THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA OFFICE OF THE SUPERINTENDENT DR. FRANK TILL SUPERINTENDENT OF SCHOOLS

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1 THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA OFFICE OF THE SUPERINTENDENT DR. FRANK TILL SUPERINTENDENT OF SCHOOLS Telephone: (954) Facsimile: (954) Memorandum with signatures is on file. June 17, 2003 TO: FROM: VIA: SUBJECT: School Board Members Katherine Blasik, Ph.D., Assistant Superintendent Office of Research and Evaluation Frank Till Superintendent of Schools SCHOOL-BASED HEALTH CENTERS EVALUATION REPORT The School Board of Broward County (SBBC) has Cooperative Agreements with Memorial Healthcare System and the North Broward Hospital District to provide healthcare services at a total of ten School-based Health Centers (SBHC) throughout Broward County. The SBHCs provide various services to students and community members including immunizations, emergency health needs, preventive and episodic health care, health appraisals (e.g., vision, hearing), growth and development screenings, health counseling, prenatal, postnatal and pediatric services. The attached report examines services provided and populations served at the ten health centers, perspectives of stakeholders, the extent that recommendations from the previous evaluation have been implemented, and how effectively the program has been operating. Findings reveal considerable program limitations related to the lack of standardized and comprehensive data collection procedures between hospital districts and Broward County Public Schools (BCPS). Currently, there is no electronic mechanism to track specific students and tie them to services received at the ten health centers. As a result, only duplicated counts of patients served are documented while definitions of different services for example, medical encounters are not consistently defined between hospital districts and individual centers. Additionally, students using health center services are not matched to students BCPS identification numbers so that data from the school district s database can be utilized to, at a minimum, report demographic characteristics, services provided, and frequency of visits. Further, some services do not provide counts that distinguish between the number of students and community patients served by the SBHCs.

2 As a result of the program limitations identified in this evaluation, a recommendation is made to establish a School-Based Oversight Committee, with representatives from each school s School Advisory Council and SBHC. The committee will serve as a mechanism for collaborating with hospital district coordinators regarding day-to-day operations, program development, data collection, service delivery, resource allocation, and program outcomes. Specifically, the committee will establish a comprehensive and uniform data collection system to link service delivery information to student identification numbers to ensure the timely reporting and accessibility of program data on an annual basis. If you have any questions or comments regarding this report, please contact Dr. Katherine Blasik, Assistant Superintendent, Office of Research and Evaluation at or Dr. Cary Sutton, Director, Research Services at FT/KAB/COS:dwv Attachment cc: Senior Management Area Directors

3 THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA CURRICULUM & INSTRUCTION/STUDENT SUPPORT Memorandum with signatures is on file. June 17, 2003 TO: FROM: SUBJECT: Dr. Frank Till Superintendent of Schools Earlean C. Smiley, Ed.D., Deputy Superintendent Curriculum & Instruction/Student Support RESPONSE TO SCHOOL-BASED HEALTH CENTERS EVALUATION REPORT RECOMMENDATION: By August 2003, the Director of Health Education Services will establish a School-Based Oversight Committee as recommended in the 1997 evaluation to provide guidance on the SBHC program. Representatives from each SBHC and each school s School Advisory Council shall be included on the School-Based Oversight Committee. This committee will provide a mechanism for collaborating with hospital district coordinators regarding day-to-day operations, program development, data collection, service delivery, and consistency of resource allocation. Specifically, the committee will: Address strategies for identifying and implementing the collection of data to ensure the timely reporting and accessibility of program data on an annual basis. Program data available should include, but not be limited to, general information (i.e., grade, race, and sex) about students who use the SBHCs, frequency of use, and the general types of services that were received. Recommend improvements regarding the SBHC Partnership Agreements with the NBHD and MHS to reflect the needs and circumstances of the schools and communities where SBHC services are offered. RESPONSE: Currently, the NBHD s School Health Manager meets with the Director of Health Education Services (HES) on a monthly basis to discuss issues related to the SBHCs. The Director also confers, as needed, with the Memorial Healthcare System SBHC s staff. To establish a more formalized and comprehensive approach, a SBHC Oversight Committee will be established. This committee will convene on a quarterly basis, beginning the school year Core representatives on this committee will include, at a minimum: Director of HES, the hospital districts School-Based Health Center Managers, a representative from each school s School Advisory Council (SAC), a social worker, a principal and area district staff.

4 Proposed Actions of the SBHC Oversight Committee: The committee will establish goals with measurable outcomes. These goals will focus on the specific health care and related social needs of the student population. A process will be established to capture student encounters at the health center, as well as the general type of services rendered on a cumulative basis. Request that the hospital district add a data element to their database indicating whether their client is a community member or a student. Discussion will also occur regarding both hospital districts having a uniform data collection system to track services received at the health centers. There will be collaboration with BCPS Research and Evaluation Department regarding data collection and evaluation process. ECS/FC/MB: cvo

5 The School Board of Broward County, Florida School-Based Health Centers Evaluation Report Lois Wexler, Chair Carole L. Andrews, Vice Chair Judie S. Budnick Darla L. Carter Beverly A. Gallagher Stephanie Arma Kraft, Esq. Robert D. Parks, Ed.D. Marty Rubinstein Benjamin J. Williams Dr. Frank Till Superintendent of Schools Katherine Blasik, Ph.D. Assistant Superintendent, Office of Research and Evaluation Cary O. Sutton, Ed.D. Director, Research Services Dean Vaughan Evaluation Administrator Arlene Brown, Ph.D., Evaluator June 2003 The School Board of Broward County, Florida prohibits any policy or procedure which results in discrimination on the basis of age, color, disability, gender, national origin, marital status, race, religion or sexual orientation.

6 School-Based Health Centers TABLE OF CONTENTS I. EXECUTIVE SUMMARY i II. INTRODUCTION 1 National Perspective 2 Funding 4 Research Findings 5 Florida Perspective 6 Broward County Perspective 8 III. COST IMPACT 9 IV. PURPOSE OF THE EVALUATION 9 V. METHODS 10 VI. FINDINGS 11 What Services are Provided at the Different SBHCs? 11 What Population is Served by the SBHCs? 19 How Well is the SBHC Program Running and how has the 22 Program Changed Since the Last Evaluation? To What Extent Have the Recommendations From the Previous 24 Evaluation Been Implemented? What Are the Perspectives of Students, Medical Personnel and School Staff Regarding the SBHC Program? 26 VII. SUMMARY 36 VIII. RECOMMENDATIONS 39 X. REFERENCES 39

7 The School Board of Broward County, Florida School-Based Health Centers Evaluation Report Executive Summary The National Assembly on School-Based Health Care (NASBHC) (2002a) defines School Based Health Centers (SBHC) as partnerships created by schools and community health organizations to provide on-site medical and mental health services that promote the health and educational success of school-aged children and adolescents. SBHCs blend medical care with preventive and psychosocial services as well as organize broader school-based and community-based health promotion efforts (Guernsey & Pastore, 1996). The SBHC program in Broward County was implemented in 1994 at three schools. Currently, the School Board of Broward County (SBBC) has Cooperative Agreements with the South Broward Hospital District d/b/a Memorial Healthcare System (MHS) and the North Broward Hospital District (NBHD) to provide healthcare services at a total of ten SBHCs throughout Broward County. The SBHCs provide various services including immunizations, emergency health needs, preventive and episodic health care, health appraisals (nutrition assessment, vision, hearing, scoliosis), growth and development screenings, health counseling, prenatal, postnatal and pediatric services. Seven of the ten centers provide comprehensive primary care services to students and community members while the remaining three centers do not provide primary care and instead provide primarily first aid and immunization services. Of the three centers that do not provide primary care, two of the centers provide services only to Broward County Public School (BCPS) students while the third center provides services to BCPS students and community members. Cost Impact The SBBC provides the building or space to operate the clinics. The hospital districts provide staff, in the form of ARNPs, nurses, midwives, physicians, and medical assistants in addition to medical supplies. The original BCPS budget request for operating the SBHCs totaled $263,456 to cover the salary and benefits of one custodian for each of the eight NBHD health centers. However, late in the school year and prior to hiring custodians, the budget request was revised to $80,750 for hiring one custodian for each of the eight NBHD health centers for the final three to four months of the school year. The two MHS health centers were not included in these budget requests. Purpose of the Evaluation The purpose of this evaluation report is to provide an updated assessment of Broward County s SBHC program. This evaluation is the second formal evaluation of the program. The first evaluation of the program was completed in July 1997 (Brown, 1997). i

8 To evaluate the current impact of the SBHC program, the following five research questions were addressed: 1. What services are provided at the different SBHCs? 2. What population is served by the SBHCs? 3. How well is the SBHC program running and how has the program changed since the last evaluation? 4. To what extent have the recommendations from the previous evaluation been implemented? 5. What are the perspectives of students, medical personnel and school staff regarding the SBHC program? Methods The research questions were addressed using both descriptive and quantitative methods. Methods to obtain information included site visits to five of the SBHCs, observations, interviews, document review, literature review, data analysis, and analysis of a survey completed by 331 SBBC students. Summary School-based health centers are one viable option to ensure that students and community members have access to medical services. The MHS and the NBHD, in partnership with the SBBC, operate ten SBHCs throughout the school district; eight in the northern end of the county and two in the southern end. Seven of these centers provide primary care while the remaining three provide episodic care and immunizations. Following is a summary of program evaluation findings. Quantitative Findings Health Centers. Since the last evaluation in 1997, there has been a closure of one SBHC, an opening of a new SBHC, as well as a reduction in services, staff and patients served at three of the SBHCs. The MHS currently operates two sites while the NBHD operates eight sites. The locations of the SBHCs are: one at an elementary school, three at middle schools, four at high schools, and two at community/alternative schools. Seven of the clinics serve community members and provide comprehensive services by a staff of physicians, ARNPs, nurses and support staff. Three of the clinics serve only BCPS students, are staffed with only one nurse, and provide primarily immunizations and first aid. ii

9 Students. There are a total of 16,658 students attending the 10 schools and centers that have SBHCs. At the ten schools with SBHCs, 12% of the students have specific health conditions documented in the BCPS database, with 57% of those students being in high school. When the ethnic composition of students at the ten sites is compared to the district total, the sites have a higher proportion of Black students (62% for sites compared to 36% for the district). The gender composition for students at the ten sites was similar to all district students with 49% male and 51% female. The proportion of students at the ten sites that are classified limited English proficient (LEP) and exceptional student education (ESE) is consistent with the district proportions. However, 42% of the students at the ten sites are eligible for free and reduced lunch compared to 37% of the district students. Services Provided. Since 1997, the ten clinics have served a duplicated count of 138,873 patients. Of the total number of patients served since 1997, 99,709 (72%) were BCPS students and 39,164 (28%) were community patients. When examining the number of medical encounters provided by individual sites across years, eight of the sites provided progressively more encounters each year starting in through with the exception of the South Broward and Hallandale centers. Medical encounters are not stratified to distinguish between BCPS students and community patients served. The number of first aid encounters has been documented by the NBHD since and by the MHS since Since 1997, a total of 49,816 first aid encounters have been provided. First aid encounters are not stratified to distinguish between BCPS students and community patients served. Immunizations given by both hospital districts increased each year from to at which time they began to successively decline for the next two years. Since , a total of 69,638 immunizations have been given at schoolbased health centers. At South Broward, the total number of referrals has steadily increased from 2 per year in to 730 in Both hospital districts achieved the Healthy Start outcomes related to babies birth weights, and immunizations for the year and from July 2002 to December iii

10 For the year, the MHS fell below the Healthy Start target for participants having a prenatal/primary health care provider, but during the first six months of the year, the MHS achieved 100%. Qualitative Findings Two of the three recommendations from the prior evaluation were not fully implemented including convening the School-Based Oversight Committee and expanding the current funding base. The School-Based Oversight Committee was charged to establish standardized goals with measurable outcomes and a standardized data collection system, identify strategies for increasing community awareness of the SBHC program, investigate expanding the centers operating hours and the feasibility of providing pharmacological services on site. The incorporation of the Consent to Treat form was implemented. Center staff and hospital district representatives expressed satisfaction with the SBHC program. Principals expressed positive feelings related to having the centers on school property. Student Surveys On a satisfaction survey administered to 331 students by BCPS, 82% agreed that they were satisfied overall with the services they received at the SBHC. The two most frequent reasons students did not use the SBHC are they receive health services somewhere else (43%) and they had heard from other people that they did not like using the health center (42%). More 6 th and 7 th graders used the SBHCs than did not use the center. Eighth grade students were equally divided between those who used and those who did not use the SBHC. Students in all the high school grades more frequently were non-users of the SBHC compared to users. When users and non-users of the SBHCs were disaggregated by race/ethnicity, Asian (9.2%) and Hispanic (16.6%) students tend to be nonusers, White students were equally divided, and Black students and other students tended to be more frequent users of SBHCs. Half (50%) of the nonusers of the SBHCs received services from a private family doctor while 35% of the nonusers received services from a clinic/health department. Of the non-users of the SBHCs, 7% did not receive health services anywhere else. Of those students who did use the SBHC, 45% also received services at the clinic/health department and 20% at a hospital/emergency room. The primary sources for referrals to the SBHCs were teachers (39%), student selfreferral (29%), other (13%), school administrator (11%), and family member (9%). iv

11 Over half (59%) of the students listed injury/physical complaint as the main reason for visiting the SBHC during their last visit. The next two most frequent reasons for visits were physical exam/immunization (18%) and preventative services (10%). This evaluation has considerable limitations related to the lack of consistent and thorough data collection procedures and definition between centers and hospital districts. Students who use the clinics are not identified by student identification numbers, which presents limitations in tracking data. Each of the SBHCs has computers that are networked into the larger hospital systems, with the exception of South Broward. However, none of the computers are networked into any BCPS databases. Therefore, there is no electronic mechanism to track specific students and tie them to services received at the centers. For future analyses to be meaningful students must be identified by student identification number. The number of student visits and services provided need to be matched to the student number so that data from the school district s database can be utilized. At a minimum, collection of demographic characteristics, identification of services provided, and frequency of visits should be collected for community patients. Recommendation By August 2003, the Director of Health Education Services will establish a School-Based Oversight Committee as recommended in the 1997 evaluation to provide guidance on the SBHC program. Representatives from each SBHC and each school s School Advisory Council shall be included on the School-Based Oversight Committee. This committee will provide a mechanism for collaborating with hospital district coordinators regarding day-to-day operations, program development, data collection, service delivery, and consistency of resource allocation. Specifically, the committee will: Address strategies for identifying and implementing the collection of data to ensure the timely reporting and accessibility of program data on an annual basis. Program data available should include, but not be limited to, general information (i.e., grade, race, and sex) about students who use the SBHCs, frequency of use, and the general types of services that were received. Recommend improvements regarding the SBHC Partnership Agreements with the NBHD and MHS to reflect the needs and circumstances of the schools and communities where SBHC services are offered. v

12 The School Board of Broward County, Florida School-Based Health Centers Evaluation Report This evaluation reports on the findings and recommendations resulting from the second evaluation of the School-Based Health Centers (SBHC) program operated in ten Broward County Public Schools (BCPS). The evaluation examines what services are provided at the different centers, what populations are served, and the perspectives of key stakeholders. Additionally, changes that have occurred since the last evaluation in 1997, the extent that the recommendations from the previous evaluation have been implemented, and how effectively the program has been operating are reported. Seven of the clinics serve BCPS students and community patients while three centers only provide services to BCPS students. Twelve percent of the 16,658 students who attend the ten schools have specific health conditions documented. Since 1997, the ten clinics have served a duplicated count of 138,873 patients with 72% of that number being BCPS students. Eight of the sites have provided progressively more medical encounters each year starting in through Two of the three recommendations from the prior evaluation completed in 1997 were not implemented. Student satisfaction surveys found that 82% of students were satisfied with the services they received from the SBHC. Tracking of data and uniform data collection procedures remains a problem that was identified in the previous evaluation. Recommendations are provided to enhance the efficacy of the SBHC program. Introduction Student health, readiness for school and ability to learn are inextricably linked. Physical and emotional health is necessary for students to be able to learn and education is necessary for students to learn to live a healthy lifestyle (Novello, DeGraw & Kleinman, 1992). Having chronic health conditions cannot only limit a youth s physical activities, it can also impact the student s ability to attend school and learn. The National Institute of Child Health and Human Development found that in 2000, 7% of children ages 5 to 17 were limited in their activities because of one or more chronic health conditions (2002). One intervention that is used to enhance student health and academic achievement is school-based health centers (SBHCs). The National Assembly on School-Based Health Care (NASBHC) (2002a) defines SBHCs as partnerships created by schools and community health organizations to provide on-site medical and mental health services that promote the health and educational success of school-aged children and adolescents. School-based health centers blend medical care with preventive and psychosocial services as well as organize broader school-based and community-based health promotion efforts (Guernsey & Pastore, 1996). The NASBHC developed seven fundamental principles that provide national standards for school based health centers (2003). The principles of SBHCs are that each center: (a) supports the school, (b) responds to the community, (c) focuses on the student, (d) delivers comprehensive 1

13 care, (e) advances health promotion activities, (f) implements effective systems, and (g) provides leadership in adolescent and child health. Common features of SBHCs, as identified by the Center for Health and Health Care in Schools (2002a) are: 1. They are located in schools. 2. They work cooperatively within the school to become an integral part of the school. 3. They provide a comprehensive range of services to meet the specific physical and behavioral health needs and the more traditional medical care needs of the students. 4. They have a multidisciplinary team of providers including nurse practitioners, registered nurses, physician assistants, alcohol and drug counselors, social workers, physicians and other health professionals. 5. The clinical services within the health center are provided through a qualified health provider such as a hospital, health department, or medical practice. 6. Parents sign written consents for their children to enroll in the health center. 7. They have an advisory board, to provide planning and oversight, consisting of community representatives, parents, youth and family organizations. The difference between SBHCs and other school health programs and other primary care providers is their use of comprehensive, multi-disciplinary approaches involving physicians, nurse practitioners or physician assistants, nurses, clinical social workers, and other mental health professionals and counselors (Dryfoos, Brindis, & Kaplan, 1996). School-based health centers are different from other health programs in four ways: (a) they are located in the schools, (b) they are operated by health professionals, (c) they provide comprehensive services and (d) they are not funded by school systems (School-Based Adolescent Program, 1993). National Perspective Research studies have provided a comprehensive overview of SBHCs in the United States. The NASBHC (2002b) surveyed over 1100 SBHCs in , the Center for Health and Health Care in Schools (2002b) at George Washington University conducted a survey of SBHCs in the 50 states in and Schlitt et al. (2000) surveyed 806 SBHCs in Additionally, a number of outcome research studies have been conducted to validate the impact SBHCs have had on students health and academic achievements. Although SBHCs differ across the country based on availability of resources and community needs, in a national survey of 1100 centers conducted by NASBHC (2002b), findings revealed that primary care was provided by physicians, physician assistants, and nurse practitioners, which resulted in a full array of medical services being offered. The most frequent services and the percent of clinics providing the services were: treatment of acute illness (94%); screenings such as vision, hearing and scoliosis (91%); asthma treatment (90%); comprehensive physicals (89%); sports physicals (87%) and immunizations (85%). In 65% of the SBHCs surveyed, services were provided to other populations in addition to the specific school s students, such as family members of students, school faculty, and students from other schools. 2

14 SBHCs are often developed as a partnership between the educational system and the health care community. The most frequent sponsors of SBHCs include: hospitals (32%), health departments (17%), federal community health centers (17%), school districts (14%) and nonprofit agencies (12%) (NASBHC, 2002a). Research has revealed that SBHCs are concentrated primarily in urban areas (58%), followed by rural (24%) and suburban areas (18%). The largest growth occurs in the suburban areas (The Center for Health, 2002). Schlitt et al., (2000) found that urban centers tend to provide a broader scope of services and longer hours of operation compared to rural and suburban centers. The types of school settings hosting the health centers are elementary (38%), middle (17%), high (34%), K 12 (5%), alternative (1%) and combined grade levels (5%) (The Center for Health, 2002). High schools provide the largest number of hours of health care staff on-site, followed by middle schools and elementary schools (Schlitt et al., 2000). Elementary schools have had the largest rate of growth since 1998 (The Center for Health, 2002b). School-based health center staff is composed of a combination of physicians, physician assistants, and nurse practitioners in 92% of the cases. Staff collectively provides physical health services an average of 27 hours per week at each site. Physicians are part of the staff and provide services and supervision at 50% of the sites for an average of six hours per week. More than 90% of the 806 SBHCs surveyed employ support staff to maximize the efficiency of the medical services provided and to support daily operations (Schlitt et al., 2000). In 60% of the centers, health care providers, usually a nurse practitioner or a physician assistant, work full time and in 40% of the centers, the health care providers work 25 hours per week or less (The Center for Health, 2002b). Neither the American School Health Association or the Center for Disease Control s Division of Adolescent and School Health have a protocol for data collection for school-based health centers (personal communication, April 8, 2003). However, the NASBHC found that 88% of SBHCs use computer-based patient tracking systems. Of those, 41% use their sponsoring agency s computer tracking program and 43% use the School HealthCare ONLINE Program, which is a system developed specifically for SBHCs (Schlitt et al., 2000). The first SBHCs, which were located in Texas and Massachusetts, were funded primarily by grants from the Robert Wood Johnson Foundation and were developed to address poor access to health care and increasing risk-taking behaviors of adolescents (Fast, 2003, Schlitt et al., 2000). The number of SBHCs has grown dramatically during the last decade. In 1990, there were 200 SBHCs (School-Based Clinics Step, 2003). That number grew to 1,322 in 2000 according to a national survey conducted by the Center for Disease Control (2000). The number of SBHCs in each state ranges from 1 to 163 with an average of 27.1 per state. As of 2000, SBHCs were located in 45 states plus the District of Columbia. The five states that had the largest number of centers included: New York (159), Arizona (116), California (102), Florida (80), and Texas (70) (The Center for Health, 2002b). Only fifty percent of all school-age children receive any health care (Fast, 2003) and approximately 39% of students served by SBHCS have no other medical home (NASBHC, 3

15 2002a). Adolescents between the ages of 10 and 19 years old have the lowest utilization of health care services of any age group and are the least likely to seek medical care (National Center for Health Statistics, 1997). Although the percent of youth under the age of 18 without health insurance coverage dropped from 13.9% in 1997 to 10.1%, as of September 2002, 7.4 million youth remain uninsured (Center for Disease Control, 2002). Both parents and students have shown support for SBHCs. More than 70% of parents consent for their child to use the center. On average, approximately 50% of enrolled students use the center, with the average visit rate being four visits per year per student (The Center for Health and Health Care in Schools, 2002a). In 1996, the U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA) with the Privacy Rule of the Act becoming effective on April 14, The regulations set forth by HIPAA will reform the health care industry and will change the privacy regulations and the information that health care providers, such as SBHCs, can share with other entities. Two of the goals of HIPAA are to give patients more control and access to their health care information and to protect individually identifiable medical information from real or potential threats of loss or disclosure. The HIPAA Security Standards, which will go into effect in 2005, specify a series of administrative, technical, and physical security procedures for providers to use to assure the confidentiality of electronically protected health information. According to the new HIPAA guidelines, health centers located in schools but operated by HIPAA-covered entities such as hospitals or public health departments are subject to HIPAA and may not release student health information to the schools in which they are situated, since the schools are not HIPAA "covered entities. Funding The funding for SBHCS has increased rapidly to keep growth with the large increases in numbers of new SBHCs. Funding has increased from $17 million in 1992 to $61.9 million in 2000 (School-Based Clinics Step, 2003). SBHCs traditionally are funded with state dollars rather than federal dollars (National Assembly on School-Based Health Care, 1999). The Center for Disease Control reports that funds from state revenue sources were received in 70.7% of the states with SBHCs (2000). In fact, during , nearly two-thirds of SBHCs (281 out of 443) in nine states received state funds totaling in excess of 30 million dollars. This funding accounted for over 50% of the operating budget for 83.6% of the centers (National Assembly on School-Based Health Care, 1999). Recently, many states have begun to cut back on state funding due to Medicaid managed care and state child health insurance initiatives. In recent years, the financial viability of SBHCs has become increasingly dependent on revenues generated from Medicaid and other third-party payers (Brellochs, Zimmerman, Zink, & English, 1996). In a survey of 129 SBHCs, Schlitt et al., (2000) found that Medicaid recipients accounted for 28% of the patients at SBHCs and Medicaid revenues averaged $7,000 annually or 5% of the operating budget of the centers. 4

16 Federal funds for SBHCs are limited to two primary revenue sources. The federal grant program Healthy Schools, Healthy Communities, allocated $14.4 million to SBHCs in The other source of federal funds that is directed towards SBHCs is the Maternal and Child Health (MCH) Block Grant (The Center for Health, 2002b). Research Findings Research studies have documented the need for and the impact of SBHCs on students and community members. The following is a compilation of findings from evaluation studies: Who uses SBHCs? Students with less access to health care due to being uninusured and those with greater self-reported health care needs were more likely than other students to visit SBHCs (Kisker & Brown, 1996). Average users of SBHCs were found to be representative of schools entire populations (McCord, Klein, Joy & Fothergill, 1993; Wolk & Kaplan, 1993). Frequent users of SBHCs (identified as 15 or more visits per year) were more likely to be female and have a lower grade point average (Wolk & Kaplan, 1993). Impact on visits for health care. Elementary students with access to a SBHC were more likely to have received medical and dental care compared to students without access to a SBHC (Kaplan, Brindis, Phibbs, Melinkovich, Naylor & Ahlstrand, 1999). Adolescent users of SBHCs received more medical treatment than adolescents in the general population (Anglin, Naylor & Kaplan, 1996). Adolescent users of SBHCs had higher use of any health care provider than adolescents in the general population (Anglin, Naylor, & Kaplan, 1996). There were mixed findings related to emergency room visits. Kaplan, Calonge, Guernsey and Hanraham (1998) found that students with access to a SBHC had decreased emergency room visits compared to those without access to a SBHC while Kisker & Brown (1996) found that SBHCs had no impact on emergency room use. Impact on academic success and absences. Students who use SBHCs were positively impacted in the areas of students progression through and graduation from high school (Kisker & Brown, 1996; McCord, Klein, Joy & Fothergill, 1993). African American male students were more than three times as likely to stay in school if they had registered in a SBHC (McCord, Klein, Joy & Fothergill, 1993). 5

17 There were mixed findings related to absenteeism. Sanchez (2001) found that students attending schools with SBHCs had lower absenteeism rates compared to students attending Texas schools without a SBHC (Sanchez, 2001) while McCord, Klein, Joy & Fothergill (1993) found that students who used the SBHC had lower absentee rates compared to students who were registered but did not use the SBHC and students who were not registered at all. These findings contradict Sanchez (2002) who found no significant differences in absences and Kisker and Brown (1996) who found SBHCs had no impact on absences due to illness compared to urban youths nationally. There were no significant differences with regard to graduation rates, dropout rates, or academic scores for schools with SBHCs in Texas compared to all Texas schools (Sanchez, 2001). Florida Perspective Florida students. Health related behaviors, often adopted in early childhood, are critically linked to either positive or negative health outcomes. For example, tobacco use, unhealthy dietary behaviors, inadequate physical activity, alcohol and drug use, sex behaviors, and violent behavior all have been documented to contribute to negative outcomes. Every two years the Center for Disease Control (Center for Disease Control, 2001) conducts the national Youth Risk Behavior Survey of students in grades 9 12 in public and private schools to monitor health risk behaviors that impact on the leading causes of death, disability, and social problems among youth and adults. Behaviors that are considered to be a risk are the leading threat to the health and well-being of adolescents. The findings related to students in Florida revealed that: 22% smoked cigarettes during the past month 8% attempted suicide during the past year 33% were in a physical fight during the past year 32% rode with a drinking driver during the past month 45% drank alcohol during the past month 25% engaged in episodic heavy drinking during the past month 23% used marijuana during the past month 10% are overweight 50% had ever had sexual intercourse 36% had sexual intercourse during the past three months 78% did not participate in moderate physical activity Florida s SBHC program. In the National Assembly of School-Based Health Centers (2000) surveyed 806 SBHCs throughout the United States with 31 Florida sites responding to the survey. Of the Florida centers responding, grade level distribution of schools served consisted of high school (55%), 6

18 combined middle and high school (10%), middle school (6%), elementary (26%) and combined grades (3%). The types of sponsor in the Florida SBHCs surveyed were local health departments (10%), community health centers (23%), hospitals (6%), and other sponsors (61%). The breakdown of community type was urban (35%), rural (39%), and suburban (26%). Table 1 provides the percent of Florida SBHCs compared to all SBHCs nationally that responded to the survey in the area of selected services provided, operations, and quality assurance and staffing. As evidenced by the table, under the category of selected services, the percent of Florida SBHCs who provided comprehensive assessments, laboratory services, prescriptions, dental sealants and STD diagnosis and treatment was lower than that of the national sample of SBHCs. Compared to the national sample, a higher percent of Florida centers provided comprehensive mental health evaluation and treatment, group substance abuse counseling and prohibition from dispensing birth control. In the area of operations, a lower proportion of Florida centers, compared to the national sample, offered the variables of Medicaid billing, computerized data collection, training of health providers and prearranged after hours care. Florida centers had lower proportions of using quality assurance methods with the exception of patient satisfaction surveys. Table 1 Components of Florida SBHCs Compared to a National Sample of SBHCs Percent of Florida SBHCs (n=31) Percent of All SBHCs (n = 775) Selected Services Provided Comprehensive Health Assessments Laboratory Services Prescriptions for Medications Dental Sealants 3 13 Comprehensive Mental Health Evaluation and Treatment Group Substance Abuse Counseling Prohibition from Dispensing Birth Control On-Site STD Diagnosis and Treatment Operations Medicaid Billing Computerized Data Collection Training of Health Providers Prearranged After Hours Care Quality Assurance Any Use of Professional Standards Any Use of QA Measures Any Use of QA Tools Chart Audits Patient Satisfaction Surveys Table 2 provides the percent of Florida SBHCs compared to all SBHCs nationally that responded to the survey in the area of staffing. In relation to the average number of hours per week that staff worked, Florida centers had higher averages for mental health and operating hours and lower hours for primary care. 7

19 Table 2 Staffing of Florida SBHCs Compared to a National Sample of SBHCs Hours/Week of Florida SBHCs (n=31) Hours/Week of All SBHCs (n = 775) Average Primary Care Average Mental Health Average Operating Hours Broward County Perspective Broward County Students. In 2000, 1,818 randomly selected sixth through eighth grade students in BCPS were surveyed to collect data related to the prevalence and patterns of drug and alcohol use, violence, gang activity and suicide (Pride, 2000). Of the nine items related to drugs and alcohol, five of the questions (smoking cigarettes, drink beer, smoking marijuana, using hallucinogens, and getting high on hallucinogens) indicated the proportion of students answering in the affirmative increased with each successive grade (see Table 3). Table 3 Medical Specialty Provided by Site 6 th 7 th 8 th Grade Grade Grade Smoked cigarettes within the past year Drank beer within the past year Getting very high or bombed when they drank beer Smoked marijuana within the past year Getting very high or bombed when they smoked marijuana Used cocaine within the past year Getting very high or bombed when they used cocaine Used hallucinogen (LSD) within the past year Getting very high or bombed when they used hallucinogen (LSD) Broward County s SBHC Program. The SBHC program in Broward County was implemented in 1994 at three schools. Currently, the School Board of Broward County (SBBC) has Cooperative Agreements with the South Broward Hospital District d/b/a Memorial Healthcare System (MHS) and the North Broward Hospital District (NBHD) to provide healthcare services at a total of ten SBHCS throughout Broward County. The SBHCs provide various services including immunizations, emergency health needs, preventive and episodic health care, health appraisals (nutrition assessment, vision, hearing, scoliosis), growth and development screenings, health counseling, prenatal, postnatal and pediatric services. 8

20 The MHS, is a nonprofit community health system composed of four existing hospitals, one hospital under construction, a nursing home, an outpatient center, and various primary and urgent care facilities. Memorial Healthcare System operates two SBHCs at: (a) South Broward High and (b) Hallandale Adult Community Center. In the Partnership Agreement between the SBBC and the MHS, the only delineation of program services is that the Hallandale site will provide health services to teen parents and their children. The MHS accepts Medicaid at the Hallandale site for services rendered by the physician. Otherwise, no fees or revenues are collected for the services that are provided at South Broward and non-physician services at the Hallandale site. The NBHD, a nonprofit community health system, is composed of more than 40 healthcare facilities that provide a full spectrum of healthcare services. The NBHD operates SBHCs throughout the northern part of Broward County at the following eight locations: (a) Blanche Ely High; (b) Charles Drew Family Resource Center; (c) Crystal Lake Middle; (d) Deerfield High; (e) Lauderhill Middle; (f) Seagull; (g) Stranahan High and (h) William Dandy Middle. In the Partnership Agreement between the SBBC and the NBHD, the SBHC program is defined as a provision of health services to students, their families, and the school s community in order to: (a) intercept and treat students with medical needs at an earlier age thereby reducing the severity of acute medical problems and promote positive health behaviors; and (b) increase the public s access to health care services through the school locations. The NBHD sets charges for SBHC services that are consistent with those fee schedules established at the hospital district s primary care centers. The hospital district provides staff that determines the eligibility of all individuals for Medicaid and identifies any third party payer that might be used to reimburse the district for services provided at the school health centers. The hospital district retains sole and exclusive right to all funds collected for services. Cost Impact The SBBC provides the building or space to operate the clinics. The hospital districts provide staff, in the form of ARNPs, nurses, midwives, physicians, and medical assistants in addition to medical supplies. The original BCPS budget request for operating the SBHCs totaled $263,456 to cover the salary and benefits of one custodian for each of the eight NBHD health centers. However, late in the school year and prior to hiring custodians, the budget request was revised to $80,750 for hiring one custodian for each of the eight NBHD health centers for the final three to four months of the school year. The two MHS health centers were not included in these budget requests. Purpose of the Evaluation The purpose of this evaluation report is to provide an updated assessment of Broward County s SBHC program. This evaluation is the second formal evaluation of the program. The first evaluation of the program was completed in July 1997 (Brown, 1997). To evaluate the current impact of the SBHC program, the following five research questions were addressed: 9

21 1. What services are provided at the different SBHCs? 2. What population is served by the SBHCs? 3. How well is the SBHC program running and how has the program changed since the last evaluation? 4. To what extent have the recommendations from the previous evaluation been implemented? 5. What are the perspectives of students, medical personnel and school staff regarding the SBHC program? Methods The research questions were addressed using both descriptive and quantitative methods. To gather information, a combination of approaches was utilized including site visits, observations, interviews, surveys, literature review, document review, and data analysis. The evaluation included qualitative evaluative techniques to address process areas. Two meetings were held with BCPS administrators with oversight responsibilities for the SBHC to plan the research design and to gather information about the program. Two meetings were held with the NBHD administrator and one interview was held with the MHS administrator. Site visits were made to five of the ten SBHCs where interviews were held, facilities were toured, and indirect observation of patients in common waiting areas was held. During the site visits, individual interviews were held with two physicians, two site managers, five nurses, one medical assistant, one outreach worker, and one principal. Interviews were also held with BCPS district employees responsible for the SBHC program as well as with hospital administrators and staff located at the centers. Interviews included questions about the current operation of the clinic, barriers encountered and suggestions for improvement, and collection of data. Telephone interviews were also held with three additional principals of schools with SBHCs. The hospital districts provided data related to medical and first aid encounters, patients served, immunizations given and Healthy Start services provided. The BCPS supplied student level data related to health conditions associated with students at the schools with SBHCs. To ascertain the utilization and satisfaction of students with the SBHC, a survey that was used in the previous SBHC evaluation (Brown, 1997) was again administered with minor revisions. Based on the total number of students at all 10 participating sites, a minimum of 390 students, based on formula driven sample size calculations, was needed in order to report in the aggregate. Students who were eliminated from the sample population included withdrawn or inactive students, students entering school after September 30, 2002, and elementary school students. These criteria eliminated Charles Drew Family Resource Center and Seagull School from the sample. The result was that the survey was distributed to a random sample of 400 students in intact classes, both users and nonusers of the SBHC, at eight of the ten schools that had the clinics. Of the 400 students identified to be included in the survey, 331 (82.8%) completed the survey. 10

22 Findings 1. What services are provided at the different SBHCs? Seven of the ten SBHCs provide comprehensive primary care services to students and community members while the remaining three centers do not provide primary care. Instead, these three centers provide primarily first aid and immunization services. Of the three centers that do not provide primary care, two of the centers (Crystal Lake and Stranahan) provide services only to Broward County Public School (BCPS) students while the third center (South Broward) provides services to BCPS students and community members. School faculty is provided medical services at the two MHS clinics for free. School faculty at the NBHD clinics can receive medical services only if they have insurance. The Partnership Agreement with NBHD identifies the services that will be supplied at their eight sites. According to the Agreement, at Seagull and Charles Drew Family Resource Center, prenatal, postnatal and pediatric services in addition to preventive episodic health services are supposed to be offered while the other six sites are to provide general episodic and preventive services only. However, actual services provided at three of the NBHD clinics have been expanded beyond the scope identified in the Agreement. These additional services include Deerfield Beach High providing OB/GYN, pediatric, and dental services; Lauderhill Middle providing OB/GYN and pediatric services; and William Dandy Middle providing pediatric services. The Partnership Agreement with MHS only identifies the Hallandale site and does not mention the South Broward site. The service listed in the agreement that MHS will provide at Hallandale is to provide health services to the teen parents and their children. Table 4 provides a summary of the medical specialty that is actually provided at each site. Table 4 Medical Specialty Provided by Site Basic Medical Care/Family Practice Immunizations, First Aid, Information & Referral Site District OB/GYN Pediatrics Blanche Ely High NBHD X Charles Drew Resource Ctr. NBHD X X X Crystal Lake Middle NBHD X Deerfield Beach High NBHD X X X X Hallandale Adult Center a MHS X X X Lauderhill Middle NBHD X X X Seagull School a NBHD X X X South Broward High MHS X Stranahan High NBHD X William Dandy Middle NBHD X X b a Teen Parent Sites. b Up to 18 years old. Services are provided to students and community members in accordance with the availability of medical staff to provide the services. To the extent that services are not available at any of the Dental 11