Maryland Locks in Financial Security for School-Based Health Centers
From 1994 to 2001, the State of Maryland Executive Department, Office for Children, Youth and Families (now called the Governor's Office for Children) further developed school-based health centers in the state, established new centers, developed the state's infrastructure to support the centers, and created a statewide organization of school-based health centers.
The project was part of the Robert Wood Johnson Foundation (RWJF) Making the Grade: State and Local Partnerships to Establish School-Based Health Centers national program.
- The Maryland School-Based Health Care Initiative created four model school-based health centers in Montgomery and Talbot counties.
- The number of school-based health centers in Maryland grew from 14 in 1993 to 61 in 2001.
- Guidelines developed by the state have helped standardize the scope of services offered by the centers.
- The Maryland School-Based Health Care Initiative secured ongoing support from general state funds to support school-based health centers.
- The project team helped form the Maryland Assembly on School-Based Health Care, which has become a mechanism for information dissemination, technical assistance and support for school-based health centers.
RWJF supported this project through three grants totaling $1,648,844.
Income levels vary considerably in the different regions of Maryland. Even wealthier areas, such as the Washington suburbs, have had to support health care access for low-income residents. The state had 14 school-based health centers (SBHCs) when it applied for a Making the Grade planning grant in 1993. The first were formed in 1985, and all were located in Baltimore, a national pioneer in creating and funding SBHCs. Maryland is unusual among states in that only the governor can put money in the state budget, with input from the lieutenant governor. The legislature can only approve, reject or cut budgets. This means that executive-branch support is critical for social programs, including SBHCs.
The primary goals of the Maryland School-Based Health Center Initiative under Making the Grade were to:
- Develop four model SBHCs in two jurisdictions.
- Develop the state's infrastructure to support SBHCs.
- Develop financing strategies to create and sustain SBHCs.
- Create a statewide organization of SBHCs that would foster communication and collaboration between the centers and the state.
The governor had created the interagency Office for Children Youth and Families in 1989 to plan and coordinate services for these populations, and it was in this office that the Making the Grade state project office was located. The Making the Grade Steering Committee (later called the MD SBHC Policy Advisory Council), was composed of a diverse group of professionals from both public and private sectors. It fostered public/private partnerships to support SBHCs, recommended funding strategies and advised the SBHC Initiative on relevant policy issues.
Starting in the first year, the SBHC Initiative focused on planning for the selection of two counties that would partner with the state to create four model SBHCs. All counties were invited to compete for planning grants, and 10 applied. A "seed fund" was used to provide technical assistance and small planning grants for potential SBHC projects in the 10 jurisdictions. (Initially, Making the Grade funds were matched to state funds to create the seed fund; eventually the seed fund was financed by the state and supported grants and technical assistance to all SBHCs throughout the state.) At the request of the National Program Office, Maryland took an extra year to refine its selection criteria, as part of an extended planning phase.
In 1996, the Maryland Making the Grade project awarded grants to the public health departments of Montgomery and Talbot counties to establish two model sites in each county. In addition to helping establish these model centers, project staff worked to promote the growth and stability of other centers throughout the state. According to the project director, the manner of growth of SBHCs in Maryland reflects the state's commitment to local control. The lack of a uniform working definition of SBHCs in Maryland, a byproduct of local control, presented a challenge to the project team. By the second planning year, the National Program Office insisted on some standardization of services and accountability to the state, consistent with the comprehensive SBHC model. In response, the state developed guidelines outlining the core services centers must provide in order to be eligible for state funds.
In 1996, the project began to develop a long-term plan to nurture political support for school-based health centers among grassroots organizations, the executive branch and the legislature in order to ensure their financial support beyond RWJF funding. As part of this effort, the project team organized a field trip for selected legislators, agency representatives, school board members and other stakeholders to a model SBHC in the Washington Heights neighborhood of Manhattan. The project also helped create the Maryland Assembly on School-Based Health Care, which became an independent source of support and mutual aid for the state's SBHCs.
Like most other states, Maryland's SBHCs have not enjoyed easy working relationships with managed care organizations or Medicaid. Initially, the project team hoped to secure reimbursement from Medicaid for the services SBHCs provided. That strategy was abandoned, however, after Maryland scrapped its generous fee-for-service Medicaid program in favor of a Medicaid managed care program called HealthChoice. Although the state had structured a role for SBHCs in HealthChoice, the centers have found it difficult to negotiate contracts with managed care organizations. A major obstacle has been the Maryland Insurance Commission's ruling (still in effect in 2002) that care received from nurse practitioners does not qualify for commercial insurance reimbursement because nurse practitioners are not classified as primary care providers under private insurance. However, the head of the Maryland Department of Health and Mental Hygiene ruled that nurse practitioners could be primary care providers for the purpose of billing Medicaid.
As a consequence, the centers' primary means of support is direct state funding. At the end of Making the Grade, the state office was still working with local centers to secure contracts with managed care organizations. Only 5 to 7 percent of funds were coming from Medicaid. Ongoing efforts to tap into Maryland's state Child Health Insurance Program (CHIP) has had slim results.
During the Making the Grade National Program, the Maryland School-Based Health Center Initiative:
- Created four model school-based health centers in two counties. The centers, in Montgomery and Talbot counties, receive ongoing state funding as "models of excellence." The number of SBHCs in Maryland grew from 14 in 1993 to 61 in 2001. All of the centers provide comprehensive primary care and mental health services, following the comprehensive SBHC model developed by the Making the Grade national program office.
- Improved financing strategies to create and sustain school-based health centers. Since Making the Grade funding ended, the state has budgeted $2 million a year in general funds to support SBHCs through "local management boards" (quasi-public agencies or county government agencies that operate in every jurisdiction as the mechanism for local control over state spending). According to the final project report, SBHCs have progressed from a "localized model" in select communities to a "firmly entrenched" strategy statewide, with accountability to the state through the core service guidelines that must be met to receive funding.
- Developed the state's infrastructure to support school-based health centers. A state infrastructure now exists to support the centers, operating out of a single unit in state government. The project developed state guidelines for SBHCs and a continuous quality improvement (CQI) tool that centers can use to track and assess their services. The state supports the executive-branch staff positions that coordinate the SBHC Initiative.
- Helped form the Maryland Assembly on School-Based Health Care, which has become a mechanism for information dissemination, technical assistance and support for school-based health centers. The assembly sponsors annual meetings and is a chapter of the National Assembly on School-Based Health Care (see www.nasbhc.org).
Project staff distributed state guidelines for school-based health centers and a self-assessment continuous quality improvement tool to all centers around the state. Staff produced two annual reports for stakeholders, detailing the services provided by SBHCs and demographic statistics on the students served, based on two statewide surveys of SBHCs. An information video and brochure, describing SBHC services and showing representative centers, was used both locally and nationally to promote the project. Project staff also has participated in numerous professional panels, legislative briefings, lectures and presentations.
- An interagency office in the executive branch is a highly advantageous location for the state program office. Aspart of the executive branch, the project director had a high-level policy context in which to operate, direct access to the lieutenant governor and the ability to cooperate closely with the state Education and Health Departments. (Project Director)
- Even good programs do not sell themselves; building support requires a comprehensive strategy to educate and inform all stakeholders on a local, state and national level. (Project Director)
- Knowledge and understanding of the educational system is critical to advancing school-based health centers. The centers are the guests of the schools they are housed in, and it is essential for state and local coordinators to know the regulations and principles that govern the school system. (Project Director)
- Having the assistance of national experts in developing state strategies is invaluable. The annual meetings, site visits, Web site and other forms of support provided by the National Program Office, as well as ongoing contact with other state directors, were all useful mechanisms of technical assistance for the state project staff. (Project Director)
- Managed care is not a promising financing source for school-based health centers because of their different objectives. School-based health care and managed care have conflicting objectives: the first, to expand access to care, and the second, to limit costs. (Project Director)
AFTER THE GRANT
In July 2002, the MD SBHC Policy Advisory Council, which began as the Making the Grade Steering Committee, became a statutory, governor-appointed advisory body on school-based health centers. The law directs the council to develop standards of care for SBHCs, a process that is expected to take them to a new level. The Dorchester County Health Department in Cambridge, Md. is a mental health services site under the Caring for Kids program, run by the Center for Health and Health Care in Schools; the site receives funding through RWJF grant ID# 044461. More information on the program is available online.
GRANT DETAILS & CONTACT INFORMATION
Maryland School-Based Health Center Initiative
State of Maryland Executive Department, Office for Children, Youth and Families (Baltimore, MD)
Dates: January 1994 to February 1996
Dates: May 1995 to August 1996
Dates: May 1996 to April 2001
Donna Behrens, R.N., M.P.H.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Washington County Adolescent Health Needs Assessment. Baltimore: Center for Adolescent Health Promotion and Disease Prevention of the Johns Hopkins University School of Hygiene and Public Health, March 1998.
"Evaluation of School Health Centers and Wellness Centers: Middle and High School Personnel Survey; Middle and High Comparison," Susan Russell Walters, Dr.P.H., Johns Hopkins University School of Hygiene and Public Health, Maternal and Child Health, Center for Adolescent Health Promotion and Disease Prevention, fielded January 1998.
"Maryland School-Based Health Center Survey," Maryland School-Based Health Center Initiative, fielded June 1998.
SchoolBased Health Centers in Maryland (7 to 10 minute video). Maryland Public Television, released in September 1998.
"Maryland School-Based Health Center Network Second Annual Conference," September 2526, 1997. Attended by 92 individuals representing 20 organizations and agencies including managed care organizations, health departments, local jurisdictions, universities and education.
"14th Annual State Conference on Teenage Pregnancy and Parenting: Building Futures With Hope: A Need for Involvement," November 25, 1997. Attended by 600 individuals and 50 organizations including education, employment, health, human resources and juvenile services.
"Public Mental Health Spring Forum," February 17, 1998, Baltimore. Attended by 15 students and faculty from the Johns Hopkins University School of Hygiene and Public Health, Department of Mental Hygiene.
Report prepared by: Susan Baird Kanaan
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Judith Stavisky