School-based health centers
School-based health centers (SBHCs) provide elementary, middle, and high school students a variety of health care services on school premises or at off-site centers linked to schools. Teams of nurses, nurse practitioners, and physicians often provide primary and preventive care, including well-child visits, vaccinations, and sports physicals, along with mental health care, sick visits, and sexual health education1. Reproductive health services may be offered in middle and high schools, as allowed by district policy and state law. Providers at SBHCs often manage chronic illnesses such as asthma, mental health conditions, diabetes, and obesity. Most patients treated at SBHCs are children insured by Medicaid or children without insurance2, 3. SBHCs are most common in urban areas and may be funded at the federal, state, or local level4. State policies vary regarding which services may be provided to a student without a parent or guardian present1.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased access to care
Improved health outcomes
Increased academic achievement
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Improved quality of care
Reduced emergency room visits
Reduced hospital utilization
Increased vaccination
Reduced health care costs
What does the research say about effectiveness?
There is strong evidence that school-based health centers (SBHCs) increase access to care5, 6, 7, 8 9, 10, 11, improve health outcomes2, 12, 13, 14, and increase academic achievement2, 10, 15 for participating children.
SBHCs also increase preventive care, including well-child visits7, 8, immunization rates2, 8, 16, nutrition7, 8 and physical activity counseling7, and screenings for body mass index (BMI) and sexually transmitted infections (STI)7. SBHCs that offer reproductive health services can reduce rates of teen pregnancy17, particularly for Black and Hispanic teens18, and improve educational outcomes for pregnant or parenting teens17. SBHCs can improve quality of care2, 19 and reduce emergency room visits and hospital utilization2, 20. SBHCs have been shown to improve students’ health behaviors including physical activity and consumption of healthy foods13.
SBHCs may reduce barriers to mental health services by offering care on-site5, 6, 7, 14. Increasing availability of mental health services at SBHCs may reduce depression, suicidal ideation and attempts, and may also reduce the use of marijuana, cigarettes, and prescription drug abuse21, 22. Girls receiving services at SBHCs may be more likely to receive mental health counseling and have a supportive relationship with an adult at school than girls not using SBHCs23. SBHCs with mental health services may be more appealing to students if they offer culturally sensitive services for student and parent engagement, develop student advisory committees to incorporate student feedback at SBHCs, and engage peer health advocates to encourage other students to seek support24. SBHCs offering mental health services are generally larger, more established clinics with more resources and state funding25.
SBHCs have been shown to reduce absenteeism17, 26, increase graduation rates, reduce dropout rates2, 17, and increase students’ connectedness to school27. Children who receive mental health services at their school’s SBHC may have higher GPAs than peers who do not receive services26. For students with a chronic illness such as asthma, receiving treatment at an on-site SBHC may increase their time in the classroom28. A Colorado-based study examining nearly 20 years of data found that schools which opened SBHCs generally had a higher overall high school graduation rate29. SBHCs can support efforts to improve school climate through crisis interventions and mental health care23. Teachers may share feedback with SBHC providers about students they know well to support their care, particularly for chronic conditions1.
SBHCs have been shown to reduce health care costs, particularly costs to Medicaid9, 14, 30 and costs from asthma-related hospitalizations9. Asthma-related visits at SBHCs may also provide significant cost savings28.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: supported by strong evidence.
There is strong evidence school-based health centers (SBHCs) have the potential to reduce disparities in health2 and access to physical and mental health care for students from groups that have been marginalized by society, such as people of color8, 9, 11, 38, students from rural areas14, 38, LGBTQ youth39, and students with disabilities9.
SBHCs can increase access to preventive and routine care for students from families with low incomes and racial or ethnic minorities40. In elementary schools, SBHCs can increase use of preventive care services for young children of color receiving Medicaid8. They can also improve asthma case management and medication adherence, particularly for Black children38. SBHCs can provide core health services including check-ups and behavioral and reproductive health care to adolescents from high need populations in rural areas, particularly American Indian youth41. Oregon-based studies suggest SBHCs may reduce disparities in access to mental health care for LGBTQ high school students, showing reductions in depression, suicidal ideation and attempts39, as well as reducing disparities in substance use42.
SBHCs have the potential to reduce disparities in academic achievement as well2, and may reduce dropout among high risk students43, and increase graduation rates at schools with larger minority populations29.
A nationwide study suggests that children that are older and uninsured may be more likely to have a SBHC as their normal source of health care44. A Denver-based study indicates that students who have public insurance, those who identify as female, and those receiving mental health services use SBHCs more frequently than their peers with private insurance, who identify as male, and who receive primary care services45. SBHCs frequently care for adolescent populations that are more racially diverse, often with risk factors that make them more vulnerable than their peers receiving care elsewhere, such as difficult family relationships, lower grades, and more school absences, along with higher rates of various health risks. Experts recommend that SBHCs offer screenings and services for mental health, reproductive health and contraception, eating disorders, and for a variety of behaviors, such as substance abuse46.
One study suggests students from minority groups and from families with low incomes may find it challenging to seek support for mental health concerns at SBHCs; this could be due to feelings of embarrassment, a belief that they should keep their feelings to themselves, fears around confidentiality or judgement, or a lack of awareness of available services47. In order to build trust and encourage use of health services, SBHCs should make efforts to engage the school community, including students and parents, in program planning and goal setting to ensure the needs of the school community are met40.
What is the relevant historical background?
Access to health care in schools began in the early 1900s with the addition of nurses to treat children’s minor injuries or illnesses emerging during the school day48, 49, and by 1911, there were 102 cities with nurses in their schools49.
By the 1960s, it became apparent that students could benefit from care beyond what school nurses could provide, particularly efforts to prevent unintended pregnancies. The first school-based health centers (SBHCs) were established in urban schools in Cambridge, Massachusetts; St. Paul, Minnesota; and Dallas, Texas48, 50, 51. Early SBHCs were primarily focused on access to family planning, teen pregnancy prevention, and supports for adolescent parents still in school48, 50. In the late 1970s, grant funding created additional SBHCs51, with 31 SBHCs across 18 urban areas by 198550.
SBHCs greatly expanded in the 1990s51, and by the end of the century, 1,135 SBHCs provided care for students across 45 states48, from elementary to high schools, and in urban, rural, and suburban communities50. There was also an increased interest in providing mental health care48. Medicaid expansions made SBHCs more sustainable, providing health insurance to adolescents from families with low incomes, who previously would have been unable to afford care50.
Funding for mental health services at SBHCs further increased in the 2000s and 2010s, particularly during the Obama Administration51, often as part of broader efforts to reduce gun violence in schools48. SBHCs became more broadly recognized as safety net health care providers for children without regular access to affordable health care51 with the Patient Protection and Affordable Care Act (ACA) in 2010, which included $200 million to add or expand SBHCs in medically underserved communities and areas with a health professional shortage51. Project AWARE—Advancing Wellness and Resilience in Education provided $40 million in federal funding for school-based mental health programs at SBHCs in 20 states48. In 2015, the Every Student Succeeds Act (ESSA) replaced 2002’s No Child Left Behind Act, expanding funds for school programs promoting health and safety, including school-based health interventions located at SBHCs52. Additional funding for SBHCs comes from state governments, school districts, private foundations, and partner organizations51.
SBHCs remained a key source of physical and mental health care for youth, especially from disadvantaged communities, during the COVID-19 pandemic53; the American Rescue Plan included additional funding for SBHCs40.
Equity Considerations
- How can students and families be involved in decisions surrounding school-based health centers (SBHCs) programming and service availability?
- What efforts can SBHCs and partners make to develop trusting, comfortable relationships between providers and underserved students and families? Can students who have benefited from care at SBHCs partner with them on outreach efforts to the broader school community?
- Can SBHCs offer care beyond the school day to accommodate parents that would like to attend appointments with their children?
- How are SBHCs and providers partnering with local health agencies and community primary care and mental health clinic providers to ensure continuity of care across locations?
- What additional funding streams (e.g., local, state, or federal government; non-profits, private organizations) can SBHC administrators consider to expand services, especially for mental health?
Implementation Examples
As of 2022, the School-Based Health Alliance has identified approximately 3,900 school-based health centers (SBHCs) in 49 states and Washington, D.C.4.
State governments may fund or manage SBHCs. Oregon, for example, operates a statewide network of SBHCs, with 78 certified SBHCs in 25 counties, as of 2017. SBHCs have operated in Oregon since 1986 through partnerships between the Oregon Public Health Division, county public health departments, school districts, public and private practitioners, students, parents, and community members31. The Colorado Department of Public Health and Environment’s SBHC program, established in 1987, prioritizes grants to SBHCs that mainly care for uninsured children and children from families with low incomes; centers that are expanding behavioral health services, prevention services for substance use disorders, or oral health services; and schools planning to establish SBHCs32.
Hospitals, health systems, and universities may also create and manage SBHCs. Mount Sinai Hospital in New York City, for example, operates six adolescent SBHCs, providing non-judgmental, culturally sensitive care for over 2,000 students each school year33. Fair Haven Community Health Care, a health system in Connecticut, supports a network of SBHCs which provide free care respecting the age, cultural values, and family life of every student; services include medical and behavioral health, and many centers also offer dental care34. In Western New York, the University of Rochester School of Nursing and the Rochester City School District established two SBHCs, serving students in grades 6 to 12, regardless of their health insurance status or ability to pay. Care is provided by nurse practitioners and licensed clinical social workers, including well-child visits, management of chronic conditions, on-site laboratory and medication dispensing, immunizations, and mental health care35.
Federally qualified health centers (FQHCs) may also partner with schools to establish and support SBHCs. The Native American Health Center (NAHC), a FQHC and Urban Indian Health Project serving California’s Bay Area Native population and other underserved communities, collaborates with three school districts to offer free care at eight school campuses, including medical, behavioral, dental, and health promotion and youth development services36.
During the 2016-2017 school year, 19% of SBHCs used telehealth services; these SBHCs are predominately managed by hospitals and located in rural communities37.
Implementation Resources
‡ Resources with a focus on equity.
SBHA-SBHC‡ - School-Based Health Alliance (SBHA). Findings from the 2022 national census of school-based health centers (SBHCs). 2023.
OSBHA - Oregon School-Based Health Alliance (OSBHA). Promote the health and academic success of children and youth through sustaining, strengthening, and expanding school-based health centers (SBHCs).
Youth Healthcare Alliance - Youth Healthcare Alliance. Operating a school-based clinic: Guidance and resources for clinic management and financing.
CDPHE-SBHCs - Colorado Department of Public Health & Environment (CDPHE). School-based health centers (SBHCs).
Zwiebel 2022 - Zwiebel H, Thompson LA. What are school-based health clinics? JAMA Pediatrics. 2022;176(4):428.
Footnotes
* Journal subscription may be required for access.
1 Zwiebel 2022 - Zwiebel H, Thompson LA. What are school-based health clinics? JAMA Pediatrics. 2022;176(4):428.
2 CG-SBHC - The Guide to Community Preventive Services (The Community Guide). Social determinants of health: School-based health centers (SBHCs). 2015.
3 Keeton 2012 - Keeton V, Soleimanpour S, Brindis CD. School-based health centers in an era of health care reform: Building on history. Current Problems in Pediatric and Adolescent Health Care. 2012;42(6):132-156.
4 SBHA-SBHC - School-Based Health Alliance (SBHA). Findings from the 2022 national census of school-based health centers (SBHCs). 2023.
5 Bains 2016 - Bains RM, Diallo AF. Mental health services in school-based health centers: Systematic review. The Journal of School Nursing. 2016;32(1):8-19.
6 Mason-Jones 2012 - Mason-Jones AJ, Crisp C, Momberg M, et al. A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health. Systematic Reviews. 2012;1:49.
7 Hussaini 2021 - Hussaini KS, Offutt-Powell T, James G, Koumans EH. Assessing the effect of school-based health centers on achievement of national performance measures. Journal of School Health. 2021;91(9):714-721.
8 Adams 2020 - Adams EK, Strahan AE, Joski PJ, et al. Effect of elementary school-based health centers in Georgia on the use of preventive services. American Journal of Preventive Medicine. 2020;59(4):504-512.
9 Guo 2010a - Guo JJ, Wade TJ, Pan W, Keller KN. School-based health centers: Cost-benefit analysis and impact on health care disparities. American Journal of Public Health. 2010;100(9):1617-1623.
10 Wade 2008 - Wade TJ, Mansour ME, Line K, Huentelman T, Keller KN. Improvements in health-related quality of life among school-based health center users in elementary and middle school. Ambulatory Pediatrics. 2008;8(4):241-249.
11 Anyon 2013 - Anyon Y, Moore M, Horevitz E, et al. Health risks, race, and adolescents’ use of school-based health centers: Policy and service recommendations. The Journal of Behavioral Health Services & Research. 2013;40(4):457-468.
12 Kong 2013 - Kong S, Sussman AL, Yahne C, et al. School-based health center intervention improves body mass index in overweight and obese adolescents. Journal of Obesity. 2013;575026.
13 McNall 2010 - McNall MA, Lichty LF, Mavis B. The impact of school-based health centers on the health outcomes of middle school and high school students. American Journal of Public Health. 2010;100(9):1604-1610.
14 Guo 2008 - Guo JJ, Wade TJ, Keller KN. Impact of school-based health centers on students with mental health problems. Public Health Reports. 2008;123(6):768-780.
15 Thomas 2020 - Thomas CL, Price OA, Phillippi S, Wennerstrom A. School-based health centers, academic achievement, and school discipline: A systematic review of the literature. Children and Youth Services Review. 2020;118:105467.
16 Federico 2010 - Federico SG, Abrams L, Everhart RM, Melinkovich P, Hambidge SJ. Addressing adolescent immunization disparities: A retrospective analysis of school-based health center immunization delivery. American Journal of Public Health. 2010;100(9):1630-1634.
17 Strunk 2008 - Strunk JA. The effect of school-based health clinics on teenage pregnancy and parenting outcomes: An integrated literature review. The Journal of School Nursing. 2008;24(1):13-20.
18 NBER-Lovenheim 2016 - Lovenheim M, Reback R, Wedenoja L. How does access to health care affect teen fertility and high school dropout rates? Evidence from school-based health centers. National Bureau of Economic Research (NBER). 2016: Working Paper 22030.
19 Riley 2016 - Riley M, Laurie AR, Plegue MA, Richardson CR. The adolescent “expanded medical home”: School-based health centers partner with a primary care clinic to improve population health and mitigate social determinants of health. The Journal of the American Board of Family Medicine. 2016;29(3):339-347.
20 Guo 2005 - Guo JJ, Jang R, Keller KN, et al. Impact of school-based health centers on children with asthma. Journal of Adolescent Health. 2005;37(4):266-274.
21 Paschall 2018 - Paschall MJ, Bersamin M. School-based health centers, depression, and suicide risk among adolescents. American Journal of Preventive Medicine. 2018;54(1):44-50.
22 Paschall 2018a - Paschall MJ, Bersamin M. School-based mental health services, suicide risk and substance use among at-risk adolescents in Oregon. Preventive Medicine. 2018;106:209-215.
23 Hodges 2021 - Hodges M, Guendelman S, Soleimanpour S. Adolescents’ use of school-based health centers and receipt of mental health supports. Children and Youth Services Review. 2021;120:105700.
24 Lai 2016 - Lai K, Guo S, Ijadi-Maghsoodi R, Puffer M, Kataoka SH. Bringing wellness to schools: Opportunities for and challenges to mental health integration in school-based health centers. Psychiatric Services. 2016;67(12):1328-1333.
25 Larson 2017a - Larson S, Spetz J, Brindis CD, Chapman S. Characteristic differences between school-based health centers with and without mental health providers: A review of national trends. Journal of Pediatric Health Care. 2017;31(4):484-492.
26 Walker 2010 - Walker SC, Kerns SEU, Lyon AR, Bruns EJ, Cosgrove TJ. Impact of school-based health center use on academic outcomes. Journal of Adolescent Health. 2010;46(3):251-257.
27 Strolin-Goltzman 2014 - Strolin-Goltzman J, Sisselman A, Melekis K, Auerbach C. Understanding the relationship between school-based health center use, school connection, and academic performance. Health & Social Work. 2014;39(2):83-91.
28 Goddard 2022 - Goddard A, Konesky A, Borkowski V, Etcher LA. Show me the money…saved! Cost savings from acute asthma care in the school-based health center. Journal of School Nursing. 2022;38(2):210-219.
29 Westbrook 2020 - Westbrook M, Martinez L, Mechergui S, Yeatman S. The influence of school-based health center access on high school graduation: Evidence From Colorado. Journal of Adolescent Health. 2020;67(3):447-449.
30 Wade 2010 - Wade TJ, Guo JJ. Linking improvements in health-related quality of life to reductions in Medicaid costs among students who use school-based health centers. American Journal of Public Health. 2010;100(9):1611-1616.
31 OSBHA-SBHC report 2018 - Oregon School-Based Health Alliance (OSBHA). Oregon school-based health centers status update 2018. Oregon Health Authority, Public Health Division, School-Based Health Center Program. Oregon School-Based Health Centers.
32 CDPHE-SBHCs - Colorado Department of Public Health & Environment (CDPHE). School-based health centers (SBHCs).
33 MSH-SBHC - Mount Sinai Hospital (MSH). School-based health centers (SBHC). New York, NY.
34 Fair Haven-SBHCs - Fair Haven Community Health Care. School-based health centers (SBHCs). Greater New Haven, Connecticut.
35 URMC SON-SBHCs - University of Rochester School of Nursing (URMC SON) School-Based Health Centers (SBHCs). East Upper and Lower School, Northeast College Prep, Northwest Jr. High at the Frederick Douglass Campus; Rochester City School District, New York State.
36 NAHC-SBHCs - Native American Health Center (NAHC). School-based health centers (SBHCs): Services on eight school campuses in collaboration with three school districts and several community-based organizations. California’s Bay Area Native population and other underserved communities.
37 Love 2019a - Love H, Panchal N, Schlitt J, Behr C, Soleimanpour S. The use of telehealth in school-based health centers. Global Pediatric Health. 2019;6.
38 Adams 2022 - Adams EK, Johnson VC, Hogue CJ, et al. Elementary school–based health centers and access to preventive and asthma-related care among publicly insured children with asthma in Georgia. Public Health Reports. 2022;137(5):901-911.
39 Zhang 2020a - Zhang L, Finan LJ, Bersamin M, Fisher DA. Sexual orientation-based depression and suicidality health disparities: The protective role of school-based health centers. Journal of Adolescent Research. 2020;30(Suppl 1):134-142.
40 Cutuli 2022 - Cutuli JJ. School-based health centers as a context to engage and serve communities. Current Opinion in Pediatrics. 2022;34(1):14-18.
41 Koenig 2016 - Koenig KT, Ramos MM, Fowler TT, et al. A statewide profile of frequent users of school-based health centers: Implications for adolescent health care. Journal of School Health. 2016;86(4):250-257.
42 Zhang 2020b - Zhang L, Finan LJ, Bersamin M, Fisher DA, Paschall MJ. Sexual orientation-based alcohol, tobacco, and other drug use disparities: The protective role of school-based health centers. Youth & Society. 2020;52(7):1153-1173.
43 Kerns 2011 - Kerns SEU, Pullman MD, Walker SC, et al. Adolescent use of school-based health centers and high school dropout. Archives of Pediatrics & Adolescent Medicine. 2011;165(7):617-623.
44 Habiyaremye 2021 - Habiyaremye MA, Clary K, Morris H, Tumin D, Crotty J. Which children use school-based health services as a primary source of care? Journal of School Health. 2021;91(11):876-882.
45 Stempel 2019 - Stempel H, Cox-Martin MG, O’Leary S, Stein R, Allison MA. Students seeking mental health services at school-based health centers: Characteristics and utilization patterns. Journal of School Health. 2019;89(10):839-846.
46 Gersh 2019 - Gersh E, Arghira AC, Richardson LP, et al. Comparison of health risks among adolescents from school-based health centers and community-based primary care settings. Health Behavior and Policy Review. 2019;6(1):71-78.
47 Ijadi-Maghsoodi 2018 - Ijadi-Maghsoodi R, Bonnet K, Feller S, et al. Voices from minority youth on help-seeking and barriers to mental health services: Partnering with school-based health centers. Ethnicity and Disease. 2018;28(Suppl 2):437-444.
48 Ryst 2021 - Ryst E, Joshi S V. Collaboration with schools and school-based health centers. Child and Adolescent Psychiatric Clinics of North America. 2021;30(4):751-765.
49 North 2020 - North S, Dooley DG. School-based health care. Primary Care: Clinics in Office Practice. 2020;47(2):231-240.
50 Love 2019 - Love HE, Schlitt J, Soleimanpour S, Panchal N, Behr C. Twenty years of school-based health care growth and expansion. Health Affairs. 2019;38(5):755-764.
51 Arenson 2019 - Arenson M, Hudson PJ, Lee NH, Lai B. The evidence on school-based health centers: A review. Global Pediatric Health. 2019;6.
52 Dunfee 2020 - Dunfee MN. School-based health centers in the United States: Roots, reality, and potential. Journal of School Health. 2020;90(8):665-670.
53 Damian 2022 - Damian AJ, Oo M. Examining school based health service utilization among marginalized youth in Connecticut during COVID. INQUIRY: The Journal of Health Care Organization, Provision, and Financing. 2022;59.
Related What Works for Health Strategies
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