LOS ANGELES—Timing may be just right for 14 wellness centers and networks that will operate in Los Angeles schools by 2014, all offering prevention, education, early intervention, and screening to students and their families.
L.A.'s school-based clinics, planned before the Affordable Care Act took effect, dovetail with reforms spelled out in the new law and take the idea of school-based health care one step further by teaming up with community clinic and mental health providers who will work not only with students, but with family members as well.
"We're very excited and have been working on this for almost four years now," said Kimberly Uyeda, director of student medical services for the Los Angeles Unified School District. "There's a certain degree of pent-up demand and need for these kinds of services. Plus, it's coinciding almost perfectly with a lot of changes in health care."
School health care delivery is decades old, but this fresh approach is creating real momentum, said Maryjane Puffer, executive director of the Los Angeles Trust for Children's Health. In 2008, the school district and L.A. County Department of Public Health joined forces with the trust, foundations and a broad group of stakeholders to evaluate health statistics at Los Angeles schools.
"The group identified health hot spots or high priority areas that experienced violence, obesity, poverty and sexually transmitted diseases," said Puffer. "In 2009, it made a proposal to the school board to create this new system of health care delivery."
Now the trust collaborates with the district's Student Health and Human Services Division and the Joint Use Development Program to increase health access at local schools through the centers. The board agreed to initially invest $28 million in funds but has since invested $34 million, Puffer said.
"That's for bricks and mortar, but nothing to pay for direct service delivery," she said. Clinics receive services from members of the Community Clinics Association of L.A. County while the school district has helped by "supporting staff to shepherd individual site progress."
The fact that wellness centers are located throughout the county in 14 separate areas is remarkable, Puffer said. "The scope of this response to student and community health and wellness is unprecedented in the nation, for nowhere else is this volume of activity targeting so many different school communities."
Centers are now open at Carson, Jefferson, Belmont and Garfield high schools.
The Los Angeles Trust for Children's Health is a not-for-profit agency formed through a 1991 resolution of the LAUSD Board of Education to support its school health programs.
Health Happens at School
The expanded wellness center model is based on a theoretical concept from the UCLA Center for Healthier Children, Families and Communities, Puffer said. She called Helen DuPlessis and Neil Halfon, senior advisers at the center, "innovators who helped build the model."
"The concept of wellness centers is being implemented gradually, but in a very thoughtful sort of way," said DuPlessis. "Schools provide nearly universal access to children for a long period in their lives, and a platform for creating opportunities for kids and their families who didn't have other regular venues for seeking health care. We can't take credit for all the innovation. Los Angeles is a big laboratory."
While "legacy" school-based clinics of the 1970s and 1980s operated with a more traditional approach -- an acute episodic care model -- the current system broadens access to children and families from a disease-based model to more of a wellness model, she said.
"The wellness centers are a one-stop shop, a place to get health information about diabetes prevention, mental health, oral health and more," said Puffer. "They're an opportunity to raise awareness of holistic health and wellness -- not just a one-time 'We've got to go to a doctor.' They elevate awareness of prevention strategies throughout the community and help students to identify career pathways in health."
Care doesn't begin and end at the doors of the center, but expands outward into the feeder school network, she said. The trust describes the process on its new website as "an experience students and families have of being connected to the essential preventive and primary care services, programs, insurance coverage and other school-based opportunities that create a healthy life at school and at home."
"Thirty years of research demonstrates there are far more determinants -- social, ecological, environmental and otherwise -- than what happens in a medical setting that determine whether or not someone is going to be healthy and achieve their potential in optimal fashion," said DuPlessis. "It's important to create better linkages with the broader health community."
"We also want to make sure people have insurance and understand it," said Puffer. School-based health centers are a logical place to accomplish both, she said. The school district's Children's Health Access and Medi-Cal programs support academic achievement and promote wellness by enrolling children and youth into health insurance programs. Healthy Start workers are also affiliated with the wellness centers. Additionally, each site's coordinating council ensures word gets out about the clinic and that operations run as planned, said Puffer.
"We expect to get pretty full in the next six months," she said. "Appointments are available. People won't be turned away, and capacity will depend on the site. Some may see 500 to 600 people a month."
Staffing varies, she said, and consists primarily of nurse practitioners or physician assistants overseen by the community clinic medical director.
'Access Point Parallel to None'
"So much activity is centered at our schools, which are integral, critical parts of the community," said Jim Mangia, president and CEO of St. John's Well Child & Family Center. St. John's, which will operate wellness centers at Manual Arts High School and Washington High School, has been involved in school-based health centers for 10 years.
Expansion of centers was a key part of the health reform law, Mangia pointed out. "School-based health centers are at a critical junction for improving health of our youth and the community at large, yet there's no operational funding to support ongoing sustainability of community health centers."
They're not profitable endeavors, but critical endeavors, he said. "Now that we've got them built, the next step in their development is a funding mechanism from both the state and federal government."
Advocates of school-based health centers in California are trying to gather support to push Congress to include $50 million in appropriations for a school-based health operations grant, said Puffer. "In the last year, through a capital investment of HRSA (Health Resources and Services Administration) funds, California schools received $1 million to help support capital and equipment," Puffer said.
L.A. County Board of Supervisors Chair Mark Ridley-Thomas has been instrumental in securing county funds to support the centers. When he was a state senator in 2007 he wrote SB-564 to establish a state grant program. Gov. Arnold Schwarzenegger (R) signed the bill in September 2008.
"A tremendous amount of strategy and leveraging must go on to make this sustainable. We don't have that path completely paved for us and much work needs to be done," said DuPlessis, who thinks the finance model could differ from that of a traditional private practice setting. "Maybe it should be more in tune with the kind of reimbursement model afforded to Federally Qualified Health Centers."
"The need and urgency to make this work are great," said Puffer. The trust coordinates the Wellness Network Learning Collaborative comprised of representatives from all 14 centers, plus school leadership, who all meet on a quarterly basis to establish benchmarks and guidelines that support the investment and to share best practices.
"The school-based health center is an access point parallel to none. This is where people go," she said.