Photo Credit: Pam Panchak/Post-Gazette
by Susan Hemingway, Tobi G. Chassie, Bobby Kelly, George A. DeVito, Suzanne Boulter, John J. Freeman, and Aimee Burke Valeras
Providing access to health care within the school system increases students’ health knowledge and access to health-related services. Doing so can potentially reduce risk-taking behaviors and increase academic success while simultaneously providing training for new doctors. This article describes the formation of a collaborative partnership between Pittsfield Middle High School (PMHS) in Pittsfield School District and the family-medicine resident physicians and behavioral health clinicians of NH Dartmouth Family Medicine Residency (NHDFMR). This collaboration resulted in the creation of a school-based health center (SBHC) to meet the needs of PMHS students, grades 7–12 (ages 11–18). Given the name PATCH—Pre-Adolescent to Teen Center for Health—by PMHS students, this partnership resulted in students getting easier access to behavioral and medical health care and referrals, and in family medicine residents learning about and gaining comfort with an at-risk adolescent population. PATCH also led to some unintended positive outcomes, such as NHDFMR’s participation in Community Collaboration and Support, a multidisciplinary, multiagency team meeting.
Collaborative partnerships between school systems and community health centers are imperative in providing preventive and primary care to adolescents (Uy-Smith, Grumbach, & Brindis, 2015). With an emphasis on prevention, early intervention, and risk reduction, SBHCs counsel students on healthy habits and how to prevent injury and illness. Specific services vary based on community needs and resources as determined through collaborations between the community, school district, and health-care providers. Nearly 2,000 SBHCs nationwide—across elementary, middle, and high schools—provide health-care access to over two million students a year (Leininger & Levy, 2015). SBHCs are more prevalent in underserved communities serving a racially and socioeconomically diverse population and often provide health-care access to the broader community in addition to the student population at the host school (Leininger & Levy, 2015).
Providing health care within a school reduces barriers for access for adolescents, who constitute a population that is traditionally difficult to reach and who spend the majority of their days in school (O’Leary et al., 2014). Access to health care through SBHCs reduces teen pregnancy and high school dropout rates (Lovenheim, Reback, & Wedenoja, 2016). This collaboration is essential for reducing health inequalities, improving academic success, improving health outcomes for students, and sustaining a healthy school system.
Studies show that adolescents rarely visit physicians’ offices for preventive visits, and they infrequently receive counseling on critical health issues like diet, exercise, weight, sex, injury prevention, and tobacco use (Merenstein, Green, Fryer, & Dovey, 2001). Depending on office-based visits misses the opportunity to address behaviors that influence health later in life. Situating family medicine residents in SBHCs serves the purpose of giving physicians adequate exposure to and training with adolescents’ health concerns in more effective ways while meeting the needs of the student population.
The Formation and Evolution of PATCH
The 1998 Kids Count report ranked Pittsfield among the poorest towns in New Hampshire, with the highest incidence of adolescents who get pregnant, smoke, or do not complete high school when compared to state and national averages. In each case, the incidence of these risk factors is about three times as high (or higher) than wealthier New Hampshire communities. The school system has a large percentage of students in the lower socioeconomic bracket: 30 percent fell below the 200 percent federal poverty level and 55 percent receive a free and reduced lunch. Also in 1998, the University of New Hampshire [UNH] Cooperative Extension and PMHS conducted a teen assessment project (Rodgers & Small, 1999) that revealed in the one month, 83 percent of girls and 61 percent of boys reported feeling depressed or sad; 28 percent of girls and 23.5 percent of boys had serious thoughts of killing themselves; and 50 percent of students were sexually active by 9th grade, with 72 percent sexually active by 12th grade. This information helped identify students at PMHS as a population with unmet and unique health-care needs.
In response, the Concord Hospital Family Health Center (CHFHC) obtained a grant to launch a three-year pilot project to fund a health educator coordinator position at PMHS. PATCH began in 1999 with startup funding provided by the Healthy New Hampshire Foundation, with in-kind support from NHDFMR, CHFHC, and PMHS. Since then, PATCH has evolved to provide on-site health and preventive services, behavioral health consultation, and referrals while serving as a learning opportunity for NHDFMR residents during their pediatric rotation.
Residents began seeing students at PATCH in the fall of 1999. PATCH was originally proposed to help PMHS secure permanent funding for a health educator coordinator while paving the way for CHFHC to work with multiple high-risk high schools. The design of PATCH was envisioned as a “guest in the school” model, where services would augment those provided by the school nurse. Residents, the health educator coordinator, and a physician preceptor saw students whose parents signed written consent forms and who were scheduled by the school nurse. The scope of services included immunizations, sports physicals, acute illness and injury assessments, risk assessments, and referrals to primary care physicians (PCP), mental health therapists, specialists, family planning, and assistance with the application for the state’s Medicaid program, NH Healthy Kids.
Through PATCH, students’ medical-care gaps were identified, including immunizations needed for state law compliance, lack of health insurance, eligibility for Medicaid, and lack of an identified PCP. One resident focused a community medicine project on providing referrals and on-site insurance application assistance to families. The most frequent concerns of students who came to PATCH were psychological issues, including disordered eating, disruptive behaviors, suicidality, anxiety, depression, adjustment, grief, abuse, and partner violence. The identification of this pattern led to more community services co-located within the school over the ensuing years to improve accessibility to vital resources. PMHS was accustomed to the “guest in the school” model, so expanding to include community services within the school was not a difficult transition to make. Riverbend Community Mental Health, Inc. (along with several other private practices), for example, placed behavioral health clinicians at the school to provide students with on-site therapy and other, more readily available mental health resources. Additionally, PMHS contracted with a student assistance program professional from a community organization, who is frequently both a referral resource and source for PATCH. The professional is a licensed clinical social worker with substance abuse prevention and treatment training and provides confidential services to students related to addiction.
PATCH in Its Current State
The collaborative partnership between PMHS and NHDFMR/CHFHC has gradually grown since 1999. Today, PMHS students and their families rely on PATCH to meet a range of age-appropriate health-care needs, including primary medical care, health education, and referrals for mental/behavioral health and substance abuse counseling. Students can be treated for acute illnesses, screened for other health issues, and referred to community resources, like family planning services. In these encounters, students often confide in PATCH providers about mental health or psychosocial issues that have not been previously identified by the school or their own PCP, as many don’t receive regular preventive care. In these situations, the student, the family, and the school team are provided with valuable guidance about the importance of establishing or reconnecting with their PCP and/or behavioral health supports.
Residents also provide consultation to the school nurse, provide in-staff training to PMHS staff, join the school’s wellness team, partnered to create an annual Wellness Day Fair, and speak in health classes on a variety of topics, like risk reduction, hygiene, health career awareness, and disease processes. PATCH also partnered with the school guidance staff to implement the Full of Ourselves curriculum for middle school girls, an eating-disorder prevention program that incorporates bully proofing and developing interpersonal and leadership skills (Steiner-Adair & Sjostrom, 2006). PATCH, in collaboration with school personnel, has hosted middle school support groups, including drop-in lunches and stress management. More recently, residents have met with students, teachers, and a school advisor to assist in the formation of a school-based Gay-Straight Alliance, an effort that was entirely initiated by student interest and is currently in progress. Overall, the physician presence has become a valued resource within the school community.
PATCH is represented at school parent nights, at 7th grade orientation, at school staff meetings, and at the annual National Night Out community event. These outreach efforts help publicize PATCH services. This exposure is necessary because although the implementation of the Affordable Care Act has resulted in more families and children having health insurance, many students continue to report that they don’t know who their PCP is or that their parents face other barriers (lack of transportation, inability to take time off work) that get in the way of making appointments. When students are not able to access traditional health care when it is needed, minor or acute issues may go unaddressed, potentially resulting in expensive and avoidable trips to the emergency department for concerns that can be addressed at PATCH.
Community Collaboration and Support
Community Collaboration and Support (CCS) is a process aimed at meeting the needs of students whose behaviors or circumstances negatively impact their academic and/or behavioral success and for whom other interventions have failed. CCS historically has included PMHS staff, at least one family member (and student, if appropriate), and representatives from one or more community supports, including Riverbend Community Mental Health, Juvenile Justice Services, Pittsfield Youth Workshop (an after-school drop-in center), UNH Cooperative Extension 4-H Youth Development, and the Division for Children, Youth & Families (DCYF). Often, these multiple agencies are working with the same student and family, which can create an unintentional, counterproductive impact. CCS uses a strength-based protocol to provide the family and multiple agencies the opportunity to engage in a collaborative conversation that generates ideas, identifies resources, and allows for an action plan that can increase the chances of success for the student and family across all domains, including community, school, home, social, and health. The CCS process has allowed for an awareness and a reduction of fragmentation and duplication of services.
Traditionally, physicians face many barriers that get in the way of playing a role in school- or community-based meetings, including time and travel distance, scheduling, billable hours, productivity demands, unawareness of meetings, or role confusion or discomfort. Through the PATCH collaboration, residents have been able to play an active role on the CCS team. Allowing residents membership in the CCS process has made room for an important but usually absent medical health perspective while simultaneously teaching residents about team-based care, community resources, and their own role in partnering with schools and other community agencies.
To prepare residents for these meetings, PMHS and PATCH staff created a “mock” CCS meeting, a half-day interactive workshop that occurs during a part of the residency curriculum in which residents learn about how to work with community partners to best address patients’ needs. Actual community-based team members, including the school staff, come to the residency site to conduct this mock CCS session based on a complex student and family scenario in which residents play specific roles. A debriefing session to discuss both the content and process of the experience is conducted after the meeting. This experience has motivated residents to explore how they can become more engaged by participating in community partnerships.
Another recent outcome of the collaboration between school and health clinic is that third-year resident physicians receive more explicit exposure to the special education process. Each resident is paired with a student who receives special education services and is also a CHFHC patient to observe and better understand the basic components of an individualized education plan, including accommodations made by the school, appreciating the context of the school, understanding the role of the school nurse, and considering collaborative opportunities for physician, school, and family/patient.
Teachers, school counselors, and administrators from PMHS have identified the role they see PATCH play in the lives of the students. As one PMHS staff member observed, “Many students have sports physicals with PATCH. Some of them would not be able to play sports otherwise due to lack of funds for the doctor visit or lack of transportation to Concord.” Seventy-five percent of surveyed PMHS staff had referred a student to PATCH for various reasons, such as acute illness, flu vaccines, sports physicals, sexual orientation questions, birth control access, and mental health concerns, including self-injurious behaviors. Many of the staff recognized the learning that residents were getting through the process, providing feedback as general as “developing a comfort level with the teen population” and as content related as “the process students go through to acquire and maintain special education services.”
NHDFMR residents echo the benefit they receive from the experience of stepping into the school environment, reporting an increased comfort level with this age group and the issues they face. One resident noted, “I feel more comfortable having the drugs/alcohol/safe-sex talk after practicing it many times at the PATCH clinic.” Additionally, their understanding of special education and the education system in general increased; as a result, they reported an increased likelihood to reach out to communicate with the school system of adolescent patients in the future. The lack of communication between health-care providers and school educators is a significant barrier to knowing what the other entity is doing. One resident noted, “It’s nice to see firsthand how the care team at school works to help keep troubled youth safe and engaged in the system.” The school-based setting is noted as providing a different context to the doctor-patient conversation. As one participant noted: “The [teens] seemed to feel more comfortable being open and honest in a setting they were used to, which is often not the case in the office.”
Adolescents who utilize PATCH point out the barriers they typically face (“I don’t have time to go to my doctor’s office”), the convenience of having access to health care at school (“I like that it is here at school”), and satisfaction with the providers’ customer service (“They are nice and quick”). Perhaps most important, the students report having gotten something useful out of their interactions at PATCH, reporting, for example, “I learned how to pace myself and what might be happening” and “They can help me with my problems.”
Adolescents who utilize PATCH point out the barriers they typically face (“I don’t have time to go to my doctor’s office”), the convenience of having access to health care at school (“I like that it is here at school”), and satisfaction with the providers’ customer service (“They are nice and quick”).
PATCH’s first 16 years have been a time of significant growth and expansion. NHDFMR plans to continue this growth with several specific efforts. Working with the school’s wellness team, PATCH is in the process of creating an advisory group, ideally consisting of students, school counselors, teachers, administration, parents, and residents to further integrate services and health-related activities. Other potential focuses of PATCH include establishing an in-school vaccine administration program, contributing to lesson planning within the current health curriculum, and helping create a student transition program that can help facilitate promotion from middle school to high school and from graduation to post–high school life.
The successes of the collaboration between PMHS and NHDFMR may pave the way for the residency to partner with other high schools in the hospital’s catchment area, ranging from the provision of basic primary preventive care to teaching health literacy to young adult learners. One area of significant collaborative potential is working with the growing adolescent refugee population in the greater Concord area, the majority of whom are patients of CHFHC, which is another population that faces many barriers to getting health care addressed in the office setting.
Exploring community partnerships and collaborations is an effective way to coordinate care and influence positive outcomes for students and resident physicians. On one hand, the PATCH model is limited in its ability to provide acute medical care or chronic disease management at the point of service without longitudinal follow-up because physicians may lack access to students’ medical records; they do not write prescriptions at PATCH, nor do they consistently communicate with students’ PCPs. Also, due to the nature of the residency, the residents spend short amounts of time at PATCH, making long-term relationships difficult to establish. On the other hand, this model has great potential to be a win-win situation for all parties involved.
Exploring community partnerships and collaborations is an effective way to coordinate care and influence positive outcomes for students and resident physicians.
This particular collaborative partnership between PMHS and NHDFMR started with a vision to meet a specific need to provide health services to an underserved community and to provide a training opportunity for residents to be exposed to the concepts of screening; collaborating with school personnel; learning about students with challenges and how to address them; participating in team meetings, including individualized education plans; and meeting the needs of students where they are. This process has not been without challenges, including the coordination and scheduling of students, residents, preceptors, and staff, as well as the differences in communication patterns or protocols across the domains of community, education, and health care.
Having a staff member from the residency at the school, learning about the school’s culture and forming professional working relationships with school administration, has been key to facilitating communication, envisioning opportunities, and implementing new ideas. These connections have provided the foundation to develop projects and outcomes beyond the initial vision of PATCH, which was limited in scope in terms of resources, time, and services provided. It has since evolved into a robust school-based health center. This success is due to the receptivity of both the school and the residency to try new approaches in addressing the ever-changing needs and interests of both students and residents. Central to this process has been the degree of willingness to collaborate and the ability of the partners to think outside the box. This project illustrates the feasibility of developing a vibrant program to meet a community need that is based on a shared vision, partnerships, and compatible goals.
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