Collaborating to Expand Access to Integrated Care Using School

Based Health CentersFrancie Wolgin, MSN,RN, Senior Program Officer

Health Foundation of Greater CincinnatiKathleen Bain, MD, Pediatrician, City Of

Cincinnati Primary CareCollaborative Family Healthcare Association 14th Annual Conference

October 4-6, 2012 Austin, Texas U.S.A.

Session #C5bOctober 6 ,2012

Faculty DisclosureWe have not had any relevant financial relationships

during the past 12 months.

Objectives• Determine the need and build a case for

support for a sustainable integrated care service model for inner city school children

• Consider how a collaborative approach could acquire a broader base of funding and support to provide start-up and implementation funding

• Integrate data and develop a map to help identify and predict the most sustainable choices or business opportunities

Background History of Health in Cincinnati Public Schools(CPS)

• Cincinnati Health Department (CHD) began providing school nurses to CPS in the early 1980’s Began in high poverty schools Quickly grew to include CHD nurse in all elementary schools

• Health problems undermine academic success 30% struggle with chronic health issues Free/Reduced lunch qualification for 74% of CPS children Students have attention, behavioral issues related to dental

decay and pain • Health Foundation funded four CPS SBHCs early 2000’s• Funding partnership between City and CPS

December 2010 Funding Crisis

• During budget crisis City Council abruptly eliminated City portion of funding for school nurses

• Decision was not based on program performance

School Based Health Centers inCincinnati Public Schools

–Ten years ago four centers opened* –Today, 10 school based health centers

(SBHCs) operate in Cincinnati Public Schools

– 6-9 more will be added this fall/Jan 2013–Number of students currently served:

>6000 students eligible at 10 sites

*Health partners were Neighborhood Health Care & Cincinnati Children’s Hospital

Community Response Beginning in January 2011 community and civic leaders stood up in partnership to advocate and maintain school health services

• Parents• Teachers• Students• Nurses

• Foundations• Churches• Civic organizations,

United Way• Hospitals and others

Response• Health Foundation of Greater Cincinnati

provided leadership and immediate financial resources to: • Continue uninterrupted school health services• Lead a planning effort to:

• Enhance school health services• Develop a sustainable long term model to ensure

health and academic success of Cincinnati children

Steering Committee Membership

Health Foundation Board of Education Board of HealthCHDCPS Growing Well Cincinnati Cincinnati Children’s Hospital Medical Center

Community Learning Center InstituteChildren’s Home of CincinnatiMindPeace United Way Deaconess FoundationGreater Cincinnati FoundationOyler School

Growing WellPhysical Health Partnership Network

1. Independent organization builds capacity and facilitates system of school based health services including school based health centers, dental and vision care, wellness and prevention.

2. Federally qualified health centers, City Health Department, 2 hospitals and Health Foundation are part of Growing Well and partnering to create a districtwide system of school based health centers – grew from 4 in 2005 to 20 projected by 2013.

MindPeaceMental Health Partnership Network

1. Independent organization builds capacity and facilitates system of school based mental health services including therapists located full-time at the community learning center and self-supporting through 3rd party billing. Includes psychiatric care and medication supervision.

2. Children’s Hospital Psychiatric Dept, 8 community mental health agencies are part of MindPeace network.

3. 49 of 54 CPS schools have full-time mental health team on-site.

The Goals of the Planning Collaborative

1. Assess and identify needs of CPS students2. Determine which schools had sufficient

services and those with gaps3. Determine sustainable financial model 4. Attract other funders to participate in the

planning and start-up of new SBHC 5. Develop sustainable financial models for

FQHC and hospital medical partners to use in their planning and staffing

Assessment

• Used CHD Data from school nurses and Growing Well

• Identified high numbers chronic conditions• SBHC were the only sustainable choice• Most cost-effective models located in schools

with Community Learning Center, >600 Children/teens with at least 75% enrolled FDL/Medicaid eligible

School Year 2008-09 2009-10 2010-11 YTD 2011-12

Census of schools served (41/57) 22217 22563 22067 32095

Health Records on File NA NA 14967 19238

Asthma 2659 2844 2890 4169

Diabetes (Insulin requiring) 35 45 52 87

Sickle Cell 56 57 55 73

Seizures 140 184 176 298

Severe Allergies Food/ Insect 286 618 630 984

Dental Problems 2338 2117 2029 2148

All Behavioral (under represented) NA 422 786 1047

ADHD (under represented) NA 1107 1113 1630

Total All Selected Conditions 7452 8745 7731 10436

Health Data to Understand Student Barriers to Learning

School Year & Grade

#Under

Weight ≤5%

Normal Weight ≥80%

Overweight 10%

Obese 5%

2005-06K only 2820 138 (4.9%) 2106

(74.6%) 301 (10.7%) 275 (9.8%)

2006-07K only 2427 152 (6.3%) 1630

(67.2%) 337 (13.9%) 308 (12.7%)

2007-08 K Only 2521 147 (5.8%) 1501

(59.6%) 444 (17.6%) 429 (17.0%)

2008-09K Only 2709 174 (6.4%) 1643

(60.6%) 337 (13.9%) 308 (12.7%)

2011-12K, 3, 5, 9 11498 341 (3%) 7056

(61.4%)1836 (16%)

1968 (17.1%)

Obesity & Body Mass Index by School Year in CPS

Case for Support

• Medical Partners: FQHC or Look-a-likes; hospitals with aligned mission

• Case based on mutual goals and consent-best to obtain early in process

• Foundation or business partners pay for planning and start-up

• Target proposal to the specific funders needs• Leverage opportunities (Community, ACO,

HRSA, vendors)

Mercy Health Example

• Used HealthLandscape to prepare maps

• Met with leadership throughout process

• Referred to other hospital partners

• Provided Planning grant and will assist in implementation

The Future: School Based Health Centers

*National Assembly on School Based Health Care

School Based Health Centers:National Assembly on School Based Care

“Students perform better when they show up for class healthy and ready to learn. • SBHC ensure that kindergarteners through high schoolers can get a flu shot,

have an annual physical, have their teeth examined and their eyes checked, or speak to a mental health counselor in a safe, nurturing place – without the barriers that families too often face.

• SBHCs exist at the intersection of education and health and are the caulk that prevents children and adolescents from falling through the cracks.

• They provide care – primary health, mental health and counseling, family outreach, and chronic illness management – without concern for the student’s ability to pay and in a location that meets students where they are: at school.

• SBHCs may vary based on community need and resources.” *

Local School Decision Making Committees

– School governance• Approves budget, selects principal• Comprised of principal, parents, teachers, other staff,

community members, students in equal proportions

Community Learning Centers• Began as part of CPS facilities plan• Serve as hubs for community services

that promote academic excellence, recreational, health and cultural opportunities for students, communities

• Nationally recognized for engaging community partnerships in schools

Why Do We Need Community Learning Centers &

School Based Health Partnerships?

Parameters for Partnerships 1. Partnerships support the mission to educate all

students to meet/exceed the district’s defined academic standards.

2. District dollars must be devoted to education. 3. Partnerships in the school must be financially

self‑sustaining. 4. Partnerships co‑located in the school will be

integrated into the school’s operation and governance by working with the LSDMC toward the mission & goals of the school’s OnePlan.

What Happens at a Community Learning Center?

Extended learning opportunities afterschool Family engagement & support Health & mental health services Dental services Wellness services Social, civic and cultural programming Adult education classes Early childhood development Community connectedness

1. Increase in Children living in Poverty 1970: 80% of children in CPS above poverty line

2011: 70% of children in CPS at or below poverty line

48% of children in Cincinnati now live at or below the poverty line, up from 35% in 2005 and compared to 21% national average

Current rate of free/reduced lunch is 74.5% for CPS

Why Do We Need Community Learning Centers &

School Based Health Partnerships?

29

Why Do We Need Community Learning Centers &

School Based Health Partnerships?

2. More children are homeless 32% of the 25,000 homeless in Cincinnati are children, more

than double the number since 1986

The average age of a homeless child in Cincinnati is 9

1/3 of all homeless children are 0-4 years old

30

3. Lack of adequate medical care for children In 2005, 22% of all children in Cincinnati had no medical home.

Rate of immunizations for children in CPS schools without health services was 77% in 2006.

Children’s Hospital’s psychiatric emergency room was seeing more children – 3500 per year – than any other Children’s Hospital in the country.

Why Do We Need Community Learning Centers &

School Based Health Partnerships?

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4. Poor health, together with poverty and homelessness, create significant barriers to learning Attendance in 2002 averaged 90.8% for CPS districtwide, below

the 93% benchmark.

Just before the launch of community learning centers, CPS students scored below proficiency in all grades in all subjects.

Why Do We Need Community Learning Centers &

School Based Health Partnerships?

Health Outcomes of Community Learning Center Health Partnerships

1. 95% immunization compliance prek-12 in 2012 (15-22% increase from starting point of CLCs)

2. 12,000+ children screened for dental in 2010 / 2200 referred for follow-up and 91% referrals successfully completed (0 students screened prior to CLCs)

3. Asthma management protocol instituted for almost 3000 students district wide (no district-wide tracking prior to CLCs)

Outcomes for CPS Community Learning Centers

1. Attendance 95.8% in 2010-11 (compare to 90.8% in 2002)

2. Graduation rate rose from 51% in 2000 to 80% in 2011.

3. Performance index 87.3 in 2010-11 – Composite score of gains on all state tests at all grade levels(compare to 53.2% in 2001)

Achievement

SBHC Benefits• Improves school/student success

• Access to care where students spend most of their day

• Reduces absenteeism and parent lost work time

• Treatment of chronic health conditions with ability to monitor health regularly

• Access to needed medications

• Reimbursement for services creates a sustainable model

• Reduces Medicaid costs and establishes access to care

• Important part of Health Safety Net, improving access to needed health care for disadvantaged children2

• Possible only through partnerships with local businesses, community, hospitals and government

• Integrates work of the school nurse

2Source: Access and Utilization Patterns of School-Based Health Centers at Urban and Rural Elementary and Middle Schools; Wade, et al; Public Health Reports / November–December 2008 / Volume 123

SBHC Benefits

1Source: Guo JJ, Wade TJ, Pan W, Keller KN. (2010). School-Based Health Centers: cost-benefit analysis and healthcare disparity. J Am Pub Health Assoc., 100(5), 1617-1623.

Medicaid Savings: A Cost-Benefit Analysis

SBHCs Cost–Benefit Analysis and Impact on Health Care Disparities1 • Compared 5056 students at schools with & without SBHCs• Medicaid is primary payer for students in those schools

• Increased costs at the outset – increased dental and mental health utilization

• Offset by larger decreases in hospitalization (esp. for students with asthma), and pharmaceutical costs

• Conclusions• SBHCs can save Medicaid $35.20 per student, per year• SBHCs reduced the barriers to access to care

Support for SBHCs in Cincinnati

– Start Up: The Health Foundation of Greater Cincinnati grants

– Private sector support

- Sustainability: Federally Qualified Health Center (Look Alike or 330) sites provide cost-based reimbursementPrivate insurance reimbursement / private paySupplemented by fundraising

2011-2012 CPS School Based Health Centers (SBHC)

& Medical PartnersCurrent Schools Medical Partner & Type

1 Academy of World Languages (AWL) Cincinnati Health Department2 Bond Hill Academy WinMed3 Hughes High School Neighborhood Health Care4 Oyler School Cincinnati Health Department5 Rockdale Academy Neighborhood Health Care6 South Avondale School Neighborhood Health Care7 William H. Taft Elementary School Neighborhood Health Care8 Winton Hills Academy WinMed9 Withrow University & International High

School Cincinnati Health Department10 Woodward Career Technical High School WinMed

2012-2013 CPSNew School Based Health Centers (SBHC)

& Medical PartnersNew School Sites Medical Partner

11 Western Hills and Dater High Schools Cincinnati Health Department12 Aiken High School Cincinnati Health Department13 Roll Hill Academy Cincinnati Health Department14 Ethel Taylor Academy Cincinnati Health Department15 Roberts Academy Cincinnati Health Department16 John P. Parker School Neighborhood Health Care17 Pleasant Ridge Montessori Neighborhood Health Care18 Mt. Washington School Mercy Health Partners19 Pleasant Hill Academy Mercy Health Partners20 Silverton Paideia Academy Mercy Health Partners

Community Investment• Health Foundation investment • Dental treatment (CincySmiles, CHD, CHC)• Capital federal grant of $500,000 (Withrow & Oyler)• OneSight Vision Center at Oyler

– OneSight investment– Cincinnati Eye Institute– Cincinnati Woman’s Club

• Ongoing investment by Health Providers annual average of $150,000:– CHD– Neighborhood Health Care– WinMed

• New investments – Mercy Health Partners– Deaconess Foundation

An Example: Oyler Community Learning Center in 2008

• Academics: Academic Emergency• Health Needs assessment

• Fewer than 10% of Oyler students received recommended care• 51% of students needed dental treatment• 25% not current with their immunizations• 22% with an identified chronic illness such as asthma, diabetes• Health care often delayed until only option was the Emergency

Room

• Attendance improved within one year from 88.9% to 92%• Serving over 70% of 700 students in SBHC each year• Dental: New program for 246 Students/367 visits to nearby

dentist in health department center• New this fall: Vision Center as a partnership with OneSight

Foundation, Cincinnati Eye Institute & Ohio Optometric Association to provide Comprehensive Vision Care to all CPS students and beyond

Oyler SBHC Improvements 2009-2012

Questions & Conversation

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Ohio Department of Education Performance Index

(0-120 points)

Cleveland Metropolitan

Columbus City

Cincinnati Public Schools

Achievement• In 2010, Cincinnati Public

Schools became the first and only major urban district to earn an Effective rating on the Ohio Report Card, repeated in 2011

• Ranked in top 2 percent in state in learning growth through Value-Added measure

• Increased graduation rate from 51 percent to 82 percent between 2000 and 2010