Veda johnson

Health,Education & School Based Health

Centers

Veda Johnson, MDAssociate Professor of

PediatricsEmory University School of

MedicineNovember 9, 2012

Why are we here?

“It is easier to build strong children than to

repair broken men.”Frederick Douglass (1817–1895)

“Free the child's potential, and you will transform him into the world.”

Maria Montessori (1870–1952)

The Problem

Educational Underachievement

Challenging Health Issues

Insufficient Student Support

The Problem

Educational Underachievement

Educational Achievement – Nationally

National Center for Education Statistics          

Table 11.1. Percentage distribution of students at National Assessment of Educational ProgressTable 11.1. (NAEP) reading achievement levels, by race/ethnicity and grade: 2005 and 2007

Grade, year, and achievement level Total1 White Black   Hispanic   Asian/Pacific Islander  

American Indian/Alaska Native  

4th grade, 2007                    

Below Basic 33 22 54   50   23   51  

At Basic 34 35 32   32   32   30  

At or above Proficient 33 43 14   17   46   18  

At Advanced 8 11 2   3   15   4  

8th grade, 2007                    

Below Basic 26 16 45   42   20   44  

At Basic 43 43 42   43   39   38  

At or above Proficient 31 40 13   15   41   18  

At Advanced 3 4 #   1   5   2 !

12th grade, 2005                    

Below Basic 27 21 46   40   26   33 !

At Basic 37 36 38   40   38   41  

At or above Proficient 35 43 16   20   36   26 !

At Advanced 5 6 1 ! 2 ! 5   ‡  # Rounds to zero.

! Interpret data with caution.

‡ Reporting standards not met.1 Total includes other race/ethnicity categories not separately shown.

NOTE: Achievement levels are performance standards showing what students should know and be able to do. Basic denotes partial mastery of knowledge and skills that are fundamental for proficient work at a given grade. (Below Basic, therefore, denotes less than this level of achievement.) Proficient represents solid academic performance. Students reaching this level have demonstrated competency over challenging subject matter. Advanced signifies superior performance. NAEP reports data on student race/ethnicity based on information obtained from school rosters. Race categories exclude persons of Hispanic ethnicity. The NAEP assessment was not administered to grade 12 in 2007. Detail may not sum to totals because of rounding.

SOURCE: U.S. Department of Education, National Center for Education Statistics, National Assessment of Educational Progress (NAEP), 2005 and 2007 Reading Assessment, NAEP Data Explorer.

Percentage distribution of 4th-grade students at National Assessment of Educational Progress (NAEP) reading achievement levels, by race/ethnicity: 2007

Percentage distribution of 8th-grade students at National Assessment of Educational Progress (NAEP) reading achievement levels, by race/ethnicity: 2007

Georgia Reading proficiency

4th graders (2009) 37% read at below basic 34% read at basic 29% read at proficient or better

18% of Low income and minority students 15% of Black students

44% of Higher income students

8th graders (2009) 33% below basic 40% @ basic 27% @ proficient or better

Georgia, 4th grade Reading proficiency

Percentage distribution of 12th-grade students at National Assessment of Educational Progress (NAEP) reading achievement levels, by race/ethnicity: 2007

Percentage distribution of 4th-grade students at National Assessment of Educational Progress (NAEP) mathematical achievement levels, by race/ethnicity: 2009

Percentage distribution of 8th-grade students at National Assessment of Educational Progress (NAEP) mathematical achievement levels, by race/ethnicity: 2009

Percentage distribution of 12th-grade students at National Assessment of Educational Progress (NAEP) mathematical achievement levels, by race/ethnicity: 2009

Percentage of 8th-graders at or above Basic on the National Assessment of Educational Progress (NAEP) mathematics assessment, by race/ethnicity and number of days absent from school in the past month: 2009

Average freshman graduation rate for public high school students, by race/ethnicity: School year 2006–07

Georgia Students Absent >15days from school

Avg. 8.8% Range: 1.5%– 19.4%

Kid’s Count 2011

Graduate from School on Time (beginning in 9th grade) 32% don’t graduate on time

(nationally 24%) Kid’s Count 2008-9

The ProblemStudent Health

Health Nationally

Approximately 28 million children nationwide from economically disadvantaged households are at risk for a variety of negative outcomes including:

1) increased rates of health problems and mortality;

2) emotional and behavioral problems. 3) increased risk of academic

underachievement, school drop-out, and unemployment; and

National Survey on Child’s Health 2007-8; Sponsored by MCH and HRSA – Phone survey by parents

Number of Chronic Conditions Reported*

Number of conditions Percent of Children

*Of 16 specific health conditions.

None 77.7

1 13.6

2 3.9

3 or more 4.8

National Survey on Child’s Health 2007-8

Asthma 9.0

Learning Disabilities 7.8

ADD/ADHD 6.4

Speech Problems 3.7

ODD or Conduct Disorder 3.3

Developmental Delay 3.2

Anxiety Problems 2.9

Bone, Joint, or Muscle Problems 2.2

Depression 2.0

Hearing Problems 1.4

Vision Problems* 1.3

Autism Spectrum Disorder 1.1

Epilepsy or Seizure Disorder 0.6

Diabetes 0.4

Brain Injury or Concussion 0.3

Tourette Syndrome

Dental Care

More than 16 million children still lack access to basic dental care despite efforts by states to improve their dental health policies, according to the 2011 50-state report card from Pew.

The State of Children’s Dental Health: Making Coverage Matter graded states' ability to serve insured and soon-to-be insured children.

Health Georgia

Adverse outcomes are widespread among children in the state of Georgia. Georgia ranks 37th in the nation overall for child well-being (Kid’s Count 2012).

43rd - child economic well-being 30th – Overall child health ( child &teen

deaths, etc.) 38th - overall education

Health…

Georgia We have the 2nd highest childhood

obesity rate in the country (37% OW/OB) 29% of our adolescents had significant

episodes of depression during the past 12 months.

26% of our children live in poverty and approx. 300,000 children are uninsured.

National Survey on Child’s Health 2007-8; Sponsored by MCH and HRSA

National Survey - Asthma

National Survey – Asthma (Race)

National Survey – Asthma (Income)

National Survey – ADD/ADHD

National Survey – ADD/ADHD (Race)

National Survey – ADD/ADHD (Income)

National Survey - Medical Home

National Survey - Medical Home (Race)

National Survey - Medical Home (Income)

National Survey of Child’s Health (2007): Absenteeism

The SolutionLeveraging health to improve academic outcomes.

Leveraging academic success to improve health outcomes.

Health and Academic Success

How does health affect the academic success of our children?

Former Surgeon GeneralDr. Antonia Novello

“Health and education go hand in hand: one cannot exist without the other. To believe any differently is to hamper progress. Just as our children have a right to receive the best education available, they have a right to be healthy. As parents, legislators, and educators, it is up to us to see that this becomes a reality.”

Healthy Children Ready to Learn: An EssentialCollaboration Between Health and Education, 1992

Health and Education

Association between health and academic success Students learn best when they are healthy Students learn best when they are present Students learn best when they are

connected to the school emotionally and socially

Students learn best when there is hope

The National Associationof State Boards of Education …

"Health and success in school are interrelated. Schools cannot achieve their primary mission of education if students and staff are not healthy and fit physically, mentally, and socially.”

— Fit, Healthy, and Ready to Learn: Part 1 – Physical Activity, Healthy Eating, and Tobacco Use Prevention, 2000

Health

The World Health Organization defines health as a “state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.”

Determinants of Health…

Determinantsof health andillness that areoutside of theindividual

Beyond geneticpredispositions

Beyond individualbehaviors

Social Determinants of Health…

Definition of social determinants of health: The economic & social

conditions that influence health …

‘The conditions in which people are born, grow, live, work and age.’

Source:www.who.int/social_determinants/en/ accessed 10-4-11

Social Determinants of Health… Factors in the social environment that contribute to

or detract from the health of individuals and communities:

Income Housing Education Transportation Access to services Physical Environment Socioeconomic status/position Discrimination by social grouping Social or environmental stressors

Source: www.cdc.gov/sdoh accessed on 11-9-07

Social Determinants of Health… Major social

determinants of health include: Social Position Where you live Race Stress

Social Determinants of Health…

Health inequities associated with socioeconomic status of children Childhood Development Asthma Obesity Diabetes Behavioral Health Oral Health

Health and Education… Poor school performance is linked to health-

related issues such as hunger, physical and emotional abuse, and chronic illness such as asthma and obesity.

Poor academic outcomes are linked to risky health behaviors such as substance use, violence, and physical inactivity which in turn affect students' school attendance, grades, test scores, and ability to pay attention in class.

Health and Education… High school drop out rates are affected

by: Forces within the school system

School readiness Elementary and Middle school underachievement Student disengagement, behavior issues, absenteeism,

and failing grades in 9th grade Forces outside of school

Health issues Psycho- social issues Caretaking responsibilities A caring adult.

American Cancer Society

“[Children] …who face violence, hunger, substance abuse, unintended pregnancy, and despair cannot possibly focus on academic excellence. There is no curriculum brilliant enough to compensate for a hungry stomach or a distracted mind.”

— National Action Plan for ComprehensiveSchool Health Education. 1992

Health and Academic Success

How does academic success affect the health of our children?

Health and Education Education is a direct

predictor of health Academic

underachievement contributes significantly to the health disparities observed in children from lower socioeconomic positions.

Health and Education Education is a direct

predictor of health… Academic success is a

predictor for adult health outcomes

Adults with higher educational achievement are more likely to be more knowledgeable, have better jobs and better opportunities to achieve and maintain healthy lifestyles.

Health and Education… In addition – ‘Academic success is an

important indicator for the overall well-being of students’ According to the

Youth Risk Behavior Surveillance System (YRBSS), students with higher grades are less likely to have participated in risky behaviors such as:

Carrying a weapon Current cigarette use Current alcohol use Being currently sexually active Watching television 3 or more hours per day Being physically active at least 60 minutes per day on fewer than 5

days

Percentage of High School Students Who Carried a Weapon,* by Type of Grades Earned (Mostly A’s, B’s, C’s or D’s/F’s), 2009**

* For example, a gun, knife, or club on at least 1 day during the 30 days before the survey.**p<.0001 after controlling for sex, race/ethnicity, and grade level.

United States, Youth Risk Behavior Survey, 2009

Percentage of High School Students Who Were in a Physical Fight,* by Type of Grades Earned (Mostly A’s, B’s, C’s or D’s/F’s), 2009**

*One or more times during the 12 months before the survey.**p<.0001 after controlling for sex, race/ethnicity, and grade level.

United States, Youth Risk Behavior Survey, 2009

Percentage of High School Students Who Ever Used Marijuana,* by Type of Grades Earned (Mostly A’s, B’s, C’s or D’s/F’s), 2009**

*Used marijuana one or more times during their life. **p<.0001 after controlling for sex, race/ethnicity, and grade level.

United States, Youth Risk Behavior Survey, 2009

Percentage of High School Students Who Felt Sad or Hopeless,* by Type of Grades Earned (Mostly A’s, B’s, C’s or D’s/F’s), 2009**

*Almost every day for 2 or more weeks in a row so that they stopped doing usual activities during the 12 months before the survey.**p<.0001 after controlling for sex, race/ethnicity, and grade level.

United States, Youth Risk Behavior Survey, 2009

How do we improve the academic achievement for students by improving their health?

The National Governors’ Association

“Policymakers need to focus on eliminating the barriers that affect these lower-performing students’ readiness to learn. Among these barriers are physical and mental health conditions that impact students’ school attendance and their ability to pay attention in class, control their anger, and restrain self-destructive impulses.”

Improving Academic Performance byMeeting Student Health Needs, 2000

Health and Education…

What we know… School health programs and policies can be

an efficient way to prevent or reduce risky health behaviors and avoid serious health problems among students.

They may also help close the educational achievement gap between disparate socioeconomic groups of students.

Coordinated School Health Program

1995 – Institute of Medicine committee adopted the term ‘coordinated school health program’ based on the concept of ‘comprehensive school health’ originated in the 1980’s by Diane Allensworth and Lloyd Kolbe.

Kolbe founded the Division of Adolescent and School Health (DASH) at CDC.

Coordinated school health programs

Recommended by CDC as a strategy to improve the health and academic performance of students

It is a coordinated approach to school health that creates a system of care that addresses the needs of the whole child by connecting health with education

Creates a school environment that promotes and supports healthy lifestyles for students, teachers and staff

Components of a coordinated school health program

Allensworth and Kolbe, 1987

Coordinated school health programs

Benefits: Engages parents, teachers,

students, families, and communities Helps keep students healthy Supports learning and success

in school Reinforces positive behaviors Helps students develop knowledge and

skills to make smart choices

Coordinated school health programs…

School based health centers exemplify the basic tenets of a coordinated school health program

School Based Health Centers (SBHCs)

Definition:

Comprehensive school based health clinics are primary care medical centers that blend medical care with preventive and psychosocial services as well as organize broader school-based and community-based health promotion efforts.

SBHCs… History:

School-based medical services began in 1890s to address contagious diseases in classroom

School nurses replaced MDs in 1902 (MDs going off to war)

Comprehensive school-based health center concept began in the late 60s –Dr. Philip Porter (Mass)

Developed a ‘system of care’ that Increased access and coordinated healthcare for poor children.  

SBHCs… Qualities:

Recognized as an effective model of healthcare that can significantly reduce barriers to medical services for children living in poor communities

Holistic integrated approach to care that emphasizes access, quality, and improved outcomes that reduces health disparities

Provide a savings to the public by reducing inappropriate emergency room usage among children and adolescents.

SBHC’S…Common Features of School-Based Health

Centers: They are located in schools or in close proximity (school-linked).

The health center works cooperatively within the school to become an integral part of the school.

The health center provides a comprehensive range of services that meet the specific physical and behavioral health needs of the young people in the community as well as providing for the more traditional medical care needs.

A multidisciplinary team of providers care for the students:  nurse practitioners, registered nurses, physician assistants, social workers, physicians, alcohol and drug counselors, and other health professionals.

SBHC’S…

Common Features…

The clinical services within the health center are provided through a qualified health provider such as a hospital, health department, or medical practice.

Parents sign written consents for their children to enroll in the health center.

The health center has an advisory board consisting of community representatives, parents, youth and family organizations, to provide planning and oversight.

SBHC’s…

Seven Basic Principles:

Supports the school Responds to the community Focuses on the student Delivers comprehensive care Advances health promotion Implements effective systems Provides leadership in adolescent and child

health

SBHC’s…

Nationally (National Census – 2007/08) Over 2200 SBHCs

56.7% in urban settings 27.2% in rural settings 16.1% in suburbs

Georgia Only 2 SBHCs from 1994 – 2009 Currently 6

SBHCs…

Research demonstrates that SBHCs effectively addresses the needs of the underserved through: Increased access to quality healthcare Improved health outcomes Decreased healthcare costs Improved school attendance and

academic performance

Decreased health care costs – Whitefoord Elementary School -

Based Health Clinic

Adams EK, Johnson V. An elementary school-based health clinic: can it reduce Medicaid costs? Pediatrics. 2000;105(4 pt 1):780–788 Compared Medicaid costs to children enrolled in a

SBHC to those not enrolled in a SBHC Summary of findings:

Decrease in total Medicaid costs per child over 2 year period w/SBHC

Significant decrease in In-Patient costs Significant decrease in prescription drug use costs Significant decrease in emergency room costs Decrease more significant across all categories if child used SBHC as

medical home For children with asthma, decrease in Medicaid cost for total yearly

expenditures with significant decreases in inpatient and drug costs.

Whitefoord Elementary and Sammye E. Coan Middle School

Based Clinics

Pediatric and adolescentprimary care health clinics providing comprehensive health services for the students, their siblings, and other children within the community

Initiated by the Dept of Pediatrics at Emory University Nov. 1994

Removed the provision of health care from the institution and placed it into the community

Whitefoord & Coan…. Goal : Increasing access to

quality health care and improving the academic achievement of students

Address the physical, mental and emotional health of the child

‘Care for the child in the context of family, home and community’

Developed the Whitefoord Community Program, a community-based support program for families of children enrolled in the clinic

Whitefoord Community Program Created to address the needs

of families as defined by the community

Mission: …‘working together with families and the community to ensure that every child has what he or she needs to succeed in school’.

Components: School based health clinics Child Development Program Family Learning & Community

Development Center

Staffing Mid-level Providers

(NP/PA)* Pediatricians/Medical

Director* RN/Clinic Manager Medical Assistant* Dentist and Dental Asst Social Worker/Mental

Health Providers* Health Educator Secretaries Clerical Assistant

*Core Staff

School Based Clinic Services Management of acute and

chronic illnesses and injuries Routine and sports physicals Immunizations Dental care Mental Health Assessments

and Counseling Social services Psycho-educational Testing Referral to Sub-specialist 24 hr. coverage

Accomplishments Increased access to physical, mental

and dental health care

Increased immunization rates for children and adolescents

Improved school attendance/?performance

Every child in school receives health education instruction on drug and substance abuse, violence prevention, safety, general health, and nutrition

Accomplishments…

Improved health outcomes for children with chronic illnesses (e.g. asthma, diabetes)

Improved risk factors for overweight/obese students Reduced BMI’s Reduced cholesterol levels Reduced insulin resistance

Reduced cost to the state’s Medicaid program Reduced ER use and hospitalization of students with

asthma

Accomplishments…

Facilitated the recovery of many emotionally troubled children.

Pre-K program School aged children and adolescents

Improved the academic achievements for children with ADHD and Learning Disorders.

Reduced the referrals of children with ADHD into Special Education programs.

Increased parental involvement Witnessed several challenged families assume proper

responsibility for their children

School Based-Health Centers - Health and academic achievements

Increases access to quality healthcare

Improves health outcomes

Decreases healthcare costs

Improves school attendance and academic performance

“It is easier to build strong children than to

repair broken men.”Frederick Douglass (1817–1895)

Contact Information

Veda Johnson, MDAssociate Professor of PediatricsEmory University School of Medicine49 Jesse Hill Jr DrAtlanta, GA 30303Phone: 404-778-1419Email: [email protected]

Urban Health Program Urban Health Program at

the Department of Pediatrics, Emory University School of Medicine

Vision: To reduce health

disparities ensuring that all Georgia children are more likely to be happy, healthy and productive members of society.

Urban Health Program… Goals of UHP:

Increase access to healthcare for underserved children through expansion of School Based Health Centers (SBHCs) throughout the state

Improve the delivery of health care for at-risk children and adolescents

Improve academic outcomes for underserved children

Train future pediatricians to address the social determinants of health