SBHC Sustainability

What Makes a School-Based Health Center Sustainable?

Children's Aid Society School Wellness CenterThe School-Based Health Alliance convened a group of experts—SBHC (school-based health center) administrators, funders, providers, finance policy analysts, and program evaluators—to answer this question. The discussions helped us organize the most important characteristics of strong and thriving
SBHCs into three aspects of a sustainable program:

  1. Strong Partnerships: Sustainable SBHCs develop and nurture partnerships with school and community stakeholders.
  2. Sound Business Model: Sustainable SBHCs create a sound business model that relies on a variety of stable and predictable funding sources (including patient revenue).
  3. High Quality Practice: Sustainable SBHCs operate health care practices that respond to the comprehensive needs of students and demonstrate the highest level of quality and patient satisfaction.

Each of these aspects is interdependent and of equal importance. Underdevelopment of any of the three can weaken a SBHC’s long-term sustainability. A more detailed description of each aspect is provided below.

Strong Partnerships

No SBHC is an island. Collaboration is essential to the model’s long-term success. Fully-engaged and accountable partners can provide support and resources to develop a sustainable SBHC. The following stakeholder groups—although not an exhaustive list—are critical to engage.

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School—An SBHC’s ability to integrate into the education environment is the key to an effective partnership with schools. Contributing to the school’s mission and delivering outcomes that matter to educators—such as reductions in student absenteeism—is vital to strengthening an SBHC’s partnership with its school. Coordination and collaboration with school administration, teachers, and support staff—school nurses, psychologists, and counselors—ensures the partnership meets student needs efficiently, effectively, and seamlessly.

Local health care providers—Successful SBHCs have formal partnership protocols with the broader health care community to ensure primary care coverage beyond the capacity of the SBHC, including oral, reproductive, behavioral, and specialty health care. As a good partner, the SBHC exchanges patient data as appropriate. This enables the SBHC to demonstrate and quantify its ability to improve quality measures and eliminate health disparities.

Students and families—Students and their families—parents, guardians, and extended family members—are key allies to achieve full enrollment in the SBHC and are important champions for raising funds or marketing the program’s success.

Sponsorship organization—Ensuring that the culture of the school and community is aligned with the priorities of a potential medical sponsor must be a priority in the SBHC’s provider selection process. Federally qualified health centers (FQHCs), behavioral health organizations, local health departments, hospitals, academic centers, solo practices, and even schools each have distinct advantages and disadvantages for the SBHC and its bottom-line. Know what each brings to the table in terms of revenue opportunities and administrative strengths.

Sound Business Model

The traditional SBHC grant-only fundraising model is no longer viable. A growing number of SBHCs competing for dwindling public and private funds has made service delivery grants obsolete. Sustainable SBHCs employ sound business models based on financial planning strategies that rely on a diversity of stable and predictable funding sources, maximize patient revenue, and right-size the role of grants to support operations for the long-term. Technical support from our sustainability resources will help SBHCs better understand costs and the sources and flow of revenue.

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Billing infrastructure—The capacity to collect patient revenue efficiently is a necessary cost of doing business. This includes health information management systems, dedicated administrative personnel, and policies and procedures.

Analysis of financial standing—Create a business plan with financial performance metrics that take into account – among other things – the cost of the program, expected patient volume by provider, and payer source. In monetizing services, consider everything that goes into the overall expenses of the program – direct and indirect alike – including staffing, facilities, pharmacy, administration, billing, care coordination, and health promotion. The more refined the analysis the better. Calculate what it costs to deliver an individual unit of service by provider type (health care visit, mental health visit, dental visit, health education visit, etc.).

Insurance policy environment—How will SBHC visits by your patients be covered? Who is and isn’t insured? What percent by Medicaid? What percent by commercial insurance? Contact your Medicaid program to develop expertise in public insurance policies, including eligible providers, covered services, and reimbursement rates. Build relationships and establish contracts with local Medicaid managed care organizations to ensure reimbursement for services.

Diversity of portfolio—Offset expenses related to non-reimbursable services and uninsured individuals with other revenue sources, such as federal, state, and local public funds, as well as private sector support from area foundations and corporations. 

High Quality Practice

SBHCs operate health care practices that respond to the comprehensive needs of students and demonstrate the highest level of quality and patient satisfaction. Achieving a first-rate, high-quality patient-centered health care practice requires attention to every dimension of program performance, including measuring quality indicators, data reporting, and routine workflow and data analysis.

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Measuring quality indicators—A number of national quality measures (HEDIS, CHIPRA, and “meaningful use,” to name a few) are being used by payers – including state Medicaid and CHIP programs – to assess, monitor, and reward health care improvements. Identify the national quality measures and clinical standards that have been chosen by your state’s Medicaid and CHIP programs, and then choose those that align with the SBHC’s strengths. These may include: immunizations, preventive visit rates for adolescents, care coordination for attention deficit-hyperactivity disorder, and asthma management.

Effective data extracting and reporting—Quality improvement efforts and sophisticated applications can’t be sustained without management information systems that collect and report data you need. Whatever data points you elect to include (quality measures, cost-per-visit, encounter rates), be certain to extract information in ways that make the information actionable, and can be shared with clinic staff, sponsors, and key stakeholders. Data increases your partnership value (see aspect one).

Routine workflow and data analysis—Quality Assessment and Improvement (QAI) is a system-level, iterative approach to identifying workflow problems, planning and testing interventions, analyzing results, and tweaking the interventions based on results until benchmarks are achieved and maintained. Typical SBHC workflow problems include non-compliance with benchmarks for lab test review and follow-up, referrals and follow-up, sustainable temperature checking system for immunization refrigerator, and well child visits. 

Tools and Resources

With the help of veteran SBHC administrators, funders, providers, finance policy analysts, and program evaluators, the School-Based Health Alliance has organized tools, resources, and recommendations proven to help SBHCs build a stable foundation.

Access our Sustainability Tools