The 252 school-based health centers (SBHCs) operating in New York State serve more than 250,000 students. These health centers provide a range of services on school premises, from primary to behavioral health care—and, in some cases, dental and vision care—and augment the health services children receive from traditional healthcare providers. On the latest episode of Policy Outsider, Senior Fellow for Health Policy Courtney Burke interviews Dr. Viju Jacob, a pediatric specialist in the Bronx who works for Urban Health Plan, which operates several SBHCs, and Ronda Kotelchuk, founder of the Primary Care Development Corporation and current chair of New York State Foundation for School-Based Health Centers, to learn more about SBHCs, the positive health and academic outcomes they support, and what is needed to maintain and expand the important services they offer to students.
Courtney Burke, senior fellow for health policy, Rockefeller Institute of Government
Dr. Viju Jacob, pediatric specialist, Urban Health Plan
Ronda Kotelchuk, founder, Primary Care Development Corporation & Chair, New York School-Based Health Foundation
H+H: Health and Hospitals
HRSA: Health Resources and Services Administration
FQHC: Federally Qualified Health Center
SBHC: School-Based Health Centers
Transcript was generated using AI software and may contain errors.
Alexander Morse 00:05
Welcome to Policy Outsider presented by the Rockefeller Institute of Government. I’m Alex Morse. Today’s episode is going to focus on school-based health centers, which provide primary health care to kids in school settings. They have been around for decades and there are currently 252 of them operating around New York state. Those 252 school-based health centers are in schools serving an estimated 253,390 students. To learn more about the centers, the types of services they provide, how these services are funded, and what their future might look like, Rockefeller Institute Senior Fellow for Health Policy Courtney Burke, will interview Dr. Viju Jacob, a pediatric specialist in the Bronx who works for Urban Health Plan, which operates several school-based health centers, and Ronda Kotelchuk, founder of the Primary Care Development Corporation and current chair of New York State Foundation for School-Based Health Centers. Coming up next.
Courtney Burke 01:00
Well, hello, and thank you for joining us today on the very important and timely topic given that it’s school season. Again, I would like to welcome Ronda Kotelchuk and Dr. Viju Jacob to our program today to talk about school-based health centers. So we know that school-based health centers are a good way for kids to have easy access to primary care. And we know that they’re located in hundreds of schools throughout New York and serve 1000s of kids across the state. But we want to learn more about them today. And we’re gonna start out with a question for Dr. Jacob. Give us a sense of the people who use these school-based health centers, are their qualifications to use them? Can anybody use them? How do they work in general?
Dr. Viju Jacob 02:03
So yes, school-based health centers are located in high need schools, all throughout New York State. And typically there are meant to serve the students that are in the building. Now there are some rural schools in New York State that sometimes do allow others to also access to care. So siblings or other family members, but typically, the school-based health centers intended for the schools, the students that are in the building.
Courtney Burke 02:29
Oh, that’s great. So it’s not just the students, but at times it can be members of their family, that’s really helpful to know. And so how are these types of centers different from the types of primary care that school child might get elsewhere from, say, a family doctor or pediatrician? Are they similar services? How are they similar or different?
Dr. Viju Jacob 02:50
So typically, school-based health centers are, I like to think of them as sort of co-providers of care for the students that are in the building. So they’re not there to replace a primary care provider or a pediatrician, we value those relationships that families have with their local providers. But many times because the student is in a school building, you know, the bulk of their time, it’s access, that’s really the bigger question. So if a student needs services, the fact that the services are in the facility that they’re in, that allows them to access the care, and we’re offering the entire realm of primary care services. So whether it’s well visits, if they get sick during the school day, or if they have an injury during the school day, rather than having to have the parent come pick up the child take them to another location, they can have those services offered to them in the school clinic. And that that’s really the big, you know, sort of sell of a school-based health center and many school-based health centers, in addition to primary care also offer mental health services. Some of us offer dental services, and a very small proportion also have some optometry services available for the students.
Courtney Burke 03:57
So it’s really a it’s a broad range of primary care and related services. And you mentioned mental mental health services as well, that’s more comprehensive than I might have guessed.
Ronda Kotelchuk 04:06
And let me add that these school-based health centers are located in schools in underserved areas, many of which lack other access to primary care. So for many of these children, this is the only access that’s available to them.
Courtney Burke 04:23
Ah, okay. So the very important service, particularly some you said, a lot of are in urban areas, but also rural areas as well, where they might not otherwise be able to access these types of services.
Ronda Kotelchuk 04:36
Yes, very important in both areas.
Courtney Burke 04:40
Okay, great. So just to understand them a little bit better, who generally operates them? Are they operated by the school? How are they paid for? How are they staffed? The think it’s a good question for either one of you. But let’s start with Dr. Jacob since since you are working in one on a daily basis.
Dr. Viju Jacob 04:59
You know, About half of school-based health centers in the state are run by what is known are Federally Qualified Community Health Centers. So they are community providers of care. And the other half roughly are operated by hospital systems. And typically, they’re funded through a combination of a little bit of everything. So you know, there’s a small state subsidy, that sort of is the base grant that we all operate out of. The biggest bulk of our revenue stream is billing to Medicaid, and Medicaid managed care to some extent, and a large part of the hole is filled in by our sponsoring agencies. So you know, many of our sponsoring agencies, you know, pick up about a third, if not more of the costs of operating, because they know this is the right thing to do for these high needs communities.
Ronda Kotelchuk 05:47
Let me and that the result is that you get financially fragile, who operate under a burden of underfunding. And therefore, you know, if if that funding were more reliable, and were more adequate, then we’d be in a much better position to spread the number of school-based health centers in these kinds of schools.
Courtney Burke 06:09
And limit Let me follow up on that Ronda, because you serve as the chair of the New York State Foundation for School-Based Health Centers. So a question for many people would be well, what is the impact of the centers relative to other sorts of primary care? What impact are they having on the students? I would say, first of all their health, but also their overall connection with their schooling, does it help improve their educational outcomes as well?
Ronda Kotelchuk 06:36
We wish the research were more robust. And that’s one of the objectives of our foundation. But through case studies, surveys and other techniques, we know that when a school has a school-based health center, the children do better academically, the rates of grade promotion and graduation are higher. We think that this positions them well, both educationally and in healthcare terms for a lifetime of success. It’s an ounce of prevention at a point in a time when you know, a whole lifetime can be affected, we know that they also are impactful on the healthcare front. So children enrolled and served by school-based health centers will have less frequent rates of use of emergency rooms, and hospitals. So it’s a savings to the healthcare system, as well as an investment in our future generations.
Courtney Burke 07:33
That’s important to know. And also important to know that you’re looking to research the topic more to see what the impacts truly are. So it seems like they’re generally positive from what you’re saying. Are school administrators also then supportive of school-based health centers?
Dr. Viju Jacob 07:48
Very much. So we’re typically in a situation where there probably more communities requesting our services than we can actually offer because of the funding paradigm that Ronda mentioned. So we’re, we’re very popular with the school community.
Ronda Kotelchuk 08:03
And school-based health centers only operate where they are wanted, and embraced by principals because it requires some investment by the school. For instance, they have to make the space available, and their cooperation being fully knowledgeable on board is therefore really important.
Courtney Burke 08:22
And what is the current state of how administrators as well as state policymakers and legislators how to how do they feel about school-based health centers generally? Do you have support? Are you looking for more support? What are the different debates the pros and cons that you hear from some of those policymakers?
Ronda Kotelchuk 08:41
Viju, I’ll let you start.
Dr. Viju Jacob 08:43
You know, in general, we’re actually fairly popular with both houses of the legislature in the last several years, they’ve actually passed legislation across the board to continue to allow school-based health centers to remain carved out or Medicaid, so we can continue to offer the services with as little burden as possible. The dilemma always becomes, you know, we’re a very small piece of the very large healthcare pie that is New York State. And so we sometimes get forgotten in how the money is doled out. But we tend to be very popular with most of our legislative colleagues.
Ronda Kotelchuk 09:19
That points to kind of a central problem, a key problem in my mind about school-based health centers. And that’s the issue of visibility. I think that we operate under the radar and have very little recognition or visibility on the policymaking fronts, on the educational front, or the healthcare front. And that’s one of the major campaigns that the the foundation supports. We need to get out there the information about how important these are and what their potential is in the community. And we seek to build greater support and partnership with the state, which provides a grante each year. And we feel like we have to defend it against the ever present need to cut back budgets. And we feel like there’s a lot that could be done in partnership with the state. The legislature is fully on board. And we certainly have appreciated that.
Courtney Burke 10:18
Well, that’s interesting. When you say that you seem to have support. I had recently read that Health and Hospitals, which is a large network of public hospitals in the city and in the state was potentially planning to close some school-based health centers. Is that part of a larger trend? Or what do you foresee happening in terms of opening or closing new school-based health centers?
Ronda Kotelchuk 10:42
Maybe I’ll start and then let you come in on this Viju. I think that H+H closing all elevens school-based health centers is a case in point for how financially fragile these are. And when a sponsoring institution comes under financial pressure, they look for where they are losing money. So that makes supremely important our ability to enhance revenue sources so that they’re reliable and they’re adequate. Each year, we see a few really financially fragile, school-based health centers operated by hospitals or FQHCs, that are under financial pressure close usually, they’re the smaller ones. But we also see sponsors who, by hook and by crook, find the resources to expand. So I think we’re pretty steady. But let me ask you your view Viju?
Dr. Viju Jacob 11:39
Yeah, so I completely agree. So we do, unfortunately, from time to time, have some locations that close and H+H. As Ronda said, you know, we’re we’re always sort of trying to balance a very, very thin margin of financial viability. And any sort of loss in that revenue stream makes a big difference. And a big part of it is everyone is eligible to get access at school-based health center. So when you walk through our door, as long as there’s parental consent, you’re offered services. So we don’t sort of say, do you have insurance, do you have this particular insurance… only going to go to private practice, if you’re not participating in the private practices plans, we generally say either you have to join the plan, or we have to go to another provider. At a school-based health center, we see all patients have walked into the door, as long as there’s parental consent. So that puts us in a unique ability to serve everybody. But that also puts us at a unique place, where if the parents do not provide us with insurance information, we still offer the care, but we’re not reimbursed for it. And that’s sort of, you know, as I said about a third plus of our operating revenues really reliant on reimbursement. And if we don’t have the insurance information, for the patients that are insured, it’s in New York State, most children are eligible for some version of insurance, if we can’t get that insurance information, which is why it’s important for us to stay carved out of Medicaid, because at least it makes it easier if we can build directly to Medicaid, rather than having to then renegotiate contracts with multiple managed care plans, who may only have one or two patients in our population. And so that becomes very cumbersome for you know, a program that’s operating right on the brink of financial viability.
Courtney Burke 13:18
Well, that’s very important to understand, because one of my questions, I guess, really for for both of you is, since they seem to have a fair amount of success with serving kids, and you’re not having to worry about some of the other administrative barriers that might get in the way to people accessing care, what stands in the way of expanding the centers even further?
Dr. Viju Jacob 13:40
An idea that we’ve sort of thrown around in New York City is typically, schools are obligated to have some level of nursing coverage. And there’s, you know, there is a steady budget line for that nursing. There is no budget line necessarily for school-based health centers. And an idea we’ve sort of tossed around in the New York City area is, you know, if there is a possibility of using some school streams of funding and not just healthcare streams of funding to keep school-based health centers operational, so potentially, in a school that when a school-based health center comes in, they take away the school nurse, because we offer those we take care of some of those services, you know, can they use some of that funding that is now potentially saved by the locality to, you know, to help fund the school-based health centers? So, you know, we’re always trying to think of different models of care that brings in new pipelines of funding to sort of cover the cost of care that we’re providing for either uninsured students or students that we just don’t have insurance information about.
Ronda Kotelchuk 14:44
And I think if if the revenue streams were more adequate and more reliable, you’d see a great expansion in the sector. I think there is no one who disputes the, well, that I don’t believe there’s many people who dispute the effectiveness of school-based health center. It’s the limiting factor is the ability to support themselves financially.
Courtney Burke 15:06
Now that’s helpful. And I think it was also helpful to hear a little bit more detail about what was happening at the state level in terms of policy positions and policy changes and whether they’re support or not. So my next question is, at the federal level, have there been any recent changes to be supportive or change how school-based health centers are funded.
Dr. Viju Jacob 15:28
Probably a decade or longer. ago, the Feds actually created a separate line item, just like they have a Federally Qualified Community Health Centers for school-based health centers. Unfortunately, they didn’t tie it to any regular stream of funding. You know, they’ve had a couple of one off funding streams primarily for setting up a school-based health center, but not necessarily operationalizing a school-based health center. So, you know, we’ve certainly at Urban Health Plan benefited from some of that funding, you know, we were able to expand our dental services the last time the funding opened up, we use other smaller grants to expand our behavioral health services. So you know, when that funding is available, we certainly are happy and are willing and open to expanding our services. But it’s not a steady stream at this point.
Ronda Kotelchuk 16:16
And I think the objective of the national organization and probably every state organization is to see appropriations tied to that line in the budget so that, you know, just the same way that HRSA supports homeless providers under the FQHC program and a variety of other specialized providers.
Courtney Burke 16:38
Before I get into some of the closing questions, I did want to search to see if there were any criticisms of school-based health centers that we should talk about or address. The only thing I could think of was the potential for them not to be completely connected to the other services and supports that child may be getting outside of the school. So if you could address that question, how do they connect services with other healthcare an individual might be receiving in other locations.
Dr. Viju Jacob 17:10
So as a requirement of becoming a patient at a school-based health center, we as the operator of school-based health centers have to notify the primary care provider that, you know, the child is now enrolled in a school-based health center. We also try our best to coordinate this care with the primary care provider. So I’ll give an example at Urban Health Plan, if I have a patient that needs a referral, you know, we happen to see them for some, you know, either sick care or welfare, and realize that they need some sort of specialty services, we typically will not take the first step of making that referral ourselves, we typically try to reach out to the primary care provider, connect with them and see if they’ll explain our concerns and, you know, coordinate with them to do their now primary care providers are just as busy as every other provider out there. And many of them don’t necessarily have a easy way of accepting this communication and or, you know, so it takes a lot of effort on both sides. And, you know, we’ve sort of had discussions with managed care plans every time that they sort of talk about care coordination is how can we as school-based health centers participate in that. We don’t necessarily have to be in managed care in order to coordinate the care, right? So New York State Medicaid gets all of the data, whether it’s from managed care companies, whether it’s from us directly billing, the school-based health centers, so the data is there, it’s a matter of looking at that data, identifying the gaps in care and using us as another potential site where we can help cover those gaps in care. So, you know, we typically will get lists from the schools where the school say, you know, we have these kids that are missing immunizations. And you know, we’re always there to immunize those children for them. So that’s a way of a local coordination, but easily that can be done at a statewide level as well.
Courtney Burke 18:48
Well, I guess, in wrapping up, I have two, two closing questions. One is, what do you envision for the future of school-based health centers? And the second was just is there anything else that we should know? So let’s start with the what is the future look like in your mind? And Ronda, why don’t we start this one with you, since you’re the Chair of the Foundation, which I’m sure is very much focused on the future.
Ronda Kotelchuk 19:10
I don’t want to sound like a broken record. But at the risk of repeating myself, the single most important factor is the revenue streams that support the operation of these centers. If we are assured of that there will be expansion, there will be new startups, there will be, there is a lot of demand for these services. But it’s really essential that people understand the importance and the role played by school-based health centers and the benefits that they render. And, you know, this is to me, it’s just the most important investment one of the most important investment you can make in the life of an underserved child. And the benefits last for a lifetime. Let me say also, I think that school-based health centers are one of the most powerful tools for addressing the disparities that are faced by these communities and these children in getting services, both educational and healthcare services? So I would say payment payment payment. This will take time it will take a campaign, it will require public visibility. But I think this is the answer you would get from almost anyone you’ve spoke to in the world of school-based health centers. Now, I’m sure there’s many other things. In the meantime, that would be helpful, but that is the most fundamental.
Courtney Burke 20:29
Okay, well, that was a very, very passionate set of statements there Ronda. I appreciate that. So why don’t we give the closing to Dr. Jacob, if there’s anything else we should know about the school-based health centers. And I know you had your own personal experience with them, as well. So anything else that the audience should know.
Dr. Viju Jacob 20:49
And just to piggyback on Ronda’s idea, so I think, if the funding stream is there, I think school-based health centers are the model that everyone sort of talks about, right? It’s a comprehensive medical, behavioral health, potentially dental all at a location where students spend most their time and I, as a new immigrant to this country, many years ago, you know, had the luxury of being in New York City that had operated school-based health center. So I got my first dental care at a school-based Elementary School dental care. So you know, they’ve walked me over from my junior high school to the elementary school, so I could see the dentist and stuff. So I think the access is, is key. So if the funding stream was there, you know, at least at all the high-needs school in the, in the city and the state, I’m pretty sure all of the school-based health center, all the all the principals and administrators will be rushing to open up school-based health centers, especially in the middle school, high school age. Adolescents are notorious for not accessing care, because you know, most of them are, quote, unquote, healthy. But this is also a very high risk time for them. And you know, the school-based health center, being in the middle schools and high schools offers that easy access, where, you know, they can just come down during their, you know, lunchtime or their break period, access to care, access to care that they may not even realize that they need, right. So whether it’s a behavioral health screening, whether it’s reproductive care, whether it’s immunizations, that you know, because they thought, oh, I already got my shots of the kid, I don’t need any more shots, but adolescents need immunizations as well and stuff. So I think that’s really the future is if there’s adequate funding, in all the all the high-needs schools, at least should have a school-based health center, if not all the schools in the state.
Courtney Burke 22:26
Well, that was a great description of the types of services and why it’s so important to have this conversation today. So thank you again to Ronda Kotelchuk and Dr. Viju Jacob for joining us today to talk about school-based health centers.
Alexander Morse 22:43
Thanks again to Courtney Burke, senior fellow for health policy at the Rockefeller Institute, Dr. Viju Jacob, a Bronx-based pediatric specialist for Urban Health Plan, and Ronda Kotelchuk, founder of the Primary Care Development Corporation and current chair of the New York State Foundation for School-Based Health Centers for joining the podcast to share their insights and experiences operating and coordinating school-based health centers in New York. To learn more about school-based health centers in New York, check out the links in the episode description for the New York School-Based Health Foundation and the New York School-Based Health Alliance websites. If you liked this episode, please rate, subscribe, and share. It will help others find the podcast and help us deliver the latest and public policy research. All of our episodes are available for free wherever you stream your podcast and transcripts are available on our website. Special thanks to Rockefeller Institute staff Joel Tirado, Heather Trela, Leigh Wedenoja and Brian Backstrom for their contributions to this episode. Thanks for listening. I’m Alex Morse. Until next time. Policy Outsider is presented by the Rockefeller Institute of Government. The public policy research arm of the State University of New York. The institute conducts cutting edge nonpartisan public policy research and analysis to inform lasting solutions to the challenges facing New York state and the nation. Learn more at Rock institute.org or by following at Rockefeller inst. That’s Rockefeller i n s t on social media. Have a question or comment or idea? Email us at [email protected]
“Policy Outsider” from the Rockefeller Institute of Government takes you outside the halls of power to understand how decisions of law and policy shape our everyday lives.
Listen to a full episode archive on Anchor, or subscribe on your preferred podcast platform.