Paul Melinkovich

School-Based Health Centers: Improving Access and Quality of Care for Low-Income Adolescents

OBJECTIVES. We sought to compare visit rates, emergency care use, and markers of quality of care between adolescents who use school-based health centers and those who use other community centers within a safety-net health care system for low-income and uninsured patients. PATIENTS AND METHODS. In this retrospective cohort study we used Denver Health electronic medical chart data, the Denver Health immunization registry, and Denver Public Schools enrollment data for the period from August 1, 2002, to July 31, 2003. The cohort included all 14- to 17-year-old Denver Public Schools high school enrollees who were active Denver Health patients and were either uninsured or insured by Medicaid or the State Childrens Health Insurance Program. “School-based health center users” were those who had used a Denver Health school-based health center; “other users” were those who had used a Denver Health community clinic but not a school-based health center. Markers of quality included having a health maintenance visit and receipt of an influenza vaccine, tetanus booster, and hepatitis B vaccine if indicated. Multiple logistic regression analysis that controlled for gender, race/ethnicity, insurance status, chronic illness, and visit rate was used to compare school-based health center users to other users. RESULTS. Although school-based health center users (n = 790) were less likely than other users (n = 925) to be insured (37% vs 73%), they were more likely to have made ≥3 primary care visits (52% vs 34%), less likely to have used emergency care (17% vs 34%), and more likely to have received a health maintenance visit (47% vs 33%), an influenza vaccine (45% vs 18%), a tetanus booster (33% vs 21%), and a hepatitis B vaccine (46% vs 20%). CONCLUSIONS. These findings suggest that, within a safety-net system, school-based health centers augment access to care and quality of care for underserved adolescents compared with traditional outpatient care sites.

Adolescent Immunization Delivery in School-Based Health Centers: A National Survey

PURPOSE Vaccinating adolescents in a variety of settings may be needed to achieve high vaccination coverage. School-based health centers (SBHCs) provide a wide range of health services, but little is known about immunization delivery in SBHCs. The objective of this investigation was to assess, in a national random sample of SBHCs, adolescent immunization practices and perceived barriers to vaccination. METHODS One thousand SBHCs were randomly selected from a national database. Surveys were conducted between November 2007 and March 2008 by Internet and standard mail. RESULTS Of 815 survey-eligible SBHCs, 521 (64%) responded. Of the SBHCs, 84% reported vaccinating adolescents, with most offering tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and human papillomavirus vaccines. Among SBHCs that vaccinated adolescents, 96% vaccinated Medicaid-insured and 98% vaccinated uninsured students. Although 93% of vaccinating SBHCs participated in the Vaccines for Children program, only 39% billed private insurance for vaccines given. A total of 69% used an electronic database or registry to track vaccines given, and 83% sent reminders to adolescents and/or their parents if immunizations were needed. For SBHCs that did not offer vaccines, difficulty billing private insurance was the most frequently cited barrier to vaccination. CONCLUSIONS Most SBHCs appear to be fully involved in immunization delivery to adolescents, offering newly recommended vaccines and performing interventions such as reminder/recall to improve immunization rates. Although the number of SBHCs is relatively small, with roughly 2000 nationally, SBHCs appear to be an important vaccination resource, particularly for low income and uninsured adolescents who may have more limited access to vaccination elsewhere.

Addressing Adolescent Immunization Disparities: A Retrospective Analysis of School-Based Health Center Immunization Delivery

OBJECTIVES We compared completion rates for adolescent immunization series administered at school-based health centers (SBHCs) to completion rates for series administered at community health centers (CHCs) within a single integrated delivery system. METHODS We performed a retrospective analysis of data from an immunization registry for patients aged 12-18 years. Patients were assigned to either an SBHC or a CHC during the study interval based on utilization. We used bivariate analysis to compare immunization series completion rates between the 2 groups and multivariate analysis to compare risk factors for underimmunization. We performed subanalyses by ages 12-15 years versus ages 16-18 years for human papillomavirus (HPV) and for the combination of HPV; tetanus, diptheria, and pertussis (Tdap); and tetravalent meningococcus virus. RESULTS SBHC users had significantly higher completion rates (P<.001) for hepatitis B, Tdap, inactivated poliovirus, varicella, measles/mumps/rubella, and HPV for ages 16-18 years, and for the combination of HPV, Tdap, and MCV4 for ages 16-18 years. CHC users had higher completion rates for tetanus and diphtheria. CONCLUSIONS SBHCs had higher completion rates than did CHCs for immunization series among those aged 12-18 years, despite serving a population with limited insurance coverage.

Rapid diagnosis of Chlamydia trachomatis pneumonia in infants by direct immunofluorescence microscopy of nasopharyngeal secretions

The recent development of a monoclonal fluorescent antibody test to detect Chlamydia trachomatis by direct microscopy in clinical specimens has allowed rapid diagnosis of chlamydial genitourinary and ocular infections. 1-4 To investigate the ability of the direct FA test to diagnose chlamydial respiratory tract infection rapidly, we compared the FA test with culture in infants with suspected chlamydial pneumonia.

Evaluation of Community-Based Health Projects: The Healthy Tomorrows Experience

OBJECTIVES. To address the “millennial morbidities,” pediatricians must partner with community-based organizations to develop interventions. Little is known about the capacity of the resulting programs for program evaluation or the importance of evaluation in project success and sustainability. The objective of this study was to examine the capacity of community-based health programs to conduct project evaluations and determine the impact of project evaluation on project outcome. METHODS. Project directors from 149 community-based programs funded from 1989 to 2003 through the Healthy Tomorrows Partnership for Children Program were surveyed regarding their project experience with evaluation and documentation of project outcomes and the current status of their project. RESULTS. Program directors from 123 (83%) programs completed the survey. Despite barriers to the evaluation process, 83% of the respondents indicated that their evaluations produced useful information. Programs that were described by respondents as “well evaluated” were more likely to report that the evaluation was implemented as planned and that the evaluation included outcome measures. Projects were more likely to be sustained in their original form when at least 1 outcome was reported on the survey. CONCLUSIONS. Evaluation of community-based programs, although challenging, is beneficial to project success and sustainability. Policy makers and funding agencies should consider ways to encourage community partnerships to incorporate evaluation into their planning process.

“Dyading” in the Pediatric Clinic Improves Access to Care

Objective: This project evaluates the effect of “dyading” on pediatric outpatient care. Methods: In “dyading,” the medical assistant (MA) works with the provider in the exam room during the chart review, history taking, and patient education. In sequential care, the patient interacts with the MA, then the provider, then the MA again, with waiting in between. The authors measured visit time (from the MA starting with patient to the end of visit), the mean number of patients seen in a clinic session per provider, and patient satisfaction. Results: After implementation of “dyading,” mean visit time decreased from 37 ± 14 to 25 ± 11 minutes, the mean number of visits/session increased from 8.24 to 9.25, and waiting in the exam room reported by families decreased from 77% to 46%. Conclusions: “Dyading” decreased visit time, which increased the number of patients seen, thereby improving access to care. Patient time in the exam room decreased, which freed up exam rooms.

School-Based Health Centers: A Model for the Provision of Adolescent Primary Care

CASE STUDY Annie (identity disguised) is a student at one of the public high schools where a school-based health clinic (SBHC) is located in the building. Annie is called to the clinic during school to receive her second human papilloma virus (HPV4) vaccination. The medical assistant checking her into the clinic noticed that she has lost quite a bit of weight. When questioned further, Annie stated that she was not trying to lose weight. The medical assistant had her see the primary care provider in the clinic instead of only vaccinating her and sending her back to class. After a history and physical examination were obtained, the clinician notes that Annie has experienced polyuria and polydipsia. A urinalysis in the clinic displays glucosuria and ketonuria. Fortunately, she was not severely acidotic at this time. Ultimately, Annie was referred to endocrinology and diagnosed as having Type I diabetes. Health care of adolescents can be challenging for a primary health care provider in a typical clinic or office setting. Adolescents are the least likely group of patients to seek health care in traditional clinic settings [1]. Many of the health needs of this age group are unique in nature related to risky health behaviors, such as unprotected sex, substance abuse, and violence. Traditional health care settings are often not adequate and primary health care providers in these settings do not have the time to delve into the risky behaviors of this patient population. Although this case study does not highlight one of these risky behaviors, it does illustrate an advantage of having a clinic in a setting that is convenient for at-risk youth. It is likely that because of barriers faced by this teenager, her presentation as a new diabetic would have been more severe had it not been for the clinic located in her school.

Welfare to Work: The Effect of a Health-Care Program in Child-Care Centers

OBJECTIVE Welfare reform has increased pressure on welfare recipients to enter the labor force. When they become employed, former recipients often do not have paid leave that can be used to care for their young children when they are sick. We wished to determine whether an on-site health-care program in child-care centers serving low-income families affected the amount of time parents took off of work to care for mildly ill children. METHODS We surveyed parents in 6 child-care centers with an on-site health-care program and in 2 comparison centers without such a program. To analyze survey results, a regression model including demographic and other variables was used to determine which, if any, variables were associated with time taken by parents from work to care for sick children. RESULTS Analyzing the variables of employer leave policy, poverty level, age of child, and enrollment in the health-care program, only the variable of health-care program enrollment was associated with taking less time from work to care for sick children. CONCLUSION Health-care programs in child-care settings can help parents meet the health needs of their children while reducing absenteeism from work, thereby contributing to job stability.