Sometimes the most effective way to keep kids healthy is to bring care to them.
By Jeanne Mettner
On a sultry morning just before summer break, Edison High School in northeast Minneapolis is uncharacteristically quiet as students hunker down to finish their finals. Oddly so, says Barbara Kyle, who manages the school-based clinics for the Minneapolis Public Schools and is giving a tour of the one at Edison, which usually has at least one student waiting to be seen by a nurse practitioner.
“I know the kids are in their classrooms taking tests, so it’s expected that it will be slow, but it’s strange not to be seeing anyone at all in this waiting area,” Kyle explains, pointing to the row of three empty chairs across from the clinic doorway. “It’s rarely like this.”
The absence of patients presents a perfect opportunity for a nonstudent to get an inside look at Edison’s school-based clinic (SBC), one of six in the Minneapolis district operated by the Minneapolis Department of Health and Family Support. Together, the clinics serve more than 2,000 high school students a year (350 alone access the SBC at Edison). The tiny classroom-sized clinic consists of a waiting area, an exam room, a consultation room for mental health counseling and patient education, and a galley area where blood is drawn and medications are stored in locked cabinets. The clinic is staffed by a full-time registered nurse, a part-time nurse practitioner, a half-time licensed mental health counselor, and a nutritionist who comes in once a week. Teens can walk in or make appointments for issues ranging from sore throats and ankle sprains to depression, asthma management, nutrition, sexually transmitted infections (STIs), and other reproductive health issues.
Edison’s SBC is one of 18 such clinics in the state. Concentrated primarily in the Twin Cities metro area, the clinics provide a comprehensive spectrum of health care services. Through their affiliations with qualified health providers (for example, private medical practices, health care systems, or a public health department), the clinics employ multidisciplinary teams to address adolescent health concerns. Team members include, but are not limited to, nurse practitioners, registered nurses, physician assistants, licensed social workers, physicians, and chemical dependency counselors. Nurse practitioners, physician assistants, and physicians who work at the clinic can prescribe or dispense a limited number of drugs such as antibiotics, asthma medications, and over-the-counter drugs; they can dispense birth control, including pills and condoms; and they can provide sports physicals and immunizations. Licensed therapists and social workers offer ongoing mental health counseling to adolescents in need of services, while health educators counsel students on issues ranging from nutrition to family planning and pregnancy. School-based clinics, which are located in the school or on school grounds, serve a particular school’s student population—typically teens. (School-linked clinics, on the other hand, have an affiliation with a school district but are usually not in the schools themselves and may serve infants and elementary and middle school students as well as high school students.)
Meeting an Age-Old Need
Minnesota paved the way for school-based clinic services in 1972 with the passage of a minor’s consent law that allows teens to receive reproductive health services, alcohol and drug abuse assessments, and emergency mental health services without their parents’ consent. At the time, the need to improve access to care for adolescents was pressing: The teen pregnancy rate was on the rise nationally and in the state, and along with those pregnancies came poor birth outcomes. To address the problem, government and public health organizations in the Twin Cities metropolitan area sought federal funding through Title V of the Social Security Act. Using dollars allocated for Title V’s maternity and infant care programs, St. Paul started the first SBC in the United States in 1973. Pilot City Health Center, which was owned by Hennepin County, opened the first one in Minneapolis a year later.
Within a few years, the model appeared to be working. Data compiled by Laura Edwards, M.D., an obstetrician/ gynecologist who was instrumental in creating the first SBC in St. Paul, showed that teen pregnancies did decline by 40 percent in the three years following the establishment of the first two SBCs in St. Paul. Her conclusion, which was published in a 1980 issue of Family Planning Perspectives, that the downward trend was because of the SBCs was later challenged by some who pointed out that national adolescent pregnancy rates were already trending downward during that time. But as subsequent SBCs opened, more robust national data revealed that they were reducing inappropriate emergency department use by teens, decreasing hospitalizations, and dramatically improving teens’ access to care. By 1983, more than 300 SBCs were up and running in the United States. Today, there are more than 1,800 such clinics across the country.
Minnesota’s School-Based Clinics
Saint Paul (operated by West Side Community Health Services)
Agape High School
Washington Technology Secondary School
Central High School
Como Park High School
Gordon Parks High School
Harding High School
Highland Park Junior and Senior High School
Humboldt Junior/Senior High School
Johnson High School
Minneapolis (operated through the Minneapolis Department of Health and Family Support)
Edison High School
Henry High School
Roosevelt High School
South High School
Washburn High School
Broadway Arts and Technology School (run by NorthPoint Health and Wellness)
Plymouth Youth Center Alternative High School
North High School
Brooklyn Center (Operated by Park Nicollet Foundation)
Brooklyn Center High School
On November 1, 2010, Minneapolis will reopen the clinic at Southwest High School. In addition, Broadway Arts and Technology High School will move to the North High School building. The clinic at North will serve students from both schools.
Location, Location, Location
The primary reason for the success of the SBCs, say experts, is their setting. “If you ask the question, How do we provide better health care services to our children and teens? you will always get the same answer: Bring the services to them,” says Christopher Reif, M.D., a family physician who served as medical director for St. Paul’s school-based clinic program from 1988 to 2000 and now directs clinical services at the University of Minnesota Community-University Health Care Center. “That’s why SBCs are doing so well; they’re following that community-health model.”
In reality, SBCs work much like any other clinic: When a teen has a concern about a reproductive health, mental health, or nutrition issue; needs an immunization; or has an acute illness or problem, he or she makes an appointment at the SBC. Students also may be referred to the clinic by the school nurse, who is not part of the SBC staff and typically cannot provide immunizations or the medical services offered in the clinics. Once admitted to the clinic, the student sits down with a medical assistant, who takes vitals, fills out paperwork, and checks to see if a parental consent form is on file. In most clinics, the medical assistant will also have first-time visitors complete the Guidelines for Adolescent Preventive Services (GAPS) questionnaire. The questionnaire provides critical information about the student’s mental health, nutritional status, sexual activity, family medical history, school performance, sexual orientation, relationships with peers and family, and physical health. “They may be coming in for a particular medical concern, but the GAPS survey may identify other things that are key barriers to improving that adolescent’s health—a mental health issue, poor nutrition, drug use, unprotected sex, or domestic abuse,” says Gloria Ferguson, program director for Health Start, a program of West Side Community Health Services that operates St. Paul’s SBCs. “We’ve found the survey actually becomes a tool for giving students the comprehensive health care they may not even know they need.”
In most cases, students will receive care from a certified nurse practitioner or physician assistant. Depending on the issues that crop up on the GAP survey, the student also may be connected with the clinic’s health educator, nutritionist, or licensed social worker.
School-based clinic visits tend to last longer than standard clinic visits—they can be as long as an hour for a student who is new to the clinic. But advocates of SBCs note the extended time providers spend with a student builds trust. And they point out that SBC visits actually take the student out of class for less time than a regular clinic visit, as they don’t have to travel to seek services. “Parents don’t end up taking time out of their work schedule to travel to the clinic, and being on site minimizes disruption for the kids,” says Lori Carlson, a pediatric nurse practitioner who works at the SBCs in Edison and South high schools in Minneapolis. “That’s important if your focus is taking care of the health and well-being of a student population.”
The clinics are well-used, and interest in them is growing. Health Start, for example, logged more than 22,000 visits at its nine St. Paul SBCs—up 29 percent from 2009. Most were for immunizations; reproductive health issues; treatment of sore throats, fevers, and rashes; and sports physicals.
The majority of parents in the districts that have SBCs support them. Findings from a 2008 survey of parents of students who used SBCs in Minneapolis indicated that they liked the fact that services are easily accessible to their children, that their teens have a safe place to talk, and that clinic staff have a great deal of experience talking to teens about health issues such as sex and pregnancy prevention, drug use, and other high-risk behaviors. “Most of the parents appreciate the convenience and accessibility of the clinics, and they like that our staff is sensitive to the needs of teens,” says Kyle, who distributes the questionnaire annually.
That may be in part because SBCs work hard to keep parents informed and allow them to retain some control over the care their child receives. Each fall, parents are provided with information about the clinics and asked to complete a consent form giving the clinic at their child’s school permission to treat their child. In the St. Paul and Minneapolis public school districts, parents can authorize their child to have access to all services that the SBCs provide, give consent for all services except contraceptive counseling and birth control prescriptions, or decline access to all SBC services.
If parents do not turn in a consent form, children can still receive care, but only for issues covered in the minor’s consent law including mental health services and reproductive health care. Once parents turn in the form, however, clinic staff must abide by the parents’ wishes. According to Jeanne Rancone, nurse practitioner supervisor for Health Start, most parents who do return the forms want their child to receive comprehensive services; fewer than 5 percent come back denying or limiting a child’s access to services. “The bulk of parents are saying that if their teen needs it, providing birth control is OK.”
Misinformation and Money
Because SBCs do provide reproductive health services to teens, they are the sporadic target of politicians and others who disapprove of such care. “Family planning has been a component of SBCs since their inception, and that always lathers some folks,” says Ed Ehlinger, M.D., who, in the 1970s, was instrumental in creating many of the SBCs in Minneapolis when he worked for the city’s public health department. “Most of our opposition came from people outside of the city who had no connection to the schools.”
Among the individuals recently agitated about SBCs is U.S. Rep. Michele Bachmann (R-Minn). Speaking on the House floor during the health care reform debate last fall, she called SBCs “sex clinics” and insinuated that a 13-year-old girl could walk into a sex clinic, have a pregnancy test done, be taken to a Planned Parenthood clinic, have an abortion, and be back at school in time to catch the bus home. The scenario Bachmann outlined, however, lacks plausibility: Laws in Minnesota require minors to have parental permission or a court bypass in order to get an abortion. And, according to Kyle, the SBCs do provide pregnancy testing and options counseling but do not arrange for abortions.
“I am always surprised when politicians say these things because I wonder what school-based clinic they’ve been in,” Reif says. “The answer is that they haven’t actually been in one but instead are just making blanket statements of what they think—or what they are afraid of.”
Although SBCs are well-established in Minnesota, keeping them in the black is a perennial challenge. School-based clinics do not require payment for services; the clinics can, however, bill families’ health insurance to defray costs. In many cases, however, the students who visit the clinics lack health insurance, have large insurance copays, or come in for confidential services that they do not want insurance to cover. Consequently, the clinics rely on public funding, grant money, and, in some cases, contributions from privately run clinics. In Minneapolis, for example, the Minneapolis Department of Health and Family Support, which runs six of the school-based clinics, regularly faces budget woes of its own. “The city [government] has traditionally been very supportive of SBCs,” says Robin Councilman, M.D., a family physician who worked at Washburn High School’s SBC for 15 years. “Still, every time the state budget comes up, everyone’s on edge, and every time the city budget gets cut, we’re even more on edge.” Nongovernment-run SBCs struggle with funding, too. The SBC at Southwest High School in Minneapolis, which was run by Children’s Hospitals and Clinics of Minnesota’s Teen Age Medical Services (TAMS), was eliminated by Children’s to save money in 2008.
Fiscal concerns also have prompted a change in the way the SBCs in Minneapolis deliver care. Two years ago, the clinics began relying more on certified nurse practitioners and less on physicians. By January of 2010, primary care providers at Hennepin Faculty Associates decreased their time at the Minneapolis SBCs by 50 percent. And after decades of providing consulting services to the SBCs in Minneapolis, Hennepin Faculty Associates officially ended its contract with the city in June of 2010. (A new medical director will be hired, Kyle says, but his or her role will be primarily consultative.)
A Model that Works
Despite the challenges, proponents of SBCs and school-linked clinics believe these programs can serve as models for health care reform. “Accessibility, preventive care, building trusting relationships with kids, reaching them where they are—those are all important aspects of health care reform,” explains Chris Johnson, M.D., medical director of the Park Nicollet Foundation, which operates school-based and/or school-linked clinics in St. Louis Park, Wayzata, Burnsville, and Brooklyn Center. “As we look at improving health care in the United States, we are constantly thinking about new ways to make primary care more affordable and accessible, and strengthening school-based clinics presents a great opportunity for meeting those objectives.”
The school-based clinic that the Park Nicollet Foundation runs in Brooklyn Center High School could be considered the gold standard for SBCs. The clinic, which opened in February 2010, offers medical services, mental health services, dental services, and social services all in a space the size of two classrooms. “It’s the model we’re trying to move toward with our school-linked clinics as well,” Johnson says. “Our vision of a complete clinic is to have all these providers available under one roof.”
St. Paul is also piloting an innovative program in four of its SBCs. Known as Fit Team, the two-year-old program is addressing adolescent obesity, the rate of which has tripled in the United States in recent years. Students who come to the Health Start clinics who are overweight or obese are invited to participate in Fit Team, which involves having a medical examination done by a nurse practitioner, a nutrition assessment by a registered dietician, and a fitness assessment by a certified fitness trainer. Students receive a personal nutrition and fitness plan, and their progress is monitored. Of the 120 students who participated in Fit Team during the 2009-2010 school year, a third successfully stabilized their weight and another third lost weight. Of those who had abnormal lab measurements (high fasting blood glucose levels, elevated lipid panels), 93.5 percent showed improvement in at least one value. Students also report getting more physical activity and eating less fast food. Rancone hopes that given the success of the program, Fit Team can expand to all nine sites by next year.
Federal lawmakers have taken note of the success of SBCs. Section 4101 of the recently passed federal health care reform act “directs the secretary [of Health and Human Services] to award grants to support the operation of school-based health centers.” It also authorizes $50 million per year for SBC facilities and equipment through 2013.
Still, the SBCs have more work to do in terms of reaching out to teens and meeting their needs. Health Start’s Ferguson cites a study of adolescents in mid-sized and rural communities in Minnesota published in a 2004 issue of the Journal of Adolescent Health in which 44 percent reported having unmet health care needs. Of those, 37 percent needed but did not receive care for STIs, 50 percent for reproductive health, and 57 percent for mental health concerns. And according to the Minnesota Student Survey, which has been administered to students by the Minnesota departments of Education, Health, Human Services, and Public Safety every year since 1992, 10 percent to 15 percent of 9th graders and 60 percent of high school seniors are sexually active and may be in need of counseling about birth control and STIs.
“Providers will tell you that if kids are sexually active, they should have protection from STIs and unintended pregnancies, and as a doctor, I know that one of the best ways to meet that need is by bringing the services to kids’ doorstep,” Reif says. “I’m hopeful about the future. I’m hopeful about the fact that for the first time, the federal government is showing support for these clinics.” MM
Jeanne Mettner is a Minneapolis freelance writer and a frequent contributor to Minnesota Medicine.