November 2003

Grant Results

National Program

Making the Grade: State and Local Partnerships to Establish School-Based Health Centers

SUMMARY

From 1994 to 2000, the state of Connecticut expanded and enhanced its system of school-based health centers (SBHCs).

The Connecticut Department of Public Health, School and Primary Health Unit led the project.

The project was part of the Robert Wood Johnson Foundation (RWJF) Making the Grade: State and Local Partnerships to Establish School-Based Health Centers national program.

Key Results

  • Connecticut Making the Grade helped form four new school-based health centers — two in Bridgeport and two in New Haven.
  • Making the Grade staff helped establish the Connecticut Association for School-Based Health Care to promote school-based health centers.
  • Making the Grade aided the state in developing a uniform service package outlining core services provided at all state-funded school-based health centers.
  • Connecticut school-based health centers won the right to participate in Medicaid, a change that opened up a new funding source but also imposed new demands on the program in the areas of contracts, standards and billing.
  • The project team spent considerable time negotiating contracts with managed care organizations and, in time, received national recognition for its experience on managed care reimbursement issues for school-based health centers.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through three grants totaling $2.2 million.

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THE PROBLEM

Connecticut remains a paradox, according to the state Department of Public Health and Addiction Services: although it boasts the highest per capita income in the nation, it also has some of the poorest cities. The state capital, Hartford, was ranked the eighth poorest city in the 1990 U.S. Census; according to the Children's Defense Fund, Hartford is sixth in the nation in terms of proportion of children living in poverty (43.8 percent).

The state had several mandates requiring school districts to provide health services for all students, but funding was strictly dependent on local communities. As a result, there was significant variation in staffing and services from one district to another. Connecticut began Making the Grade with 29 school-based health centers (SBHC) already in operation in the state and nearly $4 million in state appropriations.

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THE PROJECT

The overall goal of the Connecticut Making the Grade project was to expand comprehensive school-based health services for school-aged children and adolescents. The objectives for achieving this goal were to:

  1. Institutionalize school-based health care as a service delivery mechanism.
  2. Reorganize state and local funding resources to increase their availability to SBHCs.
  3. Implement a comprehensive communications strategy to build support for SBHCs.
  4. Enhance the capacity of the state agency to support SBHCs.
  5. Establish two new school-based health centers each in two school districts.

The Making the Grade project team was housed in the state Department of Public Health, School and Primary Health Unit, where it provided technical assistance to school-based health centers on data collection, contracts and billing, communications and staff training. It also oversaw quality improvement, monitored contracts, collected and analyzed data and facilitated policy discussions. A Project Steering Committee, created during the planning grant, linked the project office to other state agencies. The committee included representatives from state agencies concerned with child health and welfare, thus linking the project office to other state agencies.

The Making the Grade project began by making small planning grants to two communities, each of which formed an advisory board and conducted a needs assessment in preparation for creating one or more school-based health centers. The Connecticut program was one of only three Making the Grade states to complete its planning objectives and be ready to move to the implementation phase in a little over a year.

During the implementation phase, the project supported two community partners, chosen with the Steering Committee, in establishing four new SBHCs — two in Bridgeport and two in New Haven. Partners were required to provide at least one-fourth of center budgets through in-kind contributions. Connecticut requires its school-based health centers to be licensed as outpatient clinics or hospital satellites. A uniform service package outlines all core services that Connecticut SBHCs must provide. (See Results.)

As in many states, the 1996 election ushered in a more conservative governor and legislature, new executive branch appointees and fiscal conservatism. This led to spending caps and regular calls for state agencies to trim budgets as well as a transition to Medicaid managed care. Connecticut Making the Grade helped create the Connecticut Association for School-Based Health Care and engaged a marketing consultant to develop a communications strategy for creating visibility and building political support for SBHCs in the state. Connecticut communities have varied in their receptivity to school-based health centers, but a statewide campaign to suppress them never developed. Centers formed in more receptive communities, and community fears, where they did exist, were defused.

The financing strategy for the SBHCs was based mainly on a grants program, supported by the state general appropriations budget. Patient care revenues became a second strategy when the state made all SBHCs part of the managed care network for Medicaid and the State Child Health Insurance Program (called HUSKY Parts A and B, respectively). Other funding sources included funds from the multi-state settlement with tobacco companies and the federal Maternal and Child Health Block Grant program.

The ability to participate in Medicaid imposed new demands on the project in the areas of contracts, standards and billing. Working closely with the state Medicaid agency, the project team spent more than two years negotiating contracts with managed care organizations. In the process, Connecticut Making the Grade achieved recognition for its experience with managed care reimbursement issues for school-based health centers, according to project director Christensen.

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RESULTS

During the Making the Grade national program, Connecticut Making the Grade:

  • Helped form four new school-based health centers — two in Bridgeport and two in New Haven. Statewide, the number of SBHCs grew from 29 to 57 by mid-2000; three additional centers were being developed at that time. All but six of the centers receive state support. The state appropriation in fiscal year 2001 was nearly $6 million.
  • Secured a place for school-based health centers as an integral part of Medicaid managed care networks. SBHCs have been designated "essential community providers," and the state requires health plans to contract with Department of Public Health-licensed SBHCs. Staff at Making the Grade also helped SBHCs develop capacity for billing and keeping records of health care encounters.
  • Secured increased line item funding for school-based health centers in the state budget. This was achieved through increased funding to the SBHC line item in the Department of Public Health.
  • Helped the state develop and implement a comprehensive model for school-based health centers. The modelestablished the core services that must be provided at all state-funded SBHCs, including primary care, mental health treatment and preventive services.
  • Established the Connecticut Association for School-Based Health Care. Staff at Connecticut Making the Grade worked with the association and a marketing consultanton improving the visibility and credibility of SBHCs in the state. The association eventually secured independent funding and became a chapter of the National Assembly on School-Based Health Care (www.nasbhc.org).

Communications

As part of its comprehensive communications strategy, the project produced brochures, tabletop displays and press and action kits to inform parents, legislators and others about school-based health centers. The brochures and press kits were distributed throughout the state to SBHC schools, the legislature, state agency leadership, community agencies and the general public. Tabletop displays were used at parent nights, community meetings and state and national conferences. The state project office also produced annual reports for 1998 and 1999.

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LESSONS LEARNED

  1. A well-organized project steering committee can facilitate the collaborations necessary to building strong school-based health centers. The steering committee for this project played a key role in the growth of SBHCs. According to the project's final report, this interagency committee (described above) facilitated a strong partnership with the Medicaid agency as well as collaborations with and in-kind donations from the departments of Education and Correction. (Project Director)
  2. A proactive communications strategy can be pivotal in building support in local communities and in state government. The project's final report credits the communications strategy as a major factor in maintaining state funding. Such a strategy educates people not only about what school-based health centers do, but also about the needs of children and adolescents. (Project Director)

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AFTER THE GRANT

The state continues to work toward developing a reliable statewide data system for SBHCs, a goal that proved elusive during the project. The state is also working toward tapping the potential of private insurance and Medicaid behavioral health as sources of reimbursement for services provided by the SBHCs. Following Making the Grade, the Connecticut Association for School Based Health Care and the Department of Public Health reviewed SBHC outcome measures with a plan to recommend changes to improve accountability and enhance outcome data.

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GRANT DETAILS & CONTACT INFORMATION

Project

Connecticut Making the Grade

Grantee

Department of Public Health, School and Primary Health Unit (Hartford,  CT)

  • Amount: $ 100,000
    Dates: January 1994 to March 1997
    ID#:  023519

  • Amount: $ 1,543,765
    Dates: September 1995 to August 1999
    ID#:  027113

  • Amount: $ 556,235
    Dates: September 1997 to September 2000
    ID#:  032362

Contact

Donna Christensen
Dorothy Pacyna
860-509-8057
dorothy.pacyna@po.state.ct.us

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Book Chapters

Dowden SL, Calvert RD, Davis L and Gullotta TP. "Improving Access to Health Care: School-Based Health Centers." In Establishing Preventive Services. Weissberg RP, Gullotta TP, Hampton RL, Ryan BA and Adams GR (eds.). Thousand Oaks, Calif., London and New Delhi: Sage Publications, 1997.

Gullotta TP, Noyes L and Blau GM. "School Based Health and Social Service Centers." In Adolescent Dysfunctional Behavior, Gullotta TP and Blau G (eds.). Thousand Oaks, Calif., London and New Delhi: Sage Publications, 1996.

Articles

Gullotta TP and Noyes L. "The Changing Paradigm of Community Health: the Role of School-Based Health Centers." Adolescence, 30(117): 107–115, 1995. Abstract available online.

Reports

School Based Health Centers: Healthy Kids Make Better Learners (Basic Introductory Kit to School Based Health Centers in Connecticut). School and Primary Health Unit, State of Connecticut Department of Public Health, 1996.

School-Based Health Center Coordinator's Action Kit: Healthy Kids Make Better Learners (Basic Media Introductory Kit for School Based Health Centers in Connecticut). School and Primary Health Unit, State of Connecticut Department of Public Health, 1996.

School Based Health Centers 2000 Annual Report on 1998–1999 Activities. Hartford, Conn. State of Connecticut Department of Public Health, 2000.

State of Connecticut Department of Public Health. Health Needs Assessment: School Based Health Centers, Bridgeport, Connecticut. Portland, Maine: Commonwealth Marketing and Development, 1997.

State of Connecticut Department of Public Health. Health Needs Assessment: School Based Health Centers, Bridgeport, Connecticut, Executive Summary and Plan. Portland, Maine: Commonwealth Marketing and Development, 1997. Unpublished.

State of Connecticut Department of Public Health. Health Needs Assessment: School Based Health Centers, New Haven, Connecticut, Executive Summary and Plan. New Haven, Conn.: New Haven Public Schools, 2000.

State of Connecticut Department of Public Health. School Based Health Centers Annual Report 1997–1998. Hartford, Conn.: Hamer and Associates, 1999.

Su Centro de Salud en La Escuela. School and Primary Health Unit, State of Connecticut Department of Public Health, 1996.

The Voice of Connecticut Youth: a Comprehensive Adolescent Health Survey of Students in the 7th through 11th Grades in the State of Connecticut. State of Connecticut Department of Public Health, 1996.

Your School-Based Health Center. School and Primary Health Unit, State of Connecticut Department of Public Health, 1996.

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Report prepared by: Susan Baird Kanaan
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Judith Stavisky

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