"Fifteen-year-old 'Richard' wandered into the high school health center to ask us to take a look at his foot," recalls the pediatric nurse practitioner staffing the center on that day. "He seemed pretty casual, just wondering since we were there anyway if we'd see him.
"I told him, sure, feet were on special on Tuesdays; but when he gingerly removed his boot, I saw we had a problem here. He had a significant cellulitis, and the classic red lines of blood poisoning running up his leg.
"He reported having run a nail through his sneaker into his foot on the farm 5 days earlier. 'It hurt like all get-out there at first,' he told me, 'but I pulled it out and limped around for a while and it seemed OK, so I didn't think any more of it. But now it's real sore and I wonder if I busted something.'
"I doubt he'd even thought to mention the incident to his parents; even if he had, they both work and it takes an earthquake to get anyone to take a day off around here. By the time you've driven an hour to see a doc in the county seat and sat in the waiting room for a walk-in visit, been treated, maybe gone to the pharmacy, and driven your child home, there's not much point in driving another hour over the mountain to get to work.
"I checked his tetanus status and put him on a course of antibiotics to which he responded well, so he did not need to be hospitalized. This case typifies one of the problems in rural medicine: Teenagers (and people generally) wait and either get better or have a hospital-sized emergency. Richard's particular family is typical in another way, in that they earn enough to be ineligible for Medicaid, but not enough to afford health insurance, so that even a brief hospitalization to treat a systemic infection with IV therapy would have been a real burden on their finances."
Like many people across the country, we in Pendleton County are looking for ways to address preventable adolescent behavioral health problems: drinking, smoking, pregnancy, violence, STDs, HIV, attempted suicide. In particular, the presence of HIV in the national adolescent population has created a sense of urgency in all fields of education, medicine and government. This array of problems is initiated by behaviors requiring the cooperation of the adolescent, rather than by physical causes or disease; all have negative impact on academic performance and continue to cause illness and problems in the future.
Proponents of integrated services believe that poor outcomes in education, health and society for children result in part from the inability of current systems to respond in a timely, coordinated fashion to the multiple and interconnected needs of a child and his family. The present delivery system does not intervene early and broadly enough to help children overcome stressed, deteriorating families. Our social service systems are crisis-oriented, categorical (addressing very specific problems) and exclusionary (lacking universal entitlement).
Preliminary results from school-site health centers suggest that it is very difficult to change behavior, which will surprise no one; but the greatest potential for doing so may rest in school-wide and community-wide efforts. If collaborative, integrated services can be shown to produce better outcomes for children, their increased efficiency and effectiveness will be a great incentive to reorganize our massive education, health and social services systems.
Hard comparative data on efficacy are hard to produce, and there are difficulties in evaluating these programs at all, but enough experience has accumulated to suggest some realistic goals and actions. One supporter of school-site integrated services has summed up the need for data collection and evaluation by pointing out that what we know has to catch up with what we think.
For the past five school years, Pendleton Community Care (PCC) has been collecting data on the health status of our county adolescents through a survey administered in the schools to seventh- to 12th-graders. Even a cursory scan of the summary of the data compiled from the Health Risk Appraisal returned by nearly 500 students turns up some noteworthy figures. For example, although 75% of the students reported never smoking, 50% never drinking and 92% never using drugs, there were 55% who reported never or rarely wearing a helmet on a motorcycle or ATV, 63% who never or rarely used a seatbelt, 53% who were in at least one physical fight during the school year and 16% who were drunk one or more times in the previous 2 months. Five percent often considered or attempted suicide in the past year. And 40% of the eighth grade wants us to think they think sexual intercourse is appropriate at their age.
What follows is, then, a summary of what we think is true. First, it is both possible and essential to draw on the resources that already exist in the community. Second, a daunting, difficult multi-problem that children and families face is in obtaining access to needed services. For example, in Pendleton County, only 46% of eligible children receive Medicaid services. A community's incentives to try a new approach include the rising costs of health care and insurance coverage, restricted access and the need to reduce high-risk behaviors. School-based health care is an available strategy, and it has the added benefit of not being dependent upon effective family functioning for successful use of services.
"'Mary's' mother called ahead to tell us that she would send Mary to school if she could be seen at the health center. A single mother of several children who holds a job in a factory that is very strict about absences, Mary's mother does not want to jeopardize that job 'by taking days off to get every sniffle to the pediatrician.' We diagnosed an ear infection and began treatment so Mary could stay in school and her mother not sacrifice a workday. In such a case, we contact the student's regular doctor if there is one, and refer the student on if necessary."
The schools are where children are clustered in a rural community, and there may be no other central place where sufficient space and community trust are available. The rationale for the school's involvement derives partly from its location; but mainly it derives from the schools' institutional commitment to classroom performance. It is important to emphasize that recent collaborations do not ask schools to assume managerial and budgetary authority for non-education services, but to draw schools in as partners with agencies that bring their own resources to the table.
School-site health clinics often offer comprehensive services not coordinated elsewhere in the community. In Pendleton County, as in other school health centers across the country, important support for integrated services now comes from the provider community, although there is always room for more cooperative efforts. PCC is currently looking at ways to mesh our developmental and screening agenda with the elementary schools' push toward developmentally appropriate classrooms and curricula.
Other concerns involve not only the “why” but also the “how” of school-based health. A high school health center eventually should be able to provide the following services:
- Routine screening for asymptomatic conditions;
- Direct treatment for routine acute problems and illness;
- Management of chronic illness;
- Direct access to competent professional information on reproduction;
- Requested education services and classroom presentations;
- Group/individual counseling at grade level, and information on the consequences of everyday decisions regarding diet, exercise, safety, substance use and general life stress on personal health.
These services are essential and available nowhere else and are best delivered in schools. The school health center must be clearly linked to an outreach network of additional health care resources in the community, which must become well-informed about the needs of school-age clients. It should be steered by a community advisory board or committee, including school representatives. It needs to develop policies that respect confidentiality, yet allow joint data collection and the exchange of relevant information to support coordinated action.
One of the most important preventive functions of the school health staff is to be available to talk to students who are feeling, even momentarily, self-destructive. Ordinarily, these students draw no attention until they hurt themselves, and then there is lots of trauma and a longer road back.
"'Penny' just needed to talk," recalls a staffer, "and there would have been no opportunity to do so without this resource in the school. She was feeling overloaded, behind in her schoolwork, not getting any exercise. She was dating a man from the Navy base and getting somewhat isolated from her age group. And most stressful of all, she hadn't told her parents about her dating, 'because they'd flip out and have him arrested or something.'
"Penny was in over her head; we talked about some of the things that were going on that she could control. I got her in touch with a tutor to help her catch up in her two most fragile subjects, and she committed to the twice-weekly aerobics class at the library. I figured with all her evenings taken up for the last 2 months of school, the guy she was seeing might fade out anyway, but she thought not. She seemed much more relaxed, and I urged her to talk to her parents at the first good opportunity. I think she'll handle it.
"These are very important encounters, as from there we can get the machinery started if students want some counseling, or we can just let them unload and help by listening. I don't know whether I've actually prevented any suicides, but I'm sure I've defused several school dramas."
Planners should remind themselves that the objective of integrated services is less to take care of children and their families than it is to enable them to master the skills it takes to receive needed services, and to make those services more accessible. Adults working in schools should bear in mind that programs that readily acknowledge a partnership with teenagers are much more likely to be effective than those that offer support primarily aimed at the control of behavior. Young people need to know that they can make important contributions, and they need to know that adolescent behaviors can be beneficial. They may also gain a sense of their own value and ability from observing the emphasis adults put on their health and education.
The above paper reflects some of our first experiences in school-based health and gives some of the rationale for rural school-based health centers. It was written 22 years ago as we were opening the first two school-based health centers here in Pendleton County.
The youth center (see PIDInk #2), started with a grant from the Public Welfare Foundation in Washington, D.C., had been a good beginning to address adolescent health issues — and even to determine which of those issues were key for our rural adolescent population. One of the best student suggestions implemented through the youth center was a bright yellow Hotline Directory of phone numbers and crisis resources distributed to all high school students. Still, the youth center could not provide the spectrum of care that school-based health had the potential to address.
School-based health was initially funded by a 3-year grant from the Robert Wood Johnson Foundation. We began with a series of focus groups to find out what services the community felt were needed and appropriate, and to think about how the school-based health center should function. A planning committee consisting of parents, teens, school representatives and community members from churches, businesses and health care represented a variety of points of view. During several months and many committee meetings we developed a vision of what school-based health centers in Pendleton County should look like.
That vision was realized, and now 22 years later, this model has been used to initiate school-based health centers in 91 other schools across the state, in nearly every county in West Virginia. We have clinics in each of the three elementary schools and in the high school. And we have years of data from administering a Health Risk Appraisal to county students. The county has consistently been rated first in the state in the Kids Count assessment (http://www.wvkidscountfund.org/data-book) for measures of children’s health and well-being, and I believe we can demonstrate that school-based health and its mental health services are major contributors.
— King Seegar, MD