School-Based Health Centers and the Medical Home Model

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Patient-Centered Primary Care Homes (PCPCH) in Oregon

A patient-centered primary care home is a model that reinforces a patient-centered approach to providing care. The model of care promotes strong relationships with patients and their families with an emphasis on treating the whole person, therefore reducing costs, improving care through early intervention, a focus on prevention and wellness, and the management of chronic conditions.

A patient-centered primary care home, also known as a “medical home,” began as a way to describe a place that served as the source of all medical information about a patient. Today’s definition refers to a medical partnership approach to provide primary health care that depends on six core attributes linked to specific standards and measures:
  • Access to care: Patients get the care they need, when they need it.
  • Accountability: Recognized clinics are responsible for making sure patients receive the best possible care.
  • Comprehensive: Clinics provide patients all the care, information, and services they need.
  • Continuity: Clinics work with patients and their community to improve patient and population health over time.
  • Coordination and integration: Clinics help patients navigate the system to meet their needs in a safe and timely way.
  • Patient and family-centered: Clinics recognize that patients are the most important members of the health care team and that they are ultimately responsible for their overall health and wellness. 
Key services in a PCPCH include connecting patients and families to wrap-around services, routine follow up with patients to ensure effective treatment and, where school-based health centers are involved, optimizing the school learning environment.

In the state of Oregon, a PCPCH program was established in 2009 with House Bill 2009 to improve access to high-quality care, reduce costs, and support the transformation of the state’s health care system. This program, managed by the Oregon Health Authority (OHA) , operates with two primary goals: (1) All OHA covered lives, including Medicaid, public employees, educators, Healthy Kids, and Oregon’s high-risk pool, receive care through a Primary Care Home, and (2) Seventy-five percent of all Oregonians have access to care through a Primary Care Home by 2015 (regardless of insurance status).

Currently, approximately 450 clinics are recognized PCPCHs in Oregon and operate in one of three tiers:

Tier 1 – Basic Primary Care Home: Clinics have foundational structures and processes are in place.

Tier 2 – Intermediate Primary Care Home: Clinics demonstrate performance improvement with more advanced structure and processes.

Tier 3 – Advanced Primary Care Homes: Clinics use proactive patient and population management with accountability for quality, utilization, and cost of care outcomes.

PCPCH status is assigned using a range of criteria, with all three tiers adhering to 10 “must-pass” requirements. The PCPCH:
  • Provides continuous access to clinical advice by telephone.
  • Tracks one quality metric from the core or menu set of PCPCH Quality Measures.
  • Reports that it routinely offers all of the following categories of services: Acute care for minor illnesses and injuries; Ongoing management of chronic diseases including coordination of care; Office-based procedures and diagnostic tests; Patient education and self-management support.
  • Has a screening strategy for mental health, substance use, or developmental conditions and documents on-site and local referral resources.
  • Reports the percentage of active patients assigned to a personal clinician or team.
  • Reports the percent of patient visits with assigned clinician or team.
  • Maintains a health record for each patient that contains at least the following elements: problem list, medication list, allergies, basic demographic information, preferred language, BMI/BMI percentile/growth chart as appropriate, and immunization record; and updates this record as needed at each visit.
  • Has a written agreement with its usual hospital providers or directly provides routine hospital care.
  • Has a process to offer or coordinate hospice and palliative care and counseling for patients and families who may benefit from these services.
  • Offers and/or uses either providers who speak a patient and family’s language at time of service in-person or telephonic trained interpreters to communicate with patients and families in their language of choice.
As the PCPCH program has developed in Oregon and more clinics have acquired PCPCH status, it has become clear that school-based health centers (SBHCs) already provide patient-centered primary care and possess, in most cases, the necessary PCPCH attributes.

School-Based Health Centers as PCPCHs

School-based health centers in Oregon deliver quality, affordable, cost-effective health care to young people and function like a doctor's office located on school grounds. They offer a range of medical and health services, enjoy broad community support, help keep kids healthier and in school, and serve as a crucial access points for Oregon’s school aged population. With 68 state-certified centers across the state, SBHCs serve more than 23,000 students annually with three visits per student on average. Thirty-three SBHCs have attained PCPCH status, and both the Oregon School-Based Health Alliance and the Oregon Health Authority recognize the value of PCPCH standards and recommend that the number of state-certified SBHCs that acquire PCPCH recognition continue to increase.

Additionally, 50 SBHCs currently operate as part of a Federally Qualified Health Center (FQHC), and most SBHCs operating with these standards see very few barriers to achieving PCPCH recognition. In Multnomah County, for example, all SBHCs have FQHC status and are Tier 2 PCPCH certified, and the Multnomah County Health Department sees PCPCH certification as a foundation for improving quality of care and financial stability.

Generally, SBHCs are already well-aligned with PCPCH standards, sharing the same mission and intent and traditionally working to integrate primary care with dental and behavioral health care in a way that is truly patient-centered and personal. Though SBHCs are not required to acquire PCPCH recognition, moving toward PCPCH status can help SBHCs demonstrate the highest level of commitment to quality improvement and patient care, better positioning SBHCs as integral partners in regional health care delivery, serving the Medicaid population, engaging with Coordinated Care Organizations, improving business and clinical practices, and building crucial partnerships.

A recent article from Pediatrics: Official Journal of the American Academy of Pediatrics called “School-Based Health Centers as Patient-Centered Medical Homes,” demonstrated SBHC effectiveness in Colorado. Since Oregon and Colorado SBHCs operate similarly, the study is useful in understanding SBHCs as primary care homes in Oregon. Recognizing that SBHCs are known to increase access to medical care and mental health services for adolescents, the Colorado study demonstrated that SBHCs were largely meeting the service criteria expected of a primary care home. Some examples include:
  • Seventy-three percent of adolescents and 77 percent of parents reported the SBHC as doing a good or excellent job at “offering lots of different services to meet my/my child’s needs.”
  • Ninety-four percent of adolescents reported that providers usually or always ensured confidentiality of the visit.
  • Eighty-three percent of adolescents and 82 percent of parents reported that the SBHC did an excellent or good job at “respecting my family’s cultural values.”
While many SBHCs are already firmly embedded as PCPCHs in Oregon’s health care system, the role of the SBHC still needs clarification to maximize care delivery and coordination. Suggested role definitions currently include, (1) SBHC as primary care provider, (2) SBHC not the designated primary care provider, but providing a majority of care, and (3) SBHC as an ancillary provider. 

SBHC Challenges

In the Pediatrics article cited above, the research team concluded that “SBHCs appear well-equipped to serve as medical homes…offer access to mental health services for adolescents with unmet needs…and play an important role in the medical community, especially for underserved adolescents.” They also cite challenges for SBHCs serving as medical homes, including a “potential lack of after-hours and summertime support.” These challenges persist in Oregon as well, though they can be mitigated when an SBHC is integrated into a larger community health system, as is the case in Multnomah County where SBHCs operate as part of an FQHC.

Rural and non-FQHC sites are especially challenged by a lack of staff to manage the range of tasks associated with a PCPCH, including billing activities, documentation, and care coordination, and management of advanced technical systems such as electronic health records. Additional barriers to attaining PCPCH status in Oregon include the need for 24-hour telephone support, a lack of patient volume and, regardless of FQHC status, perceived competition with local primary care providers. The most significant challenge in many communities is that SBHCs are unable to refer to specialists or other providers, and that restriction is inhibiting patient care.

SBHCs are unique PCPCH providers

As more than half of Oregon SBHCs evaluate moving toward PCPCH recognition, SBHCs still struggle with the need to clarify their role in the health care system, communicating about their services to students and community partners, and creating a child and adolescent-focused service niche. Since it is difficult to uniformly define the level of care and kinds of services across all SBHCs in the state, those challenges need to be addressed at the SBHC level within the context of the local community.

SBHCs also have the ability to provide population-specific care focused on adolescent health, something that community clinics, health departments, and other providers may not be able to provide as easily, comprehensively, or consistently. In this vein, SBHCs can truly focus on serving the youth population and better represent their needs within the community and within the health care system, ensuring the needs of youth are well-represented for Coordinated Care Organizations.

Additionally, SBHCs have an excellent track record of serving communities in need and Oregon’s communities of color, with 40 percent of all visits coming from Oregon’s nonwhite populations. SBHCs can actively engage and empower young people to take control of their health care, as well as support youth development and leadership through peer education, advocacy efforts, civic engagement opportunities, youth councils, and leadership activities while working to address social determinants of health such as educational attainment. Youth participation at the SBHC level also improves service delivery, health education and literacy, and the health and academic success of students, further supporting the PCPCH model and the triple aim goals of Oregon’s health care transformation.