Collaborating to Expand Access to Integrated Care Using School Based Health Centers Francie Wolgin, MSN,RN, Senior Program Officer Health Foundation of

Collaborating to Expand Access to Integrated Care Using School Based Health Centers Francie Wolgin, MSN,RN, Senior Program Officer Health Foundation of Greater Cincinnati Kathleen Bain, MD, Pediatrician, City Of Cincinnati Primary Care Collaborative Family Healthcare Association 14 th Annual Conference October 4-6, 2012 Austin, Texas U.S.A. Session #C5b October 6,2012

Faculty Disclosure We 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 1980s 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 2000s 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 in Cincinnati 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 Childrens 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 Health CHD CPS Growing Well Cincinnati Cincinnati Childrens Hospital Medical Center Community Learning Center Institute Childrens Home of Cincinnati MindPeace United Way Deaconess Foundation Greater Cincinnati Foundation Oyler School

Growing Well Physical 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.

MindPeace Mental 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.Childrens 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 students 2.Determine which schools had sufficient services and those with gaps 3.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 Year2008-092009-102010-11 YTD2011-12 Census of schools served (41/57)22217225632206732095 Health Records on FileNA 1496719238 Asthma2659284428904169 Diabetes (Insulin requiring)35455287 Sickle Cell56575573 Seizures140184176298 Severe Allergies Food/ Insect286618630984 Dental Problems2338211720292148 All Behavioral (under represented) NA 4227861047 ADHD (under represented) NA 110711131630 Total All Selected Conditions74528745773110436 Health Data to Understand Student Barriers to Learning

School Year & Grade # Under Weight 5% Normal Weight 80% Overweight 10% Obese 5% 2005-06 K only 2820138 (4.9%) 2106 (74.6%) 301 (10.7%) 275 (9.8%) 2006-07 K only 2427152 (6.3%) 1630 (67.2%) 337 (13.9%) 308 (12.7%) 2007-08 K Only 2521147 (5.8%) 1501 (59.6%) 444 (17.6%) 429 (17.0%) 2008-09 K Only 2709174 (6.4%) 1643 (60.6%) 337 (13.9%) 308 (12.7%) 2011-12 K, 3, 5, 911498341 (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 students 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 districts 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 schools operation and governance by working with the LSDMC toward the mission & goals of the schools 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. Childrens Hospitals psychiatric emergency room was seeing more children 3500 per year than any other Childrens Hospital in the country. Why Do We Need Community Learning Centers & School Based Health Partnerships ?

31 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 children 2 Possible only through partnerships with local businesses, community, hospitals and government Integrates work of the school nurse 2 Source: Access and Utilization Patterns of School-Based Health Centers at Urban and Rural Elementary and Middle Schools; Wade, et al; Public Health Reports / NovemberDecember 2008 / Volume 123 SBHC Benefits

1 Source: 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 CostBenefit Analysis and Impact on Health Care Disparities 1 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 reimbursement Private insurance reimbursement / private pay Supplemented by fundraising

2011-2012 CPS School Based Health Centers (SBHC) & Medical Partners Current SchoolsMedical Partner & Type 1 Academy of World Languages (AWL)Cincinnati Health Department 2 Bond Hill AcademyWinMed 3 Hughes High SchoolNeighborhood Health Care 4 Oyler SchoolCincinnati Health Department 5 Rockdale AcademyNeighborhood Health Care 6 South Avondale SchoolNeighborhood Health Care 7 William H. Taft Elementary SchoolNeighborhood Health Care 8 Winton Hills AcademyWinMed 9 Withrow University & International High School Cincinnati Health Department 10 Woodward Career Technical High SchoolWinMed

2012-2013 CPS New School Based Health Centers (SBHC) & Medical Partners New School SitesMedical Partner 11 Western Hills and Dater High SchoolsCincinnati Health Department 12 Aiken High School Cincinnati Health Department 13 Roll Hill Academy Cincinnati Health Department 14 Ethel Taylor Academy Cincinnati Health Department 15 Roberts Academy Cincinnati Health Department 16 John P. Parker School Neighborhood Health Care 17 Pleasant Ridge Montessori Neighborhood Health Care 18 Mt. Washington School Mercy Health Partners 19 Pleasant Hill Academy Mercy Health Partners 20 Silverton Paideia AcademyMercy 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 Womans 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 the evaluation 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

Documents

Collaborating to Expand Access to Integrated Care Using School Based Health Centers Francie Wolgin, MSN,RN, Senior Program Officer Health Foundation of