Expanding school-based care

Over the past decade, school-based health centers have struggled with budget cuts, staffing shortages and cramped office space in their mission to keep students healthy, but the Affordable Care Act is reshaping the landscape with $200 million in funding that will expand or create new health centers in public schools nationwide.

The funds also will create new job opportunities for psychologists to work alongside physicians, nurses and social workers in an integrated-care setting in schools, says Vincent C. Alfonso, PhD, professor of school psychology at Fordham University and president of APA's Div. 16 (School). "The Affordable Care Act funding is huge," he says. "Today, there is a national crisis in serving the mental health needs of children and adolescents, and schools are good places to receive those services. We know from research that the earlier we intervene, the higher the probability of success."

The Affordable Care Act allocated $200 million from 2010 to 2013 to build new school-based health centers, modernize existing ones or purchase needed equipment. So far, $190 million has been awarded to 520 school-based health-care programs. It is the first time that federal funding has been specifically allocated for school-based health centers, although the centers have been eligible to apply for other federal health-care grants.

The money will help provide more solid financial footing for school-based health centers, which rely on a mix of grants and government funds. Even though the Affordable Care Act funding is geared toward construction and equipment, it will free up other funds to hire new staff, says Ronald S. Palomares, PhD, assistant executive director of APA's Practice Directorate.

"It has a tremendous impact, on school-based health centers and for children, to break down barriers to access for health care," says Palomares, who previously worked in school-based health centers in Dallas.

Nearly 2,000 school-based health centers operate nationwide, with 75 percent employing a mental health provider, according to the National Assembly on School-Based Health Care. The centers serve approximately 2 million students, and mental health counseling is the leading cause for visits by students, according to several surveys. The centers typically provide primary and mental health care, substance abuse counseling, case management and health education. Some clinics also offer dental exams and pregnancy prevention programs, and they often are operated as a partnership between a school district and a local community health organization.

Improving access to care

Psychologists in school-based health centers provide counseling for students with mental health problems, such as depression or anxiety. They also address behavioral issues related to treatment plans or lifestyle choices that affect chronic conditions, including asthma, diabetes and obesity. Psychologists also may lead group sessions on pregnancy prevention or substance abuse, and they work with school psychologists and teachers to address issues that may arise in the classroom because of a child's mental illness or learning disability.

Licensed psychologists who work in school-based health centers don't need to be credentialed as school psychologists as long as they have relevant education, training or experience working with children and adolescents, Palomares says. A psychologist also could enlist the help of a more experienced colleague as a mentor at a school-based health center.

School psychologists who work for local school districts may perform some of the same services as health center psychologists, such as leading group sessions, but their main focus is academics, primarily evaluating students with learning or developmental disabilities and providing services based on a student's individual education plan as mandated under federal law, Palomares says.

The services at school-based health centers often are free to students, thanks to grant funding, private insurance or Medicaid. As a result, they offer a critical resource for low-income students to access mental health care, Alfonso says.

Research has shown that school-based health centers can help reduce absenteeism and costly emergency room visits. One study showed that inner-city students were 21 times more likely to make mental health-related visits to school-based health centers than to facilities outside their schools (Journal of Adolescent Health, 2003). Another study found that students served by health centers had fewer discipline problems, course failures and school absences (Journal of School Health, 2000).

Health centers inside schools also can save tax dollars, according to a study by University of Cincinnati researchers (American Journal of Public Health, 2010). The study analyzed Medicaid reimbursement costs for more than 5,000 students in seven schools with health centers and six schools without in the Cincinnati area. The estimated savings in the schools with health centers totaled more than $1.35 million over three years, or approximately $35 per student per year, the study found.

By serving students in schools, health centers also eliminate transportation costs for parents along with the time and wages they might lose if they had to take their children to health-care appointments outside school, Palomares says. Students also may refer their friends if they notice problems, which increases the reach of the health center as the staff becomes part of the school community, he says.

‘Whatever the kids need'

In Snow Hill, N.C., that sense of school community led psychologists and doctoral students from nearby East Carolina University to help students and teachers when a tornado ripped through the small town in 2011, destroying many homes along with the middle school.

"We were out in the parking lot while the teachers were cleaning out their classrooms," says Jeannie Golden, PhD, an associate professor of psychology at East Carolina University. "Some of them were bursting into tears. We did on-the-spot crisis counseling."

Golden supervises doctoral students who specialize in pediatric school psychology and provide mental health counseling at two local middle schools and Greene Central High School in Snow Hill. Located in a trailer on the high school grounds, the health center employs a nurse practitioner and offers a pregnancy prevention program in addition to primary and mental health care. The doctoral students receive clinical experience and firsthand exposure to the challenges faced by many of the 850 high school students, including poverty, domestic violence, substance abuse and teen pregnancy. One in four children in Greene County lives below the national poverty level, and 71 percent of children qualify for free or reduced-price school meals, according to county statistics.

Depression, anxiety and suicidal ideation are common problems for the high school students, and some are undocumented immigrants who have no access to health care except at the school clinic, Golden says. Parental resistance and stigma surrounding mental illness often keep students from seeking help outside a safe school setting, she says. "A lot of these kids come from really impoverished backgrounds, and they don't even have primary-care doctors," Golden says. "We work on mental health issues that are often related to their medical issues."

Golden has helped organize several family health education fairs and a tutoring program for struggling high school and middle school students, along with obtaining an abstinence education grant to help fund work at the high school health center. "You can't just go in there and do mental health counseling," she says. "You have to do whatever the kids need."

The pediatric school psychology program at ECU, directed by Christy Walcott, PhD, seeks to combine the skills of school and health psychology to provide both clinical experience and a strong scientific foundation for future research, says Dennis Russo, PhD, who directs the behavioral medicine program in the department of family medicine.

"The program trains students to work with children to identify behavioral factors that can contribute to physical or mental illnesses and to take preventative steps to help keep them healthy," he says. "Early identification and treatment at school-based health centers can make a huge difference."

The pediatric school psychology program, which was created in 2007 and has applied for APA accreditation, prepares entry-level school psychologists to work with adolescents and children in a variety of settings, particularly school-based health centers. Students learn about the interrelationships among physical health, emotional well-being, lifestyle choices and academic progress.

Several other universities offer doctoral programs with an emphasis on pediatric school psychology, including Lehigh University, the University of South Florida and the University of Arizona.

Psychologists may find more career opportunities in school-based health centers if an additional $50 million in operations funding that was authorized under the Affordable Care Act is approved by Congress for the 2014 fiscal year budget. Members of the National Assembly on School-Based Health Care met with members of Congress in June to urge them to provide the needed funds.

More than 70 school superintendents, principals and other school officials also signed a letter in April urging congressional leaders to appropriate the additional funds. "In our schools, we have seen school-based health centers keep students healthy and at their desks," the letter stated.

Brendan L. Smith is a writer in Washington, D.C.