school based healthcare

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11/20/2009Healthcare

Divya Mohan Little

School Based Healthcare

(This is part one of a three part series.)

A Problem and An Opportunity - Everyday too many of our nation¶s youth gowithout affordable, high quality healthservices. If a student is unhealthy and doesnot have access to health care, he/she will

experience health and social problems thatcompromise academic potential, resultingin missed classes, poor academic

performance, and even school failure.

Experienced educators know that the ill affects of poor health have a direct and negative impact on studentsuccess. Every minute a student is absent from class due to an untreated condition, they miss valuablelesson time with their teacher and classmates that can lead to weak test scores and poor grades.Theseresults, if there is no intervention, can manifest into deeper problems such as the student falling behindacademically, becoming discouraged, repeating a grade, and/or eventually dropping out.

Teachers cannot teach when a student with a toothache or untreated behavioral problems disrupts thelearning environment, or if they are busy helping a child with an insulin shot, or administering other

medication. Few would argue with the fact that health issues that affect children eventually spill into theclassroom, and some see the connection between health and education as an opportunity to improve theeducation system.This is seen in thecommunity school approach that is beingembraced by leaders who want to address theeducational experience of children and youthfrom a holistic perspective.

Why Bring Health Care to Schools?

Hundreds of schools and communities acrossthe country are transforming health andeducation by uniting them under one roof.

School-based health centers (SBHCs)integrate comprehensive medical, mentalhealth and social services on the schoolcampus to optimize learning readiness.Opening school doors to health care creates

pathways to children¶s educational attainmentand lifelong well-being. SBHCs are locatedin schools where students face barriers to



accessing health care, thereby affecting their academic achievement.

School-based health centers deliver medical care to help students with chronic and acute conditions copewith disease, getting them back to the classroom faster and ready to learn. Mental health services focus onimproving students¶ emotional well-being, and decreasing high-risk, health-compromising behaviors suchas drug, alcohol and tobacco use. Health surveillance and preventive services catch health problems early

and promote a healthier, safer student body. Social services help children and families with the basicsupports of food, shelter, and safety. Youth development services, another component of many SBHCs,also build social competencies and strengthen students¶ connections to school and community. There areapproximately 2000 SBHCs in 44 states, DC, the Virgin Islands and Puerto Rico, serving approximately1,700,000 students, yet significant need exists for more SBHCs. Consider the startling and disturbingstatistics that exist today:

y Eight million uninsured children

y 15 million children with mental health challenges

y 4,717 communities with health professional shortages in the United States

Eleven percent of our nation¶s children lack health insurance, jumping to 19 percent among poor children.Due to their safe and familiar location in the child¶s school, SBHCs are able to provide patient-centered,

professional care at little to no cost to the student. They deliver essential preventive health services such aswell child exams, dental care, health education, and immunizations, and manage chronic diseases likeasthma and diabetes. SBHCs also address mental health issues that complement special education, andreduce risks associated with health compromising behaviors.

Seventy percent of the schools hosting SBHCs report that more than half their school population is eligiblefor the U.S. Department of Agriculture¶s Free and Reduced Lunch Program. The SBHC works best in

partnership with the school and community. A ³Healthy Learners Alliance´ promotes partnerships with theSBHC, local public health agencies, community health organizations, and hospitals and involves teachersand coaches, school administrators and staff, and students, to eliminate inequities in educationalachievement and health care access. School-linked integration efforts result from an increasing awarenessthat education goals are hampered bynonacademic factors such as: social,

economic, health, and emotionaldifficulties faced by children andfamilies. Access to culturally competent,high quality, first-contact primary carethrough schoolbased health centers is aneffective way to reduce health inequitiesand improve health outcomes for socially disadvantaged children andadolescents. Schools provide a logicalhub for many critical services andsupports.

In the widely accepted model of service

delivery, improving a child¶s healthstatus is addressed by providing medicalcare separately from other communityservices. In an integrated model,medical care would link the child andfamily to housing, safe neighborhoods,nutrition, social support, professionalservices, and particularly education.Community schools are recognized as avehicle that ³works´ for moving from a



linear to integrated paradigm of service delivery. The U.S. Secretary of Education, Arne Duncan, an ardentcommunity schools supporter says, ³The more we¶re co-locating services, GED, ESL, health careclinics«the more those schools become the centers of community life, the better our children are going todo.´

Hundreds of community schools across the Nation are living examples of the Secretary¶s vision (e.g. New

York, NY; Chicago, IL;E

vansville, IN; Tukwila, WA; and more ). These results-based schools are helpingstudents be healthy, by addressing health challenges health disparities among disadvantaged students andtheir families. Community schools strive to achieve a core set of results to ensure that students aregraduating ready to for college, careers and citizenship.

What are Community Schools?

Using public schools as a hub, community schools bring together a wide variety of partners within thecommunity to offer a range of services and opportunities to children, youth, families and communities. Anintegrated focus on academics, health and social services, youth and community development along withcommunity engagement, leads to improved student learning, stronger families and healthier communities.

Community schools function as both a place and a set of partnerships between the school and other

community resources. They are the centers of the community, open to everyone ² all day, every day,evenings and weekends.

What Are the Results?

Community schools focus on a core set of results that are crucial to the learning and development of students. Health outcomes are amongthe core set of results.

Unchecked or unaddressed health issuescan create barriers to students¶ learning.School-based health clinics, coordinatedschool health and community healthcenters, are all examples of partnershipsoccurring in many community schools.These centers offer services andsupports, such as eye exams, dentalcare, and preventive health, inside acommunity school to improve healthoutcomes for students, families andcommunities. Partnerships betweencommunity schools and the healthcarecommunity make a difference for students but also for their families and community. Health issues can be a key factor in whether or notstudents succeed academically or in life. If a child cannot read the chalkboard or comes to school with anempty stomach, their learning is affected.

Students inevitably perform better when they attend class healthy and ready to learn. School-based healthcenters (SBHC) deliver results that matter to schools. In Massachusetts, SBHC users had a 50 percentdecrease in absenteeism and 25 percent decrease in tardiness two months after receiving school basedmental health and counseling. In North Carolina, African American male SBHC users were three timesmore likely to stay in school than their peers who did not use the clinic. A Dallas, Texas SBHCdemonstrated that medical services helped decrease absences by 50 percent among students who had threeor more absences in a six-week period; students who received mental health services had an 85 percentdecline in school discipline referrals. How Do SBHCs Function in Community Schools?



Sayre High School, a university assisted community school, collaborates with the Netter Center for Community Partnerships at the University of Pennsylvania, to address community health needs, with theSayre Health Center. The federally funded health center provides students, families, and communitymembers with clinical, educational, and health promotion services on site. In addition to addressing healthissues, the health center serves to create an engaging curriculum.

For example, Sayre students interested in health careers get hands-on experience as they work withuniversity doctors and community members in the field. The Health Center also engages parents and other community adults through Family Fitness Nights and offer free classes in healthy cooking The SayreHealth Center involves faculty, staff, and students from across the University. The multidisciplinarycharacter of the program enables the work to be integrated into the curricula of both the public school andthe University.

The Evansville-Vanderburgh School Corporation (EVSC) in Evansville, IN, in an effort to address thehealth disparities at Helfrich Park Middle School, has fully implemented a coordinated school health (CSH)model. The CSH model offers health education; physical education; health services; nutrition services;counseling, psychological, and social services; healthy school environment; health promotion for staff; andfamily and community involvement. School staff works with local hospitals to provide back-to-school

physicals, dental care, and blood pressure screenings, along with the regular height and weight screenings.

The CSH model also benefits school staff, families, and community members. At the school level, theregistered dietician consults both students and staff on their dietary habits, needs, etc. Health awareness is akey component of EVSC¶s CSH work. Health education and programs such as walking clubs and dance-dance revolution are being provided before and after school, as well as during recess. Audra Offutt, awellness coordinator at the community school at Helfrich Park Middle School says, ³I feel like we aremaking a comprehensive effort to make a positive impact on the lives of our students!´ The EVSC¶scoordinated school health efforts are gaining attention nation-wide. The division of Adolescent and SchoolHealth of the U.S. Centers for Disease Control and Prevention (CDC) recently selected the EVSC as one of the nation¶s leading sites for coordinatedschool health. After receiving more than80 nominations from across the country,the CDC selected the EVSC¶s program as

one of only six models that exemplified best practices in coordinated schoolhealth.

To date, Helfrich¶s results are strong andmake the case for more CHCs andSBHCs. Schools report students sharinghealth experiences of trying new healthyfoods or different physical activities.Additionally, parents report to teachers,administrators, and coordinators their appreciation for the health newsletters,lessons, and activities that are available totheir child(ren). Many of those parentsreport the nutrition and physical activityfor their families have been impacted

positively at home.

Conclusion

Children who attend schools without aSBHC are at risk of receiving little or nohealth, dental and mental health services.



A recent Institute of Medicine report noted the number of teens that already rely on safety net health providers, including SBHCs, as their only source of care. The rise of SBHCs, which are thriving in thecommunity school environment, is a clarion call to the challenges faced by economically disadvantagedchildren and families in today¶s economy. Schools must get engaged more deeply in this discussion andconsider partnerships with health centers, bringing them into their buildings where the children are.Mandatory reimbursement for SBHCs under public insurance programs and/or a federal authorizing

program for SBHCs are provisions that will ensure that SBHCs can continue to provide their valuableservices to our nation¶s most vulnerable population.

03/31/2010 healthcare

ADRIENNE AMMERMAN



School Based Healthcare:

Why it is Common Sense

(This is part two of a three part serieson school-based health care.)

School-based health centers (SBHCs) provide primary care, mental healthservices, and sometimes oral healthcare to students where they are: inschool. In part one of this series fromthe National Assembly on School-Based Health Care (NASBHC) welearned why school-based health careis important, and why SBHCs are anintegral component of the communityschools model. In this second part of the series we explore what makesschool-based health care programs partof a common-sense approach to

ensuring that all children andadolescents in the United States arehealthy and achieving to their fullest

potential.

SBHCs Meet the Needs of Children and Teens

SBHCs are designed to meet the health care needs of students, and are considered one of the most effectivestrategies for delivering high quality, comprehensive, and culturally-competent primary and preventive careto adolescents ² a population that can be difficult to reach. At SBHCs, developmentally-appropriate healthservices are provided by qualified health professionals, incorporating the principles and practices of

pediatric and adolescent health care recommended by the American Medical Association, the AmericanAcademy of Pediatrics, and the American Association of Family Physicians.

SBHCs provide critical services regardless of the student¶s ability to pay, and in a location that meetsstudents where they spend most of their waking hours: at school. Because of their location, SBHCs arefirst-hand witnesses to factors that impact student health and academic achievement ² including bullying,school violence, depression, stress, and poor eating habits ² which health providers outside a schoolsetting may miss. SBHC staff have the time and the resources to address the many challenges students may

bring with them to the classroom.



³School-based health centers make sense because kids like them,´ explains Robert Nystrom, AdolescentHealth Manager, Oregon Public Health Division. ³It¶s almost as elementary as that:SBHCs are friendly, they¶re responsive, and they¶re within five minutes and 50 feet of their world.´

SBHCs Help Kids Access Care and Stay Healthy

³I see my peers and they¶re not educated on their own health,´ says Alexis Miller, a 10th grade student inGreenville, NC, who does not have a health center at her school. ³I think that if we had more school-basedhealth centers we¶d have healthier teenagers.´

Miller is right. A national multi-site study of SBHCs conducted by Mathmatica Policy Research found asignificant increase in health care access by students who used them ² 71 percent of students reportedhaving a health care visit in the previous year compared to 59 percent of students who lacked access to aSBHC.

³Data from multiple sources suggest that kids vote with their feet,´ says Dr. John S. Santelli, HeilbrunnProfessor of Clinical Population and Family Health Chair at Columbia University. ³When a young personhas access to a school health clinic they are more likely to be seen for primary care, and more likely toreceive counseling and other preventive services.´

Numerous evaluations indicate that SBHCs lead to notable improvements in adolescent access to healthcarewhen compared with utilization in other settings. This is especially true for sensitive services such asfamily planning, mental health, and substance abuse services. Students who report depression and pastsuicide attempts demonstrate greater willingness to seek counseling in a SBHC. In addition, students with

perceived weight problems report more willingness to use a school clinic for nutrition information andsexually active students are more willing to seek information on pregnancy prevention and to have generaldisease screenings.

³It¶s common sense that if you put a service right next to where the population is that you¶re trying toattract, and if you remove almost all barriers from accessing those services, you¶re going to getdramatically better use,´ says Linda Juszczak, Executive Director of NASBHC. ³School health clinics gointo places where there is high need or a hard-to-reach population, and they do an exemplary job of

increasing access in general ² and in particular for males and those impacted by health disparities.´

SBHCs Make Kids Healthier and

Ready to Learn

Many educators are painfully aware that poor health has a direct and negativeimpact on students¶ success in school andin life. SBHCs not only improve healthcare access, they may possibly improvestudent success.

Although direct links between SBHCsand student test scores and grades can bedifficult to capture, we know that SBHCsdeliver results that matter to schools,including reducing absenteeism, tardiness,dropouts and discipline referrals. Studentshave to be present and engaged in order tolearn. Studies draw major links betweenSBHCs and improved attendance. A 2009 report issued by the Oregon Department of Human ServicesPublic Health Division found that more than half (53 percent) of surveyed clinic users reported they did not



miss a class while using the center services, while a majority (75 percent) estimated they would miss one or more classes if they had to leave their school to access health services. A study by Montefiore MedicalCenter (New York, NY) of inner-city, elementary school SBHCs treating children with asthma found areduction in hospitalization and an increase in school attendance.

³There¶s no intervention for algebra in school-based health centers, but health and mental health status is an

important predictor of educational success,´ says Nystrom. ³A kid with a chronic condition like asthma thatis managed at school is likely to miss less class time. If a center can intervene early in a mental health issueor prevent an unintended pregnancy, a youth is more likely to remain in school and engaged in learning.´

As a bridge between health and education, SBHCs are well positioned to reduce dropouts through a varietyof interventions and collaborations. For example, one study in Dallas, Texas found that students whoreceived mental health services at their SBHC had an 85 percent decline in school discipline referrals.

Nidia Escobar, 19, is a member of the California School Health Centers Association Youth Board: ³Rightnow I¶m in community college, but if I hadn¶t had health center at my school I probably wouldn¶t evenhave graduated from high school. I had problems that were so personal and so big ... if the health center wasn¶t there for me it would have been too much of an obstacle to overcome on my own.´

Why SBHCs?

³For the past 25 years I¶ve worked in every health caremodel in the country ² from community healthcenters, to private practices, to school-based practices,´says Dr. Veda Johnson, Assistant Professor of Pediatrics at Emory University School of Medicine.³School-based health centers are the best model of health care in this country for at-risk populations ² and that¶s coming from a pediatrician. SBHCs increaseaccess to health care, eliminate barriers and improvehealth outcomes for essentially every patient enrolled.´

SBHCs are popular with providers, with parents, withkids, and with educators and school administrators for avery simple reason: they¶re common sense, and theywork. SBHCs assure equal access for all children andadolescents to critical health care services ² leading toopportunities for success in school and in life.

Adrienne Ammerman is director of communications at the National Assembly on School-Based HealthCare. For more information visit www.nasbhc.org.

08/23/2010

health



ADRIENNE AMMERMAN

School based health care:

How it is funded

(This is part three of a three-part series on school-

based health care.)

School-based health centers (SBHCs) provide primary care, mental health services, andsometimes oral health care to students where theyare: in school. In the final part of this three-partseries from the National Assembly on School-Based Health Care (NASBHC) we will explorehow SBHCs are currently funded, some of the

financial challenges they are facing, and how theywill benefit from the health care reform legislation.

Sources of Funding for School-Based Health

Centers

Research and evaluations have demonstrated that,in addition to being a common sense approach toensuring that all children and adolescents arehealthy and achieving to their fullest potential,school-based health centers (SBHCs) are cost-effective investments of public resources.

³Our studies have proven that we are effective in lowering the cost to Medicaid and any third-party payer system by reducing hospitalization and inappropriate ER use,´ says Dr. Veda Johnson, Assistant Professor of Pediatrics at Emory University School of Medicine. ³We¶ve demonstrated in a very practical way thatSBHCs decrease the cost of transportation because children are right there. SBHCs also reduce the cost of medication and drug use because we don¶t prescribe as many medications as in a routine physicians¶ office

because we can monitor them more closely.´

So how are SBHCs currently funded? For answers, we can look to the most recent National School-BasedHealth Care Census. This 360-degree view of the role of SBHCs in meeting the needs of underservedchildren and adolescents presents trend data on demographics, staffing, operations, prevention activities,clinical services, and policies.

Sponsors (organizations that serve as the primary administrative home) of SBHCs are most typically a local

health care organization, such as a community health center (28 percent), a hospital (25 percent), or a localhealth department (15 percent). Other community sponsors include nonprofit organizations, universities,and mental health agencies. Twelve percent of SBHCs are sponsored by a school system. SBHCs oftenreceive additional support from schools and others through in-kind donations of space and services. Themajority indicate that they do not have financial responsibility for construction and renovation,maintenance and/or janitorial services, utilities, or rent.

The majority of SBHCs bill public insurance for health center visits, including Medicaid (81 percent), theChildren¶s Health Insurance Program (68 percent), and Tri-Care (41 percent). Tri-Care is the health care



program serving active duty service members, National Guard and Reserve members, retirees, their families, and survivors. Fifty-nine percent of SBHCs bill private insurance; 38 percent bill students or families directly. A majority of SBHCs (85 percent) also assist children and families with enrollment in

public insurance programs. Improving the effectiveness of billing and collection practices and enrollingchildren and families in public insurance (so there is a payor) has been a major focus of sustainabilityefforts for SBHCs.

SBHCs also report receiving support from a variety of revenue sources not related to billing, including stategovernment (76 percent), private foundations (50 percent), sponsor organizations (49 percent), and schoolor school district (46 percent). Thirty-nine percent of SBHCs receive funding from the federal government.

A closer look at federal and state funding sources indicates support from a diverse base of federal programs. Almost a quarter (23 percent) of SBHCs receive section 330 monies through the Public HealthService Act for community, migrant, and rural health centers; these SBHCS are mainly sponsored byCommunity Health Centers. State Departments of Public Health are the most common source of state funds

± almost half of SBHCs report receiving funds from these state entities± while the departments of human or social services and education fund about 11 percent of programs. In twenty-one states, the state funds or sponsors a grant program specifically dedicated to SBHCs.

Challenges in the States: Budget Cuts and Layoffs

NASBHC¶s Census discovered that a growing number of SBHCs see members of the community beyondthe students at their school ± with just 36 percent of SBHCs reporting they serve only children who attendthe school(s) they serve. These patient populations include students from other schools in the community,out-of-school youth, faculty and school personnel, family members of students, and other communitymembers. Clearly, the weak national economy, coupled with loss of employer-sponsored health care, hasincreased the demand for affordable health care.

Yet, in the current economic climate, many state programs are struggling to maintain support for theSBHCs they currently fund. Even as communities across the country require expanded primary care hours,oral health, and expanded mental health services many SBHCs are at risk of cutting services and staff or even closing due to the current economic downturn, insufficient reimbursement for patient services, and

slashed local funding.

Layoffs and hiring freezes have also reduced the number of providers on-site to deliver care. SueCatchings is CEO of Health Care Centers in Schools in Baton Rouge: ³We have an $11 millioncommitment from the state that funds 65 clinics. The problem is that we have expenses that continue toescalate at the same time we¶ve been in flat budgets. Last year every contract suffered a 4 percent cut,which is a lot when you¶re on a shoe string budget. Every time we get cut we have to look at whether wecan afford the staff that we have ... and it becomes increasingly difficult to keep people in place.´

Angie Ruiz, Director of Jefferson Parish School-Based Health Centers in Louisiana, is responsible for fiveSBHCs. One of her centers at Bonnabel High School, just outside New Orleans, recently faced a close call

² nearly shutting its doors after the operational funding it received from a private foundation ran out. Theschool system had a $30 million budget cut and couldn¶t pick up the slack. ³Fortunately, we had a lot of

support from the community,´ says Ruiz. ³We had had some breakfasts with local business leaders duringthe year and an advocacy training with our state lobbyists. When we saw that the center was threatened wegot all of our supporters to call our Senator to ask for help ² we even got the principal who taught theSenator¶s son to call him.´

The intensive grassroots advocacy efforts paid off when the Senator was able to secure a last-minute$75,000 line item for the Bonnabel SBHC in the state budget. Ruiz says, ³We¶re continuing to pursue local

businesses, banks, and other partners and writing grants to make up the budget difference. It¶s a constantstruggle. Next year we¶ll have to go back and fight again after a year¶s reprieve.´



Indeed, NASBHC has found that state government agencies with jurisdiction over SBHC programs are notexpecting additional financial support in the coming years. In a survey conducted in late 2009, states wereasked about the funding prospects for SBHCs. Of those 39 states answering the question, only two thoughtit was even ³somewhat likely´ that state-level financial support for SBHCs would increase in the next twoto three years.

For Ruiz, one potential fix is clear: ³If we could get some federal funding to support our other sources we¶dhave more sustainable funding than relying just on the state, which is in bad shape.´

Champions of school-based health care in Congress agree about the role of the federal government:Congressman Chris Murphy from Connecticut recently said, ³We need to tell Washington that this shouldnot be just a responsibility of states and local governments; that the federal government should be steppingup to the plate in a bigger way to support local school-based health centers.´

That is exactly what SBHCs have been working to achieve over the past several years ... and the results arestarting to show.

Health Care Reform and School-Based Health Care

NASBHC ² with thehelp of champions inCongress, our stateaffiliates andassociations, andadvocates from across thecountry ± has madesignificant progress inadvancing SBHCs as avital component of healthcare reform. The PatientProtection andAffordable Care Act

(P.L.111-148), signedinto law by PresidentObama on March 23,2010, includes a federalauthorization for SBHCsin Section 4101(b) ± a huge victory for vulnerable children and adolescents and for SBHCs.

A second provision that mandates $200 million over four years to SBHCs is restricted for capital projects(Sec. 4101(a)). This provision was intended to support struggling SBHCs and to deliver services directly tovulnerable kids ² but ended up being limited to capital improvements and equipment purchases, withexpenditures for health care services and personnel specifically excluded. The capital funds could allowsome SBHCs to be built or expanded, but clinics need a sustainable source of operations funding in order to

provide services for the children and adolescents who depend on them for care.

Without support for the operational costs needed to support a clinic, the effectiveness of the capital moneyalready allocated to SBHCs in the Affordable Care Act under section 4101(a) will be greatly limited. Theoriginal House-passed bill identified a $50 million appropriation for the newly authorized school-basedhealth center program. NASBHC is asking that the $50 million identified in the original House-passed bill

be appropriated in 2010 to enable SBHCs to keep their doors open, and to give critical resources tocommunities that desire to open health centers at their schools.



For real-life examples of the critical importance of operational funding one need only look as far as NorthCarolina. Last year, the state lost funding for two clinics ($124,000, or about 10 percent of their $1.5million state funding). Five other clinics lost funding to newer centers in the state¶s concurrent granting

process, as there was just not enough to award to all that deserved. They were able to use bridge fundingfrom a local foundation to keep those clinics from closing for one year, but that funding will end this year.

Connie Parker,E

xecutive Director of the North Carolina SchoolCommunity Health Alliance, has been telling SBHCs in her state to hangin there as best they can until federal funding comes through ² but thefact that the emergency appropriations are for capital funds only will nothelp the clinics that are struggling to stay open.

³I¶m afraid we¶re going to lose at least two centers,´ says Parker. ³Another clinic has had to cut their hours in half. These communities are in poor counties with very little access to health care for this age group ... i t¶sdefinitely going to impact the health of these kids in the long run becausethey have no other place to go. We¶re trying to work as hard as we can inall the cracks and crevices of funding to try to help these folks stay open.´

The Future of School-Based Health Centers

Despite all of the challenges SBHCs face, the model appears to be here tostay. According to NASBHC¶s 2007-08 Census, seventy-two percent of the nation¶s SBHCs are five years or older, up from 41 percent in 1998.Also, 287 SBHCs opened in the past four years. These numbers attest to a continued community support of and demand for the model.

Parker reflects the optimism of many of the people in her state with whom she communicates: ³I¶mworking with three communities that are at various stages of trying to get school-based health centers off the ground. The nice thing about it for me is that it¶s the school systems that are searching for funding ² schools are recognizing that healthy students do better academically, and that¶s a big turn-around in the past15 years that I¶ve been watching the trends.´

Policymakers are also increasingly recognizing the value in supporting SBHCs. As Congressman Sarbanes(D-MD) told a crowd of hundreds of advocates at the National School-Based Health Care Advocacy Dayrally on Capitol Hill this summer, ³There has to be a school-based health center in every school ... This isan investment. We are going to save so many more multiples of $50 million over the long term if we investthose dollars today.´

If you want to support SBHCs¶ efforts to remain sustainable through federal funding, please donate to NASBHC at www.nasbhc.org/donate.

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