RESULTS

We evaluated data from 398,537 patients with asthma. The asthma-related ED visit rate was slightly lower on weekends (weekend: 18.7 [95% confidence interval (CI): 18.3-19.0], weekday: 19.6 [95% CI, 19.3-19.8], P < .001). When stratifying by age group, 3- to 5-year-olds had higher rates of asthma-related ED visits on weekends than weekdays (weekend: 33.7 [95% CI, 32.6-34.7], weekday: 29.8 [95% CI, 29.1-30.5], P < .001) and 12- to 17-year-olds had lower rates of ED visits on weekends than weekdays (weekend: 13.0 [95% CI: 12.5-13.4], weekday: 16.3 [95% CI: 15.9-16.7], P < .001). In the other age groups (6-11, 18-21 years) there were not statistically significant differences between weekend and weekday rates (P > .05).

CONCLUSIONS

In this multistate analysis of children with asthma, we found limited overall variation in pediatric asthma-related ED utilization on weekends versus weekdays. These findings suggest that increasing access options during the weekend may not necessarily decrease asthma-related ED use.

A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools

OBJECTIVE

To test the feasibility and effectiveness of a multifaceted intervention administered through school-based health centers (SBHCs) to improve asthma control for children in high-poverty schools with not well controlled asthma.

METHODS

Students 4-14 years old with persistent asthma were enrolled from three SBHCs. The centers' advanced practice providers received training on evidence-based asthma guidelines. Students randomized to the intervention received directly observed therapy of their asthma controller medication, medication adjustments as needed by the centers' providers, and daily self-management support. Students randomized to usual care were referred back to their primary care provider (PCP) for routine asthma care.

RESULTS

We enrolled 29 students. Students in the intervention group received their controller medication 92% of days they were in school. Ninety-four percent of follow-up assessments were completed. During the study, 11 of 12 intervention students had a step-up in medication; 2 of 15 usual care students were stepped up by their PCP. Asthma Control Test scores did not differ between groups, although there were significant improvements from baseline to the 7 month follow-up within each group (both p < .01). Both FEV1% predicted and FEV1/FVC ratio significantly worsened in the usual care group (both p = .001), but did not change in the intervention group (p = .76 and .28 respectively).

CONCLUSIONS

Our pilot data suggest that a multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Further study is needed to optimize the intervention and evaluate outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03032744.

The Effectiveness and Acceptability of Comprehensive and Multicomponent School Health Services: A Systematic Review

PURPOSE

Comprehensive school-based health services were reviewed as part of preparing World Health Organization guidelines.

METHODS

Six databases were searched for controlled trials with schoolchildren aged 5-19 years, involving school-linked health services incorporating 4 of 7 health areas.

RESULTS

Seventeen quasi-experimental studies conducted in high-income countries found school health services associated with reductions in suicide planning (male: 7.1% vs. 7.7%, p < .01), hospitalization (relative risks 3.403, 95% confidence interval [CI] 1.536 to 8.473, p < .05), emergency department visits (odds ratio .85, 95% CI .75 to .95, p = .006), school absence (odds ratio .78, 95% CI .69 to .87, p < .0001), carrying weapons (male: 16.1% vs. 25.1%, p < .01), fighting (male: 32.6% vs. 43.1%, p < .01), sexual activity (53.5% vs. 60.5%, p < .05), drinking alcohol (60.1% vs. 70.5%, p < .001), using drugs (28.0% vs. 38.3%, p < .001), and physical activity (female: 57.4% vs. 50.4%, p < .01). They can be cost-saving, were also associated with smoking and less contraceptive use, and had no effect on depression prevalence. Acceptability/satisfaction was good. The certainty of evidence was low to moderate. Heterogeneity was high for some outcomes.

CONCLUSIONS

Results suggest moderate desirable and trivial undesirable effects of school health services in high-income countries. This article compiles evidence on effectiveness, cost-effectiveness, and acceptability into one review, enabling decision-makers to consider all essential factors.

Aligning Partners in Pediatric Health: Using Geographical Information Systems to Plan Community Coalitions

Introduction: Compared with adults, children have higher emergency department (ED) utilization for asthma exacerbation. While community coalitions have been shown to prevent ED visits for asthma, there is little guidance on where to best implement these efforts. Geographical information systems (GIS) technology can help in the selection and coordination of potential coalition partners. This report proposes a model to be used by clinicians and child health equity advocates to strategize high-impact community health interventions. The aims were to identify the clusters of ED utilization for pediatric asthma, evaluate sociodemographic features of the population within the clusters, and identify potential primary care and school community partners. Methods: This model uses ED visit data from 450 nonmilitary California hospitals in 2012. We obtained ZIP code–level counts and rates for patients younger than 18 years discharged with a diagnosis code of 493 for asthma conditions from the California Office of Statewide Health Planning and Development’s Open Portal. We applied GIS spatial analysis techniques to identify statistically significant cluster for pediatric asthma ED utilization. We then locate the candidate community partners within these clusters. Results: There were 181 720 ED visits for asthma for all age groups in 2012 with 70 127 visits for children younger than 18 years. The top 3 geographic clusters for ED utilization rates were located in Fresno, Inglewood, and Richmond City, respectively. Spatial analysis maps illustrate the schools located within 0.5– and 1-mile radii of primary care clinics and provide a visual and statistical description of the population within the clusters. Conclusion: This study demonstrates a model to help clinicians understand how GIS can aid in the selection and creation of coalition building. This is a potentially powerful tool in the addressing child health disparities.

Show Me The Money…Saved! Cost Savings From Acute Asthma Care in the School-Based Health Center

Chronic school absenteeism directly affects educational outcomes while reducing school funding and reimbursement. Asthma is a prevalent disease associated with chronic absenteeism. This quality improvement project demonstrated classroom seat time preserved through use of school-based health centers (SBHC). The project also highlights the educational benefits, reduced emergency department utilization, potential cost savings to hospitals, and lower overall health care costs. Visit summary data were collected and analyzed to show quality asthma care and cost savings. Of 44 acute asthma visits that returned to class, an average classroom time of 3:42 hours were saved per student during the 2017-2018 academic year, resulting in a combined total of 166:07 hours saved. A minimum potential cost savings was estimated to be $67,770 for all 44 visits. Data analysis of structural, process, and outcome measures through quality improvement tools can demonstrate cost savings of SBHC care, which advocates funding for this pediatric care model.

School-Based Telemedicine for Asthma Management

Asthma affects 10% of school-age children in the United States. These numbers nearly double in high-risk populations such as low-income and minority populations. Patients in these populations frequently live in communities that are medically underserved, with limited resources to implement comprehensive asthma interventions. It is important for researchers and clinicians to explore avenues to reduce the burden of illness in this population. Incorporating innovative strategies such as school-based telemedicine programs can potentially reduce morbidity, health care utilization, work absenteeism for caregivers, and school absenteeism for children with asthma. The aim of this review is to discuss the potential benefits of school-based asthma telemedicine programs, explore potential implementation models, and provide a comprehensive review of the literature including programs that use telemedicine in schools to assist with the management of asthma. Telemedicine is a feasible approach to increasing access to primary and specialty asthma care; however, there is a need for future randomized trials to establish best practices for implementation of telemedicine programs to aid in the care for children in school settings.

A Risk Stratification Algorithm for Asthma Identification and Prioritization in a Low-Income Urban School

BACKGROUND

Asthma can interfere with school attendance and engagement. School health programs are central to asthma management. Case identification is limited by reliance on parent-completed forms, which are often missing. This project tested a low-burden screening algorithm to stratify students based on priority for nurse outreach at 2 large, urban schools with high asthma prevalence.

METHODS

Students in grades 1-8 completed a 4-item asthma screener. Two-stage stratification incorporated screener responses, school nurse records, and absenteeism. Students were assigned low, medium, or high priority for follow up. Asthma prevalence in the high priority group was calculated for substantiated asthma. Whether stratification was more likely than chance to identify new cases of asthma in the high-priority group was evaluated using chi-square tests.

RESULTS

Of 1397 students, 69.7% were screened. Secondary stratification decreased the number of students in the high and medium priority groups. New asthma cases were identified in 46.4% of high-priority families reached for follow up. High-priority students were more likely to be identified as having asthma than chance alone (p < .001).

CONCLUSIONS

A low-burden screening algorithm appropriately placed students with asthma in the high priority group. This approach may allow efficient, targeted follow up of the highest need students in high prevalence populations.

A School Nurse-Led Asthma Program Reduces Absences: Evaluation of Easy Breathing for Schools

OBJECTIVE

To evaluate whether school nurses can assist pediatricians in providing asthma care and reduce school absenteeism through a program called Easy Breathing for Schools (EzBfS), a 5-element school nurse-led asthma management program and the effectiveness in reducing school absenteeism.

METHODS

Fifteen public school nurses in an urban community implemented EzBfS during the 2015-16 and 2016-17 school years. Program elements included assessment of asthma risk and asthma control, asthma education, medication review, and a pediatrician communication tool. School absence for any reason was the primary outcome; absentee rates for students with asthma enrolled in the program were compared to students with asthma in the entire school population using negative binomial regression.

RESULTS

School nurses enrolled 251/2,126 students with physician-confirmed asthma (2015-16: n = 114 and 2016-17: n = 137). Sixty eight percent of participants were Latino and 25% were Black with a mean age of 8.7 ± 2.2 years. Absentee rates were higher in children with asthma compared to children without asthma (8.3% vs 7.0% absent, respectively P < .001). Students enrolled in the program experienced a 25% decrease in absentee rate after adjusting for age, sex, race/ethnicity, and school year (rate ratio = 0.75, 95% confidence interval, 0.67, 0.85) as compared to students with asthma not enrolled in the program. Participants also demonstrated improvement in inhaler technique score (P < .001). Ninety two percent of the nurses were satisfied with the program.

CONCLUSION

EzBfS, a pragmatic, nurse-led asthma management program, was successfully implemented by school nurses and significantly decreased school absences among a sample of students with asthma.

The Evidence on School-Based Health Centers: A Review

Context. Pediatricians working toward health equity require health care delivery mechanisms that take on dual roles: mitigating the health effects of a maladaptive social ecosystem while simultaneously working to improve the ecosystem itself. School-based health centers (SBHCs) perform these dual roles by providing medical, mental/behavioral, dental, and vision care directly in schools where young people spend the majority of their time, maximizing their opportunity to learn and grow. Evidence Acquisition. Databases were searched extensively for research studies published between January 2000 and December 2018. Evidence Synthesis. The authors began with 3 recent high-impact reviews that covered SBHC history, health outcomes, cost-benefit, and impact on health equity. Informed by these articles, the authors organized the evidence into 4 broad categories of impact: Financial, Physical Health (including medical, vision, and dental), Mental Health, and Educational Outcomes. Using these 4 categories, the authors then performed a robust literature search using PubMed for studies that fit into these themes. Conclusions. SBHCs increase access to health services for children, families, and communities, which ultimately leads to positive short- and long-term outcomes in service of a broad range of stakeholders. Educational impact requires further attention on both outcomes and methodological approaches. Three current public health topics of importance were identified that SBHCs might be well-suited to address: Youth Gun Violence, Adverse Childhood Experiences, and the Health of American Indian/Alaskan Native communities in the United States.

Childhood Asthma Disparities in Chicago: Developing Approaches to Health Inequities

We conducted a needs assessment to develop an evidence-based, locally tailored asthma care implementation plan for high-risk children with asthma in Chicago. Our team of health policy experts, clinicians, researchers, and designers included extensive stakeholder engagement (N = 162) in a mixed-methods community needs assessment. Results showed the lines of communication and collaboration across sectors were weak; caregivers were the only consistent force and could not always manage this burden. A series of recommendations for interventions and how to implement and measure them were generated. Cooperative, multidisciplinary efforts grounded in the community can target wicked problems such as asthma.

Taming Asthma in School-Aged Children: A Comprehensive Review

Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity as measured by school absences, emergency department visits, and hospitalizations. Multiple factors play a role in the development, treatment and prevention of childhood asthma including racial/ethnic and socioeconomic disparities, both the home and school environments, and medication use. The goals of this review are to summarize these aspects of asthma in school-aged children and to present an updated review of medications as it relates to treatment strategies that will help in the care of these children. We conclude that phenotypic heterogeneity and appropriate environmental assessments and interventions are important considerations in the management of childhood asthma.

Cost Benefit of Comprehensive Primary and Preventive School-Based Health Care

INTRODUCTION

The Rales Health Center is a comprehensive school-based health center at an urban elementary/middle school. Rales Health Center provides a full range of pediatric services using an enriched staffing model consisting of pediatrician, nurse practitioner, registered nurses, and medical office assistant. This staffing model provides greater care but costs more than traditional school-based health centers staffed by part-time nurses. The objective was to analyze the cost benefit of Rales Health Center enhanced staffing model compared with a traditional school-based health center (standard care), focusing on asthma care, which is among the most prevalent chronic conditions of childhood.

METHODS

In 2016, cost-benefit analysis using a decision tree determined the net social benefit of Rales Health Center compared with standard care from the U.S. societal perspective based on the 2015-2016 academic year. It was assumed that Rales Health Center could handle greater patient throughput related to asthma, decreased prescription costs, reduced parental resources in terms of missed work time, and improved student attendance. Univariate and multivariate probabilistic sensitivity analyses were conducted.

RESULTS

The expected cost to operate Rales Health Center was $409,120, compared with standard care cost of $172,643. Total monetized incremental benefits of Rales Health Center were estimated to be $993,414. The expected net social benefit for Rales Health Center was $756,937, which demonstrated substantial societal benefit at a return of $4.20 for every dollar invested. This net social benefit estimate was robust to sensitivity analyses.

CONCLUSIONS

Despite the greater cost associated with the Rales Health Center's enhanced staffing model, the results of this analysis highlight the cost benefit of providing comprehensive, high-quality pediatric care in schools, particularly schools with a large proportion of underserved students.

Utilization of Mental Health Services in School-Based Health Centers

BACKGROUND

We summarize utilization patterns for mental health services in school-based health centers.

METHODS

Administrative data on school-based health center visits in New Haven, Connecticut were examined for the 2007-2009 school years. Relative frequencies of mental health visits by age were calculated as a percentage of all visits and were stratified by sex, ethnicity/race, and insurance status.

RESULTS

Mental health visits accounted for the highest proportion of visits (31.8%). The proportion of mental health visits was highest at 8 years (42.8%) and at 13 years (39.0%). The proportion of mental health visits among boys (38.4%) was higher than among girls (26.7%). Hispanic students had a lower proportion of mental health visits than black students (23.5% vs 35.8%) in all but 2 age groups. Students in the white/other ethnicity category had higher proportions of mental health visits than Hispanic and black students between ages 12 and 15. Students with no health insurance (22.5%) had lower proportions of mental health visits than students covered by Medicaid (34.3%) or private insurance (33.9%). The percentage of mental health visits by students with private insurance was highest (37.2%-49%) in the 13-15 age range.

CONCLUSIONS

Usage patterns for mental health issues show pronounced, nonrandom variation relative to age and other demographic characteristics especially with 8-year-old boys.

Characteristic Differences Between School-Based Health Centers With and Without Mental Health Providers: A Review of National Trends

BACKGROUND

Minority racial/ethnic pediatric populations and those living in poverty are at greater risk of exposure to trauma, development of mental health disorders, and school failure yet are less likely to have access to mental health services (MHS). School-based health centers (SBHCs) staffed with mental health providers may be one strategy for decreasing health care disparities.

METHODS

Secondary analysis of the cross-sectional School-Based Health Alliance Census School Year 2010-2011 Report was conducted. Descriptive statistics and chi-square analysis were used to describe differences between SBHCs with and without onsite MHS.

RESULTS

A total of 70% of SBHCs offered MHS. SBHCs with more resources, more students, a longer history, and state funding were more likely to offer MHS, and geographic location had no impact on service availability.

CONCLUSION

Reviewing SBHC characteristics that enable inclusion of MHS may help stakeholders expand this model of care to address exposure to chronic childhood trauma.

The Role of School Health Services in Addressing the Needs of Students With Chronic Health Conditions

Children and adolescents in the United States spend many hours in school. Students with chronic health conditions (CHCs) may face lower academic achievement, increased disability, fewer job opportunities, and limited community interactions as they enter adulthood. School health services provide safe and effective management of CHCs, often for students with limited access to health care. A systematic review to assess the role of school health services in addressing CHCs among students in Grades K-12 was completed using primary, peer-reviewed literature published from 2000 to 2015, on selected conditions: asthma, food allergies, diabetes, seizure disorders, and poor oral health. Thirty-nine articles met the inclusion criteria and results were synthesized; however, 38 were on asthma. Direct access to school nursing and other health services, as well as disease-specific education, improved health and academic outcomes among students with CHCs. Future research needs to include standardized definitions and data collection methods for students with CHCs.

School-Based Health Centers' Presence: The Role of School and Community Factors

INTRODUCTION

School-based health centers (SBHCs) offer an efficient mechanism for delivering health services to large numbers of underserved youth; however, their availability varies across communities. Data on sociocontextual variables were analyzed to investigate factors that inhibit and facilitate SBHCs.

METHODS

Secondary data from 2012 to 2015 state databases were linked to examine the association between SBHCs' presence in California high schools and demand, resource, and political conservatism at the school and community levels that may influence where SBHCs are located and the number of provided health services. Data were analyzed in 2015 using hierarchical binary and Poisson models.

RESULTS

Presence of a local non-school-based family planning clinic was the strongest correlate of SBHC presence. School size, percentage non-white, and percentage receiving free or reduced-price lunches were positively associated with SBHC presence. Percentage who voted Republican in the 2012 general election and teen pregnancy rates were negatively associated with SBHC presence. None of the predictors were associated with number of services provided by SBHCs.

CONCLUSIONS

School and community factors appear to play a role in supporting or impeding the establishment of SBHCs. In addition to variables tapping communities' need for and resources available to support SBHCs, political conservatism appears to affect SBHC availability. SBHC advocates can use this information to understand where opportunities for growth might exist, identify collaborative partners, and prepare for challenges to supporting new SBHCs. Researchers may also use this information in evaluation studies to control for school-level confounders and develop appropriate comparison samples through matching procedures.

Economic Evaluation of School-Based Health Centers: A Community Guide Systematic Review

CONTEXT

A recent Community Guide systematic review of effectiveness of school-based health centers (SBHCs) showed that SBHCs improved educational and health outcomes. This review evaluates the economic cost and benefit of SBHCs.

EVIDENCE ACQUISITION

Using economic systematic review methods developed for The Community Guide, 6,958 papers were identified for the search period January 1985 to September 2014. After two rounds of screening, 21 studies were included in this review: 15 studies reported on cost and nine on benefit; three studies had both cost and benefit information. All expenditures in this review were presented in 2013 U.S. dollars.

EVIDENCE SYNTHESIS

Analyses were conducted in 2014. Intervention cost had two main components: start-up cost and operating cost. All but two of the cost studies reported operating cost only (ranging from $16,322 to $659,684 per SBHC annually). Benefits included healthcare cost averted and productivity and other loss averted. From the societal perspective, total annual benefit per SBHC ranged from $15,028 to $912,878. From healthcare payers' perspective, particularly Medicaid, SBHCs led to net savings ranging from $30 to $969 per visit. From patients' perspective, savings were also positive. Additionally, two benefit studies used regression analysis to show that Medicaid cost and hospitalization cost decreased with SBHCs. Finally, results from seven estimates in two cost-benefit studies showed that societal benefit per SBHC exceeded intervention cost, with the benefit-cost ratio ranging from 1.38:1 to 3.05:1.

CONCLUSIONS

The economic benefit of SBHCs exceeds the intervention operating cost. Further, SBHCs result in net savings to Medicaid.

School-Based Health Centers to Advance Health Equity: A Community Guide Systematic Review

CONTEXT

Children from low-income and racial or ethnic minority populations in the U.S. are less likely to have a conventional source of medical care and more likely to develop chronic health problems than are more-affluent and non-Hispanic white children. They are more often chronically stressed, tired, and hungry, and more likely to have impaired vision and hearing-obstacles to lifetime educational achievement and predictors of adult morbidity and premature mortality. If school-based health centers (SBHCs) can overcome educational obstacles and increase receipt of needed medical services in disadvantaged populations, they can advance health equity.

EVIDENCE ACQUISITION

A systematic literature search was conducted for papers published through July 2014. Using Community Guide systematic review methods, reviewers identified, abstracted, and summarized available evidence of the effectiveness of SBHCs on educational and health-related outcomes. Analyses were conducted in 2014-2015.

EVIDENCE SYNTHESIS

Most of the 46 studies included in the review evaluated onsite clinics serving urban, low-income, and racial or ethnic minority high school students. The presence and use of SBHCs were associated with improved educational (i.e., grade point average, grade promotion, suspension, and non-completion rates) and health-related outcomes (i.e., vaccination and other preventive services, asthma morbidity, emergency department use and hospital admissions, contraceptive use among females, prenatal care, birth weight, illegal substance use, and alcohol consumption). More services and more hours of availability were associated with greater reductions in emergency department overuse.

CONCLUSIONS

Because SBHCs improve educational and health-related outcomes in disadvantaged students, they can be effective in advancing health equity.

Developing, Implementing, and Evaluating a School-Centered Asthma Program: Step-Up Asthma Program

BACKGROUND

Asthma is a significant health problem among children: 9.3% of children in the United States suffer from asthma. Children with persistent asthma in inner cities have increased health care utilization, worse health care outcomes, increased school absences, and worse academic performance.

OBJECTIVE

We sought to create and evaluate a school-centered asthma program to reduce asthma morbidity and create asthma-friendly schools.

METHODS

We developed, implemented, and evaluated the Step-Up Asthma Program, a multidisciplinary school-centered asthma program. The program was designed as an outreach program with asthma counselors as a bridge between subspecialty asthma care, primary care providers, school nurses, and children with asthma. The core components of the program involve identifying children with asthma, providing evidence-based asthma education, and case management. Students' asthma knowledge, inhaler technique, and number of asthma exacerbations were evaluated over a 2-year period (2010-2012) as a pre-post study.

RESULTS

A total of 252 students enrolled in the Step-Up Asthma Program over a 2-year period. Significant improvements were noted in number of asthma action plans, rescue medications at school, and asthma controllers. Program participants had significant improvements in asthma knowledge scores (P < .001) and inhaler technique (P < .0001). There were significant reductions in asthma exacerbations defined as oral steroid courses, urgent care visits, and missed school days (P < .05) that persisted over time.

CONCLUSIONS

A guideline-based school-centered asthma program can significantly reduce asthma morbidity. The asthma counselor is the cornerstone of the program, providing asthma education and care coordination. The Step-Up Asthma Program is in its 10th year, and we believe the key elements of this program can be implemented in other school systems.

Overcoming Medicaid Reimbursement Barriers to Funding School Nursing Services for Low-Income Children With Asthma

BACKGROUND

School nurses can provide direct services for children with asthma, educate, and reinforce treatment recommendations to children and their families, and coordinate the school-wide response to students' asthma emergencies. Unfortunately, school-based health services today depend on an unreliable patchwork of funding. Limited state and local funds lead to extremely low nurse-to-student ratios, resulting in missed opportunities for prevention and care of asthma and other health conditions.

METHODS

We carried out a nonsystematic review of legal, government, private health foundation, and medical literature.

RESULTS

Many health services for asthma and other conditions provided in school settings are services typically covered by Medicaid and the Children's Health Insurance Program (CHIP) when offered in other settings. However, complex reimbursement rules, questionable policy guidance establishing a "free care rule," and other barriers have limited the ability of schools to seek Medicaid/CHIP reimbursement for these services. Recent legal developments may help overcome some of these barriers, and new flexibilities in Medicaid law bring opportunities for increased reimbursement of school-based health services.

CONCLUSIONS

Policymakers should call on the Centers for Medicare and Medicaid Services to abandon the "free care rule" and issue other guidance that would enable schools to appropriately obtain Medicaid reimbursement for nursing services.

Measuring Success: Evaluation Designs and Approaches to Assessing the Impact of School-Based Health Centers

Since the founding of the first school-based health centers (SBHCs) >45 years ago, researchers have attempted to measure their impact on child and adolescent physical and mental health and academic outcomes. A review of the literature finds that SBHC evaluation studies have been diverse, encompassing different outcomes and varying target populations, study periods, methodological designs, and scales. A complex picture emerges of the impact of SBHCs on health outcomes, which may be a function of the specific health outcomes examined, the health needs of specific communities and schools, the characteristics of the individuals assessed, and/or the specific constellation of SBHC services. SBHC evaluations face numerous challenges that affect the interpretation of evaluation findings, including maturation, self-selection, low statistical power, and displacement effects. Using novel approaches such as implementing a multipronged approach to maximize participation, entering-class proxy-baseline design, propensity score methods, data set linkage, and multisite collaboration may mitigate documented challenges in SBHC evaluation.

How the Whole School, Whole Community, Whole Child model works: creating greater alignment, integration, and collaboration between health and education

BACKGROUND

The Whole School, Whole Community, Whole Child (WSCC) model calls for greater collaboration across the community, school, and health sectors to meet the needs and support the full potential of each child. This article reports on how 3 states and 2 local school districts have implemented aspects of the WSCC model through collaboration, leadership and policy creation, alignment, and implementation.

METHODS

We searched state health and education department websites, local school district websites, state legislative databases, and sources of peer-reviewed and gray literature to identify materials demonstrating adoption and implementation of coordinated school health, the WSCC model, and associated policies and practices in identified states and districts. We conducted informal interviews in each state and district to reinforce the document review.

RESULTS

States and local school districts have been able to strategically increase collaboration, integration, and alignment of health and education through the adoption and implementation of policy and practice supporting the WSCC model. Successful utilization of the WSCC model has led to substantial positive changes in school health environments, policies, and practices.

CONCLUSIONS

Collaboration among health and education sectors to integrate and align services may lead to improved efficiencies and better health and education outcomes for students.

Establishing school-centered asthma programs

Asthma is a common chronic childhood disease associated with significant morbidity and high rates of school absenteeism, along with excessive costs for the patient and society. Asthma is a leading cause of school absenteeism, but this absenteeism is not equally distributed among those with asthma. Second to their home, school-aged children spend the largest portion of their wakeful hours at school. Opportunities exist to partner with schools to reach most children with asthma and those at the highest risk for asthma burden and in need of assistance. Asthma management at schools is important for pediatric pulmonologists and allergists, primary care providers, and the whole interdisciplinary team working alongside them to provide quality asthma care. The variability of asthma care services and programs provided in schools should prompt clinicians to understand their own school system and to advocate for appropriate services. Models of asthma care that place schools at the center or core of the model and coordinate evidence-based asthma care are applicable nationwide and might serve as a model for managing other chronic illnesses.

Differences in Access to Care Among Students Using School-Based Health Centers

Health care reform has changed the landscape for the nation's health safety net, and school-based health centers (SBHCs) remain an important part of this system. However, few large-scale studies have been conducted to assess their impact on access to care. This study investigated differences in access among a nationally representative sample of adolescent SBHC users. An analysis using multivariate logistic regression examined the association between student characteristics and access to care. We found no differences based on race/ethnicity or insurance status among adolescent SBHC users; however, we did observe significant differences with regard to unmet health needs. School nurses serve as invaluable frontline staff who can facilitate equitable access to care, provide high-quality primary care, coordinate care for students with community health services, and advocate for policy and funding support of SBHCs as a critical part of the safety net for underserved adolescents.

Geographic and racial variation in asthma prevalence and emergency department use among Medicaid-enrolled children in 14 southern states

BACKGROUND

Despite evidence-based prevention and practice guidelines, asthma prevalence, treatment, and outcomes vary widely at individual and community levels. Asthma disproportionate/ly affects low-income and minority children, who comprise a large segment of the Medicaid population.

METHODS

2007 Medicaid claims data from 14 southern states was mapped for 556 counties to describe the local area variation in 1-year asthma prevalence rates, emergency department (ED) visit rates, and racial disparity rate ratios.

RESULTS

One-year period prevalence of asthma ranged from 2.8% in Florida to 6.4% in Alabama, with a median prevalence rate of 4.1%. At the county level, the prevalence was higher for Black children and ranged from 1.03% in Manatee County, FL, to 21.0% in Hockley County, TX. Black-White rate ratios of prevalence ranged from 0.49 in LeFlore County, MS, to 3.87 in Flagler County, FL. Adjusted asthma ED visit rates ranged from 2.2 per 1000 children in Maryland to 16.5 in Alabama, with a median Black-White ED-visit rate ratio of 2.4. Rates were higher for Black children, ranging from 0.80 per 1000 in Wicomico County, MD, to 70 per 1000 in DeSoto County, FL. Rate ratios of ED visits ranged from 0.25 in Vernon Parish, LA, to 25.28 in Nelson County, KY.

CONCLUSIONS AND RELEVANCE

Low-income children with Medicaid coverage still experience substantial variation in asthma prevalence and outcomes from one community to another. The pattern of worse outcomes for Black children also varies widely across counties. Eliminating this variation could substantially improve overall outcomes and eliminate asthma disparities.

The role of school-based health centers in increasing universal and targeted delivery of primary and preventive care among adolescents

BACKGROUND

School-based health centers (SBHC) can provide equitable and comprehensive care for adolescents; yet, few studies have described how patterns of health service utilization differ among groups. The purpose of this study was to investigate differences in utilization and perceptions of SBHC care among adolescents.

METHODS

This study sample included 414 adolescent respondents to the Healthy Schools, Healthy Communities User Survey. Three outcome measures represented utilization of care, while 4 represented perceptions of care. Multivariate logistic regressions modeled the effects of user characteristics on outcome measures.

RESULTS

There were few notable and significant differences in either utilization or perceptions of care, based on sociodemographic or health status characteristics.

CONCLUSIONS

SBHCs can eliminate differences in utilization based on sociodemographic characteristics. However, null findings show that they fall short in delivering comprehensive care to high-risk adolescents, and may not be capitalizing on opportunities to offer targeted services. Results showing positive perceptions of care suggest that adolescents would be amenable to additional counseling or education services offered at SBHCs. To foster positive health outcomes among adolescents, SBHC administrators should regularly evaluate their scope of services and support quality improvement efforts.

Improving access to care through the patient-centered medical home

School-based health centers (SBHCs) serve an essential role in providing access to high-quality, comprehensive care to underserved children and adolescents in more than 2,000 schools across the United States. SBHCs are an essential component of the health care safety net, and their role in the patient-centered medical home (PCMH) continues to evolve as both collaborating partners and, when fully functioning, independent PCMHs. The American Academy of Pediatrics (AAP) supports the use of SBHCs, citing the proven benefits and exciting potential as justification, but also offers caution and recommends a focus on communication within the community. Traditional "brick and mortar" SBHCs are more likely to be located in urban communities (54.2% urban versus 18.0% rural) and be in schools with more students, allowing for a greater return on investment. Current SBHCs are located in schools with an average population of 997 students. The need for a large school population to help an SBHC approach financial viability excludes children in rural communities who are more likely to attend a school with fewer than 500 students, be poor, and have difficulty accessing health care.2 The expansion of telehealth technologies allows the creation of solutions to decrease geographic barriers that have limited the growth of SBHCs in rural communities. Telehealth school-based health centers (tSBHCs) that exclusively provide services through telemedicine are operating and developing in communities where geographic barriers and financial challenges have prevented the establishment of brick and mortar SBHCs. TSBHCs are beginning to increase the number and variety of services they provide through the use of telehealth to include behavioral health, nutrition services, and pediatric specialists. Understanding the role of tSBHCs in the growth of the PCMH model is critical for using these tools to continue to improve child and adolescent health.

Sustaining school-based asthma interventions through policy and practice change

BACKGROUND

Schools are an ideal setting for implementation of asthma interventions for children; however, sustaining school-based programs can be challenging. This study illustrates policy and practice changes brought about through the Childhood Asthma Linkages in Missouri (CALM) program to sustain such programs.

METHODS

Researchers analyzed caregiver-reported quantitative data regarding asthma-related outcomes in preintervention and postintervention surveys and qualitative data regarding sustainability efforts in schools reported by CALM grantees. A grounded theory approach was used to identify key concepts and themes that emerged.

RESULTS

In 330 children, significant improvements were seen in asthma symptoms, rescue inhaler use, health care utilization, school absenteeism, and activity limitations. Overall, 27 school-based policy and practice changes supporting program sustainability were reported, with policy changes most often concerning the assessment and/or monitoring of children with asthma in the school setting, and practice changes most often regarding institution of regular asthma education programs for students and school personnel.

CONCLUSIONS

Sustaining school-based asthma programs is challenging, but can be realized through the participation of diverse partners in enacting policy and practice changes that support the institutionalization of programs into the day-to-day processes of the schools.

Roles of the state asthma program in implementing multicomponent, school-based asthma interventions

BACKGROUND

Asthma is a leading chronic childhood disease in the United States and a major contributor to school absenteeism. Evidence suggests that multicomponent, school-based asthma interventions are a strategic way to address asthma among school-aged children. The Centers for Disease Control and Prevention (CDC) encourages the 36 health departments (34 states, District of Columbia, and Puerto Rico) in the National Asthma Control Program (NACP) to implement multicomponent, school-based asthma interventions on a larger scale.

METHODS

To gain a better understanding of replicable best practices for state-coordinated asthma interventions in schools, an NACP evaluation team conducted evaluability assessments of promising interventions run by state asthma programs in Louisiana, Indiana, and Utah.

RESULTS

The team found that state asthma programs play a critical role in implementing school-based asthma interventions due to their ability to (1) use statewide surveillance data to identify asthma trends and address disparities; (2) facilitate connections between schools, school systems, and school-related community stakeholders; (3) form state-level connections; (4) translate policies into action; (5) provide resources and public health practice information to schools and school systems; (6) monitor and evaluate implementation.

CONCLUSIONS

This article presents evaluability assessment findings and illustrates state roles using examples from the 3 participating state asthma programs.

Barriers to providing school-based health care: international case comparisons

BACKGROUND

This article reports on an international collaborative study which compared school-based health care in the United States of America, Canada and Australia.

METHOD

Tri-nation school-based health care was compared and contrasted through the utilisation of a series of interpretive case studies. Grounded theory approaches informed the data analysis and reporting processes.

FINDINGS

Unlike the US, Canadian and Australian school students rarely have access to school-based health care on site. All three nations face structural, cultural and societal barriers, often related to limited resources which limit the effectiveness of school-based health care.

DISCUSSION

The benefits of school-based health care and providing comprehensive services through schools can include healthier children, better learning, healthier parents, and healthier communities. Unfortunately, based on our research, comprehensive school health services have not been adequately implemented in the US, Canada or Australia.

IMPLICATIONS FOR PRACTICE

Given the findings of this study, increased comprehensive school-based health services are urgently needed in the US, Canada and Australia.

Cost benefits of a peer-led asthma self-management program for adolescents

OBJECTIVE

Frequent use of health-care services associated with pediatric asthma places substantial economic burden on families and society. The purpose of this study is to examine the cost-saving effects of a peer-led program through reduction in health-care utilization in comparison to an adult-led program.

METHODS

Randomly assigned adolescents (13-17 years) participated in either peer-led (n = 59) or adult-led (n = 53) asthma self-management program. Health-care utilization data were collected at baseline and at 3-, 6-, and 9-months post-intervention. Negative binomial regression models were conducted to examine the effects of the peer-led program on health-care utilization. Net cost savings were estimated based on the differences in program costs and health-care utilization costs between groups.

RESULTS

Significant group differences were found in acute office visits and school clinic visits after controlling for race and socioeconomic status. The incidence rate of acute office visits was 80-82% less for the peer-led group during follow-ups. The peer-led group was four to five times more likely to use school clinics due to asthma than the adult-led group during follow-ups. The non-research cost of peer-led program per participant was lower than the adult-led program, $64 versus $99, respectively. The net cost saving from the reduction in acute office visits and the lower program costs of the peer-led program was estimated $51.8 per person for a 3-month period.

CONCLUSIONS

An asthma self-management program using peer leaders can potentially yield health-care cost savings through the reduction in acute office visits in comparison to a traditional program led by health-care professionals.

School-based health centers in an era of health care reform: building on history

School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs' impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths' academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation's youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.

School-based health centers and pediatric practice

School-based health centers (SBHCs) have become an important method of health care delivery for the youth of our nation. Although they only represent 1 aspect of a coordinated school health program approach, SBHCs have provided access to health care services for youth confronted with age, financial, cultural, and geographic barriers. A fundamental principle of SBHCs is to create an environment of service coordination and collaboration that addresses the health needs and well-being of youth with health disparities or poor access to health care services. Some pediatricians have concerns that these centers are in conflict with the primary care provider's medical home. This policy provides an overview of SBHCs and some of their documented benefits, addresses the issue of potential conflict with the medical home, and provides recommendations that support the integration and coordination of SBHCs and the pediatric medical home practice.

Community-based approaches to controlling childhood asthma

The prevalence and burden of childhood asthma remain high and are increasing. Asthma hot spot neighborhoods around the country face particular challenges in controlling the effects of the condition. Increasing attention is being paid to developing interventions that recognize the child and family as the primary managers of disease and to introducing assistance that reaches beyond the clinical care setting into the places where families live and work. A range of types of community-focused interventions has been assessed in the past decade in schools, homes, and community health clinics, and programs using electronic media and phone links have been evaluated. Stronger evidence for all these approaches is needed. However, school-based programs and community coalitions designed to bring about policy and systems changes show particular promise for achieving sustainable improvements in asthma control. Research is needed that emphasizes comparisons among proven asthma control interventions, translation of effective approaches to new settings and communities, and institutionalization of effective strategies.