sbha_logo

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
sbha-map

This map display is pulled from Google Maps, which uses a close variant of the Mercator projection.

Growth

TOTAL NUMBER OF SBHCs IDENTIFIED

There are 2,315 SBHCs that serve students and communities in 49 of 50 states and the District of Columbia.

The number of SBHCs nationally grew 20% since the 2010-11 Census of SBHCs, with 385 new centers recognized in our database.

More &
Great

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.

Access

SBHCs address the inequitable distribution of health care resources in our nation
that results in too many children and adolescents lacking the care they need.

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.

2.7% are
school-linked.

0.2% are
telehealth-only.

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.

Rural Areas

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.

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.

Comprehensive Care

The staff and services of SBHCs are organized to identify, prevent, and remedy threats to student health, wellbeing, and academic success.

Staffing

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.

Physical Health

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:
86.2%

influenza immunizations

77.9%

diptheria / tetanus / acellular pertussis immunizations

75.1%

hepatitis B immunizations

72.1%

varicella immunizations

70.9%

polio immunizations

84.3%

vision screenings

83.4%

individual chronic disease management

Behavioral Health

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.

Percent of SBHCs that screen for:

76.1%

Depression

71.2%

Anxiety/Nervousness/Phobias

71.5%

Social Skills/Relationship Issues/Conflicts

67.7%

Attention / Concentration  Disorders (ADD / ADHD)

Oral Health

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.

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%)
    screenings (66.1%)
    risk assessments (68.5%)
    fluoride supplements (21.5%)
    fluoride treatments (17.2%)
    sealants (9.7%)

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.

Adolescent-Centered Care

Adolescents have long been at the heart of the SBHC movement. Census findings reveal that the unique developmental needs of this age group remain a dominant focus:
Eight in ten SBHCs today serve students in sixth grade or higher.

Preventive Activities

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:

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.

Among SBHCs providing group-based services to adolescents, topics include:

59.6%

Emotional health and well-being

58.3%

Positive youth development

55%

Interpersonal relationships

49.4%

School safety/climate

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.

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

SBHCs that dispense contraceptives on-site provide:

96.8%

Barrier Methods

82.9%

Hormonal Methods

73.3%

Emergency Contraception

39.8%

Implantable Devices

Health System Partnerships

Federally-qualified health centers (FQHCs) and Look-Alikes, hospitals, and health departments are expanding their delivery of care into schools to provide services for hard-to-reach school-age youth in their communities.

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

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

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.

Health Departments

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:

Boston, MA
Cleveland County, NC
Denver, CO
Minneapolis, MN
Multnomah County, OR
Seattle/King County, WA
and Washington, DC.

Sustainability

The pillars of SBHC sustainability include public sector grants, patient revenue, and philanthropic investments.

State Government

State funds are an important source of financial support.

7 in 10 SBHCs report receiving state dollars for operations.

18 states report dedicating nearly $85M in state general funds, federal block grants, and other taxes to SBHCs.1

Top investor states include Michigan ($13.5M), Connecticut ($12.3M) and New York ($12.3M).2

Local Government

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:

Insurance

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%).

Federal Government

Federal grants are a critical funding source for
53.6% of SBHCs.

Top Three Sources of Federal Funds

Private Foundation

SBHCs often seek and receive additional support from private foundations.

40.4% of SBHCs
receive funds from private foundations.

Accountability

SBHCs routinely evaluate performance against accepted standards to achieve optimal outcomes for students, and increasingly use technology to help achieve high quality care.

Quality Improvement

SBHCs document and report performance data in accordance with state and national child quality measurement frameworks.

77.2%

of SBHCs report that they collect quality outcomes based on state-defined tools and measures.

65.3%

of SBHCs collect performance data based on Healthcare Effectiveness Data and Information Set (HEDIS) measures.

55.3%

of SBHCs collect the Children's Health Insurance Program Reauthorization Act (CHIPRA) recommended core set of child health quality measures.

Accreditation

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.

State Certification
%
43.9%
Joint Commission
%
41.1%
NCQA
%
22.2%

Technology Use

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

TELEHEALTH

Adoption of telehealth technology is not widespread among SBHCs (7.3%).

However,  rural areas are more likely to use telehealth services (12.7%).

  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.