2013-14 Digital Census Report
School-based health centers (SBHCs) provide convenient, accessible, and comprehensive health care services for children and adolescents where they spend the majority of their time: in school. These powerful investments in the health and academic success of children ensure they thrive.
This census report highlights findings from our 2013-14 Census of SBHCs, completed by 82.1% of the field.
Learn about the growth of SBHCs nationwide and how they provide access to a variety of comprehensive health services, including adolescent-centered care. SBHCs are integrated into health care systems through community partnerships, have sustainable business models, and high standards for accountability .†
SBHC Locations by County
This map display is pulled from Google Maps, which uses a close variant of the Mercator projection.
|Colorado||55||Maine||21||North Carolina||73||Virgin Islands||1|
|District of Columbia||6||Michigan||91||Oregon||66||West Virginia||96|
The School-Based Health Alliance has committed to reaching two goals by 2018: we aim to grow the field by 30% more SBHCs and to support the highest quality of care being delivered in SBHCs through our National Quality Initiative.
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Where Are SBHCs Located?
SBHCs are located in and near schools across 49 states and Washington, D.C.
SBHCs BY SCHOOL TYPE
SBHCs BY SCHOOL GRADE RANGE
94.1% are located on school property.
3% are mobile health centers.
After Delaware’s first school-based health center was established in 1985, financial, community, and political support blossomed, especially after then-governor Tom Carper pledged to have a health center in every public high school. Today, 29 out of 32 public high schools in Delaware have an SBHC.
For three decades now, the state legislature has supported school-based wellness centers to provide comprehensive care and tackle challenges like obesity, sexually transmitted infections, and emotional and behavioral stress.
“Every child in America deserves access to high quality health care and, often, the best place for them to get it is at school,” said Senator Carper. “I’ve long believed that, if possible, schools should have a health center to serve its students, which makes it easier for our children to get the treatment they need, while minimizing the disruption to their day of learning.”
Providing Care to Diverse and Underserved Populations
SBHCs serve low-income children and adolescents who experience disparities in health care access and outcomes.
NATIONWIDE, THE STUDENT POPULATION OF SCHOOLS WITH SBHCs
Among the 55.9% of SBHCs that report serving populations other than the students in the school:
- 83.6% serve students from other schools,
- 65.8% serve family of student users,
- 61.4% serve out-of-school youth,
- 59.9% serve faculty/school personnel,
- 35.5% serve other people in the community.
77.6% of SBHCs serve schools that are Title I. 76.5% of SBHCS are located in schools where more than 50% of students were eligible for free or reduced-price lunch.
Los Angeles Unified School District (LAUSD) in partnership with The L.A. Trust created 14 Wellness Centers on the edge of campus to serve students and the community in high-need areas, in addition to their SBHCs. LA County has many pockets of children in poverty and uninsured, and as part of their master plan, the LAUSD Board of Education earmarked an additional $50 million on top if its original investment of $36 million from the district’s joint-use facilities to further support Wellness Initiative expansion.
To assure student privacy and user-friendliness, Wellness Centers are divided with separate entrances and exam rooms. These Wellness Centers take a life-course approach for students and non-students, supplementing standard medical and dental services with coordination of family support services and health insurance enrollment and renewal.
Rural areas present unique challenges that make SBHCs an ideal model to increase access to quality primary, behavioral, and oral health care for children and adolescents.
For instance, in rural areas parents may have to drive long distances and take time off work to bring children to medical appointments. Likewise, serving students in schools helps to minimize seat time disruptions. A greater proportion of rural SBHCs (68%) serve populations in addition to students at their school compared to SBHCs located in suburban (62.3%) or urban (46.3%) areas.
In many rural parts of West Virginia, schools make a natural outpost for health care. Students, many who commute long distances between home and school, are captive audiences. For the close to 100 West Virginia schools that partner with primary health centers to bring care directly to campus, students don’t lose valuable classroom seat time commuting to a sports physical, check-up, or acute care visit.
- Percent of WV schools with SBHCs: 13
- Percent of counties with SBHCs: 61
- Percent of WV FQHCs administering SBHCs: 67
According to West Virginia School-Based Health Assembly’s Executive Director Kelli Caseman, “Our SBHCs work very closely with schools and communities to pull together resources and collaborate on healthy lifestyle programs and services. We all recognize that it will take a change in our culture to eliminate health disparities, and SBHCs are a cornerstone in the infrastructure we’re building to do it. We’re fortunate that our state recognizes SBHCs as a valuable model for delivering preventive care.”
The largest growth of SBHCs since the 2010-11 census has been in rural areas, accounting for nearly 60% of new SBHCs recognized in the database.
The majority—67.2%—of SBHCs are staffed by a primary care provider and a behavioral health provider.
The primary care-behavioral health team has long been a hallmark of the SBHC model.
PERCENTAGE OF SBHCs WITH AN EXPANDED CARE TEAM
In a growing number of sites, the team is complemented with experts in nutrition, health education, social services, oral health, and/or vision care.
SBHCs provide high-quality services students would receive in traditional medical offices, including well-child visits, preventive screenings, and immunizations.
Percent of SBHCs that provide:
diptheria / tetanus / acellular pertussis immunizations
hepatitis B immunizations
individual chronic disease management
Cincinnati sought to close an inequitable health care access gap for children and teen by providing high quality school-based medical care and preventive services, and the results have been impressive: asthma-related emergency room visits and hospitalizations decreased while immunization rates climbed steadily.
Cincinnati has built on these early successes by expanding services to treat health problems affecting students’ academic performance. The OneSight Vision Center at Oyler School offers full vision services, including eyeglasses, to students from every school in the district. In the 2014-15 school year, the center served over 3,000 students and distributed over 2,000 glasses. The Cincinnati Women’s Club helps fund student transportation to Oyler. Dental services are the next frontier of Cincinnati schools: last year there were over 10,000 visits across three full-time centers offering dental care and Cincinnati plans to continue expanding oral health services in the future.
SBHCs play a critical role in preventing, screening, and treating some of the most common behavioral issues known to affect student performance, health, and personal safety: depression, anxiety, social conflict, toxic stress, and attention disorders.
In Alameda County, California, SBHCs are embracing trauma-informed care to help students manage the multiple stressors of community violence, family separation, poverty and neglect, so they may succeed in school and life. Several SBHCs in East Oakland administer a school-wide screen to identify students who have experienced chronic stress. Center staff organize trauma-focused support groups, healing circles, behavioral health consultations, and coordination of services to reduce the effects of—and build resilience against—trauma and toxic stress.
Additionally, some of the SBHCs provide teacher trainings to help them understand how childhood adverse conditions often manifest as learning difficulties in the classroom. The California School-Based Health Alliance recently received a $2 million grant from the San Francisco Foundation to partner with the Oakland Unified School District and Alameda County's Center for Healthy Schools and Communities to expand similar innovations to all SBHCs in Oakland.
Percent of SBHCs that screen for:
Social Skills/Relationship Issues/Conflicts
Attention / Concentration Disorders (ADD / ADHD)
Poor access to oral health care remains one of the most persistent health disparities in the United States. SBHCs solve this problem by bringing dental services to children in school.
In Clark County, Nevada—the nation’s fifth largest school district—a school-based oral health care program called Future Smiles brings much-needed preventive services directly to students in Las Vegas area schools. In several Clark County schools, as many as six in ten children have experienced untreated tooth decay. A broad array of services—screenings, oral health education, dental cleaning, sealants, fluoride varnish, and case management—are delivered through SBHCs and mobile dental units.
Future Smiles recognizes the importance of engaging teachers as partners in meeting student needs. Future Smiles earns high marks from teachers who attribute education-related results to the program, like increasing ability to pay attention in class and decreasing out-of-seat time. One teacher applauded the program because it “look[s] at the whole child, and the entire school has benefited.” Read More
In 2015, the School-Based Health Alliance launched a national oral health learning collaborative—in partnership with DentaQuest Foundation—to integrate oral health services into the ten largest school districts in the United States. Read More
Many SBHC primary care providers employ a suite of preventive services to promote oral health in children and adolescents who lack access to dental care. These include:
oral health education (88.7%)
risk assessments (68.5%)
fluoride supplements (21.5%)
fluoride treatments (17.2%)
SBHCs also have oral health providers as a member of staff (17.7%), and one in five SBHCs provides oral health exams by a dentist or dental hygienist on-site.
SBHCs work upstream of the most prevalent—and preventable—adolescent morbidities by focusing on the knowledge, attitudes, skills, beliefs, and behaviors that empower adolescents to make positive decisions about their own health.
Topics most frequently covered by SBHC prevention and harm reduction counseling with individual studentS:
Substance abuse disorders have significant and long-lasting health and academic consequences for young people. To address this issue, the School-Based Health Alliance is conducting a two-year pilot project that will train SBHC providers to employ SBIRT methods in their health centers to test the feasibility of this approach in a school-based setting. These pilot projects are already underway and the early results are promising. In Beaverton, Oregon, Merlo High School’s SBHC staff make routine classroom visits to promote their services, develop rapport, and, ultimately, motivate students to seek out support from the SBHC on sensitive topics like substance use and abuse.
At nearby Beaverton High School, assistant principals make direct referrals to the clinic for SBIRT when they suspect a potential substance use issue. California’s United for Success Academy and Skyline High School found success with Teen Intervene, a brief, early intervention program for youth in the early stages of alcohol or drug use. Student participants have created a peer support group to help each other deal with social pressures to use substances.
Read more about the Alliance’s SBIRT in SBHCs initiative.
Peer Groups Support Social and Emotional Health
More than half of SBHCs (61.3%) have effectively harnessed the power of peer influence in adolescence by providing group-based activities and education.
All too often, schools resort to punitive measures when dealing with students who act out in class. A common practice is to remove these students from the classroom and send them to in-school suspension (ISS). However, this leaves the underlying problems that can cause this behavior unresolved. Proviso East High School in Maywood, Illinois, is targeting students assigned to ISS with a therapeutic option that tackles the root causes of dysfunction in the classroom. Through a processing form, students are asked to reflect on why their behavior resulted in ISS and identify alternative choices they might make in the future. The processing forms are used by teachers and social workers to identify the most at-risk students and provide appropriate follow-up and support.
As part of the program, students in ISS now receive education and interpersonal skills-building to equip them with strategies for dealing more appropriately with anger, stress, substance abuse, and life after high school.
According to Adriane Van Zwoll, MJ, LCSW, the SBHC practitioner and social worker implementing the program, “I feel I’ve been able to connect with some of the hardest-to-reach students who might have never crossed through the SBHC doors.”
Among SBHCs providing group-based services to adolescents, topics include:
Emotional health and well-being
Positive youth development
Healthy Eating and Active Living
SBHCs promote a culture of health in schools and the community. A particular emphasis on healthy eating and active living has been undertaken by SBHCs for individual counseling, group work, and with parents and community members.
As part of the Hallways to Health initiative to move beyond the clinic walls, Northwood High School’s SBHC engaged in several efforts to build a culture of health. They have hosted cooking classes that emphasized healthy eating and sponsored an afterschool nutrition education program for students. Their "Take Pounds Off Sensibly" (TOPS) program has proven popular among employees, and Zumba fitness classes have brought students and employees together to be more active.
85.6% of SBHCs...
provide one-on-one healthy eating/active living/weight management education for students.
45.6% of SBHCs...
do group education on healthy eating/active living/weight management.
26% of SBHCs...
facilitate activities with parents or community members that promote healthy eating, active living, or weight management.
Sexual and Reproductive Health
Many SBHCs offer adolescent sexual and reproductive health services that address the issues of teen pregnancy and sexually transmitted infections (STIs). These services are aligned with national standards and are in accordance with local policies.
Sexual and reproductive health (SRH) services delivered by SBHCs in 2013-14
Policies, most commonly at the school-district level, limit half of SBHCs from dispensing contraception. However, the percentage of SBHCs that dispense contraceptives has been increasing for the last decade.
Sources of policy that restrict SBHCs from dispensing contraceptives
Montefiore’s SBHC reproductive health services have evolved with local department of education and health department support to include pregnancy testing, rapid HIV oral testing, and on-site dispensing of contraceptives including condoms, hormonal contraception, long-acting reversible contraceptives (LARCs) like Nexplanon and intrauterine devices (IUDs), and emergency contraception. The biggest strength of on-site reproductive health is being able to provide care when students decide they want or need a service.
“We are where they are,” notes Margee Rogers, Director of Primary Health Care. “Before we were able to dispense or insert [contraceptives] on site, many students did not fill their prescriptions or complete their referrals.”
SBHCs that dispense contraceptives on-site provide:
Sponsor Type Over Time
(Percentage of SBHCs)
Federally Qualified Health Centers (FQHCs) and Look-Alikes
FQHCs and Look-Alikes are on trend to be the dominant SBHC sponsor type.
More than 750 SBHCs are sponsored by FQHCs and Look-Alikes.
About 18.6% of the 1,359 Health Center Program grantees and Look-Alikes nationwide partner with an SBHC to deliver care. Further growth in Health Center Program grantee and Look-Alike sponsorship of school-based health services could help increase access to services for more students across the U.S.1
Denver Health’s investment in SBHCs has grown nearly 50% just in the past five years (16 sites as of 2013-2014 school year). This FQHC SBHC partnership has been serving an additional thousand students each year to meet community needs. Denver Health’s status as an FQHC allows the SBHCs it sponsors to qualify for additional grants and bill at an enhanced rate. This helps them to remain sustainable and keep their focus on providing services to the students of Denver Public School including the underserved and underinsured.
Denver Health reports that their FQHC network and integrated health care delivery system ( which includes Mental Health Services and Health Education) yields a more comprehensive medical home for students using their SBHCs. The data collection and reporting requirements for FQHCs promote high performance of their affiliated SBHCs, drive continuous quality improvement, and helps them show the impact of their work.
1 This denominator includes 330 Health Center Program grantees, organizations that receive grants under section 330 of the Public Health Service Act (including FQHCs), and Look-Alike organizations that meet all the Health Center Program requirements but do not receive Health Center Program grants. Health center data for Uniform Data System 2014 were retrieved here.
Hospitals across the country redirect health care out of the medical complex and into neighborhoods where children live, grow, and learn. In communities with underserved populations where children have inequitable access to health care and preventive services, hospital investments in SBHCs can yield an important return on investment in population health.
More than 100 hospital systems
across the country have invested in SBHCs:
these 113 hospital systems
sponsor approximately 330 SBHCs.
In the course of its 25-year SBHC history, Henry Ford Health System (HFHS) has opened health care access sites in elementary, middle, and high schools across the Detroit metro area. Today, HFHS sustains both fixed and mobile sites serving schools through their community benefit dollars and direct investment and in-kind support.
The School-Based and Community Health Program (SBCHP) can access the legal, administrative, and financial departments of HFHS, ensuring lower costs and higher sustainability of their SBHCs. HFHS partners with a coalition of local health systems to share data, conduct community health needs assessments, and communicate about the impact of SBHCs in the community.
Sixty-five local health departments from across the country administer approximately 135 SBHCs as part of their public health mission, often with diverse partners.
Some of the largest health department sponsored initiatives are located in:
Cleveland County, NC
Multnomah County, OR
Seattle/King County, WA
and Washington, DC.
State funds are an important source of financial support.
7 in 10 SBHCs report receiving state dollars for operations.
After a two-decade long break, Arkansas state leaders committed funding to re-establishing school-based health services. Their goal: to increase access to quality health care and mental health services for students and improve academic outcomes.
According to Tamara Baker, School Based Health Center Advisor with the Arkansas Department of Health, the administration looked for ways to improve the economic picture in Arkansas in the long run and improve Arkansans' lives in the short run. SBHCs have been an important part of that effort. Allocations for fiscal year 2014 included $2M for 21 SBHCs.2
SBHCs partner with many stakeholders to create an integrated, county-wide system of school-based health care.
SBHCs report receiving support from the following LOCAL sources:
With $5.4 million allocated from a special levy on property owners in the city of Seattle, Seattle & King County Public Health Department, area hospitals, and community health centers have joined together to create a city-wide system of SBHCs that reaches 26 schools, more than 6,500 individual students and facilitates more than 35,000 visits each year.
This levy provides about 70% of the funding for all Seattle school-based health centers. This taxpayer commitment to SBHCs began with the 1991 Families and Education Levy for six new centers and was renewed in 1998, 2004, and 2011, with the goal of ensuring that all Seattle’s children succeed in school and beyond.
Sustainability of the SBHC model relies on patient revenue. Nine in ten SBHCs seek reimbursement for services from public and private health insurers.
PERCENT OF SBHCs THAT BILL:
* MCO = Managed Care Organization
While fee-for-service remains the standard payment method for SBHCs (78.3%), some sites receive monthly or annual capitated payments for primary care (34.8%), “pay for performance” supplements (26.7%), or monthly or annual capitated payments for care coordination (18.8%).
Medicaid, the federal-state health insurance program that covers low-income children, is especially vital: 89.0% of SBHCs report billing Medicaid through state agencies and 78.1% through Medicaid managed care organizations (MCOs).
On average, SBHCs report that billing revenues cover one-third (33.6%) of program costs. Average patient revenue from billing, as a percentage of total operational expenses, varies by SBHC sponsor types: FQHCs (50.7%), hospitals (28.5%), health departments (20.8%), and schools (10.4%).
Several states protect Medicaid reimbursement in managed care environments by waiving the prior authorization requirement for SBHCs (Illinois, Louisiana, Michigan, North Carolina, West Virginia) or carving SBHCs out of health plan requirements (New York). Read More
Federal grants are a critical funding source for
53.6% of SBHCs.
Top Three Sources of Federal Funds
Wichita area community health and education partners seized a federal funding opportunity in the Affordable Care Act to expand health care access in its most underserved schools. In 2011, GraceMed Health Clinic, an FQHC, coordinated a strategic partnership with school districts and the Sedgwick County Health Department to submit multiple proposals for the construction of new SBHCs. All were successfully funded. With grants totaling $3 million, Wichita made a home to five SBHCs in 2013-14 and has plans for continued expansion.
While the influx of Capital Program funding for building and construction provided the essential foundation for a sustainable future for their clinics, GraceMed has continued to raise the necessary capital funding for all of their SBHCs. They have accomplished this through support from Kansas and Wichita-based foundations, companies, and individuals, as well as the United Methodist Church, with whom GraceMed is affiliated.
SBHCs often seek and receive additional support from private foundations.
40.4% of SBHCs
receive funds from private foundations.
The Zeist Foundation, a private philanthropy dedicated to at-risk children, youth, and families, is changing the SBHC landscape in Georgia. A five-year Foundation-funded effort by the Emory Pediatric Urban Health Project has resulted in 29 SBHC planning grants spanning 34 counties. The Emory team has also raised $6 million in public and private matching funds for Georgia SBHCs.
SBHCs document and report performance data in accordance with state and national child quality measurement frameworks.
The School-Based Health Alliance is charting new territory with the launch of its School Health Services National Quality Initiative (NQI). The Alliance’s goal is to encourage at least 50% of SBHCs to document and report a standardized set of performance measures by 2018. SBHCs in CT, CO, NC, and WA will be the first to participate in a national learning collaborative to adopt, report, and accelerate improvements around key quality measures.
With national, state, and local partners working together to align performance measures, SBHCs will be able to compare themselves at every level, assess their strengths and areas for improvement, and provide compelling metrics to funders. Learn more.
of SBHCs report that they collect quality outcomes based on state-defined tools and measures.
of SBHCs collect performance data based on Healthcare Effectiveness Data and Information Set (HEDIS) measures.
of SBHCs collect the Children's Health Insurance Program Reauthorization Act (CHIPRA) recommended core set of child health quality measures.
SBHCs participate in rigorous accreditation efforts similar to other health provider organizations to document standards for coordination, access, comprehensiveness, and cultural competence.
70.3% of SBHCs are accredited by any source.
The School-Based Health Center Improvement Project (SHCIP) was a joint project of Colorado and New Mexico to identify effective, replicable strategies for enhancing the quality of health care for children and youth. The five-year (2010-15) project was one of ten awards made to states and child health providers by the federal Centers for Medicare and Medicaid Services.
Twenty-two SBHCs participated in SHCIP, 11 in each state. Key findings included: staff time and health center resources must be devoted to quality improvement in order to ensure meaningful change; data collection and reporting can help identify problems, suggest ways to improve practice and policies, and assure SBHC contributions are recognized by the greater health care system; youth feedback should be solicited to make improvements in care delivery; and the use of a youth-friendly electronic risk and resiliency screening tool increased efficiency, enhanced counseling messages, and improved care integration.
The dramatic uptake of technology by SBHCs over the years (including use of electronic health records [EHR]) reflects a sector eager to adopt tools that greatly enhance quality and accountability through documentation, coordination, and the exchange of information with care partners.
SBHCs using Electronic Health/Medical Records
Adoption of telehealth technology is not widespread among SBHCs (7.3%).
However, rural areas are more likely to use telehealth services (12.7%).
The Center for Rural Health Innovation in North Carolina operates a school-based telehealth program to improve access to care among rural children and adolescents in close to 20 schools.
In North Carolina’s mountainous western counties public schools are often remote and have smaller than average school populations. Telehealth bridges access to care for children in schools such as these that cannot support a physical SBHC. Telehealth technology maximizes provider time and student seat-time by eliminating the need for transportation.
In 2013-14, after completing their rollout to all of the schools in their two-county service area, the Center proudly boasted that “every student in every school in Mitchell and Yancey County has access to health care every school day.”
† The census is a one-of-a-kind survey that documents the role of SBHCs in meeting the health care needs of children and adolescents with a full range of clinical services and prevention activities that are provided by diverse staff. The survey describes the funding sources that support the health centers, policies, and characteristics of schools where SBHCs are located. Data for the 2013-14 Census of SBHCs were collected from July 2014 to May 2015 and 2,315 centers and programs connected with schools nationwide were identified. The highest completion rate (82.1%) in the history of the census was achieved, representing 1,900 known programs. The analysis and data presented in this report includes SBHCs that provide primary care (n=1,737). The 163 centers excluded from the analysis provide access to behavioral and/or oral health services but not primary care. They were excluded because unlike those providing primary care, their identification was arbitrary and we are not confident that the data pertaining to these alternative models is generalizable. Missing data and "do not know" responses were excluded from the analysis, and the number of respondents for each question is reported in our full methodology. For more information on the census methodology, please click here.
Acknowledgements: The census was supported by two cooperative agreements from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS): 1) U30CS09738-08-00, award title “Technical Assistance to Community and Migrant Health Centers and Homeless” for $450,000; and 2) U45MC00176, award title “National Center on School-Based Health Care Cooperative Agreement Program” for $1,330,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. In addition, we gratefully acknowledge the support of the Atlantic Philanthropies.
The national Census is conducted by the School-Based Health Alliance. This report was prepared by Hayley Lofink Love, Erin Schelar, Kyle Taylor, John Schlitt, Matt Even, Anna Burns, Suzanne Mackey, Megan Couillard, Jessica Danaux, Anna Mizzi, Dela Surti, and Daisha Windham. We gratefully acknowledge the support of Census advisors Melina Bersamin, Jill Daniels, John Dougherty, Sarah Knipper, Mona Mansour, Jan Marquard, Margo Quiriconi, Mary Ramos, Samira Soleimanpour, Jennifer Salerno, Michele Strasz, and Terri Wright, as well as SBHC professionals who generously provided data for their programs. This report honors the work that they do every day.