By Carol Chmelynski
11/23/04 -- During the past decade, school-based health clinics have been appearing on a growing number of public school campuses as a way to reach children often missed by the health care system.
Proponents of clinics say healthier children do better in school and have fewer absences. Clinics also can help reduce teen pregnancy, smoking, and alcohol use; ensure children are immunized; and contribute to fewer hospitalizations.
There are about 1,500 school-based clinics in the United States, compared to just 200 in 1990, reports the Center for Health and Health Care in Schools. School-based clinics are in all but a handful of states. They are in urban, rural, and suburban communities, with the largest growth in rural areas.
Public schools have long emphasized good health, and there were actually pediatricians stationed in U.S. schools at the beginning of the 20th century. That later gave way to the school nurse.
Access to health care
But it wasn't until the 1970s that schools in disadvantaged urban areas began to see the need for health clinics, says John Schlitt, executive director of the National Assembly of School-Based Health Care. The first clinics appeared in Denver, Dallas, and St. Paul, Minn., when educators realized that students might not follow up after leaving the school nurse's office, he says.
Illinois has 44 school-based clinics, 24 of them in Chicago. The Illinois Department of Human Services distributes about $4 million a year in grants to the clinics, says state agency spokesperson Vyki Jackson. Just under half of that money comes from Illinois' settlement of its class action suit against tobacco companies.
The on-site clinic at Nicholas Senn High School in Chicago treats students for such problems as bronchitis, asthma attacks, and sports injuries. It also provides prenatal care, pap smears, and mental health counseling, one of the most common reasons students visit a clinic.
Educators value health care clinics for one simple reason: Healthy students are better learners. A student who is feeling ill can go to the clinic and go back to class and not miss a day of school. And parents don't have to take time off from work.
More than 90 percent of Senn's students are poor and many have no access to health care other than what's offered through the center, says Christopher Moffat, site manager for Heartland Health Outreach, the agency that runs the center.
According to Moffat, Chicago Public Schools paid $295,000 to renovate what used to be the high school's woodshop and convert it into a health center. The clinic's $140,000 annual budget is supported by grants from the Polk Bros. Foundation, Lurie Foundation, and the Grant Healthcare Foundation.
"There's a $3 fee to visit the clinic, but we don't turn anyone away based on their inability to pay. If students have Medicaid or private insurance, there's no fee," Moffat says.
Teaching healthy habits
"The most beneficial difference between school-based clinics and regular health care is the emphasis placed on educating children on preventive measures and the harm of engaging in risky behavior," Jackson says. "School-based clinics really focus on teaching kids to become responsible for their own health."
The Senn clinic is not open to the community at large, but Moffat hopes that will happen in the future. Many school-based clinics do serve students' families and other community members.
Nationally, one of the most important benefits of school-based clinics is providing health care to immigrant children, especially undocumented immigrants, who otherwise have no access to health care. It's estimated that more than a million undocumented children under 18 live in the United States.
Federal, state, and local resources to open and operate school clinics are limited, but community partnerships, realizing the need for such convenient havens, have stepped in with the necessary resources.
Jackson describes a community project in Urbana, Ill., where local carpenters, electricians, and plumbers volunteered their time and materials to build a school-based clinic. "They did it because they felt there were a lot of kids, maybe even their own kids, who had difficulty getting access to health care and they needed such a center in their school," she says.
One of the main obstacles to establishing school-based clinics is the public's resistance to giving students easy access to contraceptives. "In fact, only about one in four clinics in middle and high schools actually dispense contraceptives. But data supports that it is not one of the more frequently prescribed services students come in for," says Schlitt.
"We can talk to students about birth control and contraceptives, but we can't distribute condoms," says Lashekia Peterson, a medical office assistant at the Wellness Center at Lakeside High School in Wilmington, N.C. Lakeside is a small alternative high school with a fluctuating population of about 235 students.
The Wellness Center, run by Wilmington Health Access for Teens (WHAT), has been open since 1999 and sees around 20 students a day, says Peterson.
New Hanover County Schools and WHAT opened a second clinic at the 1,700-student New Hanover High School in October, with a three-year $395,000 grant from the Duke Endowment.
In the first two weeks, that clinic saw more than 60 different students, says WHAT Executive Director Connie Parker.
It took three years to get the new clinic started because the school board was initially opposed to it, but new board members were elected who favor the clinic, Parker says.
"It doesn't matter how good the school is, if the child is sick or hungry or hurting in some way, they will not be able to learn," she says.
The health care professionals on the WHAT staff have been specifically trained in adolescent health. They include a physician, medical director, nurse practitioners, mental health counselors, registered nurses, a health educator, nutritionist, and additional support from staff of the partner agencies.
The clinic is just for adolescents; adults and young children won't be treated.
But anyone age 11 to 22, whether they attend New Hanover High or not, can come in with parent permission for acute illnesses; immunizations; sports physicals; vision, hearing, and dental screenings; mental health counseling; and nutrition services. Fees are based on a sliding scale, but no one is turned away.
WHAT, a private, non-profit organization, grew out of the need to help the adolescent population with input from the school system, health department, local hospital, and community, says Parker.
Limited funding
"We would love to have more" clinics in the district, she says, but funding is limited. "The schools contribute the space, but all the money to run the clinics comes from grants, contributions, and a small amount, maybe a quarter of the operating cost, comes from patient revenue."
School-based clinics in New Mexico got a boost when state Medicaid officials received federal approval in September to use Medicaid funds to match administrative dollars schools spend on health care. That should bring in about $3 million, says Carolyn Ingram, director of the state's Medicaid program.
The New Mexico Department of Health currently funds 35 of the 43 or so school-based health clinics in the state with an annual budget of $490,000, says Jane McGrath, the state public school health officer.
New Mexico Gov. Bill Richardson wants to double the number of school-based clinics within a year to address such teenage health problems as suicide and obesity.
McGrath, who advised Richardson that the current school-based clinics are running on a "starvation diet," estimates that school clinics in New Mexico need $150,000 to $200,000 a year to operate full time, while the state Health Department provides just $10,000 to $40,000.
In Syracuse, N.Y., the school district has received approval to open two new clinics, at a high school and an elementary school, but did not receive the necessary funding, says Cheryl Vitaletti, the district's supervisor of student heath services.
The 23,000-student district has been running three clinics -- at Dr. King and Dr. Weeks elementary schools and Shea Middle School -- for about 10 years, the last three years in partnership with the Syracuse Community Health Center.
The budget for the three clinics is just over $1.5 million, she says. "No parent is ever charged a co-pay or any fee. We bill Medicaid when students don't have insurance. Our main goal is to get every child on some form of insurance."
Limited funding is the biggest barrier to providing the best care, she says. "Also, we get some people who don't buy into it because they think they should be going to their own doctors. But what works for us is that most of the kids already attend Syracuse Community Health Center so it's a really good marriage in a sense."
Fewer absences
Vitaletti says clinics on school sites provide a tremendous benefit to students, parents, and schools. "The kids can be seen right at school so they don't have to miss school. The kids' test scores reflect the conditions they live in. . . . Most of the children live in poverty, and their families have many challenges. Many have mental health and dental problems."
There's a national and local shortage of dentists, and on-site clinics come in handy because students don't have to miss so much school when they have toothaches, Vitaletti says. "We don't provide vision care; we just give referrals. But, boy, would we love to be able to do that on site."
"Out goal is really to support the academic mission of the school district. We want to reduce every possible barrier we can to learning," she says. "We do that in health services by making sure children are not out of class for long periods of time. We're intervening early, and if a child has been screened and needs to be referred out, we do it quickly and efficiently."