School-Based Health Centers and Pediatric Practice

School-based health centers as an approach to address health disparities among rural youth: A study protocol for a multilevel research framework

School-Based Health Centers (SBHCs) are important healthcare providers for children in medically underserved communities. While most existing research on SBHCs has focused on urban environments, this study protocol proposes a mixed-methods, multi-level research framework to evaluate the role of SBHCs in addressing health disparities among underserved children and adolescents in rural communities. The study area includes four high-poverty rural counties in New York State served by Bassett Healthcare Network that permits a comparison of school districts with SBHCs to those without SBHCs, all served by providers within the Bassett Healthcare Network. We employ a human ecological framework that integrates the micro layer of individuals and families, the meso layer of school districts and community institutions, and the macro layer of local and state policies. Our research framework first identifies the socioecological health risk factors, and then proposes innovative strategies to investigate how SBHCs impact them. We propose evaluating the impact of SBHCs on the individual (micro) level of child healthcare utilization using patient records data. At the meso level, we propose to investigate how School-SBHCs partnership may facilitate greater cross-agency collaboration and broader structural and social determinist of health to address health disparities. At the macro level, we propose to assess the impact of SBHCs and cross-agency collaboration on outcomes associated with a culture of community health. This study protocol will enable researchers to assess how SBHCs reduce rural health disparities, and provide evidence for organizational and public policy change.

Effect of a Comprehensive School-Based Health Center on Academic Growth in K-8th Grade Students

OBJECTIVE

School-based health centers (SBHCs) improve health care access, but associations with educational outcomes are mixed and limited for elementary and middle school students. We investigated whether students enrolled in a comprehensive SBHC demonstrated more growth in standardized math and reading assessments over 4 school years versus nonenrolled students. We also explored changes in absenteeism.

METHODS

Participants were students enrolled in 2 co-located Title I schools from 2015-19 (1 elementary, 1 middle, n = 2480). Analysis of math and reading was limited to students with baseline and postbaseline scores (math n = 1622; reading n = 1607). Longitudinal regression models accounting for within-subject clustering were used to estimate the association of SBHC enrollment with academic scores and daily absenteeism, adjusting for grade, sex, body mass index category, health conditions, baseline outcomes (scores or absenteeism), and outcome pretrends.

RESULTS

More than 70% of SBHC-enrolled students had math (1194 [73.6%]) and reading 1186 [73.8%]) scores. Enrollees were more likely than nonenrollees to have asthma (39.7% vs 19.6%) and overweight/obesity (42.4% vs 33.6%). Adjusted baseline scores were significantly lower in math and reading for enrollees. Mean change from baseline for enrollees exceeded nonenrollees by 3.5 points (95% confidence interval [CI]: 2.2, 4.8) in math and 2.1 points (95% CI: 0.9, 3.3) in reading. The adjusted rate of decrease in daily absenteeism was 10.8% greater for enrollees (incident rate ratio 0.772 [95% CI: 0.623, 0.956]) than nonenrollees (incident rate ratio 0.865 [95% CI: 0.696, 1.076]).

CONCLUSIONS

SBHC enrollees had greater health and educational risk but demonstrated more growth in math and reading and less absenteeism than nonenrollees.

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.

Chronic Health Condition Management and School-Based Health Centers in New York: Findings From the 2020 School Health Profiles Survey

School-based health centers (SBHCs) are associated with numerous positive aspects of student health services. Many schools in the United States (US) do not have transparent policies on chronic health condition (CHC) management. Of particular concern is the underreporting of the delivery of health services in U.S. schools concerning CHC management and its relationship with the presence or absence of a SBHC. Data from the 2020 School Health Profiles (SHP) Survey were examined in New York public secondary schools. Specific health services were reviewed, together with the presence or absence of a SBHC, including daily medication administration, stock rescue medication, case management services, community partners, chronic disease-specific education, and assurance that students with CHCs were enrolled in an insurance program. A significantly greater proportion of schools with a SBHC compared with schools without a SBHC provided: (1) daily medication administration (92.9% vs. 86.5%; p < .001), (2) stock or rescue medication (84.9% vs. 77.4%; p < .001), (3) case management services (83.1% vs. 67.2%; p < .001), (4) disease-specific education for families (63.1% vs. 57.2%; p = .022), (5) student and family connection to community health services (84.2% vs. 76.5%; p < .001), and (6) ensured that a protocol existed whereby students with a CHC were enrolled in an insurance plan if eligible (79.6% vs. 66.8%; p < .001). Findings suggest that data on a national scale include essential facts for states to consider concerning school health policies and practices. Additional research should examine the intricacy of elements connected with school-based health care to understand better the care provided to children with CHCs.

Exploratory Qualitative Focus Group Analysis of School-based Health Center Policy Issues: Insights From State Leaders

INTRODUCTION

School-based health centers (SBHCs) provide students with critical, cost-effective access to health care. The pandemic accelerated a shift in SBHC care delivery. From the viewpoint of SBHC state leadership, this study aimed to describe changes since the last national SBHC health policy survey in 2017 through the COVID-19 pandemic.

METHOD

Leaders from state offices funding SBHCs and of School-Based Health Alliance affiliates participated in semistructured virtual focus groups in early 2022. Qualitative researchers triangulated focus group data with open-ended survey questions and performed thematic content analysis.

RESULTS

The results confirmed a priori themes of increased funding, challenges in alignment around the definition, standardization, and metrics of SBHCs, and pandemic-related changes. Emerging themes included: (1) increased mental health services, (2) a shift toward telehealth and increased access delivery models, and (3) workforce challenges.

DISCUSSION

These themes drive further exploration to sustain positive change, overcome challenges, and guide future quantitative SBHC policy analysis.

An Imperfect Space: Logistical Considerations in School-Based Health Centers

BACKGROUND

From a range of perspectives, scholars have demonstrated the value of school-based health centers (SBHCs) in recent decades, but few studies have examined the logistics of establishing SBHCs.

METHODS

Semi-structured interviews were conducted with 9 hospital and 6 school employees involved in a network of SBHCs. After common themes were identified, cluster analysis was performed. Finally, quotes were identified within each thematic cluster for further qualitative analysis.

RESULTS

The most prominent themes were (1) differences in physical space (between schools and clinical settings), (2) collaboration and communication, and (3) privacy and compliance.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

This study points to several high yield considerations for the practice of SBHCs. First, we identified three distinct needs: (1) clear funding streams for construction costs for health services on school grounds, (2) improved understanding of SBHC space needs, and (3) blueprints for collaborating within SBHCs. Second, this study points to a future in which new-build and renovated schools should include space for SBHCs.

CONCLUSIONS

This qualitative thematic analysis provides a picture of health and educational professionals engaged in creative, collaborative, and adaptive work to meet children's health care needs within SBHCs, but also highlights the challenges of navigating physical space, compliance, and collaboration within SBHCs.

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.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Teen and caregiver perspectives on success, clinician role, and family involvement in ACTION PAC, a weight management intervention trial

OBJECTIVE

Describe perspectives of teens and caregivers regarding motivations, successes, and challenges related to participation in ACTION PAC (ClinicalTrials.gov: NCT02502383), a two-year weight management trial.

METHODS

Intervention group participants received 16 short motivational interviewing (MI) sessions with school-based health center (SBHC) primary care clinicians over two years. Post-study, we conducted semi-structured interviews with purposefully sampled intervention group teens and their caregivers. Interviews were audio recorded, transcribed, and managed in NVivo 11. Three independent coders analyzed the data, developed a coding tree, examined how codes intersected and clarified relationships through memo writing.

RESULTS

The clinician's role and use of motivational interviewing and family involvement in behavior changes were cited as critical to success. Some adolescents noted difficulty in sustaining behavior changes post-intervention and social and systemic barriers to behavior change.

CONCLUSION

Future studies should identify strategies to sustain teen motivation, better involve families, and address systemic barriers.

INNOVATION

In this study, which simulated real-world SBHC conditions, adolescents appreciated the use of an MI approach and felt that was key to their success, indicating the potential to continue use of this approach to motivating behavior changes in SBHC settings.

School-Based Health Center Utilization During COVID-19 Pandemic-Related School Closures

BACKGROUND

Little is known regarding utilization of school-based health centers (SBHCs) during prolonged school closures, such as those that occurred during the COVID-19 pandemic. We sought to compare SBHC utilization before and after pandemic-related school closures across a network of SBHCs affiliated with a large Southern Californian urban school district.

METHODS

We conducted a secondary analysis of encounter data extracted from electronic health records from 12 SBHCs that remained open despite school closures, including patient demographics and diagnostic and billing codes. We used the Clinical Classifications Software Refined to group encounters for common primary care conditions. Utilization before and during pandemic-related school closures was compared using logistic regression with cluster-robust standard errors to account for clustering within clinics, after adjusting for month of encounter.

RESULTS

During the pandemic, study SBHCs conducted 52,530 encounters and maintained ∼4040 encounters/month. The frequency of encounters for annual preventative health exams increased for school-aged patients but decreased for other age groups while the frequency of encounters for mental health problems increased for all age groups.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Despite pandemic-related school closures, SBHCs appeared play a critical role in providing primary care to vulnerable communities.

CONCLUSIONS

SBHCs may hold value beyond their co-location with academic instruction.

Rates, Patterns, and Predictors of Follow-up Care for Adolescents at Risk for Substance Use Disorder in a School-Based Health Center SBIRT Program

PURPOSE

To examine rates, patterns, and predictors of follow-up care for adolescents screened as being at risk for substance use disorder (SUD) in a school-based health center (SBHC) Screening, Brief Intervention and Referral to Treatment (SBIRT) program.

METHODS

Electronic health records were extracted of adolescents who received health care services from one of three high school-based health centers implementing SBIRT. Patterns and predictors of engagement in follow-up care within 8 weeks following the week of a positive SUD risk screen were analyzed using item response theory (IRT) modeling.

RESULTS

Out of 1,327 adolescents receiving SBHC services, 81.2% completed a health screening questionnaire. Of screened adolescents, 17.7% were positive for SUD risk. Across the 8-week follow-up period, 65.4% of adolescents at risk for SUD received at least one follow-up visit. IRT modeling indicated that high levels of engagement in follow-up care were characterized by contact with a behavioral health care (BHC) provider. The percentage of adolescents having follow-up contact with a BHC provider increased significantly after the onset of the COVID-19 pandemic. Engagement in follow-up care was predicted by risk for depression, history of suicidal behavior, being female, and previous sexual activity.

DISCUSSION

SBHCs provide a favorable setting for screening and detecting adolescents at risk for SUD. Adolescents at risk for SUD should receive follow-up contact with a BHC provider. Enhanced follow-up engagement efforts may be warranted for adolescents at risk for SUD without risk for depression or suicidal history, as well as for females and those with previous sexual activity.

Disparities in School Referrals for Agitation and Aggression to the Emergency Department

OBJECTIVES

Describe the demographic and clinical characteristics of children presenting to the emergency department (ED) for agitation and aggression from school versus other sites.

METHODS

We performed a retrospective cross-sectional study of children 5 to 18 years old who were evaluated in an urban tertiary care pediatric ED with a chief complaint of agitation or aggression. We examined demographics, disposition, and payments for children presenting from school versus other sites. We conducted multivariable logistic regression to identify predictors of referral site (school versus all other sites, school versus home) and discharge status (home versus higher level of psychiatric care).

RESULTS

Of the 513 included children, 147 (29%) presented from school. Children were more likely to present from school versus other sites if they were Black (adjusted odds ratio [aOR] 2.26, 95% confidence interval [CI] 1.32, 3.88), Latinx (aOR 2.91, 95% CI 1.42, 5.97), or had special educational needs (aOR 2.55, 95% CI 1.64, 3.97). These associations persisted in the analysis of school versus home referrals. Children presenting from school versus all other sites were more likely to be discharged home (aOR 1.60, 95% CI 1.05, 2.44), although this difference did not persist when comparing school versus only home referral. A total of $154,269 (median $367 per encounter) was paid for school referrals to the ED.

CONCLUSIONS

Children with agitation and aggression referred from school were more likely to be Black, Latinx, or have special educational needs. Future efforts should identify and address root causes of this disparity to decrease ED referrals, reduce healthcare spending, and address inequities.