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Reaching our Hispanic Children Through MetroHealth’s School Health Program Christine Alexander, MD SHP Medical Director Lisa Ramirez, PhD SHP Director of Behavioral and Community Health August 26, 2016

The following report is confidential information of The MetroHealth System and will not be disclosed in whole or part to any external parties without the express consent of The MetroHealth System. This document is intended to be used internally for The MetroHealth System discussion.


Better health leads to better education which leads to better health Health and success in school are interrelated. Schools cannot achieve their primary mission of education if students and staff are not healthy and fit physically, mentally, and socially.� — National Association of State Boards of Education

Test scores increase more in schools where students report caring relationships at school, high expectations at school, and meaningful participation in the community.


Summary and Objectives

Summary: We will review our school health program and describe specific efforts to address issues facing children in Cleveland, including our Hispanic patients.

Objectives: 1. Review the background and purpose of our School Health Program 2. Describe specific challenges our Hispanic pediatric populations face 3. Summarize our teamwork and community partner-based approach to addressing these challenges

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Why do kids need care on site? Uninsured and underinsured

Parents can’t take off of work Transportation challenges Disengaged parents Reduce absenteeism Shortage of nurses


How we came to be BACKGROUND:

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In partnership with Cleveland Metropolitan School District (CMSD), MetroHealth School Health Program (SHP) offers clinical services to scholars within CMSD focused on primary and preventive health care delivery to achieve both health and educational outcomes. Care is delivered within a mobile unit and in-school services via care coordination and collaboration between CMSD School RN and MH SHP Staff.

Program piloted in November 2013 with in-school clinic and has expanded to cover 14 CMSD schools

SHP provides clinical services to CMSD scholars enrolled in program, but also works to connect scholars’ families to MH via insurance enrollment and referrals

SHP program focused on Healthy Scholars, Healthy Schools, Healthy Community


SHP Mission and Values Our Mission Improve access to healthcare by partnering with the community, to advocate for and support the health and well-being of our children.

Our Values Compassion Collaboration Innovation Strive for Excellence


2013-2014: Two schools 2014-2015: Eleven schools 2015-2016: Fourteen schools 2016-2017: Full day clinics*


SHP Mobile Unit


Current Care Model MetroHealth SHP offers care via one In-School Clinic and one Mobile Unit Clinical services: • • • • • • • • • • •

School, sports, camp physical exams Immunizations Urgent care visits Common health concerns (acne, menstrual, and weight problems) Follow-up as requested by PCP Mental and behavioral health screenings and referral to services in school Parent and student health education Basic lab testing Vision and hearing screening Well child visits Reproductive health visits

In-School Clinic • Housed within Mound-STEM (Pre-K to 8 School) • One clinic day per week Mobile Unit • Operates daily Monday-Friday • Total Schools Served: 12

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SHP Trends: Enrollment and Visit Volumes (Academic Year)

• 1,042 students

2014-2015 • 18.8% of potential Enrollment SHP population

2014-2015 Visit Volumes

• 612 visits

2015-2016 • 1,542 students • 29.3% of potential Enrollment SHP population

2015-2016 Visit Volumes

930 visits

2016-2017 Goal

• 2500 Visits

2016-2017 Goal

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• Enroll 60% of potential SHP population


Population Health Management: Clinical Outcomes Population Health Gains

Annual Preventive Visit HPV Series Initiation HPV Series Completion Tdap and Meningococcal by 13yrs

Ohio Medicaid

National Medicaid

MetroHealth School Health

42%1 52.5%4 N/A N/A

45%2 51%4 19%3 66%2

72% 71.3% 17% 74%

Healthy People 2020 Goals 76% -80% 80%

Table 1.0 Comparison of State and National Rates of Recommended Preventive Service to Rates in School Health Enrollees 1 - Data from http://medicaid.ohio.gov/Portals/0/Medicaid%20101/QualityStrategy/Measures/MC-QualityMeasures.pdf 2 - Data from https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/2014-child-sec-rept.pdf 3 - Data from http://www.cdc.gov/mmwr/pdf/wk/mm6442.pdf 4 - http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm?s_cid=mm6429a3_w 12


Population Management: Hispanic Students at Risk Standard primary care services address known risks: !

1/3 of Hispanic children live in poverty

!

Over 1/5 are obese, 40% are overweight

!

As a group, are least likely to have well-child visits !

up to 15% have not seen doctor in last year

!

Implication: decreased likelihood of having vaccinations required for school

!

Hispanic females are least likely to use reliable birth control

and have pregnancy rate as high as 2x White peers

http://www.childtrends.org/wp-content/uploads/2014/09/2014-38AmericaHispanicChildren.pdf


Population Management: Hispanic Students at Risk • At higher risk for depressive symptoms, acculturative stress, substance use

• Barriers to parental engagement in school (e.g., language, cultural isolation) • Limited contact with medical providers leads to higher rates

of need for urgent care visits and treatments •

Asthma causes three times more school absences than any other chronic disease causing 60% of students with asthma to miss school days every

year, higher rates in Hispanic children

http://www.childtrends.org/wp-content/uploads/2014/09/2014-38AmericaHispanicChildren.pdf


Hispanic Population Percentages

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

47.3

10

15.3

20

4.8 Cuyahoga Cleveland County Hispanic

CMSD

School Health

Non-Hispanic

Lincoln West


2014-2015 Academic Year

Buhrer

Black, NonHispanic

Hispanic

Multiracial

White, NonHispanic

Asian

5.1%

86.4%

NC

7.7%

NC

28.4%

6.3%

21.8%

NC

47.3%

3.1%

13.8%

6.2%

18.1%

68.4%

NC

12.%

NC

21.4%

61.3%

NC

14.6%

NC

23.6%

53.6%

NC%

20.7%

NC

(49% LEP)

Garrett 41.1% Morgan High School (12% LEP)

Lincoln-West 29.6% High School (41.5% LEP)

Luis Munoz Marin (49.8 LEP)

Scranton (43.4% LEP)

Walton (27% LEP)


Positive Impact for Hispanic Students •

SHP is having a dramatic influence on bringing healthcare to children who would not otherwise receive care by helping to overcome access and coverage barriers •

57.8% of all children with SHP visits had no known primary care contact in the 2 years prior to their visit .

14.6% of children in the School Health Program were uninsured as compared to just 5% of MetroHealth pediatric patients.

SHP’s percentage of Hispanic pediatric patients was almost 20%, double that of the main hospital

The percentage of patients who reported Spanish as a primary

language was 16%, also double that of the main hospital.

http://www.childtrends.org/wp-content/uploads/2014/09/2014-38AmericaHispanicChildren.pdf


Positive Impact for Hispanic Students •

To try and address mental health risks:  Behavioral health screening for high school students  Referral to in-school services *

Hispanic teens are less likely to seek out services on their own

Social issues and care coordination – health insurance status is not a barrier for access to the SHP program

Provide education around effective birth control

Lab tests and treatments to prevent absences: nebulizers, antibiotics, pain medicine, etc.

http://www.childtrends.org/wp-content/uploads/2014/09/2014-38AmericaHispanicChildren.pdf


SHP Community/Parent Engagement

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Community Health Screenings Sports Physical Days

Back to School Fairs Open House Nights Parent and Student Education

Teacher and Nurse Professional Development HPAC Involvement Lectures to Health classes

Clinics at Boys at Girls Clubs over summer breaks Collaboration with other MetroHealth Programs (Wellness, Arts in School)


Teamwork and Community Partners

Coordination with: 1.

School-based mental health agencies

2.

Investment school site coordinators

Be Well initiative across schools •

E.g., Mindful Mondays, Thankful Thursdays

Sexual health education and peer educators Lincoln West Science and Health School

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How to participate in SHP Register/Consent •Complete the Patient Registration Form •Sign the Consent Form two times, front and back Return •Return both signed forms to the school nurse Payment •No cost to families and no copays •Insurance will be billed, when able Schedule •Contact the school nurse to schedule an appointment for the child to be seen Appointment •Parents can come, but do not have to be present for clinic visits •Parents can be called on the phone during a visit Ready to Learn •After Visit Summary is sent home •Student is back in class ready to learn


Questions about School Health Program

• Talk to the CMSD School Nurse • SHP Website • http://www.metrohealth.org/school-health

• School Health Program Phone • 216-957-1303



Reaching our hispanic children through metrohealth’s school health program