DenverDenverDenver Denver SchoolSchool--Based Health Based Health Centers (SBHC)Centers (SBHC)Centers (SBHC)Centers (SBHC)

Dr. Steve Federico M.DDr. Steve Federico M.DDr. Steve Federico M.D Dr. Steve Federico M.D Kari Kari KukaKuka M.S. CHESM.S. CHES

IntegrationIntegration

DD

IntegrationIntegration

Denver Denver Health Health

Medical Medical CenterCenter

911911

Rocky Mtn Rocky Mtn Center for Center for Medical Medical

Response toResponse to

Rky Mtn Rky Mtn Regional Regional

Trauma CtrTrauma Ctr

Regional Regional

Response to Response to TerrorismTerrorism Public HealthPublic Health

Family Family Health Health CentersCenters

ggPoison Poison

Center & Center & NurselineNurseline

Denver Denver Correctional Correctional

Denver Denver Health Health

Medical PlanMedical Plan

SchoolSchool--based based H lthH lth CaresCaresCareCare

Medical PlanMedical PlanHealth Health CentersCenters

Choices for primary careChoices for primary care?p yp y

• Delivery Settings• Delivery Settings– Private practice

Private non profit (HMO)– Private non-profit (HMO)– Public

Community health center• Community health center• Migrant clinic• School-based health centerSchool based health center

North High SchoolNorth High Schoolgg

Not just a Denver thing…Not just a Denver thing…

NationallyNationally45 states, 2000 SBHC¾ urban/suburban65% offer mental health65% offer mental health30% offer contraception

A little historyy

20 f SBHC20 years of SBHCDenver as a pioneerRobert Wood Johnson fundingCollaborationCollaboration Regardless of ability to pay…

How bad is it?

CO ranks 44th i % kid NOT d44th in % kids NOT covered

80% immunization rate70% had routine dental visit70% had routine dental visit

41st in % adolescents NOT covered32nd in % working age adults NOT32nd in % working-age adults NOT covered39th in % of low birth weight babies39th in % of low birth weight babies (9%)

Adolescents at DH: Sit f CSite of Care

Crossover, 2832 16%

CHC, 7959, 46%

2832, 16%

SBHCSBHC, 6574, 38%

Denver Public Schools

StudentsStudents72,000: 151 schools18 000 9 12th18,000 9-12th

15,000 6-8th

57% H 20% W 18% B 3% A 1%57% H, 20% W, 18% B, 3% A, 1% NA20% English language learners20% English language learners

West High SchoolWest High Schoolgg

NOT a small operationNOT a small operationpp

13 clinics13 clinics7 high schools2 middle/high schools2 middle/high schools4 middle schoolsPlus feeder elementaryPlus feeder elementary

8900 patients12,000 students

32,000 visits

The Students ’10The Students ’10--11'11'

8622 served / >35 000 visits8622 served / >35,000 visits– >20,639 medical visits

> 9 113mental health visits– > 9,113mental health visits– > 6,200 reproductive health education

D hiDemographics– 74% Hispanic– 13% African American– 7% White– 4% Other

Primary CarePrimary Careyy

>10 000 immunizations>10,000 immunizations4000 physicals700 th ti700 asthmatics200 patients with depression1000 reproductive healthDiabetes Seizures Acute CareDiabetes, Seizures, Acute Care

Health Services in SBHCsHealth Services in SBHCsHealth Services in SBHCsHealth Services in SBHCs

Physicals, risk assessmentsy ,anticipatory guidancescreenings: vision, hearing, BMI, anemia

Immunizationshigher rates than national average

Acute illness careAcute illness carepharmacy and laboratory services

Chronic disease managementgasthma: meds, visits, lung function tests

Mental healthReproductive Health Education

Our ModelOur Model

Nurse Practitioner/PhysicianNurse Practitioner/Physician AssistantMedical AssistantMedical AssistantMental Health therapistHealth EducatorInsurance case workerSchool NurseSchool Social WorkerSchool Social WorkerPhysician

The MoneyThe Moneyyy

$4 million in free care$4 million in free care<50% public coverageG t t tGrants, grants, grants

27% fed/state25% revenue17% DH in kind16% foundation15% partners

20092009--10 Funding10 Fundinggg

Federal/State Grants 18%Foundation Grants 30%Partner Match 7%Patient Revenue 42%Patient Revenue 42%Denver Health In-Kind 3%

PolicyPolicyHealth Care ReformHealth Care Reform

RecognitionC t ti F dConstruction Fund

State LegislatorsWorking with local health systemsMaximize fundingLobby federal policy-makers

Space, it is an issue!Space, it is an issue!p ,p ,

Space varies by site: take what weSpace varies by site: take what we can get

New vs oldNew vs. old

Provisions are the sameLi it d f l di i fLimited formulary dispensaries: freeFull stock of available vaccinesOn-site lab: upt, ua, hgb, rsCourier to DH micro and chemistry l b i l di ti’ tlabs: including sti’s, etc

Rachel Noel Clinic RoomRachel Noel Clinic Room

Does it work?Does it work?

D t SBHC l d tData- SBHC lead to: Decrease inappropriate ER usage

Increase appropriate use medical and mental health services

Improved immunization ratesImproved immunization ratesReduce hospitalization for asthmatics

Summary of obstaclesSummary of obstaclesyy

Highly underserved populationHighly underserved populationDifficult to financeLimited spaceLimited spaceConfidentiality

School rules vs. Health Care rules

The TrailThe Trail

FFrom the Trenchesrom the Trenches

A female student dating her boyfriend forA female student dating her boyfriend for 6 months, states both sets of parents are pressuring them to get married and havepressuring them to get married and have children. She wants to go to college.A mother calls and asks that we talk toA mother calls and asks that we talk to her daughter about puberty

f l d b bA female student wants to be abstinent but her boyfriend is pressuring her and h d ’ k h dshe doesn’t know what to do or say.

DHSBHC DHSBHC –– Health Education Health Education ProgramProgram

2007 – Needs AssessmentSelected a Science Based ProgramSelected a Science-Based Program Motivational Interviewing, Client -

dCenteredIn 2010-2011 – 7 HE, reached over 2,400 students in 6,200 visits –Average of 3 visits per student

HEP StudentsHEP Students

What We Know..What We Know..

69% of Latina teen mothers never finish high school and69% of Latina teen mothers never finish high school and only 2% of all teens who have a baby before age 18 ever graduate from college

Eight in ten teens (80%) say that it would be much easier for teens to delay sexual activity and avoid teeneasier for teens to delay sexual activity and avoid teen pregnancy if they were able to have more open, honest conversations about these topics with their parents.

The National Campaign – Latina Teen Pregnancy Report 2009The National Campaign Latina Teen Pregnancy Report 2009The National Campaign – With One Voice 2010 data report

What What We Know..We Know..

One-third (34%) agree “it doesn’t matter whether you use birth control or not, when it is your time to get pregnant, it will happen.” Six in ten teens (63%) and adults (62%) agree that the primary reason teens don’t g p yuse contraception is because they are afraid that their parents will find out. p

Empowering StudentsEmpowering Students

Abstinencebst e ceHealthy RelationshipsPartner and Parent CommunicationPartner and Parent CommunicationContraceptionSTI’sAnatomy yPuberty

Consent LawsConsent Laws

In CO All minors may consent toIn CO, All minors may consent toContraceptive ServicesSTI servicesSTI servicesPrenatal CareAd tiAdoption

** However, for the DHSBHC HEP program, a student must have parental consent to be seenstudent must have parental consent to be seen in the clinic. This is an agreement with the school districtschool district. A list of State-by-State Consent laws is provided

Cost AnalysisCost Analysisyy

In 2009‐2010 cost savings based on aIn 2009‐2010  cost savings based on a Contraception Risk Index which determined the number of averted pregnancies. 

Public Sector Cost Savings

One Year Five Years Fifteen Years

p g

One Year Five Years Fifteen Years

Federal Savings $6,969.90 $297,978.64 $1,025,624.86

State and Local Savings

$10,823.43 $466,068.87 $1,604,182.47