Different Setting, Different Care: Integrating Prevention and Clinical Care in School-Based Health Centers

School-based health centers (SBHCs) are widely credited with increasing students’ access to care by making health services affordable and convenient.SBHCs can also provide a qualitatively different type of health care for children and adolescents than that delivered by community providers. Health services offered in a school setting can integrate clinical care with public health interventions and environmental change strategies. This ability to reach outside the walls of the exam room makes SBHCs uniquely positioned to address the multiple determinants of health.We describe innovative California SBHC programs focusing on obesity prevention, asthma, mental health, and oral health that represent new models of health care for children and adolescents.Although insuring the 8.1 million uninsured children in the United States is a critical first step, improving children''s and adolescents’ health requires going beyond insurance coverage and providing better access and preventive services. Obesity, adolescent pregnancy, dental disease, uncontrolled asthma, and many mental health conditions are serious child and adolescent health concerns whose amelioration requires a combination of clinical services and preventive strategies. The pediatric health care system falls far short in the delivery of preventive care.^1,2 A recent study examined pediatric medical records for 175 indicators of quality care defined by an expert panel of physicians. Adherence to these quality standards was 67.6% for acute care but only 40.7% for preventive care, dropping to 34.5% when only adolescents were considered.³Many authors have highlighted the need to tackle the multiple determinants of children''s health. The resiliency paradigm emphasizes the importance of supportive environments and psychosocial skill development as protective factors mediating both adolescent risk behaviors and health outcomes.⁴ The life course health development framework points to the importance of biological, behavioral, social, and economic determinants of health status that require integrated health interventions.⁵ Most recently, with the growing obesity epidemic, we are seeing increasing attention to environmental determinants of health such as opportunities for physical activity and access to produce. A successful system for children''s health requires a multisector approach that integrates medical, public health, educational, and social services—sectors that today remain an uncoordinated patchwork of categorical programs.⁶The ability of school-based health centers (SBHCs) to increase access to health care has been well documented.^7–9 SBHCs, which deliver primary medical and mental health care, increase access and utilization by providing health care in a location that is convenient for students and their families. Less well recognized, however, is that health care services can be qualitatively different in an SBHC than they are in a community provider''s office. Because of their unique location, SBHCs have the potential to implement health care models for children and adolescents that fully integrate prevention—primary, secondary, and tertiary—into clinical care and that address biological, behavioral, social, and economic determinants of health. We describe 4 school-based programs that exemplify this integration of clinical and preventive care and discuss opportunities for expanding these innovative models.