School clinics are in session

NEW YORK CITY—Every week, Ishtar Gonzalez and her fellow social workers provide mental health services for the 25 to 30 students who walk into their clinic in a high school building in the Bronx, the city's poorest borough. Virtually all are recent immigrants or come from low-income families.

During 45-minute sessions in a clinic next to the Christopher Columbus Educational Campus' auditorium, the mental health professionals help teenagers cope with anxiety, depression, immigration issues or trauma endured at home or in daily life. It's one of many services the Montefiore Medical Center-sponsored clinic provides for approximately half of the 2,400 students who spend their school days in a blocklong, five-story brick building.

Montefiore's school-based health center is one of 23 such clinics it sponsors across the borough to provide students with primary, mental health, reproductive and dental care without leaving school. It's part of the system's commitment to improving the overall health of the area's mostly immigrant population, many of whom do not have a regular doctor, much less access to specialized services. The system started the program in 1983 with three elementary school clinics.

“Kids tend to fall through the cracks,” Gonzalez said. “The beauty of being at a school is you can connect with them here and with their families.”

According to New York City's Health and Mental Hygiene Department, there are nearly 150 school-based health clinics in the five boroughs. Approximately half of the students who use the centers are on Medicaid, which provides a good chunk of their funding.

School-based health centers have been opening across the country as a new method to provide healthcare to vulnerable populations. In 2014, there were 2,315 school-based health centers across the country, marking a 20% increase since 2011 according to the School-Based Health Alliance, an advocacy group based in Washington, D.C. The clinics are especially prevalent in rural and low-income areas. According to a 2014 census by the alliance, 76.5% of school-based health centers are located in schools where more than half the students are eligible for free or reduced-price lunches.

Click on the map below to see which hospitals are running school clinics in New York City's boroughs.

While most school-based health centers provide primary-care and mental health services, some are now adding vision screenings and dental services. And 1 in 5 of the centers provided oral health screenings, according to the alliance's 2014 census; studies have shown untreated dental disease can lead to chronic health issues, as well as mental health and social development issues.

“We see the field pushing and growing toward more (centers) providing more comprehensive services,” said Kara Ann McRae, who until August was associate director of research and evaluation at the alliance. “But there's great variability in the resources available.”

The centers often provide medical services that students wouldn't receive otherwise, regardless of their insurance status. That issue is especially noticeable in the mental health field, according to Dr. Roger Platt, director of school health for New York City's Health and Mental Hygiene Department.

Parents are reticent to take their children for mental health counseling when they are having serious problems. “There seems to be much less resistance to having a mental health professional working in a school-based health center,” he said.

School-based health centers started popping up across the country in the late 1970s as adolescent centers in high schools. Providers quickly saw a need for additional services, such as preventing sexually transmitted diseases, conducting sports physicals and promoting healthy living.

“The school-based health centers were really a public health mandate by the states as a mechanism for engaging adolescents in care,” said Dr. Linda Carmine, head of the school-based health clinic program for Northwell Heath. “They're really also meant to be community supports.”

Northwell's predecessors—North Shore Health System and Long Island Jewish Medical Center—sponsored their first school-based health centers in Queens and Brooklyn in 1989. The New Hyde Park, N.Y.-based health system now runs six centers in Brooklyn, Staten Island and Queens.

Currently, there isn't a single model for school-based health centers or specific care they must provide. States that support the programs develop their own guidelines for what they can or must cover. Montefiore has gone further than some other school-based health center sponsors by providing dental care and cooking classes for students at its clinics.

“What you see at Montefiore is that whole comprehensive model where you provide all of the care at the school,” said Laura Brey, vice president for strategy and knowledge management at the School-Based Health Alliance. “Basically, you could be the medical home for a young person right at the school.”

When students receive health services while at school, they miss fewer classes and are more likely to graduate from high school. They can receive pain medication and antibiotics as well as diabetes and asthma maintenance during the day, according to Dr. Michele St. Louis, a primary-care physician at Montefiore's Columbus campus school center.

According to a study published in the Journal of School Health in August 2010, school-based health centers directly affect educational outcomes. Students with access to care at school are less likely to get sent home and miss school time.

Providing comprehensive services isn't cheap. While New York City may assist interested clinic sponsors with grant money for their capital investment, it's up to the health systems and foundations to fund the day-to-day operations.

In 1993, Montefiore and others lobbied Congress for Medicaid reimbursement equal to their outpatient rate for school-based health center services. That regulatory change beefed up payments from $20 to $93 per visit, which led Montefiore and other health systems to expand their programs, according to Dr. David Appel, director of Montefiore's school health department.

The program has mushroomed from five paid staff in 1993 to 180 full-time workers, and the health system plans to open another two to four new clinics in the next school year.

School-based health centers have also received support from the Affordable Care Act, though that has generated controversy. HHS established 200 grants totaling $100 million for school-based health center construction and renovation in fiscal 2011. House Republicans have tried to defund the program.

Even with Medicaid reimbursements, running a school-based health clinic can be difficult. Providers often have to outfit the space with equipment and staff the facilities with a physician, nurse practitioner, social worker and other health workers.

“Insurance covers about 75% of our budget,” Appel said. The system has renewable public grants on the city, state and federal level that cover the rest, he said.

When the program exceeds its budget—which Appel says happens some years—the health system picks up the difference. They have never once had to lay off staff. “The school-based health program aligns very well with Montefiore's mission of doing more in the community and seeing that everybody, and all children, have great access to all the services that Montefiore affords,” he said.

Montefiore tries to integrate school clinic services with its overall health system by using the same electronic health record system and referring students within the system for treatment they can't get in the school setting. “The idea is that we are looking to be part of an integrated healthcare system,” Appel said.

But some other providers may not have convenient and widespread ambulatory networks such as Montefiore's. At Northwell, their school-based health centers harness community resources to augment their care.

It's possible New York's move to fund managed care and value-based payments over the traditional fee-for-service model will hurt school-based health providers. New payment models could threaten current reimbursement rates and hurt the centers' bottom lines.

It's led to some health systems and foundations that are interested in sponsoring the centers to hold back from opening new facilities. “The whole system is in flux,” Platt from the city's health department said. “We'll have to see as the whole healthcare system evolves if more people get closer to the Montefiore population health model, which the state certainly is encouraging with the Medicaid redesign.”

Some sponsors are looking to partner with federally qualified health centers to open new school-based health clinics and take advantage of their guaranteed higher Medicaid reimbursements, Platt said.

While the state would like the clinics to start billing private insurance when students come from families with coverage, health privacy concerns have stymied that since some teenagers seek reproductive health services at school without their parents' knowledge. High school clinics have been a factor in lowering teen birth rates in New York.

Private insurers would send information about reproductive health visits to students' homes, according to Carmine. That could discourage teens from accessing birth control or STD tests.

At the Columbus campus in the Bronx, St. Louis says they're continuing to gain traction with kids and their families as more sign up to use the clinic's services and learn to trust the providers.

“The challenges are making sure people know who we are,” she says. “It requires continuing those conversations.”