Sustainability

Introduction

What is the secret sauce for staying power when you are a newer delivery method of healthcare services? There is no one-fits-all answer. Sustainability is a goal for any program, but there are unique challenges for school-based mobile healthcare programs. The answers will be just as unique as the communities each mobile unit serves. For mobile healthcare programs working at the intersection of health and education by partnering with school-based health centers, schools, students, families, and their communities, addressing the needs and interests of all its stakeholders is a difficult task, but if achieved, can lead to a program’s longevity and success.

According to key informants of school-based mobile healthcare programs, mobile healthcare is a viable and sustainable option. While these programs are not without barriers and challenges related to cost, logistics, and stakeholders, they reach historically underserved or inaccessible communities to provide initial contact with the healthcare system. These programs engage with the community to make sure that the care they are providing is the care that is needed and continually communicate and collaborate with schools, partners, and communities to make explicit what their capabilities are, what their needs are, and what they hope to accomplish together.

Promising Practices

Over the years, the School-Based Health Alliance worked with local, state, and national partners to develop best practices for the sustainability and excellence of the school-based healthcare model. Schools, communities, and healthcare organizations partnering in the school-based healthcare field found that sustainable school-based health centers share three common characteristics:

Successful school-based healthcare models include:

Strong Partnerships: Develop and nurture Strong Partnerships with school and community stakeholders committed to school-based mobile healthcare.
Sound Business Model: Create a Sound Business Model that relies on a variety of stable and predictable funding sources.
High-Quality Practice: Operate health care practices that meet the comprehensive needs of students and demonstrate a High-Quality

Each characteristic is interdependent and of equal importance and needs thoughtful planning and implementation over time to all three. Underdevelopment of any of the three characteristics can weaken the long-term sustainability of any school-based healthcare model. Below is a more detailed description of each characteristic.

Strong Partnerships

Foundational to all school-based healthcare work is the development of partnerships. Implementing a sustainable school-based mobile healthcare program will require early engagement of collaborative partners, while also identifying and engaging additional partners over time to help sustain your school-based mobile healthcare efforts.

Each partner brings something different to the table.
Each partner often has strong trust or credibility within the community they serve.
Partners can advocate for continuing, linking, or expanding your school-wide wellness efforts.
Working with partners can provide information and insight, foster other partnerships and funders, and lead to financial and non-financial resources to continue the work.

Essential partners include education partners, students, parents/guardians, and key stakeholders in the community, such as other healthcare providers. Working with partners in different sectors broadens the possible user base, yielding more school-based mobile healthcare users.

Partnerships with sponsor organizations, such as hospitals, local health departments, and health centers, can bring many administrative and revenue opportunities to the school-based mobile healthcare program.

Your partners can help determine the parameters for operating a school-based mobile healthcare program most efficiently for the students based on the needs of the students, families, school, and community. Your partners can assist in answering the following questions, which will also influence the sustainability of a school-based mobile healthcare program:

Will they serve only students?
Or will they also provide services to teachers and school staff?
Will they serve students’ families and the broader community?
If they serve other clients than students, how will they keep the focus on the students?
What services will they provide if they include additional target audiences for services?
What practitioners will they need to hire to provide those services?
How will these services impact patient revenue?

See the Collaborations & Partnerships section of the toolkit for further information and resources on developing and nurturing strong partnerships with school and community stakeholders committed to school-based mobile healthcare programs.

Sound Business Model

A robust and sound business framework is essential to achieving longevity and effectiveness in establishing a sustainable and thriving school-based mobile healthcare program. This comprehensive approach encompasses strategic elements such as financial planning, a thorough analysis of financial standing, a resilient billing infrastructure, a nuanced understanding of the insurance policy environment, a diversified funding strategy, and targeted outreach and marketing strategies. Each of these components plays a pivotal role in shaping the success and sustainability of a school-based mobile healthcare program, providing a solid foundation for its operational continuity and the delivery of high-quality healthcare services to the school community.

Financial Planning
A sound business model requires Financial Planning that relies on a diversity of stable, predictable funding sources, in-kind partner contributions, maximizing patient revenue, and the right-size role of grants in supporting long-term operations. Funding streams for school-based mobile healthcare programs nationwide may include grants from foundations state, federal, and school districts. Our focus group respondents note it is essential to use either a specialty code for the mobile unit or the place of service code for their physical location when billing for services. Without the specificity in coding for the school-based healthcare mobile unit service, the revenue generated by the mobile unit may not result in revenue associated with that service.

Analysis of Financial Standing
The Analysis of Financial Standing helps you understand the program costs to reach sustainability. What will it cost to operate a school-based mobile healthcare program? What will income and expenses look like? The key to developing a Sound Business Model is a comprehensive analysis of financial standing. One option to understand the current and future finances might be a pro forma or a budget. Consider all financial aspects, including the cost of maintenance, parking, staffing, operational expenses, and supplies. Healthcare organizations often have the infrastructure to provide a pro forma or a budget and adjust the requirements and influences on financial standing over time.

While it may seem like a long, gruesome process, completing a business plan helps ensure that all the components are in place for creating a sustainable program. Many of the written components of the business plan help write grant proposals and aid in the development of presentations to potential funders and community partners.

Funders must see that you have a solid, well-thought-out business plan. We recommend these eight elements for a year-one school-based mobile healthcare program business plan.

Needs Statement (developed through the Readiness Assessment process)
Collaborating Partners
Vision/Mission Statement
Goal Statement and Year One Objectives
Services and Staffing
Location/Facilities/Equipment
Marketing and Outreach
Pro-FormaSummary

Billing Infrastructure
The ability to bill health insurers requires significant time and resources. Successful SBHCs and school-based mobile healthcare programs consider the extra staff and resources needed to bill insurers when developing their business plan. A school-based mobile healthcare program needs a cost center to track its revenue and expenses and develop recommendations for increasing revenue and spending revenue. The sponsoring agency must remember that a school-based mobile healthcare program’s revenue may be considerably less than their main health center’s revenues. It’s vital to ensure that school-based mobile healthcare program staff members focus aggressively on seeking reimbursement for their services and report the revenue it generates.

Insurance Policy Environment
Sustainable school-based mobile healthcare programs understand the insurance policy environment in their service area and the state policies that may influence reimbursement. It is critical that you know what your state says about prior authorization from the Primary Care Provider (PCP) to bill for well-child visits. Suppose the school-based mobile healthcare program sponsor is not the student’s assigned PCP. In that case, many state Medicaid agencies may require school-based health programs to seek prior authorization from their patient’s assigned PCP to bill for any well-child visits. The school-based mobile healthcare program will need to establish a formal partnership with the PCP (how you’ll share medical record info, request prior authorization, etc.) to ensure that they can bill Medicaid for all well-care and acute care visits. Without these partnerships, the school-based mobile healthcare program, like SBHCs may not be reimbursed by Medicaid for any services provided to children for whom they aren’t the assigned primary care provider.

Diversity of Funding
Diversity of funding is paramount and can include grants, in-kind donations, and health reform efforts like Medicaid reimbursement as possible funding sources. A sound business model for a school-based mobile healthcare program requires a multifaceted funding strategy to ensure resilience and adaptability in the face of an evolving healthcare landscape. By embracing a diverse range of funding streams, this model secures the immediate financial health of a school-based mobile healthcare program and fortifies its capacity to deliver accessible, comprehensive, and high-quality healthcare services.

Outreach and Marketing
Outreach and marketing are essential to your school-based mobile healthcare program’s bottom line. Marketing to increase awareness and build trust leads to more students enrolling and using your program. There are many creative ways to implement outreach efforts to students and families, including school-wide events such as back-to-school nights or registration round-ups, sports events, parent-teacher conferences, and health fairs. Plan for open houses where students and families can tour the mobile unit, developing awareness, familiarity, and trust. An open house can help the students and families connect to the school-based mobile healthcare unit, just like they would a health center in a building.

When you involve youth in outreach and marketing efforts, they will develop timely, creative, and relevant ways to communicate with their peers. You can do this through a Youth Advisory Council (YAC) specific to the school-based mobile health unit or engage a leadership group or marketing class to focus on the school-based mobile healthcare program and enhance ways to get students accessing care.

Outreach to your education partners is also a key to success for sustainability. To solidify and maintain relationships with your education partners, school-based mobile healthcare programs need to nurture consistent communication, collaborative scheduling, program updates, progress, and engage in quarterly/yearly planning. Leadership and staff turnover with your education partners affect the level of trust in the school-based mobile healthcare program, ultimately affecting your program’s utilization.

When your education partners understand what you do and how you do it, they will depend on the ability to refer students to your school-based mobile healthcare program. Besides engaging your education partners in planning and implementing the school-based mobile healthcare program, you can develop specific outreach events for the staff. Health partners have found success when they plan an open house for school staff to visit the mobile unit, offer a blood pressure check-up, arrange a flu shot event, etc. Visiting the school-based mobile healthcare unit takes away any presupposed understanding or attitude towards a school-based mobile healthcare program.

Here are sample communications on program planning:

Outreach to parents/guardians and families is also a key to success for sustainability, as they are critical partners in their children’s health. Targeted communication and outreach are essential to developing trust, increasing engagement, and improving health outcomes. Work with your school, community, parents/guardians, and families to develop messages and communications that work for your specific audience. Take into consideration reading levels, local language differences, and health literacy.

Here are sample promotional/marketing communication:

High-Quality Practice

Delivering services using best practices and evidence-based tools with integrity will ensure a solid foundation for sustainability.

Having a plan for data collection and reporting to highlight and share the results of your school-based mobile healthcare program’s service delivery is another way to support a program’s journey to sustainability. Being intentional about data collection and what you’re asking of your program can ensure that you speak to all your stakeholders. When you share with your stakeholders the data collected through various avenues such as qualitative, quantitative, anecdotal, in-depth interviews with the end users, or through great storytelling, you communicate the value and benefit of the school-based mobile health program.

Investing time in assessing data and identifying ways to improve practices will improve the quality of care that students receive in your school-based mobile healthcare program. Data also increases your partnership value by being able to describe the quality of care being delivered in your school-based mobile healthcare program. Presenting your data in various formats helps with messaging to a diverse group of stakeholders, whether you use infographics, graphs, charts, or other visuals to present your data.

Here are sample program progress and data communication:

- Sample Dental Data Infographic
- One pager 2022-CHP-2954987 SBHC Data Flier Update-v4_web.pdf

Stories from the field

The School-Based Health Alliance (SBHA) partnered with the DentaQuest Foundation in 2015 – 2020 to explore how school districts could increase children’s access to oral health services in the ten largest school districts in the U.S. SBHA created a learning community focusing on increasing the consent rate, which in turn would hopefully result in more students receiving oral health services and positively impacting sustainability. The consent rate was the common denominator for all the school districts, with most of the participants at or below the national average for oral health consent. In Chicago Public Schools, the consent rate dropped from around 65% to 18% over the years. The school district successfully improved consent rates in one year through a youth-led outreach campaign. The youth prioritized messaging through poster development and a silicon wristband campaign. The youth used their own ideas on topics important to students during the school year to develop their poster messages. Below are four examples of the student-led campaign.

The posters were displayed throughout the school, and the youth provided more information and consent forms in the cafeteria during lunch periods. The wristbands were very popular amongst students. When students turn in a signed consent, they receive a wristband. When students made an appointment and showed up, they received another wristband. Students who returned for additional oral health services received another wristband.

Empower the youth to be creative, relevant, and support them in their planning. The adults on this project had to remind themselves to ‘get out of the way and let the youth lead.’ It proved successful in improving oral health consent, leading to increased utilization, decreasing oral health disease, and improving oral health equity.

Metro Health in Cleveland, OH, operates school-based health centers and a school-based mobile healthcare program. They developed this online video to help with their outreach efforts. This not only promotes their program but speaks to the health and education benefits, thus would appeal to health and education partners (see more information).

Tips

Identify organizations that have grant and funding opportunities that align with school-based mobile healthcare.
Use data to demonstrate the value of school-based mobile healthcare services to students, parents/guardians, schools, communities, partners, policy makers, and payers. This data can demonstrate improved health outcomes of student populations following healthcare delivery, making a case for the type and amount of payment to request from payers. It can also lead to maximizing billing and reimbursement.
Outreach and marketing are essential to your school-based mobile healthcare program’s sustainability, and it is key to include students in these planning efforts by empowering students to be creative and relevant when developing messaging to deliver to their peers.