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Issues
at a Glance
The
School-Linked Health Center: A Promising Model of Community-Based
Care for Adolescents
During the
last decade, a number of reports have documented the significant
health problems of American youth. In Code Blue: Uniting
for a Healthier Youth, the National Association of
State Boards of Education and the American Medical Association
reported that "never before has one generation of
American adolescents been less healthy, less cared for,
or less prepared for life than their parents were at the
same age."1
The Carnegie
Council on Adolescent Development also described the problem
in urgent terms: "In the 1990s, the state of adolescent
health in America reached crisis proportions: large numbers
of ten- to fifteen-year-olds suffer from
depression that may lead to suicide; they jeopardize their
future by abusing illegal drugs and alcohol, and by smoking;
they engage in premature, unprotected sexual activity;
they are victims or perpetrators of violence; they lack
proper nutrition and exercise. Their glaring need for health
services is largely ignored."2
Despite
these problems among adolescents, data indicate that teens
underutilize the health care system, largely because of
access barriers, including a lack of insurance coverage,
transportation problems, and a shortage of age-appropriate
services. The National Research Council reported: "Adolescents—and
especially adolescents who engage in high-risk behavior—have
no apparent home in the U.S. medical system.
They have relatively low visit rates in office-based practices,
and their problems are poorly represented in standard medical
data."3 The fragmentation
of the current system makes it especially difficult for
adolescents to access services for their diverse needs.
As a result, teenagers do not seek health care and their
problems often go undetected and untreated.
School-Based
and School-Linked Health Centers
In response
to this need for adolescent-oriented health services, a
number of communities have established school-based health
centers (SBHCs) and school-linked health centers (SLHCs).
The more than 1,000 SBHCs nationwide are popular as providers
of affordable, convenient, confidential, and comprehensive
services at the school. Although SBHCs are praised for
their delivery of comprehensive services, they often are
pressured to omit reproductive health care, mental health,
and substance abuse services because of community or state
opposition.
"Many
states prohibit the provision of contraception on school
sites. Even in states with no restrictions, most school
health centers do not provide comprehensive family planning
services to students."4 In
the past year, many states considered
or enacted more restrictive legislation, and many school
boards tightened policies regarding contraceptives.
For those
communities wanting to provide reproductive health care
and mental health service, the school-linked health center
model is a viable option. School-linked health centers
maintain the advantage of accessing school
populations, but are less restricted than school-based
health centers.
To date,
very little is known about SLHCs and their effectiveness.
In 1986, researchers demonstrated a 30 percent reduction
in teenage pregnancy within three years of implementing
a multi-modal teen pregnancy prevention program through
a nearby school-linked health center. Schools without SLHCs
showed a 58 percent increase in teenage pregnancy during
the same three years. The study further found that the
program helped delay sexual initiation for younger clients
by seven months and increased the use of contraceptives
among sexually active teens.5
To learn
more about the SLHC model, the Support Center for School-Based
and School-Linked Health Care at Advocates
for Youth conducted an informal study of 21 SLHCs. Descriptive
and statistical information from a written survey was followed
up with telephone interviews and site visits. Findings
indicate that although the history and design of each SLHC
is unique, there are a number of shared characteristics
that make this delivery vehicle an attractive option for
communities attempting to meet the health care needs of
their adolescents.
Age-Appropriate,
Comprehensive Care
SLHCs appeal
to young people because they respond to adolescent health
and development issues and the providers are experienced
in serving this population. Most SLHCs provide a wide array
of general medical services, counseling services, reproductive
health care, and social services designed for adolescents.
By offering comprehensive services, SLHCs can respond to
multiple problems at one time, and adolescents have one
central place to go for all needs. In addition to offering
a breadth of services, most SLHCs staff employ specific
procedures to facilitate and encourage adolescent use of
services, such as calling to remind them of appointments
and to conduct follow-up.
Linkage
with Schools
SLHCs' special
relationships with schools gives them a distinct advantage
over other community-based models of care. SLHCs reported
various types of formal and informal linkages with schools.
Regardless of the degree of interaction, the school provides
the health center with a natural audience for outreach
and education. The relationships with school staff facilitates
two-way referrals and consultations, improving overall
quality and continuity of care.
Ability
to Reach High-Risk Youth
School-linked
health centers typically reach beyond school populations
and serve dropouts, homeless youth, runaways, and youth
in detention centers, shelters, and other social service
programs. A significant strength of the SLHC model is that
it allows communities to reach those at high risk of unwanted
pregnancies, HIV infection, drug abuse, violence, and the
other morbidities.
Versatility
in Service Design
One distinct
advantage of school-linked over school-based health centers
is that they have more autonomy to decide their scope of
services. According to the Support Center's survey of SBHCs
in 1993, 74.4 percent of the responding centers reported
that provision of contraceptives was restricted. These
restrictions were by state policy (11.7 percent), school
district policy (81.4 percent), policies of sponsoring
agencies (20.7 percent), and by health center choice (17.9
percent).
For communities
attempting to prevent and reduce adolescent pregnancies
as well as HIV and other STD infections, providing reproductive
health care to teens is critical. SLHCs usually do not
face as many barriers, and they typically
operate with strong community support.
The SLHC model's ability to provide confidential, age-appropriate,
reproductive health services is one of its major strengths.
Ability
to Serve More than One School
One clear
benefit of the SLHC model is that it serves students from
more than one school. The programs are located on sites
convenient to a number of schools and neighborhoods. This
not only improves adolescents' access to services but is
less expensive than establishing a health center at each
school. When a SLHC serves both junior and senior high
schools, it can offer continuity of care throughout the
adolescent years.
Extensive
Hours
Unlike SBHCs,
whose schedules are determined by the school, SLHCs provide
services in the evenings, during school vacations, and
in the summer. A few SLHCs offer services on Saturday.
Extended hours are a distinct advantage for adolescents
who require scheduling flexibility.
Financing
Most SLHCs
charge a fee, even if minimal, for each service. Sliding
fee scales and innovative billing systems allows SLHCs
to recover some of their costs. Since they are community-based
health care providers with a history of communicating with
other providers and billing clients for services, SLHCs
are better positioned to negotiate with managed care plans.
SBHCs are not independent health centers, have limited
experience billing clients, and are less likely to meet
the stringent criteria imposed by the managed care plans
(e.g., hours of service, composition of staff, record/information
exchange, and billing procedures).
Potential
Disadvantages
Despite
the models many strengths, there are a few drawbacks to
consider. Although the SLHC serves multiple schools and
out-of-school youth, its location off school grounds can
be a barrier for some adolescents. Some teens do not have
the time or will not make the effort to get to a community-based
health center. Some cannot afford the cost of transportation.
Others are intimidated by the notion of going to a community
health center. For some, even the minimal cost of a visit
is prohibitive. Further, it is more difficult to follow-up
with clients at SLHCs than SBHCs where providers can access
students in the classrooms. As a result, utilization per
student is usually lower at SLHCs than at SBHCs. Finally,
rent and overhead add to the costs of running SLHCs.
Conclusion
For those
planning community health care programs or policies for
adolescents, SLHCs are a promising model for providing
affordable, age-appropriate, confidential, convenient services
to a traditionally hard-to-reach population. The SLHC's
ability to provide reproductive health care to adolescents
is a particularly significant strength of the model. Further
research is needed to determine the impact of SLHC programs,
the viability of negotiating with managed care organizations,
and methods to reduce barriers to accessing SLHC services.
Written by: Kate Fothergill, MPH, Director, and Beth Orlick,
Program Associate, Support Center for School-Based & School-Linked
Health Care, June 1997
References
- The
National Commission on the Role of the School and Community
in Improving Adolescent Health, National Association
of State Boards of Education, American Medical Association. Code
Blue: Uniting for Healthier Youth. Alexandria, VA:
National Association of State Boards of Education, 1990.
- Hechinger
F. Fateful Choices: Healthy Youth for the 21st Century. New
York: Carnegie Council on Adolescent Development,
1992.
- National
Research Council. Losing Generations: Adolescents in
High-Risk Settings. Washington, D.C: National
Academy Press, 1993.
- Dryfoos
J. Full Service Schools. San Francisco:
Jossey-Bass, 1994.
- Zabin
LS, Hirsch MB, Smith EAet al. Evaluation of
a pregnancy prevention program for urban teenagers. Fam
Plann Perspect 1986;18:119-126.
School-Linked
Health Centers: Facts From Advocates for Youth's 1995
Survey
- Roughly one-quarter of SLHCs have
clearly defined formal linkages with the schools
they serve in writing. More commonly, SLHCs and
schools have informal arrangements, either verbal
or implied.
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- On average, 68 percent of SLHC users are females.
Most SLHCs report serving a racial/ethnic population
that is representative of the community at large.
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- Almost all of the SLHCs surveyed offer routine
and sports physicals, give immunizations, prescribe
and dispense medications, and conduct their own lab
tests. Eighty-one percent provide primary care services.
One-quarter of the SLHCs surveyed provide pediatric
care for the children of their adolescent patients.
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- The estimated mean percentage of SLHC users who
are out of school is 15 percent. Eighty-one percent
of SLHCs surveyed reported providing services to
homeless youth. More than half provide care to pregnant
teenagers, and up to 30 percent of SLHCs see youth
who are in the social services system and detention
centers.
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- All SLHCs provide one or more type of reproductive
health service. All sites diagnose and treat sexually
transmitted diseases; 90 percent offer gynecological
exams, pregnancy testing, HIV testing, HIV/AIDS counseling,
and family planning follow-up; 91 percent dispense
one or more family planning method; and about 80
percent of the SLHCs surveyed supply birth control
pills, condoms, and Depo-Provera. Close to one-third
of the sample provides prenatal care.
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- The SLHC staff usually includes, at a minimum,
a director or administrator, a primary care provider,
and a registered, licensed, practical or public health
nurse. About 70 percent of the SLHCs employ at least
one or more health educators, and 50 percent employ
mental health counselors. Twenty-five percent or
fewer of the SLHCs have social service counselors,
substance abuse counselors, nutritionists or dentists
on staff. Peer counselors are used in 25 percent
of the SLHCs.
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- Eighty-six percent of centers surveyed provide
one or more counseling services, including substance
abuse, depression, suicide, violence prevention,
rage and anger, sexual abuse, and dysfunctional families.
Nearly one-fifth offer all types of counseling services.
Seventy-one percent of SLHCs surveyed provide one
or more social service.
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- All of the SLHCs have summer hours. SLHC staff
reported that their busiest hours are typically after
school, on Saturdays, and during the summer. Most
SLHCs require scheduled appointments, although all
but one accept walk-in appointments.
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- All but one of the SLHCs responding to the survey
require parental consent for the provision of general
medical services. Parental permission is most often
obtained via consent forms available at the SLHCs.
A few will accept verbal permission by telephone.
Most states have statutes that protect an adolescent's
right to confidentiality in seeking reproductive
health services; thus, the SLHCs surveyed do not
require parental consent for this type of care.
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- SLHCs are usually established in communities with
a clear need for additional youth services, and are
typically located near a community school to facilitate
access for students. About one-half of the SLHCs
deliver their services to youth within a ten-mile
radius of the SLHC. Over half of the health centers
in the survey are located in urban areas, but many
reach youth in outlying areas.
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- The average SLHC serves 5.9 high schools in their
community. While 71 percent reported serving students
from middle/junior high schools, only 9.5 percent
of SLHCs serve students from elementary schools.
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- While all of the SLHCs described adolescents as
their primary target audience, one-third reported
providing services to other age groups, including
young adults up to age 23.
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