In the summer of 2024, the Rockefeller Institute of Government held a series of public hearings across New York State to solicit input from education stakeholders on reforming the state’s Foundation Aid school funding formula. Among the most pressing issues facing schools and districts cited in these testimonies was the need to improve access to, delivery of, and funding for student mental health services. These observations reflect findings of the Centers for Disease Control and Prevention that 42 percent of high school students suffered from “overwhelming stress and anxiety,” a whopping 50 percent increase from 2011.

There is a growing movement in New York to replace or supplement traditional school nurses’ offices with more complete school-based health centers (SBHCs). The New York State Department of Health (NYSDOH) notes that these clinics provide more comprehensive and immediate health services to students, including such things as:

• comprehensive physical health assessments;
• diagnosis and treatment of acute illnesses and chronic conditions, such as asthma;
• vision, hearing, dental, nutrition, and other screenings;
• management of chronic diseases, such as diabetes;
• health education;
• immunizations;
• sports physicals; and
• referrals to specialists.

Many SBHCs also provide behavioral health services, including mental health assessments, counseling, and referrals. Indeed, NYSDOH requires SBHCs to provide referrals to mental health services if not direct access to them: “On-site services should include mental health care in both individual and group settings, including assessment, treatment, referral, and crisis intervention.”  

Currently, there are approximately 250 school-based health centers in New York, an increase of around 25 percent from 16 years ago, and they now serve more than 250,000 students, many from low-income families in some of the state’s highest-need communities. These centers typically are not run by the schools or school districts themselves, but rather operate in partnership with and under the management of local public and private hospitals, regional health centers, and other medical service providers in the community. These partner organizations provide all or most of the medical equipment, supplies, and staffing—including mental health counsellors—that are used every day in the school health centers. A 2019 review of the evidence of SBHCs summarized the centers’ impact succinctly: “SBHCs increase access to health services for children, families, and communities, which ultimately leads to positive short- and long-term outcomes.

For many school districts—particularly smaller and rural districts—providing quality mental health services for students (let alone comprehensive general health services) is challenging at best. A 2020 analysis of school-based mental health services in urban, suburban, and rural locations noted that schools “in rural communities were most challenged providing diagnostic assessment and treatment for students by school mental health professionals.” A lack of qualified therapists and other health care professionals who are available and seeking to work in sparsely populated areas strained school budgets because of relatively low total student enrollment and required long-distance travel if the job was split between two districts. These and other factors combined to make it difficult to create a workable and sustainable service-provision structure for students. A September 2022 report by the Kaiser Family Foundation found that “a shortage of qualified mental health professionals continues to stymie schools’ mental health service response,” and the National Education Association has more recently noted that “mental health services… are limited in rural communities.”

Importantly, the infrastructure for improving the situation appears to be precarious, too. A June 2025 report by the Center for Healthcare Quality and Payment Reform found that 58 percent of New York’s rural hospitals are at risk of closure, with 34 percent at immediate risk to close. This means that there are likely to be fewer healthcare providers even available to establish school-based health centers in partnership with rural school districts.

These challenges are not insurmountable. In 2023, a team of researchers from Cornell University conducted a case study of the efforts by the Bassett Healthcare System, headquartered in Cooperstown, to grow school-based health centers in rural school districts. The study found that “students attending [rural] schools embedded with nonprofit-run health clinics received more medical care, relied less on urgent care, and missed less school” than a peer comparison group. Bassett has now grown to be the primary operator of school-based health centers in the Otsego-Northern Catskills BOCES region, with clinics operating at 21 different school sites. And in the North Country, ConnextCare—Oswego County’s largest primary care provider network, including 19 mental health practitioners—has established SBHCs at eight elementary, middle, and high schools in the region.

In 2021, the New York School-Based Health Foundation (NYSBHF), with funding support from the New York Health Foundation, launched its “Data Hub” project. The Data Hub collects clinical service and demographic data from more than half of the SBHCs in the state, and this data is used by the operating partners to develop actionable plans to improve and grow healthcare service delivery to students.”

State policymakers could use the experiences of existing SBHCs in New York—particularly the work of Bassett Healthcare System in rural areas and information from NYSBHF’s Data Hub—to inform support for models that centralize, coordinate, and spark collaboration among rural and small school districts to grow access to mental health services for public school students. There are 280 school districts in New York that each enroll fewer than 1,000 students (this translates to 42 percent of the state’s school districts serving only six percent of its K-12 total student population);[i]  these limited-resource districts could be prioritized for the most immediate attention.

As the Rockefeller Institute previously noted, however, “While establishing a full health clinic in each school across the state might be impractical, at least in the short term, using the cooperative shared-services, or ‘Co-Ser,’ approach currently in place at every BOCES across the state offers a strong model to emulate. In addition to enhancing state support for existing SBHCs, New York policymakers could use this well-developed framework to ensure the provision of and access to student mental health services” in some of the state’s most rural and sparsely populated school districts.

Under the Co-Ser model, clinical social workers, community mental health workers, school psychologists, and other mental health service providers would be located at a regional BOCES and access to them would then be shared by all constituent districts. A number of benefits accrue to districts from this approach, including shared costs and the ability to continue services for students even if one provider is absent or on leave, as another member of the health services team at BOCES would be able to cover that person’s shift.

Bringing this model to scale across New York State’s more rural areas likely would need to be a multi-year effort. Still, policymakers could initiate a long-term plan for the growth of SBHCs statewide. The Rockefeller Institute first introduced a potential five-year framework for such a plan in its December 2024 Foundation Aid reform report, that is now expanded upon here.

A Five-Year Framework for Expanding SBHCs

Year One

• With BOCES leadership, select the first regions to pilot the initiative. These could include two or three regions that can fairly be classified as “very rural” and two or three that are “mostly rural,” regions characterized by low K-12 total student enrollment (fewer than 34,000 students districtwide), extremely low density of student populations (less than 30 students per square mile), or both.

“Very Rural” BOCES Regions	“Mostly Rural” BOCES Regions
Cayuga-Onondaga	Clinton-Essex-Warren-Washington
Cattaraugus-Allegany-Erie-Wyoming	Broome-Delaware-Tioga
Delaware-Chenango-Madison-Otsego	Erie 2-Chautauqua-Cattaraugus
Franklin-Essex-Hamilton	Genesee Valley
Herkimer-Fulton-Hamilton-Otsego	Greater Southern Tier
Otsego-Delaware-Schoharie-Greene	Hamilton-Fulton-Montgomery
Madison-Oneida	Jefferson-Lewis-Hamilton-Herkimer-Oneida
Sullivan	Oswego (CiTi)
	Questar III (Rensselaer-Columbia-Greene)
	St. Lawrence-Lewis
	Tompkins-Seneca-Tioga
	Ulster
	Wayne-Finger Lakes

• Recruit a community healthcare provider for each selected region, and work collaboratively with the BOCES to administer a thorough onboarding process.
• Ensure that sufficient administrative and operational infrastructure exists at each participating BOCES to accommodate having students on-site for healthcare services.
• Ensure commitments from partner healthcare providers for staffing sufficient to meet projected service demands for students from throughout the region.
• BOCES and the partner provider work together to ensure or create sufficient treatment space at the BOCES site.
• Enter into Co-Ser agreements as needed with districts and individual schools.
• Allow time for training of school district leadership and the partner providers before service delivery to students begins.  

Year Two 

• Start the roll-out of mental health services (and other general health services, as able and appropriate) to students in the selected pilot BOCES regions.
• Begin start-up (Year One) activities with a second pilot group of BOCES, to again include a few “very rural” and a few “somewhat rural” districts.

Years Three through Five

• Add two or three “very rural” and two or three “mostly rural” BOCES districts to the model each year until all 18 of the noted BOCES regions have an established student mental health services program in place.

The Otsego-Northern Catskills BOCES, a “very rural” region where Bassett Healthcare System’s well-developed network of school-based health centers already exists, could serve as an advisor to each of the BOCES regions throughout the process. Also, as the program matures, partner healthcare providers may seek to move from the regional model to setting up individual school-based health centers. In such instances, the NYSBHC Foundation could work collaboratively as an advisor with BOCES leadership, local school districts, and the partner healthcare provider organizations to help ensure a smooth transition to school-based centers.

As a state initiative, it would be reasonable to plan state funding that would accompany this effort to ensure a successful launch, planned expansion of the model, and continuing effective implementation. Such funding could be targeted to specific key items and activities, if desired, and reasonably could include: shared mental health service staff at each BOCES location; capital costs and supplies to ensure sufficient appropriate treatment space, which could be attached to commitments from private healthcare service partners to provide equipment; and, start-up operational costs. 

Additionally, more innovative approaches—including mobile health care clinics and expanded use of telehealth for behavioral health—could be explored. Partnerships between the New York State Education Department and the New York State Office of Mental Health could be established to facilitate any needed changes in regulations and practice that currently limit these delivery methods and, where needed, the centralized BOCES could serve as the physical “brick-and-mortar” hub through which the portable mobile clinics and virtual telehealth services flow.  

Sustained state support for annual operating costs, even if shared among community partner organizations and local school districts, could help ensure the long-term success of this model of regionalized delivery of student mental health services, better meet the urgent and immediate need for these services, and serve as a solid foundation for the development of individual school-based health centers in rural districts wherever possible.

ABOUT THE AUTHOR(S)

Brian Backstrom is director of education policy studies at the Rockefeller Institute of Government

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[i] New York State Education Department. Enrollment Database https://data.nysed.gov/files/enrollment/23-24/enrollment_2024.zip. NYSED Data Site. https://data.nysed.gov/downloads.php