Best Practice Case Studies
The Carle Mobile Health Clinic brings affordable, non-urgent medical services to Champaign, Urbana, Danville, and Bloomington communities. The 40-foot, wheelchair-friendly mobile medical clinic offers full-service medical care for infants, children, and adults to ensure families stay healthy. Practitioners have experience in pediatrics, family medicine, and women’s health and pregnancy. While they do bill for services and accept all types of insurance, the onsite social worker assists any families who lack health insurance with their applications. The Mobile Health Clinic provides:
- Chronic condition management and education
- Treatment of acute illness
- Physicals, wellness care, and assessments
- School and sports physicals and immunizations
- Lab testing
- Referrals and applications for social services
The clinic is currently partnering with eight different school districts in Champaign, Vermilion, and McLean counties to reach children in need. While the mobile clinic usually scheduled patients at assigned community locations, in 2019, they began holding large-scale events during the summer months at specific high-needs schools. That was the best time to get new and returning students in for well-visits and needed vaccinations. Of course, these stopped when everything closed down in 2020 due to COVID-19. Gradually, they returned to full service and now see many students for well-visits, sports physicals, missed immunizations, and COVID-19 vaccinations.
Carle is an extensive healthcare system with a marketing department. Although the mobile clinic utilizes Carle’s marketing department, it primarily relies on each community and their schools to get the word out about the assigned dates for the clinic. Schools know the dates well in advance and prepare paperwork for the clinic staff. The clinic staff requires each school or community organization to provide two staff members as contact persons who take care of setting up appointments and ensuring all paperwork is complete.
Before the pandemic, the clinic did not use an appointment system but allowed people to walk in. Since the pandemic required distancing, they went to an appointment system and found that this works much better. Thus, they plan to keep up with this procedure.
Note: Although not school-based and not serving school-aged children, staff mentioned that they came up with a unique way to see their youngest patients during the pandemic. In 2020, they transitioned to seeing infants and toddlers for their regular well-visits outside the brick-and-mortar Carle clinic. A practitioner would do height, weight and head circumference, and shots; a pediatrician followed up with a virtual office visit for the infant.
Since 2001, Healthy Kids Express (HKE), created by St. Louis Children’s Hospital, has seen more than 250,000 children. The program brings healthcare to children from 1-18-years-old who reside in St. Louis, surrounding counties, and the Metro East. HKE provides services to approximately 20,000 children per year. The generosity of donors to the St. Louis Children’s Hospital Foundation makes this possible.
HKE, a site-based program, partners with local school districts, Head Start programs, local daycare centers, and other community sites to offer services. HKE community health workers connect families to community resources such as low-cost health insurance and healthcare providers.
There are currently three HKE vans—screening, asthma, and dental—with a fourth one opening in 2022 in partnership with Washington University to provide diabetes care and education. By the end of 2023, they will add two additional dental vans. The HKE Screenings mobile unit offers hearing and vision screenings, lead and iron deficiency testing, immunizations, and height and weight checks. When they identify issues, children receive referrals for appropriate medical and social services, which are essential for these children to receive the intervention they need to thrive. They provide asthma care, education, and resources to approximately 500 children and their families through the HKE Asthma mobile unit. Children in the community receive much-needed dental services and education through the Dental mobile van. All essential care is provided free of charge. HKE does not currently bill Medicaid or private insurance companies for any services. The new diabetes van, through a partnership with Washington University, will bill for its services. In addition to the vans, services can be provided in school buildings, Head Start programs, community centers, and community-based organizations, as needed or requested.
HKE serves students in six-to-seven school districts across the Metro St. Louis area, primarily those in Title I schools. In response to a school’s identified need or request, HKE will schedule clinics for routine immunizations, including HPV and COVID-19 vaccinations. They also provide school readiness screenings and vaccinations for those children entering pre-K, Head Start, and kindergarten programs. Collaboration with school nurses, social workers, and teachers ensures that HKE can identify and follow up with children in need.
They provide wrap-around services rather than only focusing on well-child visits. When they identify a particular problem or issue, a practitioner or community health worker will reach out for generalized or specialized services for that child. HKE does not act as a “medical home” for students but will make a community health referral to ensure that the child gets a provider.
The Child Health Advocacy and Outreach department also offers a Healthy Kids Healthy Minds (HKHM) program. This program allows schools to purchase services such as school nurses and behavioral health therapists at a discounted rate. Schools absorb all costs after the first three years of providing services. This program is made available by generous donors to the St. Louis Children’s Hospital Foundation. Since early 2020, the program has offered virtual behavioral health services. The expectation is that 18 schools will run virtual behavioral health services in the 2022-2023 school year.
Important points and lessons learned:
- Since they typically see students during the school day, HKE staff must reach out to parents/guardians via telephone to discuss any pertinent issues
- The pandemic allowed for the creation of student telehealth visits when schools are closed. Plus, virtual visits provide follow-up care to asthma patients
- HKE developed consent forms tailored to each school or school district
- HKE staff stay mindful of all HIPPA and FERPA laws
- Due to a high number of immigrants and refugees, HKE values interpretive services, the translation of documents, the importance of serving everyone in the family, the need for culturally competent staff, and the importance of parent and school staff input
All PR/marketing is specific to the school community since each community has its own culture and level of sophistication in terms of social media:
- Sample letters and announcements for schools to send out
- Consent forms
- Use of school social media sites (HKE does not have its own)
- Attendance at school staff meetings, PTO/PTA, and community forums
Louisiana State University Health Sciences Center Department of Pediatrics operates the school-based health center (SBHC) at New Orleans Charter for Science and Math High School. For over 20 years, a registered nurse (school nurse), nurse practitioner, administrative support person, and a licensed clinical social worker staffed the clinic, supervised by a medical director and program manager. A grant received through Children’s Hospital pays for the behavioral health therapist and supports psychiatry bi-weekly at the SBHC. The school of over 500 students, grades 9 through 12, has a population that is 62% FARMS and 72% Medicaid eligible. Over 70% of the students live more than 10 miles from the school and come from 18 different zip codes. In addition to English, Spanish and Vietnamese are languages spoken at home. The SBHC serves all registered students (consent forms signed by parents/guardians) and sees those students up to one year following graduation. The center also accepts siblings of students if they are over the age of 12, but not younger children since staff only serve adolescents. The clinic does not bill students for their services but bills Medicaid and private insurance companies. The clinic offers sports physicals, annual well-visits, STI testing, and HPV vaccinations but no contraception services due to Louisiana state law.
Since the onset of the pandemic, the school has closed on and off depending on COVID-19 case numbers. The school closed for more than a month after Hurricane Ida, but the SBHC remained open when the school opened for administrative staff. As a result of the adoption of telehealth, the number of behavioral health visits increased while somatic health visits declined. In response to this situation and the proposal from HRSA entitled Promoting Pediatric Primary Prevention (P4) Challenge: Innovations in Pediatric Primary Care to Improve Child Health, the SBHC implemented their Reversal of Flow program. The behavioral health provider referred those students lacking up-to-date immunizations and well-care visits to the nurse and nurse practitioner. The social worker’s role as a trusted adult enabled them to encourage follow-up with the primary care provider.
Although the SBHC is not officially part of the school, many families regard them as one due to the long-standing partnership between the school and the SBHC. The SBHC uses the school’s various forms of marketing and community outreach. They often add items to the morning announcements and school newsletters and participate in school and parent meetings. They can request the school to send “alerts” to all students. The SBHC has a page on the school’s website (https://noscihigh.org/sbhc). The SBHC sends information to specific patients via their Electronic Health Record’s web program and individual phone calls, texts, and emails.
Care Connection is a partnership between Nationwide Children’s Hospital and area schools to provide access to healthcare for students in the Columbus area. The 14 school-based health centers (SBHCs) reside in 11 high schools, two elementary schools, and one middle school. Additionally, two mobile units provide services to the greater Columbus communities.
During the pandemic’s school closings, Nationwide Children’s utilized their two mobile units to connect with students already enrolled in their system and who had established appointments. Health center staff found that students attending schools with onsite health centers were on schedule or quickly scheduled to keep up with well-child visits and immunizations. Staff used “purposeful” and targeted outreach to reach students at neighboring schools. School nurses reviewed records to identify children in need, and then health center staff pursued these families using telephone calls and letters, even accepting verbal parent/guardian consent for services.
In addition to the school-based staff, Nationwide Children’s has a “roving vaccine program.” This program’s staff sets up at community centers, parks, or other locations to offer vaccinations. The program expanded to include COVID along with all other vaccinations.
Historically, behavioral health services comprise a large portion of their comprehensive services. Before the pandemic, they began utilizing telehealth; the pandemic made the adoption even simpler.
Families needing assistance with using their existing insurance, the uninsured, or applying for Medicaid or other insurance through the ‘Exchange’ receive referrals to the hospital’s financial counseling and billing department.
Nationwide Children’s has sponsored these SBHCs for seven years. Just recently, their medical director started serving as the medical consultant to the Columbus school system. These persistent and focused efforts ensure that their staff remains incorporated into each school’s culture resulting in students and their families trusting the SBHC staff and their services.
Community Health Center, Inc. operates full-service school-based health centers (SBHCs) at over 25 schools in suburban Connecticut. Their staff consists of licensed healthcare providers who work with school nurses to provide expanded medical, behavioral health, and dental services to students during the school day. They work with all students’ primary care providers to support their healthcare needs. They currently serve over 17,000 students throughout Connecticut. All students can be seen at the SBHC regardless of insurance status. The bill insurance for services, but families incur no out-of-pocket costs for medical or behavioral health services. For students without insurance, there are small fees associated with dental services.
SBHC at O’Brien Technical High School: During the pandemic’s school closures, some staff provided office visits; however, many students used telehealth. Now they are in the “catch-up” period for well-care visits and immunizations. Many students are requesting sports physicals, which lends itself to providing any missed immunizations. At the high schools, those include HPV, HepA, flu, and COVID.
SBHC staff use the school’s newsletter to share information about their services for marketing purposes. They also piggyback on the school nurse’s end-of-year mailings and the principal’s monthly meetings with parents. Staff also make themselves known by speaking on different topics during health classes.
The school-based health center (SBHC) at River Rouge High School has served Wayne County students ages 10-to-21 years for the past six years. The Beaumont Foundation and Michigan Department of Health and Human Services/Michigan Department of Education, with support from the River Rouge School District, fund the SBHC. Plus, they receive some grant funding and revenue from fees for services.
The SBHC provides the following services:
- School, sports, and camp physicals
- Immunizations—school shots
- Sick care
- Asthma screening and management
- Vision and hearing testing
- Health promotion
- Mental and behavioral health counseling services/crisis management*
- Pregnancy and STI testing*
- HIV testing and counseling*
- Nutrition counseling
- Prevention education
- Michigan Health Insurance Marketplace assistance
*confidential services available
Beaumont Health, an extensive health and hospital system serving metropolitan Detroit, currently has eight SBHCs. Each one is a slightly different model. When establishing these SBHCs, Beaumont Health worked closely with the superintendents and administrators from the respective school districts.
SBHC at River Rouge serves a diverse population, with approximately 90% of the student population qualifying for free or reduced-price meals and many of the students living miles away from the school. About 20% of the student body has asthma and receives treatment through the SBHC. Although the staff works to link all students with a medical home, the SBHC becomes the medical home base for many of them.
The school views the SBHC as an integral part of the school community and includes it in school meetings and communications. The SBHC utilizes the school’s communication strategies: website, letters home, and newsletters.
When COVID caused the schools to close in March 2020, the SBHC staff quickly developed creative new ways to reach their students. Like the entire nation, the school saw a decline in immunization uptake. They designed a pilot nurse-led program to increase vaccinations and address the social determinant needs during the pandemic. Following multiple team meetings and meticulous planning, the staff held two drive-up immunization clinics. Initial observations showed an overall increase in immunization uptake, and 97% of participants became current with recommended vaccinations. Most parents (93%) said they would attend again and recommend it to others. They also felt that infection control precautions helped make the care delivered safe and efficient. Social determinants of health were assessed and addressed. This method of vaccine delivery is a viable model going into the future.
The Care-A-Van is a rural health center that provides teen-friendly medical and mental health services to all students at Anna Jonesboro High School, Frankfort High School, and Project Echo Alternative School throughout the school year. The mobile unit is at the Jonesboro and Frankfort schools one day per week and two days per week at Project Echo Alternative school. The area served is rural, and the closest SIU clinic is approximately 20 miles away.
In addition to preventive and sick care, Care-A-Van therapists offer behavioral health services. Since the van does not have refrigeration capacity, staff cannot give immunizations. However, they provide well-care visits and identify those youth who are missing or late for immunizations. They refer them to their primary care provider, the SIU clinic, local health department, or pharmacy to receive the immunizations. Since students returned to in-person classes, the van staff reports an increase in the number of well-care visits and sports physicals, despite not receiving the usual referrals from the school nurse. Van staff says that the school nurses are overwhelmed by COVID-19 testing, reporting, and immunizations and are thus unable to identify students in need of well-care visits.