Nikki Reiss directs and supports strategic communication planning, government relations and advocacy efforts, policy analysis, and strategy development for Advocacy & Communication Solutions. A female- and minority-owned consulting firm, ACS has a national reputation for its deep understanding of policy and advocacy, especially for organizations in the early childhood, Medicaid, and K-12 education sectors.
Interact for Health: Nationwide, where are school-based health centers gaining the most traction?
Reiss: We’ve observed that school-based health centers are gaining ground in regions that benefit from a strong pediatric provider community, either through pediatric hospitals or Federally Qualified Health Centers, or because they have a state health structure that incentivizes those school-based clinics.
Interact for Health: What is the biggest obstacle preventing more widespread adoption of SBHCs?
Reiss: It appears to be a couple of elements. First, it’s the inherent barriers to combining two large systems: health and education. Both involve a significant amount of sensitive data and many competing and challenging priorities for staff. It is a big lift to achieve the necessary degree of communication and cooperation so students and families see the benefit of having health care accessible on campus. Folks who already have more tasks than they can reasonably accomplish in a day are being asked to do more. Systemically, we need to look for opportunities to decrease the burden on those interacting directly with students. It is also a challenge for families to trust and understand what is available to them; health care is such a personal topic that families and students can be wary of something new. School staff and health care providers have to intentionally work to build the trust in any community especially with those populations who have been traditionally underserved or ignored.
School-based health centers are only one piece of a school health system. School nurses, psychologists, psychiatrists, counselors, and other support personnel all have an important role to play in making a student feel supported. Trust building among all parties within a school health initiative is probably the most critical element for widespread success.
Interact for Health: Once the centers are in place, what is the greatest challenge to their sustainability?
Reiss: Consistent and stable long-term funding. ... Some states provide direct line-item care, some municipalities have tax levies that specifically address student wellness needs, and some states do neither but have made changes to their Medicaid programs and reimbursement structures to provide additional resources. Often an SBHC is reliant upon philanthropic dollars, or community investment, to cover the necessary costs of outreach and administrative support not covered by the other funding streams. Everyone we’ve talked with pieces together their budget from a variety of sources, and we expect that to continue. What stands out is that, in those places where SBHCs have survived for a decade or more, there is at least one stable and well-supported source of funding that allows them to grow and flex as needed and as they are able based on other funding.
Interact for Health: What policies or strategies adopted by other states would you suggest for Ohio, Kentucky and Indiana to consider for SBHC sustainability?
Reiss: Several states have used increased Medicaid flexibility to allow for greater school health support, so we’d encourage the states to review what could be done in that space. Ohio has also used some of its American Rescue Plan Act funds to increase SBHC sites around the state, but the grant had some geographic and participant restrictions that left some areas out, so we’d like to see each state think about how these one-time use dollars could be used to stand up sites in brand new areas and bring more partners into the work.
We’d also encourage them to think creatively about what a SBHC is. We know some districts could really use a full-scale clinic building that would also serve community members, but that in other areas the best way for most people to access health care is through a mobile unit. We also know that telehealth seems great in theory, but there are large swaths — urban and rural — where lack of connectivity makes telehealth impossible. It’s important for policy makers to understand that SBHC aren’t a one- size fits all solution, and flexibility is needed to serve the various needs.
Interact for Health: What is the biggest challenge you encounter as an advocate, and what advice to you have for others trying to advocate for SBHC issues?
Reiss: It’s the complexity around the issue. We are talking specifically about school-based health centers here, but as I said, that’s just one piece of the larger school health conversation, and sometimes even those of us in this space aren’t as clear as we should be about the topic. There are so many avenues one could advocate for in this space — types of care, where care is provided, who provides it, how it gets paid for — it can be overwhelming! Most conversations focus primarily on physical and mental health, but dental and vision are also key to a student’s health, and how we integrate those into the rest of a program takes a lot of thoughtfulness and cooperation. Right now, our advocacy is focused on financial sustainability, because we believe that solving at least one small piece of that puzzle will create more time and space to start answering some of the other questions — including how we measure the effectiveness of the various models of care.
The best piece of advice I can give is this: be clear in your statements, don’t assume others have the same expertise you do, build relationships with other stakeholders, and don’t let the perfect be the enemy of the good. We aren’t going to tear down all the barriers in one attempt. The more we can work together to find a reasonable solution for at least one barrier, the better our chance to solve more issues later.
Interact for Health: What are the key data that SBHCs in operation should be reporting on to demonstrate their importance to policymakers?
Reiss: Policymakers often prioritize evidence of a high return on investment, so SBHCs that are able to demonstrate positive improvements in health and academic outcomes for students should certainly share that data. Those kinds of broad outcomes are difficult to show and take years to manifest, so in the short-term, demonstrating that more students are using available services and that the SBHC is well-received by students, families and staff is important and beneficial in making the case for ongoing investment.
Interact for Health: What about your work most excites you?
Reiss: The potential for real systemic change. I don’t think anyone would advocate for schools being all things to all people, but the reality is that for many kids, it’s the most stable place, and for almost all kids, it’s where they spend the bulk of their time. If we can create a system that provides children with wraparound services where they not only feel safe discussing concerns or receiving care, but also learn to advocate for themselves and ask questions and ask for help, we create adults who can and will do the same. No one functions well when they feel sick, and if we can in some small way address the basics of health, we will be on our way to improving overall population health and literacy. That’s exciting to me.
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