Section 12: School Based Health Centers

A School-Based Health Center (SBHC) brings healthcare right into schools with parental consent. SBHCs offer high-quality care for learners that mirrors the same high quality healthcare a child would receive in the community, just in a different location. The care is delivered in school through in-person on school grounds, in-person off school grounds, or telehealth care.  School nurses, school community leaders and the SBHC licensed providers know that healthy students learn better. 

School nurses understand parents come from various perspectives and contexts to include young parents, grandparents raising grandchildren, and parents of children with special needs.

School Nurses and SBHC Collaboration 

School nurses collaborate with providers of SBHCs and work with parents in a number of ways.

• School nurses and SBHCs have similar goals to ensure students are safe and healthy. 
• School nurses and SBHCs build the health skills of families, deepen family’s engagement with school based health and education programs, and work to influence parental behaviors and interactions towards healthcare by offering value-based care. 
• School nurses and SBHCs build the overall capacity of families by providing the tools, referrals, and healthcare resources parents need to foster their children’s development. 
• School nurses and SBHCs engage parents to build family advocacy and leadership skills, strengthening parents’ ability to advocate for change in health outcomes on behalf of themselves and their children. 

Families, School Nurses and SBHC Collaboration

SBHCs helps parents by getting the healthcare their children need while also impacting:

• reduction in transportation barriers, 
• reduction in parent’s missed work or loss of income,
• enhanced access to the child’s healthcare provider, and
• enhanced collaboration with school nurses and the learners' families to support academic success at school or program.

Services of SBHCs

SBHCs may provide health services to all students preschool thru twelfth grade and may be offered on-site (i.e.school-based centers, in-school space, modular spaces on school grounds) or off-site (i.e. school-linked centers, mobile units, telehealth services). SBHCs are often established in schools and are available to parents to serve students living in the school community area and incorporate the following characteristics: 

• provides primary health care and may also include mental health care, social services, dentistry, and health education 
• care services may be provided by a single licensed health professional, or comprehensive services may be provided by multi-disciplinary teams of licensed health professionals
• services may be available only during some school days or hours, and may also be available in non-school hours, depending on the center 
• All learner(s) participation requires parental consent. Parents have the greatest stake in their children’s well-being and are invaluable partners for schools and SBHC(s) striving to improve the lives of kids and families. 
• Services may also be provided to school or program staff, the child’s family members, and others within the surrounding community dependent on the center 

Schools that want to house their own SBHC with licensed providers may do so with the following considerations:

Iowa does not require nurse practitioners to have a collaborative agreement. Nurse practitioners can practice in Iowa, and they have full practice authority, meaning they can diagnose, treat, and prescribe medications without physician oversight. 

If your school does not have a nurse practitioner, the school may seek out a nurse practitioner or licensed physician from the community or other health entity to bridge the healthcare needs of learners either through telehealth, in-person onsite, or collaborative in-person community care.

Common SBHC Questions & Answers

1. What is the difference between the school nurse and SBHC(s) providers?
   Answer: The school nurse is responsible for the entire school population, assuring the safety and health of the students, performing nursing and health service delivery outlined by all of the student’s individual healthcare providers, delegating health service delivery while triaging daily health concerns of presenting students.
   
   Nurse practitioners, physicians, and other licensed providers employed in SBHCs are trained to diagnose and treat conditions on-site, which include physical examinations, mental health, preventative care and treatment of acute health conditions.
2. Can appointments to SBHCs be made during the school day?
   Answer: Appointments may be made during the school day. SBHCs should work with schools to make every effort to schedule appointments so that students do not miss core classes.
3. How does a student receive services?
   Answer: To receive services, the parent or guardian must complete the initial consent and registration form, except as allowed by minor consent laws. After that, the registration form must be updated each year. Students who do not have a completed SBHC registration form on file will not be able to use the SBHC. Registration in the SBHC is voluntary and can be completed at any time. There are no eligibility requirements except to be a student enrolled in the school that the SBHC serves.
   
   A parent may call their child’s school nurse, the SBHC staff, or send a note to arrange for the child to be seen at the SBHC. Parents are welcome to accompany their children to the SBHC. If a child is too ill to attend school and the parent would like him/her to be seen by the SBHC staff, parents may call the school nurse or the SBHC to arrange for a same-day appointment.
4. Are school nurse services still available if the child goes to the SBHC?
   Answer: Yes. The school nurse will continue to provide all students with the same school nursing and health services as in the past regardless of a student’s enrollment in a SBHC.
5. Who has access to the child’s medical records?
   Answer: All medical records are confidential to the SBHC. Confidentiality is important in order to provide quality, comprehensive healthcare to the students enrolled. To release records to any other entity, parents would have to sign consent to release and exchange information.

SBHC Road Map

The following are topics and resources that will need to be considered, mapped out and addressed prior to schools inquiring with a community provider or opening a SBHC (noninclusive list): 

• Administration: A SBHC may have a sole owner (healthcare provider) or many. The practice may be a sole practitioner, partnership, or corporation.
• Billing: A SBHC may employ their own personnel to complete billing or contract with a vendor. 
• Private Insurers: Each insurance has a procedure for enlisting providers. The licensed health personnel in the SBHC must meet the requirements of the health insurance(s) they will accept. 
• Business Associates: Under the Health Portability and Accountability Act (HIPAA), the business associates of healthcare providers are required by contract to protect the privacy of information if the business associate has access to the information and complete an agreement to this effect. 
• Call: The SBHC should set up a system to have 24 hour access to the provider(s). Service hours may differ.
• Compliance: If the practice will bill third-party payers, the practice should have a compliance plan that describes how it will oversee the practice in accordance with payor rules. For example: OIG Compliance Program
• Computer System: A noninclusive list of questions to ask when a provider is selecting software and systems if the SBHC will be school-operated:
  • What software will be used for billing? For medical records? For tracking quality data?
  • Is the software compatible with Medicare and Medicaid?
  • Does it meet the federal standards for e-scribing? 
  • How many terminals are needed in the school regardless of delivery location type?
  • Will providers enter medical record data, and if so will the entry be done in the exam room with the patient present if in-person? Telehealth processes?  Transscriptionist need for dictation?
  • What sort of network is needed?
  • Will the internet be required by the SBHC? Email?
  • What are the provisions for patient confidentiality of data kept on a computer?
• Confidentiality: Each SBHC should have a HIPAA compliance plan.
• Credentialing: Records should be kept for each licensed provider type, to include (noninclusive):
  • a copy of the current and unencumbered  licensed health care provider’s license
  • a copy of any pertinent certifications by a certifying organization
  • A statement signed by the licensed provider(s) that there has never been a conviction of felony, is not under investigation for suspected commission of a felony, is not under investigation by a licensing board, and has not been suspended from Medicaid or Medicare provider status
  • a statement of the licensed provider(s) malpractice history through the National Practitioner Data Bank
  • Prescribing authority Drug Enforcement Administration number
  • A copy of the prescriber’s CPR certification
  • The provider(s) Nation Provider Identifier
• Disability: SBHCs must meet all accessibility, patient, and employee laws required.
• Emergency Plan: The SBHC should have established written emergency plans
• Hours of Operation: SBHC(s) meet required hours of operation if managed care organizations have a requirement.
• Housekeeping: Address who, how and when cleaning, extermination, snow removal and hazardous waste removal will occur for SBHC operated by a school.
• Malpractice Insurance: The licensed health practitioner(s) is individualized to the licensed provider type.
• OSHA Compliance: The SBHC must meet all OSHA requirements.
• Laboratory: The SBHC must either ensure (if applicable to services provided):
  • They have completed the paperwork to comply with the State Laboratory Administration and Clinical Laboratory Improvement Amendment (CLIA)
  • They may fall under the CLIA waiver from the department.
• Physical Space: 
  • The SBHC established in a school should consider the following types of spaces if providing in-person care:
    • conference room
    • exam room(s)
    • waiting area
    • laboratory
    • utility room
    • offices
    • storage
• Security: SBHCs should consider after hours care, personnel and patient safety
• Reimbursement: SBHCs need to develop a patient intake procedure to ensure insurance information is correct. If the school based health clinic will do a sliding scale, develop a fee schedule. The fee schedule for visits and procedures should utilize appropriate CPT codes.
• Quality Assurance Plan: SBHCs should have a mission statement and method for evaluation, practice guidelines, and review.
• Referral Directory: SBHCs keep a referral directory updated on a continuing basis with local and state specialist providers.
• Forms and Agreement(s) to consider:
  • Parental Consent Form and Patient Enrollment/Registration Form
  • Independent Contractor Agreement for Schools
  • Professional Service Agreement
  • Business Agreement