The Role of School-Based Health Centers - Filling the Gaps in Local Healthcare

The St. Mary's County Health Department (SMCHD) is the local health department for St. Mary's County, Maryland. SMCHD's Vision is to promote healthy choices, opportunities and environments for all who live, work and play in St. Mary's County. 

SMCHD serves a population of 114,468 according to the U.S Census Bureau. 

St. Mary's has been described as historically rural”, but has experienced a 31.7% increase in population since 2000. The demographics of the population are 77.5% White, 15.2% Black or African American, 5.7% Hispanic or Latino, 3.0% Asian, 0.5% American Indian, 0.1% Pacific Islander and 3.7% Two or More Races. The median household income in the county is $95,864. 5% of people within the county 65 or younger do not have health insurance and 3.6% of children are uninsured. 

SMCHD's primary goal with this practice was to establish two School Based Health Centers (SBHCs) which deliver high quality medical care to the students and staff of St Mary's County Public Schools. The public health issue that this practice was designed to engage with is improving access to somatic and behavioral health care in two Health Professional Shortage Areas, (HPSA). 

Spring Ridge Middle School (SRMS) is located in a HPSA for behavioral health and primary care while Margaret Brent Middle School (MBMS) is located in a HPSA for behavioral health care. This designation suggests students and staff have limited access to immunizations, chronic disease management, mental health services, and other primary care services. These barriers to care impact their attendance at school and outcomes for academic achievement. 

The objectives of these two SBHCs are to increase access to care, decrease barriers to care, and improve student health and wellness. This will be measured by the number of SBHC appointments, patient evaluations, and improved academic outcomes. In addition, although the SBHCs are currently only at two locations, they are open to any teacher or student enrolled in St. Mary's County Public Schools and no student will be denied services for inability to pay. 

Activities and dates:

1. SMCHD wrote and was awarded a Maryland Community Health Resources Commission (CHRC) grant for $650,000 to operationalize two new SBHC with the goal of promoting health equity and health care access (2020, awarded 2021) 

2. Building the SBHC sites on each campus. (2021)

3. Expanding relationships between SMCPS and SMCHD. Building trust with school leadership and health services to establish SBHCs, gain their buy-in to assist with marketing and community awareness and SBHC utilization. (2021 and ongoing) 

4. Policy and procedure writing (2021) 

5. Recruiting and hiring for SBHCs (2021,22) 

6. EHR build out, training (2021,22) 

7. Payer enrollment, credentialing billing training for team (2022) 

8. Training of staff on SBHC services both technical and processes (2021,22) 

9. SBHCs opened in 2021, while schools were still doing virtual classes, to provide COVID-19 testing and vaccine access for the local community. During this time, SBHCs were also used for school required immunization clinics.

10. SBHCs opened fully for students and staff in August 2022.

Results and outcomes:

The largest public health impact of the SBHC's is that now two thousand students plus hundreds of staff have access to primary care and mental health services during the school day. This exponentially increases, after school hours, when we are able to provide services for any student or staff member of SMCPS. St. Mary's county has a 3.6% child uninsured rate which is higher than the average child uninsured rate in Maryland. In the 2019-20 school year SMCPS reported that 51 students were uninsured along with 49 others that were referred for insurance. The SBHCs provide services regardless of one's ability to pay. There is a sliding scale in place for those without insurance and payment plan options as well.

During the first three months of full operations, the SBHCs have completed over 183 visits as of 12/13, with the top visit types being sick visits, sports physicals and immunization appointments.  

There has been a significant improvement in vaccine compliance at these schools, with SRMS and MBMS historically starting the school year with 80% compliance, when this year, both schools achieved 100% compliance by October 2022 with support of SBHC services.

Due to the still ongoing COVID-19 pandemic, these sites have also been utilized for community testing and mass vaccination efforts. The SBHCs initially prioritized telehealth appointments to connect and provide services to the community during the Covid-19 pandemic but currently have on-site patient visits. Telehealth visits are still vital in providing the community safe access to primary care and mental health services

In regards to community partnership, the St Mary's County Sheriff's Department, St Mary's County Health Department and St. Mary's County Public Schools came together to formalize the St. Mary's County Equity Task. This task force came about as the importance for collaboration across all sectors to better address equity overall was realized. SMCHD is the fiscal agent and lead for the operation of the two new School Based Health Centers (SBHCs). This support from the Equity Task Force allows SBHCs access to resources and expertise of SMCPS and SMCSO to help clients reach their goals.

Additional community partnerships in this effort are with St. Mary's County Public Library who provides an onsite library for staff and students. Collaboration with University of Maryland Extension has provided nutritional education support. Collaboration with the Health Promotions team and Behavioral Health teams at SMCHD allow us to bring their programs to staff and students onsite at the SBHCs. These programs include Asthma Treatment program, Smoking Cessation, Suicide Prevention, Youth Mentoring and many others. SBHC teams continue to work closely with the SMCPS Health Services team to identify unmet health and socioeconomic needs of SMCPS students that can be addressed through the comprehensive resources offered at the SBHCs. Additional partnership and advocacy support has been received from the St Mary's Board of Education, St Mary's County Commissioners, and State legislature. 

SMCHD's primary goal was to establish two School Based Health Centers (SBHCs) which deliver high quality medical care to the students and staff of St Mary's County Public Schools. The goals of these two SBHCs is to increase access to care, decrease barriers to care, and improve student health and wellness with the goals of decreasing missed class time and improving overall health and school outcomes.

St. Mary's county has a 3.6% child uninsured rate which is higher than the average child uninsured rate in Maryland. In the 2019-20 school year SMCPS reported that 51 students were uninsured along with 49 others that were referred for insurance. Children that are uninsured, in addition to being located in a HPSA, are more vulnerable to negative health and academic outcomes.

The target population for this practice are the Mechanicsville and Lexington Park areas in St. Mary's County. SMCHD specifically selected these locations because they are both federally-designated Health Professional Shortage Areas (HPSA). Spring Ridge Middle School which is located in Lexington Park (20653) is a HPSA for both primary care and mental health services. The second site selected was Margaret Brent Middle School which is located in Mechanicsville (20659), a HPSA for mental health services. 

Lexington Park (as well as the subpopulations located in Great Mills and Park Hall) have a geographic designation as a primary care and behavioral health HPSA, which indicates a provider ratio of less than 1 per 3,500 residents. Lexington Park has one of the highest poverty rates in the county (13.4%) and is almost two times higher than that of the county poverty rate, which is 7.8%.The median household income in Lexington Park is $74,598, which is much lower than the county's median of $95,864. The number of uninsured residents is also higher than the Maryland average, 8.0% to 5.0%. The lowest life expectancy in the county is also in the greater Lexington Park area. Lexington Park is home to the highest percentage of minority residents in St. Mary's County. 35.5% of Lexington Park identifies as Black in comparison to that of the county as whole, which is 15.4% Black.. 7.0% of Lexington Park residents identify as Hispanic in comparison to that of the county, which is only composed of 5.6% of people who identify as Hispanic. 5.0% of the Lexington Park community identified as Asian in comparison to that of the county, which is 2.9% Asian. 52.2% of residents identified as White in comparison to 77.5% of the county.

Mechanicsville has a geographic designation as a mental health services HPSA. Mechanicsville has a 1.1% poverty rate and a median household income of $99,041. 10.7% of people in Mechanicsville are without health insurance. 85.7% of Mechanicsville residents identified as white, 5.9% as Black, 3.5% Hispanic or Latino, .7% as Asian.

Looking at the demographic data, the root causes for students without access to primary care and mental health services is due to lack of access, evidenced by the two areas being federally designated HPSA, and also financial, for example higher than average rates of uninsured residents at each location. 

The School-Based Health Center Model is an evidence based practice endorsed by the Guide to Community Preventive Services, Healthy People 2030, and many other resources. SMCHD identified this model as a practice that the organization could adopt to alleviate certain health disparities. While SBHCs are not new to the field of public health, this practice is innovative by identifying a county-wide issue, St. Mary's County having a higher than the state average child uninsured rate, and pinpointing areas that had been disparately affected by social determinants of health so that the SBHCs could have the most impact.

Additionally, the SBHC staff work in tandem with the SMCPS employed school nurses at each site to develop a continuum of care that does not overlap or duplicate the school nurse's responsibilities. Because it is more typical for SBHCs to render their services through a local provider, the relationship between the SMCPS nurses and the SBHC run by a LHD provide a template for other county health departments to partner with their public schools.

Incorporating Health Equity principles was a main focus of this practice. This project was one of the first realizations of St. Mary's County Equity Task Force, a collaboration between ​​the St. Mary's County Sheriff's Office, St. Mary's County Public Schools, and the St. Mary's County Health Department to address inequitable outcomes in health, education, and public safety. During the planning, social determinants of health such as financial stability, access/quality of healthcare, and education access/quality were identified as areas where the SBHC's could alleviate inequality.

In the past SMCHD has provided clinical services at a sliding fee scale and referrals for uninsured patients through our Health Clinic. However the Health Clinic was located in Leonardtown, a ways away from Mechanicsville and Lexington Park for community members who lacked transportation. The SBHC's appear to be a more effective model for reaching community members who would be likely to use SMCHD's health clinic, but have difficulty getting to the office in Leonardtown during the operating hours.

The SBHC model addresses health inequities by meeting people where they are and  significantly cutting down on barriers to care. Students enrolled in the SBHC now have access to quality care for improved chronic disease management, infectious disease prevention, health maintenance, and behavioral health that can be billed to insurance or billed per a sliding fee scale that accounts for a variety of factors. 

Since the main goal of the SBHCs is supporting students without access to immunizations, chronic disease management, primary care services, and mental health services the following public health areas were selected as the SBHCs primary focus: 

1.  Primary medical care

2. Behavioral health care (mental health and substance use counseling)

3. Health education and promotion

4. Case management

5. Nutrition education

Using data provided by St. Mary's County Public Schools (SMCPS), SMCHD and SMCPS were able to collaborate to identify three objectives for improving student health within the SBHCs primary focus. They identified vaccinations, student physicals, and asthma maintenance as areas where the SBHCs could make an immediate impact on the target population. 

For the 2019-20 school year SMCPS reported a 99% rate of vaccination compliance for their total population with 165 outstanding non-compliant. Out of the 165 unvaccinated students, 53 are from Spring Ridge and 23 are from Margaret Brent, 46% of the outstanding non-compliant students. By having mandatory vaccinations available at the school-sites with the highest non-compliance rates, the SBHC will reduce the burden for families who may have trouble accessing the doctor's office as well as decreasing the risk for outbreaks within the community. 

For the 2018-19 school year SMCPS reported 3,087 new students, 14% of which were without physicals. 49 students without physicals said they could not obtain a physical due to no access to care along with 38 due to financial reasons. For the 2019-20 school year SMCPS reported 2,909 new students, 18% of which were without physicals. 53 students without physicals said they could not obtain a physical due to lack of access to care alone.

For the 2019-20 school year SMCPS reported that 2,341 students in their system had been diagnosed with asthma. 551 of those students were in middle school with 144 from Spring Ridge and 157 from Margaret Brent. By targeting asthma maintenance 55% of middle school students in St. Mary's County with asthma and 13% of the overall student population with asthma would have access to care through the SBHC's.

Additionally, it was important to SMCHD that the SBHC goals support and align with SMCHDs Healthy St. Mary's Partnership (HSMP) goals and objectives. HSMP serves as a focal point for local health improvement for St. Mary's County. Through coalition procedure and operation, the HSMP addresses priority health areas identified by the most current cycle of the community health improvement process. Priority health areas are identified by coalition members through a collaborative community health needs assessment process that receives input from residents and partners, involves evaluation of quantitative public health data, and statewide health improvement priorities. Currently the priority health issues are Behavioral Health, Chronic Disease Prevention, Environmental Health, and Violence, Injury, and Trauma.

While SMCHD is the fiscal agent and lead for the operation at the SBHCs, the St. Mary's County Equity Task Force which includes St. Mary's County Public Schools (SMCPS) and St. Mary's County Sheriff's Office (SMCSO) helped build and operationalize the two new SBHC facilities. Additionally SMCPS and SMCSO lead other initiatives that have proved helpful in partnership with SMCHD and the SBHCs.

SMCPS health equity initiatives include coordinating a School Health Council, ensuring behavioral health services in each middle and high school, social-emotional learning curriculum, a FLOW mentoring program, DARE curriculum, as well as several education efforts for substance use prevention. 

The project's partnership with SMCPS has been important in engaging stakeholder buy-in. By December of 2020 the SBHC sites launched with certain COVID-19 services targeting students and their families. Due to SMCPS promoting SBHC services targeting pandemic response, and a quick launch time of services, community stakeholders have a broadened awareness of the new SBHCs and their services.

SMCSO has also implemented several initiatives with an impact on Health Equity. SMCSO established a Youth Gun Violence Task Force to explore and address factors affecting this issue, uses Predictive Policing software to better prevent violent crime, and continues to develop initiatives to address diversion from incarceration for those with underlying substance misuse - including a pretrial services program, Law Enforcement Assisted Diversion program, and Day Reporting Services Contributions. 

Additional advocacy support was received from the St Mary's Board of Education, St Mary's County Commissioners, and State Legislatures. 

Start up costs/Funding streams:

Estimates say about $500k of CARES Act funding was used for each of the SBHC sites. 

$650k from Community Health Resource Commission (CHRC) for start up staffing/build-out of the practice 

$108k from Maryland Department of Health 

SBHC's success has resulted in thousands of students and community members having access to primary care and mental health services which had previously been unavailable. Future plans for the SBHCs include additional primary care services for example, a more robust asthma maintenance program, nutritional counseling, and other mandatory school vaccinations. These services will be key to further improving health outcomes for students who face barriers accessing health care.

Since opening fully in August 2022 the SBHCs have completed over 183 visits as of December 13, with the top visit types being sick visits, sports physicals, and immunization appointments. SMCHD has seen a significant improvement in vaccine compliance at the SBHC schools with both achieving 100% compliance in October 2022 with support of SBHC services.

We hope to see improvements in the Maryland State Department of Education (MSDE)  report cards for each school site (tracks academic progress, achievement, language proficiency) but these report cards are not being updated at this time due to COVID-19 impacts. To evaluate whether the expected outcomes have been met, the project's goal is to increase both the middle schools MSDE report cards 5 points each by the end of CHRC funding. 

Other future evaluation methods include: 

1. Complete Self-Assessment for new SBHCs: Completed self-assessment will determine what services, programs, or supplies still need to be addressed outside of initial services and critical for expansion. 

2. Develop intake and outtake assessments for patients visiting the SBHC. SBHC staff and school nurses will work collaboratively to continuously improve the SBHC visit process. 

3. In the summer of each year SBHC staff and SMCPS nurses meet to go over data collected by SBHC and assess how objectives are progressing. The assessment will determine how the SBHC can improve and adjust objectives and identify successes. 

From the evaluation SMCHD has been able to do, three key findings were identified as ways to improve the practice: 1. Leverage partners' influence in the target population and community to notify stakeholders about enrollment and other opportunities through the SBHC. 

2. Prepare centers for infectious disease outbreaks and vaccine clinics.

3. Promote the use of Telehealth visits which will further increase access to services for those in rural areas

SMCHD is confident about the sustainability of the SBHCs, both for financial sustainability as well as stakeholder commitment and community buy-in. SMCHD SBHCs share the following three common sustainable characteristics for SBHCs as outlined by National Alliance for School Based Health Centers:

1. Develop and nurture Strong Partnerships with school and community stakeholders committed to SBHCs.

2. Create a Sound Business Model that relies on a variety of stable and predictable funding sources.

3. Operate health care practices that meet the comprehensive needs of students and student families to demonstrate a High Quality Practice.

Collaboration is essential to the model's long-term success. During the SBHCs development, SMCHD coordinated and collaborated with school administration, teachers, school nurses, and counselors during integration into the school. In turn SMCHD hopes for the SBHCs to become a positive contributing factor to the school environment. This could be seen in improved attendance, better management of chronic conditions, and for behavioral conditions to get quick expert attention. We want students and their families to have a positive experience so that they become SBHC advocates. Stakeholder buy-in will play a critical role in sustainability.  SMCHD will also continue looking for partnership with community-based health care providers and organizations. This collaboration will be vital for building out services and could lead to in-kind contributions of staff or resources, trainee internships, patient information cross sharing, referrals and linkage agreements for specialty care, and marketing/promotion of the SBHC. While SBHCs have historically relied on supplemental funding for sustainability, SMCHD has partnered with RS&F Consulting to complete our payer contracting and credentialing. This will ensure our program is set up to be able to bill insurance companies for services provided. SMCHD is also conducting an internal audit of our revenue cycle processes, to ensure we are maximizing opportunities to collect payment for all billable services. Oversight of SBHCs in Maryland has recently transitioned from MSDE to MDH. One of MDH's primary goals is to ensure long term sustainability of SBHCs by leveraging Medicaid billing as well as strategic disbursement of an annual budget of $9 million to SBHCs in Maryland. This supplemental funding can be used to fill gaps in funding and support infrastructure updates and opening of new SBHCs. SMCHD SBHC team has developed a marketing plan to increase awareness of and enrollment in SBHCs. This includes getting info to parents through a variety of channels including: SMCPS social media, email blasts, routine email communications, attendance and info sharing at SMCPS events, partnerships with SMCPS school health services teams, open houses, and group educational offerings. In addition, other potential sources of funding may come from the local county government. As the benefits of SBHCs are realized by our community, funding may also come from local sources.