The Whole Child: School-Based Health Centers

by Michelle McKenzie

Roosevelt Middle School is a New Deal-era structure with an attractive art deco façade in East Oakland’s San Antonio neighborhood.

In the basement of the school is one of the more widely used doors on campus. It leads to the school health center, and by the end of the school year, all 517 of Roosevelt’s sixth- through eighth-grade students will pass through this door at least once to receive free health services.
Roosevelt Health Center was not Oakland Unified School District’s first school-based health center (that distinction belongs to Tiger Clinic, which opened at Fremont High School in 1989), but it was the first in the county to locate on a middle-school campus. It opened in 2000, and in 2010 moved into its current home in a renovated wing formerly occupied by storage rooms and a girls’ gymnasium.
 The transformed space contains a patient waiting room; front desk staff who can assist with Covered California insurance enrollment; two fully equipped medical examination rooms; a dental exam room, where services — everything but extractions and orthodontia — are available three days a week; a health education office; a first-aid room; and a laboratory where blood draws, immunizations and body mass index screenings occur and medications are dispensed. The school nurse’s office is also located in the center.
 The floors gleam and warm smiles are worn by staff, who passionately carry out RHC’s mission: to improve adolescent health, well-being and success in school by increasing access to comprehensive and high-quality health care services, reducing barriers to learning and supporting families and communities by providing basic medical care, behavioral health services and health education in a respectful, youth-centered environment.

Like all SBHCs in the district and county, Roosevelt Health Center provides services in five core areas: medical, behavioral health, dental, health education and youth development.

Students can refer themselves for care, provided they have a consent for treatment form on file, but many referrals come through the Coordination of Services Team — an interdisciplinary, inter-agency team that fields and manages referrals from parents, teachers and others in the community. Every school with an SBHC has one of these teams. COST is one way that school health centers, as a best practice, integrate themselves closely with schools to ensure that the students most in need of care are served.
 “Part of the goal with COST is to have a team that’s able to get students connected to services so that teachers can focus on teaching in the classroom,” Mara Larsen-Fleming, director of health and wellness at Oakland USD, says.
 To maintain that focus, students must also have a pass when visiting the health center during class hours. They may visit on a drop-in basis after school lets out at 3 p.m. The center closes at 4:30. Before teachers issue passes, they call the health center to confirm that staff is available to see the student, thereby ensuring students don’t miss instructional time unnecessarily.
 Roosevelt Health Center, like other middle school SBHCs, is in a unique position to reach students who, at their age, are unlikely to have learned how to navigate the health system and identify or ask for the services they need.
 Mizan Alkebulan-Abakah is the clinic supervisor at Roosevelt Health Center. She works with La Clinica de la Raza, the agency contracted by the Alameda County Health Care Services Agency to lead six Oakland USD health centers. She describes how a student might first interact with the health center:
 “First aid can be a door-opening. Students may initially come in to ask for a Band-Aid or a granola bar. They’re testing the waters and our energy, so that when they do have something larger, such as changes they’re experiencing with their body, or a stressful family matter, they’ll know that this is a safe place to have that conversation.”

School-based health for us is really broad,” Larsen-Fleming says. “It has to do with school climate, behavioral health, nursing and a lot of environmental work that’s happening on campuses, like health education, health insurance enrollment and health access initiatives … All of our agencies are committed to serving the whole child.”
 Research shows that poor student health — physical and behavioral — leads to poor attendance and learning, which in turn lead to poorer academic outcomes. By locating health services on or adjacent to a school campus, where students spend most of their daytime hours, students are more likely to receive the care they need and miss less school due to illness, injury or off-site appointments. For low-income students and students in neighborhoods lacking a family clinic, the SBHC may be the only, or primary, link to health services.
 Alkebulan-Abakah adds, “We’ve used our position as a school-based health center to not only support health within the walls of the center, but to get farther out into the Rest of the campus and community to try to impact health more broadly, through a public health lens. All of our efforts are housed in the concept of the full service community school.”
 Extended services include screenings for medical health insurance, vaccination and sexually-transmitted infections. (Oakland’s Youth Heart Health Center also hosts a “Tacos and Testing” day, which lets students grab a free taco once they’ve completed all of the testing stations.) The latter is a way to enforce the importance of regular screenings and practicing sexual safety.
 The center also coordinates day-long health fairs that engage the entire school; restorative Justice circles for teachers; yoga and mindfulness stress-reduction courses; a Spanish-language newcomers support group; behavioral health screenings for all students; “know your rights” peace campaigns; clothing and school supply giveaways; and healthy eating contests among other programs and activities.
 Increasingly popular among Roosevelt students are what RHC calls gender-specific, question-based healing circles. Four years ago, RHC brought together all of the female African-American students on campus for a “sister circle.” Facilitated by an expert in the field, the day-long retreat and follow-up sessions were designed around the theme of “seeing the beauty in our differences.” The circle not only helped to eliminate some of the classroom disruptions that were occurring, but helped the students work with each other to resolve their conflicts.
 The circles have since been expanded to serve African-American males, Latino boys and girls and Asian-Pacific Islander students.
 Although staff agrees it is sometimes hard to tell how students are taking it all in during the circles, the little reinforcements do come. Among the best of them? Walking past a group of girls in the hall and overhearing “I wish we had sister circle today.”

In 2014–15, Oakland USD’s 16 SBHCs provided 38,441 visits to 8,194 unduplicated clients in elementary, middle and high schools. Most of these were students, but some were family and community members. RHC, for instance, has started offering part-time services to nearby Garfield Elementary, a feeder school to Roosevelt.
 To help inform the services RHC provides, the center examines data obtained from the California Healthy Kids Survey, which has a module about SBHCs. (For more information on CHKS, read this issue’s infographic on page 8 and “From the Field” on page 15.) Also, Alameda County contracts with the University of California, San Francisco to receive an annual evaluation report on how well the county’s SBHCs are doing.
 “Getting data from both teachers and students, particularly students’ own assessments of their social-emotional wellness, has been very helpful,” Alkebulan-Abakah says.
 In the 2015 survey, 92 percent of healing circle participants answered that the healing circles “definitely” or “somewhat” improved How they feel about themselves. The survey data showed an impact in other areas as well. For example, students reported reduced consumption of fast food (49 to 32 percent) and increased consumption of raw fruits (from 13 to 20 percent) after taking a nutrition education class.
 Countywide, according to the 2013–14 UCSF evaluation report, 97–100 percent of students “strongly agreed” or “agreed” that SBHC staff treat them with kindness and respect, help them to work through concerns and issues and are easier to talk to than other doctors or nurses.

Of course, all of this extensive work and outreach requires funding, but equally critical are partnerships — and knowing how to leverage them.
 The Unity Council, an Oakland-based nonprofit, uses its county dollars to place a case manager in the center every day. Three days a week, the case manager facilitates healing circles for the school’s Latino males.
 Another community-based provider, Asian Community Mental Health Services, is contracted to provide behavioral health support services.
 RHC is also taking part in a three-year national effort called Hallways to Health, which is part of Kaiser’s Thriving Schools movement and is co-sponsored by the statewide nonprofit California School-Based Health Alliance. And CSHA is implementing a $2 million grant from a private donor fund at the San Francisco Foundation that supports SBHCs in implementing trauma-informed care practices.
 “Roosevelt Health Center is seen as a national leader in terms of their school integration, the programs they’re running and their ability to see all students,” says Juan Taizan, associate director of programs at CSHA. “It doesn’t look like this across the state,” he says. “That’s part of our role — to help SBHCs enhance the medical model through relationship-building with multiple partners and the school site.”
 Marta Lutsky, quality improvement coordinator, Center for Healthy Schools and Communities, Alameda County Health Care Services Agency, agrees that the number and depth of RHC’s programs and outreach make it exceptional. “Some of our health centers are still starting up. Gaining the trust of the school principal and teachers and building all of these relationships takes time,” she says.
 Still, Larsen-Fleming stresses that all of Oakland USD’s SBHCs are doing the necessary work: “Different funding and initiatives come in, and all of the centers weave it together to provide a beautiful array of programming that goes well beyond the required core components of a school-based health center.”

It costs $1.5 to $2 million to build a schoolbased health center today, depending on such factors as the size of the center, how many exam rooms it contains and whether it’s an existing space renovation or a brand new building. The centers must also be up to the medical and education building codes.
 The newer centers are primarily built through local voter-approved facilities bond dollars administered by Oakland USD, but district, county, federal and philanthropic dollars also factor in.
 When determining where to build, high-need schools and areas take priority. Just over 95 percent of Roosevelt Middle School students qualified for a free or reduced-price lunch in the 2014–15 school year.
 Lutsky says the county does assessments to help determine that need. Sometimes it might be that an area needs more specific help — in the way of a dental van or a better connection with a federally qualified health center, for instance.
 Alameda County’s next health center is due to open in Emeryville before the end of this summer, but in the immediate future, efforts will focus less on building new centers and more on maximizing partnerships with existing service providers.
 “We have this incredible network of 16 health centers,” Larsen-Fleming says. “We can’t possibly build and sustain centers for all of our schools — but we can use the network we have to connect as many schools as possible to reinforce health in feeder schools and neighborhoods.”
 Back in 2010, Roosevelt Health Center’s newly renovated health center was celebrated with a ribbon-cutting. Larsen-Fleming recalls that as the students walked into and surveyed the health center for the first time, one student stopped in his tracks and said, “This is for us … we don’t deserve this.”
 “That broke my heart because that’s exactly why we built it,” Larsen-Fleming says. “They absolutely deserve it, and they don’t always know that. It’s the least we can do for them, and it lets them know how we value them.”

Michelle McKenzie was a former staff writer for California Schools magazine, where this article first appeared.