School-based health centers (SBHCs) are designed to improve efficiency in health care, and that showed recently at the Manor Mustang Health Center, which serves a geographically large area between Austin and Elgin. A young student presented with foot swelling that turned out to be caused by kidney disease.
“The [health care professional] examined the student at our school-based health center, then contacted me as the medical director,” said Celia Neavel, MD. She is an Austin family and adolescent medicine physician at People’s Community Clinic, which helped set up the SBHC eight years ago with Manor Independent School District and the local mental health authority, Integral Care. “I spoke with the pediatric nephrologist that day to review the case since it already was Friday afternoon.”
Instead of rushing the boy to what would have been an expensive – and needless – emergency department (ED) visit, Dr. Neavel set up a timely appointment with the specialist. “The uninsured student received efficient care and didn’t have to go through the ED over the weekend,” she said.
SBHCs treat students from pre-K through 12th grade and may be located at a school or off-site. The national School-Based Health Alliance estimates Texas had roughly 120 of these centers between 2016 and 2022. They often serve schools in low-income communities and offer a range of health care services that vary from district to district. But they all provide a significant step up in medical care from what a traditional school nurse can offer.
“They’re all different,” said Dr. Neavel, who co-chairs TMA’s Committee on Behavioral Health. “Some might have dental. Others may focus on behavioral health. Some may do more acute care. Some, like ours, may be more like a medical home with support from our main [People’s Community] clinic. There’s quite a range of services that could be offered in an SBHC.”
In 2023, TMA updated its long-standing policy supporting SBHCs and funding for them, recognizing “that SBHCs have been shown to increase access to health care, contribute to better academic performance among students, mitigate emergency room use, and expand access to behavioral health services” (tma.tips/SBHCpolicy).
SBHCs have gotten a fresh look, in part, because of the fallout from COVID-19, says Nhung Tran, MD, a developmental pediatric specialist in Austin and consultant to TMA’s Committee on Behavioral Health. The pandemic exacerbated concerns about physical health, as well as an already growing mental health crisis among young people.
“Kids without mental health issues had brand-new onset symptoms; the kids with subclinical [problems] surged to clinical; and the kids who already were diagnosed with mental health conditions got worse,” Dr. Tran said.
By taking care directly to kids in schools, SBHCs are an efficient way to bring physicians to a population of patients with big medical needs, she says.
“Parents may weigh distance against perceived urgency on whether to seek care for their child’s behavioral health problem, and this can delay care earlier in the course,” Dr. Tran said. “They may think, I’m not sure if this problem is big enough right now to regularly take my kid out of school, take time off work, go all the way to the doctor – who may be double-digit miles away [in rural areas] – be there for 30 to 60 minutes, then drive all the way back.”
Reaching kids where they are
Addressing health care needs at school is convenient for patients, but it also improves health care outcomes – as in the case of the boy with the kidney disorder – and provides health care for students with no insurance or primary care physician. That is one reason the Community Preventive Services Task Force, a panel of health experts set up by the U.S. Department of Health and Human Services, recommends SBHCs in low-income areas (tma.tips/SBHCrecommendation).
“Kids who feel connected to their school have better mental health and are healthier overall,” Dr. Neavel said. “School-based centers can help facilitate that sense of connectedness for students and physicians.”
SBHCs are vital for improving mental health of Texas children, and – again – convenience is one of the most important reasons they’re helpful, Dr. Tran says. Young people are six times more likely to complete mental health treatment offered in schools versus other community settings, according to the National Center for School Mental Health at the University of Maryland School of Medicine (tma.tips/UMarylandSchoolMentalHealth).
SBHCs with adequate behavioral health staff can help students who would have no hope of getting adequate care otherwise, Dr. Tran says.
“Imagine a youth who has a student health clinic where they can talk to a certified behavioral health counselor twice a week or twice a month, whatever is needed, and go right back to school,” she said.
But not all SBHCs have the funding for behavioral health professionals. Most funding for SBHCs comes from the federal government, according to the School-Based Health Alliance. States, school districts, and private organizations also fund them. The Texas Department of State Health Services used to support some SBHCs, but the funding for that has run out, according to an agency spokesperson.
Physicians preparing for the next session of the Texas Legislature in January can speak with lawmakers about better funding for both SBHCs and the programs they provide, says Keller pediatrician Jason Terk, MD, who formerly chaired TMA’s Council on Legislation and the Texas Public Health Coalition.
“Mental and emotional health is one of the most important crises that we are dealing with in adolescence,” he said. “Without appropriate resources being devoted to the mental health crisis, we will unfortunately continue to have horrible events like teen suicides and school shootings.”
SBHCs frequently use programs funded by the Texas Child Mental Health Care Consortium, which oversees five important mental health programs.
One of the most important programs used by SBHCs is the Child Psychiatry Access Network (CPAN), which provides telehealth consultation and training in behavioral health to physicians and other health care professionals. Another is the Texas Child Health Access Through Telemedicine (TCHATT) program, which provides in-school behavioral telehealth care to at-risk children and adolescents.
Thanks to TMA efforts, Texas lawmakers have improved mental health funding in recent sessions of the legislature and created initiatives like the consortium. In 2023, Texas allocated $2.3 billion for mental health services, with a focus on community mental health services and grant programs for adults and children.
While that improved funding is welcome and needed, Texas physicians must continue pushing for more to help keep up with the state’s surging population and to overcome decades of neglect in behavioral health, says Dr. Tran, who serves as CPAN’s pediatric consultant and the Texas Pediatric Society’s liaison to CPAN.
“The money [the state] has set aside for CPAN and TCHATT, I will applaud Texas legislators for that,” she said. “But it is just a down payment to the rest of the investment that we owe children because we’ve been underfunding children and youth’s mental health care for so many years.”
SBHCs also help solve another thorny health care issue: treating uninsured children. Right now, 11% of Texas children are uninsured, the most of any state in the U.S., according to the Georgetown University Center for Children and Families (tma.tips/TexasInsuredKids). The need is particularly acute in rural areas, where the few hospitals and clinics available may be dozens or hundreds of miles away.
“There’s a shortage of primary care, and there are a lot of uninsured [children], so this might be the only way people are getting primary care,” Dr. Neavel said.
SBHCs vary in how they accept students, Dr. Neavel says. Some might have parents sign up for services at the start of the school year; others might accept students who are referred from the school nurse or have parents bring students directly to the SBHC.
“There’s always demand for sports physicals,” she said. “That’s a really great service that a school-based clinic can offer. Also, if kids need vaccines to attend school, they can get them at the SBHC. Chronic disease management, such as with asthma, is another way SBHC keep students healthy and in school.”
More SBHCs are needed, especially in rural areas where health care and behavioral care options are limited, Dr. Tran says.
But setting one up requires buy-in from a wide range of stakeholders, says Michelle Gallas, DO, medical director for the Austin Independent School District and a member of TMA’s Committee on Child and Adolescent Health.
“It’s not as simple as walking onto a campus and saying, ‘I have this idea,’” she said. “There are a lot of things to consider – the [school] leadership, the families, the facility, who’s going to run it, and funding.”
TMA’s updated policy endorses funding for SBHCs at the state and federal level, “including, but not limited to their recognition as a provider under Medicaid.”
Another concern is communication between the SBHC and local physicians. The Texas Pediatric Society supports SBHCs but cautions that a child’s pediatrician must stay involved in their care after treatment at an SBHC.
That might be difficult given the obstacles many health care organizations have in sharing medical records and other information, Dr. Gallas says.
And Dr. Neavel adds SBHCs typically are sensitive to the importance of communicating with a child’s primary care physician, if there is one.
SBHCs are “not there to undermine that relationship,” she said. “However, uninsured youth may not have a primary physician or medical home.”
And the centers have the potential to build relationships that help patients in ways that ordinary clinics and physician offices find difficult to replicate, she says. For example, the physicians and other medical staff at SBHCs have access to school social workers and teachers – people who know the students and their families best – which helps identify behavioral and health problems before they escalate.
“We can actually staff cases together, and that’s just very collaborative,” Dr. Neavel said.