A SECONDARY ANALYSIS OF SBHC-REPORTED MENTAL HEALTH SERVICES, 

STRUCTURAL CHARACTERISTICS, AND STATE LEVEL SUPPORT FROM 2005-2014 

 

By 

 

Tatiana Elisa Bustos 

 
 
 
 
 
 
 
 
 
 
 
 
 
 

A THESIS 

 

Submitted to 

Michigan State University 

in partial fulfillment of the requirements 

for the degree of 

 

Psychology—Master of Arts 

 

2018 

 

 

 

ABSTRACT 

A SECONDARY ANALYSIS OF SBHC-REPORTED MENTAL HEALTH SERVICES, 

STRUCTURAL CHARACTERISTICS, AND STATE LEVEL SUPPORT FROM 2005-2014 

 

By 

 

Tatiana Elisa Bustos 

 

Background: More than 20% of children and youth in the U.S. experience mental health 

difficulties, with only about 30% receiving adequate mental health treatment services. School 

based health centers (SBHCs)—a comprehensive service delivery model integrating physical and 

mental health services within school settings—reduce barriers to health services faced by low-

income families and children. Given the potential of SBHCs to improve the lives of children with 

mental healthcare needs, it is necessary to explore the delivery of mental health (MH) services 

among SBHCs longitudinally, and identify key structural characteristics, networks, and state 

level supports that promote delivery of MH services across U.S. states. Method: Guided by the 

contextualist approach, secondary analyses of two longitudinal datasets (National SBHC Census 

& State Policy Survey) were carried out to: (1) identify the number of MH services reported to 

be delivered by state over time, and (2) identify inner and outer contexts of SBHCs with a MH 

component related to number of services. The consolidated framework for implementation 

(CFIR) was used to organize variables and guide interpretation of findings related to the 

interplay of contexts and delivery of services. Findings: Results suggest that specific inner and 

outer setting variables are related to more MH services from 2005 to 2014, but the variables had 

differential impacts on which type of MH service was delivered. Moreover, mandatory policies 

for state-funded SBHCs demonstrated more MH services over time than those otherwise. 

Discussion: Understanding the factors facilitating delivery of MH services is necessary to better 

inform policy efforts that can increase service access among underserved youth.  

 

 

ACKNOWLEDGEMENTS 

 

I would first like to acknowledge my late sister, Thalia Karina Bustos, for being my 

guardian and for giving me the strength to overcome all my struggles and challenges thus far. 

You are the only reason I am here.  

I would like to thank my close friends and family in Florida for their distant, but constant, 

support throughout my transition to Michigan and my graduate program. Thank you, to my ECO 

peers and professors, who have dedicated time and resources to help me reach my 

accomplishments. 

I am forever grateful for my advisor, Dr. Amy Drahota, for her support and for believing 

in my abilities as a scholar. I want to thank my supportive and enthusiastic thesis committee, 

Drs. Kaston Anderson Carpenter and Miles McNall for their contributions to the development of 

this project as committee members. I want to further acknowledge Dr. Deb Kashy's support in 

developing the analytic plan for this project and for her patience in teaching me how to 

successfully tackle challenging statistical approaches. Lastly, I want to thank Kevin James 

Graham for balancing me with his energy, everlasting patience and ongoing encouragement. 

Thank you!

 

 

 

 

TABLE OF CONTENTS 

 

LIST OF TABLES..........................................................................................................................vi 

LIST OF FIGURES......................................................................................................................viii 

 
 
 

INTRODUCTION...........................................................................................................................1 
School-Based Health Center Model.........................................................................2 
Variations in School-Based Health Centers.............................................................4 
Limitations of Mental Health Services through School Based Health Centers.......6 
Organizational Context Influences SBHC Implementation.....................................7 
 
LITERATURE REVIEW..............................................................................................................11 
SBHC Mental Health Services...............................................................................12 
SBHC Effectiveness...............................................................................................13 
 
METHODS....................................................................................................................................21 

 

 
 

 
 

state from 2005 to 2014?............................................................................21 
Reported mental health services................................................................21 
Data cleaning & missing data....................................................................22 

 
RQ1. What is the number of mental health services reported to be delivered by  
 
 
 
 
 
 
 
RQ2. Which inner setting variables (structural characteristics and networks) are  
 
related to number of mental health services reported to be delivered from  
 
 
 
2005 to 2014?.............................................................................................22 
 
 
Data cleaning & missing data....................................................................23 
 
RQ3. Which outer setting variables (e.g., funding sources, policy and standards,  
 
oversight and support) are related to the number of mental health services  
 
 
reported from 2005 to 2014?......................................................................24 
 
 
 
Data cleaning & missing data....................................................................24 
 
Participants.............................................................................................................25 
             
Providers....................................................................................................25 
 
 
Policy makers.............................................................................................25 
Measures................................................................................................................25 
 
National Census of SBHC Survey.............................................................25 
 
 
 
 
SBHC State Policy Survey........................................................................26 
Procedures..............................................................................................................27 
 
School Based Health Alliance (SBHA).....................................................27 
 
 
 
 
Data collection procedures.........................................................................28 
 
Data Analysis.........................................................................................................28 
Exploratory data analysis...........................................................................28 
Linear mixed model (LMM) analysis........................................................30 
 
RESULTS......................................................................................................................................33 
Descriptive analyses.............................................................................................33 

 

 

 

 

iv 

 

 

 

 

Screening & assessment services...............................................................33 
Medication management services..............................................................34 
Substance use treatment services...............................................................35 
Referral services.........................................................................................36 
Inner Setting Variables..............................................................................38 
 

The National Census Survey-Structural Characteristics 

 

 

   subscale..........................................................................................38 

 

 

 
 
 

The National Census Survey- Network Communications  
subscale..........................................................................................39 
Outer Setting Variables..............................................................................40 
The State Policy Survey- Funding Sources subscale....................40 
 
 
 
The State Policy Survey- Oversight and Support subscale...........41 
 
 
The State Policy Survey- Policy and Standards subscale.............42 
 
LMM Analyses: Inner Setting Variables & MH Services.....................................42 
Screening & assessment services...............................................................42 
Medication management services..............................................................44 
Substance use treatment services...............................................................47 
Referral services.........................................................................................49 
LMM Analyses: Outer Setting Variables & MH Services....................................50 
Screening & assessment services...............................................................52 
Medication management services..............................................................54 
Substance use treatment services...............................................................56 
Referrals services.......................................................................................59 
 
DISCUSSION................................................................................................................................61 

 
 

 
 
 

 
 

state from 2005 to 2014?............................................................................61 

RQ1. What is the number of mental health services reported to be delivered by  
 
RQ2. Which inner setting variables (structural characteristics and networks) are  
related to number of mental health services reported to be delivered from  
2005 to 2014?.............................................................................................62 
The National Census Survey - Structural Characteristics subscale...........62 
The National Census Survey - Networks Communications subscale........66 

RQ3. Which outer setting variables (e.g., funding sources, policy and standards,  
 
 

oversight and support) are related to number of mental health services  
reported to be delivered from 2005 to 2014?.............................................67 
The State Policy Survey - Funding Sources subscale................................67 
The State Policy Survey - Oversight and Support subscale.......................68 
The State Policy Survey - Policy and Standards subscale.........................69 
Limitations.............................................................................................................70 
Conclusion.............................................................................................................70 

 
 
 

 
APPENDICES...............................................................................................................................73 
APPENDIX A: National SBHC Census Survey....................................................74 
APPENDIX B: State Policy Survey......................................................................94 
 
REFERENCES............................................................................................................................. 98 

 
 

 

v 

 

 

 

LIST OF TABLES 

Table 1: Consolidated Framework for Implementation Research Constructs, Definitions, 

Variables & Dataset.............................................................................................................9 

 

Table 2: Sample Sizes Across Time-Points...................................................................................33 

Table 3: Screening & Assessment Services...................................................................................34 

Table 4: Medication Management Services...................................................................................35 

Table 5: Substance Use Treatment Services..................................................................................36 

Table 6: Referral Services..............................................................................................................37 

Table 7: Summary of Structural Characteristics by Time Point....................................................39 

Table 8: Percent of Sites’ Reported Health Center Partnerships by Time.....................................40 

Table 9: Summary of External Policy & Incentives by Percentage of Sites (N) and 

Time...................................................................................................................................41 

Screening/Assessment Services, Controlled for Time.......................................................43 

Controlled for Time...........................................................................................................49 
 

Table 17: Estimated Marginal Means of Referrals by Inner Setting Variables.............................50 

 

vi 

 

Management Services, Controlled for Time......................................................................45 

Variables............................................................................................................................44 

 

 

 

 
Table 10: LMM: Type III Test of Fixed Effects for Inner Setting Variables on  
 
 
Table 11: Estimated Marginal Means for Screening/Assessment by Inner Setting    
 
 
Table 12: LMM: Type III Test of Fixed Effects for Inner Setting Variables on Medication  
 
 
Table 13: Estimated Marginal Means for Medication Management by Inner Setting  
 
 
Table 14: LMM: Type III Test of Fixed Effects for Inner Setting Variables on Substance   
 
 
Table 15: Estimated Marginal Means of Substance Use Treatment Services by Inner  
 
 
Table 16: LMM: Type III Test of Fixed Effects for Inner Setting Variables on Referrals,    
 

 

 

Variables............................................................................................................................46 

Use Treatment Services, Controlled for Time...................................................................47 

Setting Variables................................................................................................................48 

 

Table 18: Type III Tests of Fixed Effects for Outer Context Variables on    
 

Screening/Assessment, Controlled for Time.....................................................................51 
 

 

 

 

Table 19: Type III Tests of Fixed Effects for Outer Context Variables on Medication  
 

Management, Controlled for Time....................................................................................51 
 

 

Table 20: Type III Tests of Fixed Effects for Outer Context Variables on Substance Use    
 

Treatment, Controlled for Time.........................................................................................52 
 

Table 21: Type III Tests of Fixed Effects for Outer Context Variables on Referrals,  
 

Controlled for Time...........................................................................................................52 
 

 

Table 22: Estimated Marginal Means of Screening/Assessment by Outer Setting    
 

Variables............................................................................................................................54 
 

 

Table 23: Estimated Marginal Means of Medication Management by Outer Setting  
 

Variables............................................................................................................................56 
 

 

Table 24: Estimated Marginal Means of Substance Use Treatment by Outer Setting  
 

Variables............................................................................................................................58 
 
Table 25: Estimated Marginal Means of Referrals by Outer Setting Variables............................60 

 

 

 

 

 

vii 

 

 

LIST OF FIGURES 

 

Figure 1: Stacked Bar Count ("Yes") of School Characterization by Time..................................72 

 

 

 

 

 

viii 

 

 

INTRODUCTION 

It is estimated that more than 20% of children and youth in the U.S. experience mental 

health difficulties, with only about 30% receiving adequate mental health treatment services 

(Bains & Diallo, 2016; Brown & Bolen, 2003; Merikangas et al., 2011; Simon, Pastor, Reuben, 

Huang & Goldstrom, 2015). In fact, most children between the ages of 6 to 17 years, who are in 

need of mental health services, do not receive treatment (Langer et al., 2015; Jensen et al., 2011; 

Katoaka, Zhang, & Wells, 2002; Bains, Cusson, White-Frese, & Walsh, 2017). Moreover, 

children from low-income families are reported to have higher rates of mental health difficulties 

than children from higher income families who do not experience economic hardships (Guo, 

Wade, & Keller, 2008; Hill, Ohmstede, & Mims, 2012). Given these rates, there is a critical need 

to increase access and funding of mental health services in underserved areas.  

School based health centers (SBHCs) have proven successful in reducing barriers to 

reach children and youth with the greatest level of need (Allison et al., 2007; Armbruster & 

Lichtman, 1999; Larson & Chapman, 2013; Mason-Jones et al., 2012). Families in low-income 

areas tend to face more challenges related to limited resources (e.g., availability of health care 

providers or clinics) and more barriers in access to quality health services (Bains & Diallo, 2016; 

Baquiran, Webber, & Appel, 2002), including mental health services. These barriers include 

transportation, language, costs of services, work schedules, availability of appointments, 

culturally compatible services, and insurance status (Anderson, Howarth, Vainre, Jones, & 

Humphrey, 2017; Agudelo-Suarez, 2012, Brown & Bolen, 2003; Gulliver, Griffiths, & 

Christensen, 2010; Guo, Wade, Pan, & Keller, 2010).  

Further, children from low-income families are more likely to be uninsured and lack a 

usual source of health care, which decreases their likelihood of having health professional visits 

 

1 

 

(Allison et al., 2007; Bains & Diallo, 2016; Baquiran et al., 2002; Bloom, Jones & Freeman, 

2013). SBHCs offer a comprehensive source of care to children without medical coverage 

(Baquiran et al., 2002). For example, through school-based health centers, mental health services 

can be made affordable to families in need, either because the services are free-of-charge, low-

cost, or billable to Medicaid (Brindis, Kapphahn, McCarter, & Wolfe, 1995; McNall, Lichty & 

Mavis, 2010).  

In the U.S., 70% of SBHCs include a mental health component. However, among schools 

with a SBHC, 30% do not have a mental health provider on staff (School-Based Health Alliance, 

2016; Larson, Spetz, Brindis, & Chapman, 2017). While 70% of SBHCs can offer a range of 

mental health services, there remains a need for expansion of comprehensive mental health care 

that can be optimized with more organizational resources, such as mental health providers on 

staff (Larson et al., 2017).  The purpose of this project is to identify key structural, network, and 

state level support characteristics of SBHCs that have contributed to the delivery of mental 

health services over time.  

School-Based Health Center Model 

School-based health centers (SBHCs), a comprehensive service delivery model that 

integrates physical and mental health services, responds to children’s unmet needs by increasing 

access to treatment and preventive services within the school setting (Baquiran et al., 2002; 

Harold & Harold, 1993; Langer et al., 2015; McNall et al., 2010; Silberburg & Cantor, 2008). 

The SBHC model was designed to function as a medical home for children in urban, low-income 

areas (Dowden, Calvert, Davis, & Gullota, 1997; Gullota & Noyes, 1995). The model shares a 

common goal to optimize students’ potential and success by increasing access to prevention and 

treatment services for improved health (School Based Health Alliance, 2016). In fact, SBHCs are 

 

2 

 

 

in a unique position to reduce barriers commonly faced by low-income families (Guo et al., 

2008). Schools have been identified as effective primary settings for mental health care, 

particularly among low-income communities (Bains & Diallo, 2016; Brindis et al., 1995; Hill et 

al., 2012). SBHCs have an opportunity to make a direct positive impact on children’s health and 

education outcomes at a location where the child is present all day. SBHCs have helped reduce 

barriers related to stigma, conflicting work schedules, and financial obstacles by augmenting 

access to services that are affordable, confidential, and convenient (Guo et al., 2008; Armbuster 

& Lichtman, 1999; Lai, Guo, Ijadi-Maghsoodi, Puffer, & Kataoka, 2016).  

Since inception, SBHCs have continued to expand throughout the United States. 

According to the 2013-2014 SBHC Census, there are 2,315 centers in 49 of the 50 U.S. states 

and District of Columbia (School-Based Health Alliance, 2016). Fifty percent of SBHCs are 

located in urban areas, 34.6% in rural areas, and 14.2% in suburban areas. Ninety four percent of 

these SBHCs are located on school property, and the majority are affiliated with traditional 

public schools, community schools, or magnet schools. Centers can remain open annually or 

open only during the school year, depending on resources. SBHCs serve children in schools 

including all grade levels from K-12 (27.9%); high schools (9-12; 23.4%); elementary schools 

(15.3%); middle schools (8.8%) and non-traditional grade levels (24.6%). According to a census 

survey from 2013-2014, student demographics of schools with SBHCs is reported as 31% White, 

30% Hispanic/Latino, and 25% Black/African American (Larson et al., 2017). Shared 

characteristics across the SBHCs include: a multidisciplinary team of (1) health care providers, 

including registered nurse, nurse practitioner, physician assistants, social workers, physicians, 

counselors, and other health care professionals; (2) collaboration with the school system; (3) 

providing a comprehensive range of services to meet physical and behavioral health needs of 

 

3 

 

 

children and youth in the community; (4) providing clinical services through a hospital, health 

department or medical practice; (5) requiring parents to sign written consents in order for 

children to receive all services provided; and (6) having an advisory board consisting of 

community representatives, parents, youth, family organizations for planning and oversight 

(School Based Health Alliance, 2016). 

Variations in School-Based Health Centers 

The seven core competencies of SBHCs (e.g., access, student focus, school integration, 

accountability, school wellness, systems coordination, and sustainability) help guide the 

development of new SBHC models. However, standards and guidelines for a center are defined 

by the states in which they are located. Centers may also vary structurally in center 

demographics, hours of operations, staffing size, networks (e.g., partnerships), sponsorships and 

available resources (Bains & Diallo, 2016; Brindis et al., 2003; Dreyfoos, 1995). For example, 

general staffing profiles for centers can include only a primary provider or a primary provider 

with a behavioral health professional on site (Price, 2016). In SBHCs with a mental health 

component, the most common staff profile comprised of a licensed social worker, therapist, or 

counselor with medical assistants, registered nurses, and health educators (Larson et al., 2017). 

Differences in networks and partnerships can influence availability of resources and services. For 

example, centers that are coordinated with larger health systems, such as the local hospital and 

community health center can offer more facilities, appointments, referrals to off-site services, 

and funding opportunities (Dreyfoos, 1994). Differences in sponsorships have also been found 

among SBHCs with and without a mental health component. Centers with a mental health 

component are more likely to be sponsored by school and university departments than public 

health departments when compared to centers without a mental health component (Brindis et al., 

 

4 

 

 

2003). There is a critical need to identify the role of variations in structural characteristics within 

SBHCs with a mental health component on services. In the absence of such knowledge, further 

understanding of variations impacting mental health service delivery over time remains unlikely.  

Variations in SBHCs may be attributed to state level support. State level support refers to 

“the allocation of funding directly to school health centers, having state agency staff dedicated to 

SBHC program, promulgating and monitoring program standards, providing technical assistance 

for school health center operations and evaluation, convening the statewide network, collecting 

and reporting program data and performance measures, and establishing reimbursement policies 

for Medicaid and SCHIP” (Schlitt, Juszczak, & Eichner, 2008; p. 733). Sources and allocation of 

funding varies from state to state. To date, only 18 states direct funds to a SBHC grant program 

(National School-Based Health Care Census, 2014). However, some SBHCs have developed 

partnerships with regional grant makers directly for the evaluation of services and outcomes 

(Rose, Mansour, & Kohake, 2005. Other funding sources for SBHCs include patient revenue, 

government grants, partner contributions, and private sector funding (School-Based Health 

Alliance, 2016). Patient revenue sources include Medicaid, private insurance, Child Health 

Insurance Program (CHIP) or self-pay. Government grants include state, federal, and local level 

grants. Partner contributions refer to funds from community and school settings. Private sectors 

refer to funding from foundations, managed care, or other corporations, and are the least 

common funding source reported. State government and managed care organizations have been 

found to be the most common funding source among SBHCs with a mental health component 

(Larson et al., 2017). There is a critical need to identify key factors in state level support that 

impact development of mental health services in SBHCs over time.  

 

5 

 

 

Variations in structural characteristics and state level support can significantly influence 

availability of mental health services (Price, 2016). While 70% of SBHCs in the U.S. include a 

mental health component (Bains et al., 2017; Larson et al., 2017), specific intervention services 

are not consistent across sites that include a mental health component. SBHCs offer mental 

health services that range from risk assessments, referrals, screening, evaluation and treatment, 

substance abuse counseling, assessments of learning problems, to prescription management 

(Bains & Diallo, 2016; Larsen et al., 2017; Lofink, Kuebler, & Juszczak, 2013). Some centers 

may not be as well-equipped as others to provide these services. Structural characteristics, such 

as a larger student body, increased hours of operation, partnerships, and higher grade levels, 

increase the likelihood of making mental health services more available (Dreyfoos, 1998; Larson 

et al., 2017).  Moreover, state funding and policy support can influence the sustainability of 

available services over time (Anyon et al., 2013; Armbruster, 2002; Hacker & Wessel, 1998). 

Limitations of Mental Health Services through School Based Health Centers 

Among SBHCs with a mental health component, sites can differ significantly. To the 

researcher’s knowledge, only one study has compared characteristics of SBHCs with and without 

a mental health component to examine differences in reported structural characteristics and 

funding sources (Larsen et al., 2017). SBHCs with a mental health component were reported to 

have more resources, more students, a longer history of establishment, and more state funding 

than SBHCs that do not offer mental health services at their site (Larsen et al., 2017). While this 

helps inform characteristics of SBHCs offering mental health services, studies have not 

examined differences within these characteristics (e.g., structural characteristics, state level 

support).   

 

6 

 

 

Most studies on SBHCs with a mental health component discuss their findings as an 

aggregated group (Bersamin et al., 2016; Keeton, Soleimanpour, & Brindis, 2012; Silberberg & 

Cantor, 2008). Exploring differences in structural characteristics and state level support within 

SBHCs that offer a mental health component can reveal factors that have shaped types of mental 

health services reported to be delivered over time. Further, most studies have paid little to no 

attention to the diversity of contexts (Keeton et al., 2012; Silberberg & Cantor, 2008). Limited 

attempts have been made to explore the influence of site components related to structural 

characteristics and state level support on types of mental health services reported to be delivered 

(Silberberg & Cantor, 2008). There is a need to compare contexts of SBHCs with a mental health 

component to understand what factors have facilitated or promoted types of mental health 

services delivered through SBHCs.  

Organizational Context Influences SBHC Implementation 

Specifically, context refers to the unique set of circumstances surrounding an 

implementation effort, such as the service delivery model for mental health services through 

SBHCs (Damschroder et al., 2009). According to a contextualist approach, research should 

explore contexts and their interconnections to better understand an organization’s process of 

change (Pettigrew, Woodman, & Cameron, 2001). Organizational contexts are complex and can 

generate variations in services from setting to setting (Bauer, Damschroder, Hagedorn, Smith, & 

Kilbourne, 2015). Inner contexts, outer contexts, and their interconnections are hypothesized to 

mediate an organization’s development over time (Damschroder et al., 2009; Pettigrew et al., 

2001). The outer context refers to political, social, and economic context in which the 

organization was established (Damschroder et al., 2009; Pettigrew et al., 2001). The inner 

 

7 

 

 

context refers to the organization’s structural, cultural, and political features that direct the 

process in which service provision proceeds (Damschroder et al., 2009; Pettigrew et al., 2001).  

Guided by this approach, this thesis project is designed to identify inner and outer 

contexts of SBHCs with a mental health component that have influenced the number of mental 

health services reported to be delivered over time. Using longitudinal datasets from the School 

Based Health Alliance, the inner and outer contexts will be informed by two surveys, the Census 

Survey and State Policy Survey, administered to SBHCs and stakeholders across the U.S. from 

2005 to 2014. The Census Survey will inform inner contexts, which include variations among 

centers’ demographics, hours of operation, staffing, networks, and student demographics. The 

State Policy Survey will be used to inform outer contexts of SBHCs, emphasizing the role of 

state level support on the number of mental health services reported to be delivered over time. 

Building on the contextualist approach, dissemination and implementation science 

theories also consider context in evaluating implementation efforts. The Consolidated 

Framework for Implementation Research (CFIR) provides a more comprehensive framework of 

constructs relevant to an implementation effort and justification for how these constructs are 

applied in context (Damschroeder et al., 2009). The CFIR includes five major domains: 

intervention characteristics, outer setting, inner setting, characteristics of individuals, and process 

(Damschroeder et al., 2009). Each of these domains also includes 39 constructs and sub-

constructs that are theorized to impact change processes related to a specific program or practice 

(Damschroeder et al., 2009). For the thesis project, CFIR will be used to organize the inner and 

outer contexts of SBHCs with a mental health component and will guide data interpretation. 

Focus will be placed on two of the five domains: outer setting and inner setting (See Table 1).  

 

8 

 

 

While CFIR provides the framework for organizing contexts, it does not specify or 

explain how the interaction between inner and outer level settings may affect the delivery of an 

innovation (Damschroeder et al., 2009). However, the framework can be used to examine the 

process of change in organizations over time. As a variant of the contextualist approach, studies 

of organizational development emphasize the role of contexts in explaining changes in service 

delivery (Pettigrew et al., 2001).  This approach in organizational development studies the  

Table 1: Consolidated Framework for Implementation Research Constructs, Definitions, 
Variables & Dataset 

Construct 

 

Description 

Variable 

 

II. Outer Setting 

State Level Support 

D. External Policy & Incentives 

Funding, oversight and 
support, policy and standards 

Includes external strategies to 
spread innovations, including 
policy and regulations 
(governmental or other central 
entity, external mandates, 
recommendations and guidelines, 
pay for performance, 
collaboratives, and public or 
benchmark reporting 

III. Inner Setting 

Structural Characteristics 

A. Structural Characteristics 

The social architecture, age, 
maturity, and size of an 
organization 

B. Networks & Communications  The nature and quality of webs of 
social networks and the nature and 
quality of formal and informal 
communications within an 
organization 

Health center demographics, 
health center operations, health 
center care team, school 
characterization 
Health center partnerships 

Data 
Set 
State 
Policy 
Survey 

Data 
Set 

Census 
Survey 

Census 
Survey 

relationship between multiple levels of context to show how inner and outer contexts interact and 

shape change processes (Pettigrew et al., 2001). The thesis project aims to study change 

processes related to structural characteristics, networks and state level support, and explore how 

these contexts have shaped the number of mental health services reported to be delivered by 

SBHCs from 2005 to 2014. 

 

9 

 

 

Because SBHCs are targeting at-risk communities with high rates of mental health 

disparities, it is important to examine how inner and outer contexts have influenced the types of 

mental health services reported to be delivered. Changes in inner and outer contexts can 

influence implementation efforts (Damschroeder et al., 2009). Exploring inner and outer contexts 

of SBHCs with a mental health component can reveal conditions needed for the gradual 

development of more comprehensive services. The thesis project will address the following 

questions:  

RQ1. What is the number of mental health services reported to be delivered by state from 2005 

to 2014? 

RQ2. Which inner setting variables (e.g., structural characteristics and networks) are related to 

number of mental health services reported to be delivered from 2005 to 2014? 

RQ3. Which outer setting variables (e.g., funding sources, policy and standards, oversight and 

support) are related to number of mental health services reported to be delivered from 2005 to 

2014? 

In the following section, this paper will briefly discuss the current state of mental health 

disparities among U.S. children in underserved communities, provide a brief history of SBHCs, 

and discuss the expansion of mental health services. Then, the paper will discuss the current state 

of literature on SBHC effectiveness and prospects of SBHCs with mental health services, and, 

lastly, explain the role of policy and funding on SBHC development and sustainability.  

 

 

 

10 

 

 

 

LITERATURE REVIEW 

School-based health centers, also known as school-based health care and school-based 

health clinics, are one of the most effective strategies for delivering physical, mental, and 

preventive health services to underserved youth populations (Mason-Jones et al., 2012; Schlitt et 

al., 2008). School based health centers (SBHCs) represent a service delivery model capable of 

functioning as a medical home for children, providing primary care for both their physical and 

behavioral health care needs, with the capacity to promote health and prevent illness (O’Leary et 

al., 2014; School Based Health Center Alliance, 2016). For this thesis project, school based 

health centers will be defined as a comprehensive health service delivery model located at or 

near the school but will only include SBHCs with a mental health component. 

SBHCs were first established during the 1970s in Dallas, Texas, St. Paul, Minnesota, and 

Cambridge, Massachusetts (Brindis et al., 2003; Dryfoos, 1994; Jennings, Pearson, & Harris, 

2000; Marone, Kilbreth, & Langwell, 2001). SBHCs were initially developed in response to high 

pregnancy rates in inner city high schools, offering only preventive and primary care services to 

youth in urban areas (Brindis et al., 2003; Brown & Bolen, 2003; Dryfoos, 1998, Flaherty, Weist, 

& Warner, 1996). Currently, more than half of SBHCs are located within urban low-income 

areas (Bains & Diallo, 2016). However, since the inception of the SBHC model, SBHCs have 

expanded to rural and suburban locations (Silberberg & Cantor, 2008; Bains & Diallo, 2016) and 

widened their target population to include preschool, elementary and middle school aged 

children (Bains & Diallo, 2016; Silberberg & Cantor, 2008).  

With the ongoing school reform movement to improve child and adolescent health, more 

comprehensive SBHCs began to integrate mental healthcare into their model (Dreyfoos, 1994; 

Flaherty et al., 1996). Mental health services were deemed necessary to curtail increased rates of 

 

11 

 

 

risky health behaviors, such as suicide, school drop-out and homicide, which was prevalent in 

targeted urban communities during the early 90s Dreyfoos, 1994; Flaherty et al., 1996). 

Expanding mental health services through SBHC not only provided services for treatment, but 

also incorporated preventive services to enhance children’s well-being (Flaherty et al., 1996). 

The mental health component of SBHCs is now considered a prominent model for school mental 

health (Armbuster, 2002; Flaherty et al., 1996). 

SBHC Mental Health Services 
 

Early onset of mental health difficulties during childhood is positively correlated with 

severity of mental health illness across the lifespan and into adulthood, if untreated (Simon et al., 

2015). In school-aged children, mental health illness has also been linked to poorer academic 

performance, higher risk-taking behaviors, substance abuse, and developmental difficulties 

(Padilla-Frausto, Grant, Aydin, Anguilar-Goxiola, 2014). As a result, early identification and 

treatment of mental health difficulties is critical to optimize the outcomes of children experiences 

mental health disorder symptoms. SBHCs are designed to provide prevention of early onset 

mental illnesses in young children (Santor, Poulin, LeBlanc, Kusumakar, 2006), and thus are a 

vital service delivery mechanism to meet the need of children who are experiencing mental 

health symptoms but may have limited access or utilization of community-based mental health 

services. 

Over 70% of SBHCs in the U.S. offer some type of mental health assessment and 

treatment services (Bains & Diallo, 2016; Lofink et al., 2013; Morone et al., 2001). These 

services can include referrals, assessments, screenings, grief and loss therapy, counseling, crisis 

intervention, substance abuse counseling, family therapy, and other therapeutic interventions 

(Bains & Diallo, 2016; Lofink et al., 2013). Services are offered by providers from various 

 

12 

 

 

disciplines and training backgrounds, including social workers, psychologists, counselors, and 

nurses (Flaherty et al. 1996). However, master’s level social workers and mental health 

counselors have previously been reported as the most common mental health providers among 

all the centers (Brown & Bolen, 2003). These services are designed to target a range of disorders 

related to attention, depression, anxiety, eating disorders, substance use, suicide, trauma, and 

grief. Some centers, however, vary on capacity to offer services to treat specific behaviors. For 

example, one site may not have the proper training to address grief because its primary target for 

the given school population is treating suicide and substance use (Price, 2016). Inner context 

variables, such as structural characteristics of SBHCs (e.g., length of establishment and staffing), 

can influence the provision of services (Pettigrew et al., 2001). Similarly, outer context variables, 

such as funding sources, technical support, networks (e.g., partnerships), sponsorships, available 

resources and policies, can also influence development of such services over time (Pettigrew et 

al., 2001).  

SBHC Effectiveness  

 
SBHCs that offer mental health services have improved mental health outcomes, 

improved academic performance, and increased access to treatment for children from various 

ages and mental health illnesses (Allison et al., 2007; Armbruster & Lichtman, 1999; Larson & 

Chapman, 2013; Mason-Jones et al., 2012). SBHCs continue to optimize student’s health for 

success. Adolescent and children's mental health outcomes have been greatly improved with the 

integration of SBHCs in different geographical locations (Jennings et al., 2000; Wade et al., 

2008). A high school SBHC located in Baltimore showed that students receiving mental health 

treatment reported more improvements in self-concept and reduced depression scores than those 

who had not received any mental health services (Weist, Paskewitz, Warner, & Flaherty, 1996). 

 

13 

 

 

Students have reported improvements in dealing with stress and anxiety with the help of their 

SBHC (Soleimanpour, Geierstanger, Kaller, McCarter, & Brindis, 2010). SBHCs have also 

promoted prosocial behaviors and facilitated the development of relationships with caring and 

supportive school-based staff (Stone, Whitaker, Anyon, & Shields, 2013). 

Mental health is strongly correlated to children’s academic performance (Hill et al., 

2012). SBHCs can reduce impacts from poor health on academic related outcomes (Knopf et al., 

2016; Sprigg, Wolgin, Chubinski, & Keller, 2017). A longitudinal study examined the 

differential impacts from medical and mental health service use in a high school-based SBHC. 

Mental health service use was more strongly related to increased GPAs over time than medical 

service use offered in SBHCs (Walker, Kerns, Lyon, Bruns, & Cosgrove, 2010). Other case 

studies evaluating SBHC mental health service use have demonstrated improved academic 

outcomes through lowered rates of absenteeism (Brown & Bolen 2003; Bains et al., 2017).   

Additional research has examined individual level factors facilitating mental health 

service offered in SBHCs. Student and parent satisfaction with services was generally reported to 

be high throughout several studies (Kaplan, Calonge, Guernsey, Hanrahan, 1998; Silberberg & 

Cantor, 2008; Soleimanpour et al., 2010). Reasons reported for SBHC satisfaction included its 

affordability, confidential services, convenience, and familiarity with the environment 

(Soleimanpour et al., 2010). This suggests that parents and students are receptive to mental 

health services offered through their centers because of tailored needs.  

Several studies support that SBHCs increase access to mental health services among 

children and adolescents with the highest level of needs (Armbruster & Lichtman, 1999; Bains et 

al., 2017; Juszczak, Melinkovich & Kaplan, 2003; Santor et al., 2006). For example, students 

who frequently utilize SBHC services are more likely to be children whose parents are 

 

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uninsured, living in low-income areas, and utilizing SBHCs as their only source of regular 

mental and physical care (Allison et al., 2007; Baquiran et al., 2002; O’Leary et al., 2014; Wade 

et al., 2008). Students who make frequent visits to their centers are also characterized as having 

higher risk behaviors, such as substance use or risky sexual behaviors (Wolk & Kaplan, 1993). 

This suggests that SBHC are successfully reaching at-risk populations and have designed 

culturally appropriate services to match their needs.  

Mental health concerns account for one of the largest proportion of reasons students visit 

their SBHC (Bains et al., 2017; Kaplan et al., 1998; Santor et al., 2006). In fact, students with 

SBHCs have been found to be ten times more likely to make mental health visits to centers when 

compared to students without access to SBHCs (Guo et al., 2008; Kaplan et al., 1998; Santor et 

al. 2006; Soleimanpour et al., 2010). Another study found that students with mood disturbance or 

other mental health difficulties accounted for 46% of SBHC visits (Santor et al., 2006). Students 

who identified a problem (e.g., mood disorder or other mental illness) were more likely to visit 

their SBHC than individuals who do not report any problems (Santor et al., 2006). In multiple 

studies with high school students, mental health visits were sought after for substance abuse 

treatment or other mental health related illnesses, such as depression or suicidal thoughts (Kaplan 

et al., 1998; Pastore, Juszczak, Fisher, & Friedman, 1998; Szumilas, Kuthcer, & LeBlanc, 2010). 

In sum, findings show that SBHCs have successfully increased access to physical and mental 

health care for students who need treatment.  

Additionally, mental health services provided through SBHCs have been found to be cost 

effective. SBHCs have decreased familial and societal costs by reducing the number of 

emergency room visits by children with access to SBHCs when compared to other delivery 

sectors, such as community health network facilities (Adam & Johnson, 2000; Brown & Bolen 

 

15 

 

 

2003, Juszczak et al., 2003; Kaplan et al., 1998; Schlitt et al., 2008; Smith, 2013; Young, 

D’angelo & Davis, 2001). When SBHCs are coordinated with larger health systems, such as 

local hospitals or community health networks, cost of mental health services can be reimbursed 

through managed care systems, such as Medicaid (Armbuster, Andrews, Couenhoven, & Blau, 

1999; Guo et al., 2010; Ran, Chattopadhyay & Hahn, 2016). An analysis on the economic cost 

and benefit of SBHCs indicated that benefits of SBHCs greatly exceeded the cost to run them 

(Ran et al., 2016). Specifically, findings from this economic analysis demonstrated decreased 

costs in Medicaid, as well as positive impacts to students’ educational and health outcomes and 

students’ sense of responsibility toward achieving their academic goals (Ran et al., 2016).  

Individual-level factors, such as age, gender, and insurance status are found to moderate 

impacts of mental health services on students’ behavioral health outcomes and frequency of 

service use at their centers. Some studies found that a higher number of visits are made by older 

students and female students (Bains et al., 2017; Parasuraman & Shi, 2014; Wade et al., 2008; 

Wolk & Kaplan, 1993). Impacts from age were also documented in a SBHC in New Haven that 

showed 13-year-old students were 3 times more likely to visit their health center than younger 

children over time (Bains et al., 2017). More studies will need to account for these factors to 

examine maintenance of health outcomes. Organizational level factors, such as location and 

length of establishment, are also suggested to influence frequency of visits to centers (Johnson & 

Hutcherson, 2006; Wade et al., 2008). For instance, a longitudinal study found that mental health 

service use increased over a 3-year span among 8 SBHCs in rural and urban school districts 

(Wade et al., 2008).  

Yet, few studies have focused on the sustainability of SBHC in service delivery and in 

maintaining beneficial mental health outcomes over time (Brindis et al.2003; Silberburg & 

 

16 

 

 

Cantor, 2008). Limited research has been attributed to a lack of consistency across service 

delivery, diversity of contexts in these organizations, and limited use of rigorous designs 

(Dryfoos, 1994; Silberberg & Cantor, 2008). Research has also suggested for more comparisons 

between community-based and school-based settings of service delivery to better understand 

quality of care (Langer et al., 2015). Yet, another issue relates to the fact that most evaluations of 

SBHCs are comprised of small sample sizes, case studies, and attrition in student population 

(Keeton et al., 2012; Weist et al., 1996). Cases studies do not allow for comparative analyses due 

to measures that are not comparable to one another. More studies focusing on these dimensions 

can be made difficult when individual schools function within unique inner and outer contexts.  

Specifically, inter-organizational structures are formal or informal networks that can 

strongly influence adoption of innovations (Greenhalgh, Robert, Macfarlane, Bate, & 

Kyriakidou, 2004). Networks include partnerships, collaboration, and sponsorships. As 

previously discussed, SBHCs vary in these structures, which can potentially hinder full delivery 

of their health care model (Kaplan et al., 1998; Brindis et al., 2003). Community partnerships 

have been found to facilitate the process of integrating SBHCs into existing schools as well as 

community-based health care systems and, thus, support the sustainability of SBHCs 

(Armbruster, 2002; Dreyfoos, 1994; Swider & Valukas, 2004). Collaboration in systems of 

coordinated care can help bring in more resources, funding sources, and stronger community 

support (Liu, Ramowski, & Nystrom, 2010; Swider & Valukas, 2004). For example, a SBHC in 

Chicago developed a partnership with the school, local health department and local hospital, 

which led to more funding opportunities, services, and increased sustainability (Swider & 

Valukas, 2004). SBHCs that are not part of an integrated system of care may not have the 

resources needed to successfully meet standards for quality care measures for Medicaid and 

 

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Child Health Insurance Program (CHIP), facing more obstacles related to third party billing 

(Allison et al., 2007). However, inconsistent systems of coordination between schools and 

SBHCs have been documented for some SBHCs (Richardson, 2007). 

The sustainability of SBHCs is contingent upon funding from state, federal and local 

level grants, financial support from partner contributions and patient revenue, and community 

support and collaboration (Anyon et al., 2013; Hacker & Wessel, 1998; Armbruster, 2002; Rones 

& Hoagwood, 2000). State government entities, such as the Department of Education, carry out 

the greatest oversight of schools (Anyon et al., 2013). The most common funding sources have 

been previously reported from direct state funding, state general revenue and Title V of Social 

Security Act (Schlitt et al., 2008; Swider et al., 2004). Third party billing (e.g., to Medicaid or 

other private insurance) poses another obstacle for the implementation and sustained use of 

SBHCs. These billing codes are frequently denied by managed care networks (Silberberg & 

Cantor, 2008). Managed care organizations are reluctant to authorize mental health services 

provided through SBHCs because of perceived lack of quality of the mental health services 

(Armbruster, 2002). 

Furthermore, state level and national level policies directly impact the growth of SBHCs 

(Sprigg et al., 2017). For example, some states receive funding from the Patient Protection and 

Affordable Care Act (ACA), which then encourages the development of SBHCs by providing 

support to create and expand services through mandates or collaborations (Doll, Nastasi, Cornell, 

Song, 2017). State funding and resources enhanced through partnerships can increase the 

likelihood of a SBHC including mental health services (Larson et al., 2017). State policies can 

help SBHCs develop strategies to design frameworks that meet educational statues, which 

increases resources accessible to the center (Anyon et al., 2013). Policies with state level funding 

 

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for SBHCs may also reduce funding insecurity related to billing for the physical and mental 

healthcare services (Sprigg et al., 2017). Yet, comparisons between SBHCs with different outer 

contextual factors, particularly, funding and state policy support, are not well examined. 

School based health centers are complex systems that interact with surrounding variables. 

Because SBHCs function within distinct contexts, such as inner and outer settings, it is important 

to understand how these factors have influenced types of mental health services reported to be 

delivered over time. Research on SBHCs with a mental health component has not been examined 

through the lens of context. A contextualist approach offers an alternate perspective on 

previously noted study limitations. This approach examines variables (e.g., contexts) unique to 

each SBHC and views them as essential to the process of mental health service delivery over 

time. Given that structural characteristics, staffing, funding sources, policy, funding, 

partnerships, and provider availability can vary greatly among SBHCs with a mental health 

component, a contextualist approach can more closely examine how these contexts have shaped 

service delivery over time.  

Previous studies have not used CFIR to organize unique contextual factors relevant to 

SBHCs. Using CFIR as a framework for examining the inner and outer contexts of SBHCs can 

help identify barriers or facilitators to the developmental process of service provision 

(Damschroeder et al., 2009). Understanding contextual impacts can inform strategies for more 

effective SBHC designs and service delivery. As suggested by Silberberg and colleagues (2008), 

comparing SBHCs with a mental health component with one another can also help identify any 

likelihood of support (funding or policy) for a site with specific characteristics. In response to 

these suggestions, the current study aims to describe the number of mental health services 

reported to be delivered by SBHCs from 2005 to 2014. Moreover, this study aims to identify the 

 

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inner and outer setting variables of SBHCs from 2005 to 2014. Findings will emphasize the inner 

and outer contexts of SBHCs with a mental health component to focus more on differential 

impacts on mental health services reported to be delivered. Findings will also promote discussion 

on the role of state level support in mental health services delivered through SBHCs. 

 

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METHODS 

This thesis project explored the role of inner and outer contexts on the number of mental 

health services reported to be delivered within SBHCs across the U.S. The project involved 

secondary analyses of two longitudinal quantitative datasets, and utilized descriptive statistics 

and generalized mixed model approaches. The datasets used for the project were restricted to 

data that had already been collected through surveys administered from a third party, the School 

Based Health Alliance. Participating SBHCs for the current project needed to meet the following 

inclusion criteria: (1) located at a school or on school property; (2) include a mental health 

component in their model; and (3) provide enough data for analyses. All data analyses were 

conducted with SPSS 25. The study addressed the following research questions:  

RQ1. What is the number of mental health services reported to be delivered by state from 

2005 to 2014? 

For the purposes of the project, mental health was defined as “successful performance of 

mental functioning, resulting in productive activities, fulfilling relationships with other people, 

and the ability to adapt to change and cope with adversity” (Hill et al., 2012, p. 120). This 

complements the School-Based Health Alliance’s shared vision of promoting health for student 

success. “Mental health” incorporates treatment and activities designed to promote youth’s 

mental well-being. Mental health services will refer to screening and assessments, medication 

management, substance use treatment, and referrals. Descriptive analyses, specifically 

frequencies, were used to describe and summarize mental health services reported by state on the 

National Census of SBHC Survey from 2005 to 2014.  

Reported mental health services. Variables selected for mental health (MH) services 

reported by state included: (a) screening/assessment; (b) medication management; (c) substance 

 

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use treatment; and (d) referrals. These variables were selected because of their consistency 

throughout the four time points. Some adjustments were made to minimize the number of 

outcome variables and to adhere to consistency. For example, screening and assessment were 

originally two independent items reported in earlier assessments, but were combined in later 

assessments. To maximize consistency, these variables were combined to create 

“screening/assessment” across all time points. All other items that were not consistent across the 

time points were excluded from analyses. Examples of these include grief/loss therapy and 

classroom behavior management.  

Data cleaning & missing data. Missing values were handled as random missing cases, 

using substitutions to recode. Substitution was considered the best approach to have two clean 

categories for the discrete outcomes. Moreover, outcome variables were transformed to count 

variables to facilitate further analyses. Count variables accounted for the number of “yes” 

occurrences among centers within a state by each time point. For example, if three centers in GA 

were assessed in 2010 and only two reported “Yes” to referrals; then the count variable for 

referrals would be equal to 2. This was done for all other outcome variables by state and time 

point. This allowed the opportunity to treat outcome variables as continuous variables, 

facilitating the procedure for main analysis. 

RQ2. Which inner setting variables (structural characteristics and networks) are related to 

number of mental health services reported to be delivered from 2005 to 2014? 

The National Census of SBHC Survey was first explored using descriptive statistics. 

Results provided an overview of health center demographics, health center operations, health 

center care teams, school characterizations and health center partnerships from 2005 to 2014. 

Guided by the CFIR, constructs were then organized into inner setting variables (structural 

 

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characteristics; networks and communications) by state. Variables for the inner setting were 

selected because of consistency and sufficient data reported throughout the four administrations 

of the Census survey. The specific inner setting variables used to describe SBHC structural 

characteristics included: (1) health center demographics (geographic location, year of 

establishment, school enrollment number, grades served: elementary, middle, high school), (2) 

health center operations (number of days open weekly, hours open weekly), (3) health center 

care team (total hours worked for mental health service providers, location of behavioral health 

provider), and (4) school categorization (Title I, charter, alternative, vocational, magnet, and /or 

public school). The inner setting variable used to describe networks and communications was 

agency sponsor. Frequencies were run by time points to further explore the inner setting 

variables within the data set. Further, a linear mixed model analysis (LMM) was conducted to 

identify key variables within the inner settings of SBHCs that related to the number of mental 

health services reported over time.  

Data cleaning & missing data. Some surveys had inconsistencies in response choices 

for items. For example, geographic location coded response items differently in 2008 when 

compared to all the other assessments. To promote consistency, these variables were recoded, 

when necessary. Missing-data imputations (average of available values) was used to handle 

missing responses in the following variables: days open weekly, hours open weekly, and total 

mental health staff hours worked. Other missing values in agency sponsor and geographic 

location were changed to 999 for “IDK” to promote consistency and avoid deletion of a large 

number of cases. Corrections were also made to have appropriate values for a given response. 

For example, responses reported for the number of days/week should have a maximum value of 

seven. However, some sites reported numbers exceeding that. Therefore, for values greater than 

 

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seven, it was assumed that sites referred to days open in a year. These were then converted to 

days/a week based on 180 days within a school year.  

RQ3. Which outer setting variables (e.g., funding sources, policy and standards, oversight 

and support) are related to the number of mental health services reported from 2005 to 

2014? 

The SBHC Policy Survey was also first explored using descriptive statistics. Results provided an 

overview of funding sources, policy and standards, and oversight and support from 2005 to 2014 

by state. Guided by the CFIR, constructs were organized into multiple outer setting variables to 

inform the domain of external policy & incentives. Outer setting variables selected for the 

current study explored funding (i.e., presence/absence of a SBHC grant program, funding source, 

and state agencies reported as funding sources); oversight and support (i.e., technical assistance 

and presence/absence of SBHC data collection); and policy and standards (i.e., operating 

standards for SBHCs, and state requirements for data collection). LMM was also used to identify 

key variables within the outer settings of SBHCs that related to the number of mental health 

services reported over time.  

Data cleaning & missing data. Data cleaning was done to enhance accuracy of the 

dataset for further analyses and to ensure consistency across survey administration time points. 

When appropriate, missing data was replaced with a “0” to indicate absence of a variable. Other 

responses that could not justifiably be replaced with absence (“0”) were recoded as a missing 

value (“999”) for “no response” (NR). Cases that were missing more than 3 time points or a 

considerable amount of data were dropped from analyses. Variables that indicated multiple 

responses (“select all that apply” items), were recoded to binary data (e.g., “1= yes” or 2= no”).   

 

24 

 

 

Participants 

 

Providers. The National Census of SBHC Survey targeted populations aimed at site 

levels. Inclusion criteria for SBHC sites that participated in the Census Survey are reported as: 

partnerships between schools and community health organizations that deliver health care to 

students within a SBHC; health care programs that are linked with SBHCs (e.g., school-linked 

centers); programs delivering services without a fixed site (e.g., mobile); and programs 

delivering services through telehealth (tele-health only sites). At each time point, the survey 

requests that the person most knowledgeable about the services provided in the SBHC respond to 

all questions. Examples of these include nurse practitioner or clinical director. Morever,  

Policy makers. The SBHC Policy Survey’s inclusion criteria included: persons most 

knowledgeable about state level policies, funding, and programming related to SBHCs. 

Specifically, targeted policy maker participants were State agency staff in maternal, child, 

adolescent, and school health divisions and Medicaid agency members who were most 

knowledgeable of reimbursement policies (Schlitt et al., 2008). All surveys were mailed to an 

identified individual within the various departments.  

Measures  

National Census of SBHC Survey. The first National Census of SBHCs was collected 

in 1998. The survey is administered every 3 years. The Census provides up to date information 

on centers’ structural demographics, prevention activities, financing strategies, staffing, services, 

student demographics, clinical policies, and mechanisms for quality improvement. For National 

Census of SBHC Survey items, see Appendix A. Data from this survey was used to identify 

inner contexts of SBHCs, to the extent possible. The longitudinal dataset selected for this study 

examined responses collected from 2005 to 2014, which equals four survey administration time 

 

25 

 

points. Most survey items have remained the same since 2005, with little changes (Larson et al., 

2017). However, changes that have occurred include removal of several survey items, addition of 

new choice responses to survey questions, or rewording of items. An example of added items can 

refer to responses such as tele-health or mobile clinics that were not provided as response options 

in earlier administrations (e.g., 2005 or 2008) of the survey. Moreover, reworded items were 

compared to earlier administrations to determine whether they collected similar responses to 

previous years. Questions that were considerably missing or inconsistently reported throughout 

the four time points were not included in the analyses. That is, if an item was only asked in 2005, 

but not in the any other time-point, the researcher dropped the item for further analysis. 

SBHC State Policy Survey. In collaboration with the Robert Woodcock Johnson 

Foundation, the School Based Health Alliance created a State Policy Survey. The State Policy 

Survey was designed to collect information from State public health and Medicaid offices. The 

survey is administered every four years, with its first assessment completed in May 2005 (Schlitt 

et al., 2008). The survey explored the role of policy and state-level support on the development 

and sustainment of SBHCs. State-level support was operationalized as “allocation of funding 

directly to school health centers, having state agency staff dedicated to SBHC program, 

promulgating and monitoring program standards, providing technical assistance for school health 

center operations and evaluation, convening the statewide network, collecting and reporting 

program data and performance measures, and establishing reimbursement policies for Medicaid 

and SCHIP” (Schlitt et al., 2008; p. 733). The State Policy Survey was adapted from a survey 

conducted by the Center for Health and Healthcare in Schools, excluding collection of 

information regarding structural characteristics (e.g., staffing, school type). The first survey was 

mailed to all State public health departments and one Governor’s Office for Children, Youth, and 

 

26 

 

 

Families. To optimize the rigor of the survey, the following activities were carried out in 

subsequent survey administrations: identifying appropriate individuals to complete the survey 

(e.g., knowledgeable of SBHCs and reimbursement policies); implementing efforts for best 

response rates (e.g., mailing surveys to state health departments); inspecting survey content, data 

cleaning, and data recording once surveys were received back (Schlitt et al., 2008). Subsequent 

survey administrations continued to target participants who were most knowledgeable of state-

level policies, funding, and program support related to SBHCs. Survey items were consistent 

throughout the time points collecting information on: (1) number of SBHCs for the current 

administration’s school year, (2) source of state funding directed to SBHCs, (3) state criteria for 

funding distribution, (4) technical assistance, (5) performance data collected, (6) state 

perspectives on future outlook, and (7) Medicaid/SCHIP policies for reimbursement (Schlitt et 

al., 2008). For State Policy Survey items, refer to Appendix B. 

Procedures 

School Based Health Alliance (SBHA). The School Based Health Alliance is a non-

profit, multidisciplinary inter-organizational network that was founded in 1995. The Alliance, 

formerly known as the National Assembly on School-Based Health Care (Larson et al., 2017), 

serves to advocate SBHCs across the nation and increase access to children and adolescents in 

need of physical and mental health care. Twenty-one states have an affiliated status with the 

School Based Health Alliance. These partnerships share in the mission, vision and core values of 

the Alliance. The Alliance membership is diverse, comprised of school staff, health practitioners, 

researchers, physicians, professors and non-profit organization directors. In collaboration with a 

technical advisory committee comprised of researchers, the Alliance developed the National 

School Based Census Survey in 1998 to document, track, and disseminate information about 

 

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centers across the U.S. The survey collected a variety of information on structural demographics, 

services offered, clinical policies, staffing, student demographics, and strategies used to evaluate 

program quality assurance (Brindis et al., 2003). The School Based Health Alliance has surveyed 

centers throughout the U.S. from 1998 to 2017, every three years. The School Based Health 

Alliance has also surveyed stakeholders and policymakers on State level support for SBHCs with 

the State Policy Survey. 

Data collection procedures. To gain access to the datasets, the researcher contacted an 

Alliance member, as instructed on the School Health Alliance website. The Alliance member 

informed the researcher about the process of requesting and accessing the datasets, which 

included a brief telephone meeting and submission of a data request form. The telephone 

meeting occurred on May 31, 2017. The researcher provided the Alliance member with 

information regarding the thesis project’s goals and aims. After the meeting, the Alliance 

member emailed a data request form, which was prepared in collaboration with the researcher’s 

thesis advisor. The data request form was submitted on June 30, 2017. A research committee 

member from the SBHC Alliance contacted the researcher on August 8, 2017 with clarifying 

questions regarding the project design and purpose of using multiple survey time points within 

the data. The researcher addressed clarifying questions and was asked to revise and resubmit the 

data request form with the updated details. Once the revised data request form was submitted, the 

committee member confirmed receipt and prepared the datasets to send through email. Complete 

datasets were received on September 18, 2017.  

Data Analysis 

Exploratory data analysis. The National Census of SBHCs Survey and State Policy 

Survey are two independent longitudinal datasets. The National Census Survey dataset has 

 

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repeated measures that have been collected at 4 time points, each representing an academic year: 

2004-2005, 2007-2008, 2010-2011 and 2013-2014. Data was collected on reported mental health 

services delivered, structural characteristics, and networks. Additionally, the State Policy Survey 

dataset has repeated measures that have been collected at 4 time points, 2004-2005, 2008-2009, 

2010-2011 and 2013-2014, on outcomes related to state level support (e.g., funding sources, 

policy and standards, oversight and support). To better understand these datasets, descriptive 

analyses were conducted to explore mental health services, structural characteristics, networks 

and partnerships, and state level support within each SBHC at the state level. Multiple 

descriptive analyses were conducted for the Survey Subscales. Specifically, the National Census 

Survey - Services subscale was analyzed to describe the number of behavioral services reported 

to be delivered within each state over the four time points. The National Census Survey - 

Structural characteristics subscale was analyzed to describe health center demographics, health 

center operations, health center care team, and school characterization over the four time points. 

The National Census Survey- Network communications subscale was analyzed to describe health 

center partnerships over the four time points. The State Policy Survey - Funding sources subscale 

was explored to describe the source of state funding directly dedicated to SBHCs over the four 

time points. The State Policy Survey - Policy and standards subscale was analyzed to describe 

states’ criteria for operating standards and requirements for data collection defined by the states 

over the four time points. The State Policy Survey - Oversight and support subscale was 

analyzed to describe technical assistance provided and designation of data collection units over 

the four time points. Results from both the National Census Survey and State Policy Survey were 

aggregated at the state level.  

 

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Linear mixed model (LMM) analysis. A linear mixed model (LMM) approach fit by 

restricted maximum likelihood estimation (REML) was used to assess the significance of inner 

setting and outer setting variables in explaining variations of mental health services reported to 

be delivered over time. LMM is an extension of linear models that can add random effects to 

fixed effects models and account for variance within repeated measures that are grouped or 

collected from the same subject (IDRE, 2017; Mcculloch, & Neuhaus, 2013; Zhang et al., 2011; 

Zuur, Ieno, Walker, Saveliev, & Smith, 2009). The longitudinal data included in the current 

study had inter-dependent observations that did not allow for regression techniques. Therefore, 

the adjusted relationship between inner setting variables and mental health services were 

analyzed using linear mixed effects model in SPSS 25. 

For the current study, the dependent variables for mental health services included: 

screening and assessment, medication management, substance use treatment, and referrals. To 

facilitate LMM analysis, these binary variables (yes/no responses) were transformed to count 

variables, quantifying the number of “yes” occurrences within each state. The predictor variables 

included components of the survey that were theorized as inner and outer setting factors based on 

the CFIR, which were mostly categorical variables. All inner setting variables and outer setting 

variables selected for the current study were fixed factors. “Time” was evaluated as a random 

effect and then as a fixed effect to assess variance.  

Independent LMM analyses were carried out for each of the dependent variables (DVs). 

Further, inner setting and outer setting variables were assessed independently within each DV. 

Four different models were created and independently run for each DV in the following order: 

(1) intercept-only model; (2) random intercept and slope for time; (3) unadjusted fixed effects 

model; and (4) adjusted model. First, the researcher fit the model to each dependent variable 

 

30 

 

 

without allowing any predictor variables. This intercept-only model demonstrated the variation 

of each mental health service between states (Winter, 2013). Second, the researcher tested 

whether each mental health service significantly varied with time (e.g., random intercept model). 

The random intercept model assessed the total variation of services accounted for by time 

(Winter, 2013). Third, the researcher assessed the relationship between each independent 

variable and dependent variable without adjusting for any other variable in the model. The 

unadjusted fixed effects model, which is similar to bivariate analysis, assessed the relationship 

between each independent variable and dependent variable, without any interactions of other 

variables (Winter, 2013). Last, the researcher added all independent variables to the model to 

assess the relationship between each variable after adjusting for other variables (e.g., interaction 

term). This adjusted model helps us understand the relationship between each inner setting or 

outer setting variables on mental health services, given the interactions of other predictor 

variables within the same model (Winter, 2013). Time was run in the LMM model as random 

effects, but was also run as fixed effects to assess variance. All other models controlled for time 

as a covariate. Overall, all models assessed mental health services, inner setting, outer setting, 

and time effects. Results from the adjusted fixed effects model were expected to provide the 

most robust results and were used to report findings (Winter, 2013). 

The REML method was preferred over maximum likelihood (ML) method because 

REML helps correct for degrees of freedom resulting from estimating fixed effects (Zhang, 

2011). While both models produce the same estimates for fixed effects, the models differ for 

random effects (Kenward & Roger, 1997). Given that the conditions of the datasets are 

disproportionately clustered and missing repeated measures at each time point, REML was 

considered the best approach to compare random effects from the variable “Time.” Fixed effects 

 

31 

 

 

model was selected because it is the most commonly used strategy for LMM, unless a theory 

driving the study explicitly specifies for a random effects model instead (Mcculloch, & Neuhaus, 

2013; Zhang et al., 2011). 

The variables used for analyses were mostly categorical from multiple time points and 

from several sites within 41 states in the U.S. Moreover, the data had clustered observations 

(e.g., multiple observations) from the same SBHCs over time. The nature of the datasets violates 

assumptions of normality needed for a linear model approach. However, LMM allows for 

assessment of non-independent data with fixed and random effects (Zhang et al., 2011; Zurr et 

al., 2009). Given the longitudinal context of the data, LMM was needed to account for the 

random effects from the four time points administered with each survey (Zurr et al., 2009). LMM 

is considered one of the best approaches for assessing inter-dependent sources (e.g., repeated 

measures within subjects; Mcculloch, & Neuhaus, 2013; PennState, 2017; Winter, 2013; Zhang 

et al., 2011; Zurr et al., 2009).  

 

 

 

32 

 

 

RESULTS 

The final sample size used for the current study was 4,232 and represented 41 of the 50 U.S. 

states. Seven states were excluded because of a significant amount of missing responses or 

inconsistencies in responses for the four time points: Idaho, Kansas, Montana, Utah, Virginia, 

Wisconsin, and Wyoming. Two states were excluded because they did not report any SBHCs in 

operation from 2005-2015: Hawaii and North Dakota. The total number of eligible sites for each 

time point ranged from 913 to 1,244. Table 2 presents the final sample size collected from the 

SBHC Census Survey and the SBHC Policy Survey. 

Table 2: Sample Sizes Across Time-Points 
SBHC Census Survey 

SBHC Policy Survey 

Time 
Point 

Total 
SBHCs 
Assessed 

Total 
SBHCs 
Eligible 

Total 
States 

Assessed 

Total 
States 
Eligible 

States 

States 

Excluded 

Excluded 

(No 

(No 

SBHCs) 

consistency) 

2004-
2005 
2007-
2008 
2010-
2011 
2013-
2014 

1,227 

1,156 

1,225 

919 

1,381 

913 

1,627 

1,244 

49 

49 

52 

18 

37 

36 

41 

17 

7 

11 

7 

- 

5 

2 

4 

1 

Descriptive analyses 

Screening & assessment services. Overall, the percentage of sites that reported 

delivering screening and assessment services varied by state and time point. More than half of 

participating and eligible states had 55% or greater of the sites reporting availability of screening 

and assessment services throughout the four time points. Moreover, there was a significant 

increase in the percentage of sites delivering this service over time (T2 and T4). Table 3 presents 

the percentage of sites that reported delivery of screening and assessment services within each 

state at T1, T2, T3, and T4.

 

33 

 

Table 3: Screening & Assessment Services 

Time 
Point 

T1 

T2 

T3 

T4 

Percentage of 

States 

Sites 
100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

Less than 50% 
None reported 

100% 

90-99% 
80-89% 
70-79% 
60-69% 

None reported 

100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

Less than 50% 
None reported 

100% 
90-99% 
80-89% 
70-79% 
6-69% 
50-59% 

Less than 50% 
None reported 

(Number) 

9 
7 
7 
6 
1 
1 
6 
4 

30 

5 
1 
0 
1 
3 
10 
11 
2 
2 
4 
1 
3 
7 
11 
10 
10 
3 
1 
2 
3 
1 

States 
(%) 
22% 
17% 
17% 
15% 
2% 
2% 
15% 
10% 

States 

DC, DE, GA, IN, MO, PR, TN, VT, WA 

CO, LA, MA, ME, NM, NY, OR 

CT, CA, FL, IA, MN, OH, TX 

KY, IL, MD, MI, NC, WV 

NJ 
SC 

AL, MS, SD, PA, RI, OK 

AK, NE, NH, NV 

AK, AL, CO, DC, DE, GA, IA, KY, LA, MA, MD, ME, 

73% 

MN, MO, MS, NC, NE, NH, NJ, NM, NY, OH, PA, PR, SC, 

12% 
2% 
0% 
2% 
7% 
24% 
27% 
5% 
5% 
10% 
2% 
7% 
17% 
27% 
24% 
24% 
7% 
2% 
5% 
7% 
2% 

TN, TX, VT, WA, WV 

FL, IL, CA, OR, CT 

MI 
- 
IN 

OK, NV, RI 

AL, CO, GA, IA, MN, PA, PR, RI, SC, WA 

FL, CA, CT, IL, LA, ME, MI, NC, NM, NY, OR 

DE, MD 
OK, WV 

KY, MA, TN, SD 

OH 

DC, NJ, TX 

AK, MO, MS, NE, NH, NV, VT 

AK, AL, DC, DE, IN, ME, MN, OK, PA, RI, SD 

CT, IL, LA, MA, MD, NC, NM, OR, TN, TX 
CA, CO, GA, IA, KY, MI, NY, NE, SC, WA 

NV, OH, WV 

FL 

MO, VT 

MS, NH, NJ 

PR 

Medication management services. Overall, there was an equal distribution between the 

percentage of sites that reported delivery of medication management services and those that did 

not, with the exception of sites responding at T3. Moreover, there was a significant increase in 

the number of participating states that reported all sites delivering services over time. 

Interestingly, all sites in New Hampshire (NH) did not report the availability of medication 

management services at any time (see Table 4).

 

34 

 

 

Table 4: Medication Management Services 

Time 
Point 

T1 

T2 

T3 

T4 

Percentage of 

States 

Sites 

100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

(Number) 

4 
0 
0 
5 
4 
5 

Less than 50% 

17 

None reported 

100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

Less than 50% 
None reported 

100% 

90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

Less than 50% 
None reported 

100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

Less than 50% 
None reported 

5 
8 
1 
6 
6 
5 
7 
2 
6 

23 

6 
3 
2 
1 
1 
2 
3 
5 
1 
6 
7 
2 
7 
8 
5 

States 
(%) 

10% 
0% 
0% 
12% 
10% 
12% 

41% 

12% 
20% 
2% 
15% 
15% 
12% 
17% 
5% 
15% 

56% 

15% 
7% 
5% 
2% 
2% 
5% 
7% 
12% 
2% 
15% 
17% 
5% 
17% 
20% 
12% 

States 

GA, PR, VT, WA 

- 
- 

CO, ME, NM, NY, TN 

CT, IA, KY, OR 

DC, MN, MO, OH, TX 

AL, CA, DE, FL, IL, IN, LA, MA, MD, MI, MS, NC, 

OK, PA, RI, SD, WV 
AK, NE, NH, NV, SC 

GA, MO, MS, NJ, PA, SC, SD, VT 

WA 

CO, KY, NM, TN, TX, WV 

CT, DE, FL, IA, MA, OR 

IL, LA, MD, MN, NC 

AK, AL, CA, DC, ME, MI, NY 

IN, OH 

NE, NH, NV, OK, PR, RI 

AK, AL, CO, DE, GA, IA, KY, MA, MD, MI, MN, MS, 

NC, NE, NY, OR, PA, PR, RI, SC, SD, VT, WA 

NM, ME, LA, CT, IL, CA 

FL, IN, WV 

OH, OK 

TN 
TX 

DC, NJ 

MO, NH, NV 

AL, MN, NE, OK, SD 

OR 

CO, IL, MA, SC, TN, TX 

LA, ME, NC, NY, PA, WA, WV 

KY, MI 

CT, GA, IA, MO, NV, RI, VT 

CA, FL, IN, MD, MS, NJ, NM, OH 

AK, DC, DE, NH, PR 

Substance use treatment services. Over half of the eligible states had more than 50% of 

sites reporting delivery of substance use treatment services, with the exception of sites 

responding at T4. Moreover, there was a significant decrease in the number of participating 

states that reported 100% of sites delivering services over time. Also, sites in New Hampshire 

(NH) did not report delivery of substance use treatment services at any time (see Table 5).  

 

35 

 

Table 5: Substance Use Treatment Services 

Time 
Point 

T1 

T2 

T3 

T4 

Percentage of 

Number of 

Sites 
100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

Less than 50% 
None reported 

100% 

90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

Less than 50% 
None reported 

100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

Less than 50% 
None reported 

100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 

States 

5 
3 
7 
7 
4 
5 
5 
5 

19 

9 
4 
1 
0 
2 
1 
4 
6 
1 
6 
1 
7 
4 
8 
8 
1 
0 
0 
2 
4 
2 

Less than 50% 

None reported 

17 

15 

States 
(%) 
12% 
7% 
17% 
17% 
10% 
12% 
12% 
12% 

46% 

22% 
10% 
2% 
0% 
5% 
2% 
10% 
15% 
2% 
15% 
2% 
17% 
10% 
20% 
20% 
2% 
0% 
0% 
5% 
10% 
5% 

41% 

37% 

States 

GA, MO, PR, VT, WA 

DE, IN, NM 

CO, LA, MA, ME, MN, NY, OR 

CT, DC, FL, IL MI, TX, WV 

CA, IA, NJ, OH 

KY, MD, NC, SC, TN 
AL, MS, OK, PA, RI, 
AK, NE, NH, NV, SD 

AL, AK, CO, DE, GA, KY, ME, MN, MO, MS, NE, 

NJ, OR, PA, PR, SD, VT, WA, WV 

FL, CT, IL, LA, MA, MD, MI, NM, TX 

CA, IA, NC, NY, OH 

IN 
- 

DC, SC 

TN 

NH, NV, OK, RI 

AK, AL, KY, MS, PR, SC 

NM 

DE, IA, IN, ME, MD, NC 

NY 

CA, FL, GA, IL, MA, PA, SD 

MI, MN, WA, WV 

CO, CT, LA, NJ, OH, OR, TN, TX 
DC, MO, NE, NH, NV, OK, RI, VT 

DC 

- 
- 

MN, TX 

ME, MI, NM, SC 

CO, MO 

CA, CT, DE, FL, IA, IL, IN, LA, MA, MD, NC, NY, 

OH, OR, PA, WA, WV 

AK, AL, GA, KY, MS, NE, NH, NJ, NV, OK, PR, RI, 

SD, TN, VT 

 

Referral services. There was significant variation among sites reporting delivery of 

referral services by state and over time. For example, 29 states reported that all of their sites 

delivered referral services at T2; however, no states reported that all sites delivered referral 

services at the next assessment time point (see Table 6). 

 

36 

 

 

 

T1 

T2 

T3 

T4 

 

 

of Sites 
100% 
90-99% 
80-89% 

70-79% 

60-69% 
50-59% 
Less than 

50% 
None 

reported 

7 
6 
7 

9 

1 
1 

6 

4 

100% 

29 

93-99% 

67% 
None 

reported 

100% 
90-99% 
80-89% 
70-79% 
60-69% 
50-59% 
Less than 

50% 

None 

reported 

100% 
90-99% 
80-89% 

70-79% 

60-69% 
50-59% 
Less than 

50% 
None 

reported 

 

8 
1 

3 

0 
6 
3 
2 
1 
1 

12 

30 

7 
1 
3 

11 

4 
3 

8 

3 

Table 6: Referral Services 
Time 
Point 

Percentage 

(Number) 

States 

States (%) 

States 

DE, GA, MO, PR, TN, VT, WA 

LA, MA, ME, NM, NY, TX 

CA, CO, FL, MI, MN, OH, OR 

AL, CT, DC, IL, IA, KY, MD, NC, 

WV 
NJ 
SC 

IN, MS, OK, PA, RI, SD 

AK, NE, NH, NV 

AK, AL, CO, DC, DE, GA, IA, KY, LA, 
MA, ME, MD, MN, MO, MS, NE, NH, 
NJ, NM, NY, OH, PA, PR, SC, SD, TN, 

VT, WA, WV 

CA, CT, FL, IL, MI, NC, OR, TX 

IN 

NV, OK, RI 

 

CA, CT, IL, LA, ME, NM 

FL, IN, WV 

OH, OK 

TN 
TX 

CA, CO, DC, FL, IL, LA, MI, NM, 

NY, TX, WA, WV 

AK, AL, CO, CT, DE, GA, IA, IN, 
KY, MA, MD, ME, MN, MO, MS, 
NC, NE, NH, NJ, NV, OH, OK, OR, 

PA, PR, RI, SC, SD, TN, VT 
AK, AL, DC, MN, OK, RI, SD 

OR 

LA, WV, MD, 

CT, DE, FL, KY, IL, ME, MI, NV, 

NY, PA, TX 

CA, MA, NC, NM 

GA, MO, OH 

IA, IN, MS, NH, NJ, SC, TN, WA 

NE, PR, VT 

17% 
15% 
17% 

22% 

2% 
2% 

15% 

10% 

71% 

20% 
2% 

7% 

0% 
15% 
7% 
5% 
2% 
2% 

29% 

73% 

17% 
2% 
7% 

27% 

10% 
7% 

20% 

7% 

37 

 

Inner Setting Variables 

The National Census Survey – Structural Characteristics subscale. The Structural 

Characteristics subscale was explored to describe the maturity, size and social architecture of 

health centers. Maturity of health centers is represented by the site’s length of establishment. The 

size of health centers is represented by school enrollment and health center care team. Moreover, 

“health center care team” provided the location of a behavioral health provider at each site and a 

summary of total hours reported for all mental health staff affiliated with the SBHC. The social 

architecture of health centers is informed by each site’s geographic location, grade levels served, 

health center operations, and school characterization. School characterization determined the 

type of schools working with the SBHCs. These included the following categories: (1) Title I; (2) 

Charter school; (3) Alternative school; (4) Vocational school; (5) Magnet school; and/or (6) 

Public school. It is important to note that responses collected for school characterization were not 

mutually exclusive and often overlapped with one another across all four time points. That is, a 

site was able to report multiple responses for school  characterization, such as "Title I" and 

"Public School" or "Magnet school" and "Vocational school." However, at T4, 0% of sites 

reported multiple responses for school characterization, with the exception of public school and 

Title I (5%). Figure 1 depicts the number of "yes" occurrences for school characterization by 

each time point. Table 7 presents a summary of frequencies for structural characteristics by time 

point. 

 

38 

 

 

Table 7: Summary of Structural Characteristics by Time Point 
 
Health Center Demographics 
Geographic Location 

T3 

T1 

T2 

Rural 
Suburban 
Urban 

Year of Establishment 

Prior to 1989 
1990 – 1994 
1995 – 1999 
2000 – 2004 
2005 – 2009 
After 2010 

Grade Levels Serviced 
Pre-K to 5th grade 
6th to 8th grade 
9th to 12th grade 

School Enrollment 

1 – 699 
700 – 1999 
2000+ 

 
27% 
15% 
58% 
 
11% 
19% 
31% 
28% 
4% 
  - 
 
49% 
54% 
48% 
 
34% 
50% 
8% 

 
15% 
60% 
25% 
 
10% 
14% 
23% 
20% 
28% 
  - 
 
39% 
46% 
60% 
 
45% 
46% 
9% 

 
27% 
19% 
54% 
 
9% 
13% 
25% 
18% 
25% 
10% 
 
41% 
51% 
61% 
 
41% 
51% 
8% 

Health Center Care Team 
Behavioral Health Providers 
Located off school site 
In school but separate from SBHC 
In school and co-located in SBHC 

Total MH Staff Hours 

Less than 40 
Greater than 40 
SBHC Operations 
Days Open, Weekly 

Less than 5  
Greater than 5  

Hours Open, Weekly 

Less than 9  
9 to 30 
Greater than 30 

School Characterization 

Title I 
Charter 
Alternative 
Vocational 
Magnet 
Public 

 
1% 
68% 
14% 
 
88% 
12% 

 
16% 
84% 
 
16% 
20% 
64% 
 
40% 
2% 
6% 
3% 
5% 
60% 

 
18% 
58% 
17% 
 
85% 
15% 

 
15% 
85% 
 
10% 
15% 
75% 
 
27% 
2% 
6% 
3% 
6% 
67% 

 
32% 
51% 
15% 
 
78% 
22% 

 
17% 
83% 
 
11% 
18% 
71% 
 
68% 
5% 
7% 
6% 
9% 
84% 

T4 

 
19% 
49% 
32% 
 
12% 
10% 
18% 
15% 
24% 
21% 
 
49% 
53% 
59% 
 
44% 
45% 
11% 

 
10% 
49% 
18% 
 
85% 
15% 

 
20% 
80% 
 
5% 
18% 
76% 
 
78% 
2% 
6% 
6% 
9% 
68% 

 

The National Census Survey – Network Communications subscale. The Network 

Communications subscale was explored in order to describe the nature of formal and informal 

communications within SBHCs. The subscale included health center partnerships reported as 

 

39 

 

primary sponsors over time. Types of agencies included local departments of health, community 

health centers, school systems, hospital/medical centers, mental health agencies, universities, 

private/non-profit organizations, tribal government systems, and federally qualified health 

centers. Community health centers and hospital/medical centers were most frequently reported as 

primary SBHC sponsors from T1 to T3. At T4, hospital/medical centers and school systems were 

most frequently reported as primary sponsors. Table 8 provides a summary of the most 

frequently reported health center partnerships by the percentage of sites at each time-point. 

Table 8: Percent of Sites’ Reported Health Center Partnerships by Time 

Agency Sponsor 

Local Department of Health 

Community Health System 

School System 

Hospital/Medical Center 

Mental Health Agency 

University 

T1 

18% 

22% 

15% 

28% 

1% 

4% 

T2 

17% 

28% 

13% 

24% 

1% 

3% 

Private, non-profit Organization 

12% 

11% 

T3 

13% 

30% 
13% 

T4 

8% 

0% 

15% 

29% 

18% 

2% 

4% 

7% 

5% 

3% 

8% 

 

Outer Setting Variables 

The State Policy Survey - Funding Sources subscale. The Funding Sources subscale 

explored state funding directly dedicated to SBHCs over the four time points. The subscale 

included the following variables: (1) presence/absence of a state government funding or 

sponsoring a grant program dedicated to SBHCs; (2) grant program funding sources (e.g., Title 

V MCH, State general fund; Tobacco Settlement); and (3) state agency responsible for allocation 

of grants or funds to state’s SBHC program. Frequencies showed that more than 70% of states 

had a grant program dedicated specifically to SBHCs from 2005-2014. Funding sources were 

primarily from state general funds. Moreover, public health agencies were the most frequently  

reported agencies responsible for allocation of funds, see Table 9.   

 

40 

 

 

Table 9: Summary of External Policy & Incentives by Percentage of Sites 
(N) and Time 
 
Funding Sources Subscale 
SBHC Grant Program 

T1 

T2 

T3 

T4 

Grant Program dedicated to SBHCs 
No program available 
 

Grant Program Funding Source 

Title V MCH Block 
Tobacco Settlement 
State General Fund 
 

State Agency 

Public Health Only 
Human Services Only 
Public Health & Education 
Public Health & Human Services 
None 

Oversight & Support Subscale 
Technical Assistance 

Unit provides TA to SBHCs 
Does not provide TA 

SBHC Data 

State collects data 
State does not collect data 
Policy & Standards Subscale 

Operating Standards 
Yes, for state funded SBHCs only  
Yes, for all SBHCs regardless of funding 
source 
No operating standards 

State Requirements for Data Collection 
Mandatory for state funded SBHCs 
Mandatory for all SBHCs regardless of 
funding source 
Mandatory for state funded SBHCs and 
Voluntary for SBHCs not funded by state 

 
81% 
17% 
 
 
44% 
13% 
66% 
 
 
54% 
5% 
5% 
2% 
28% 

 
62% 
39% 
 
 
27% 
4% 
59% 
 
 
53% 
0% 
7% 
0% 
41% 

 
72% 
26% 
 
 
38% 
23% 
65% 
 
 
61% 
10% 
4% 
3% 
22% 

 
84% 
15% 
 
 
31% 
11% 
61% 
 
 
74% 
4% 
6% 
0% 
16% 

 
69% 
29% 
 
 
80% 
4% 

 
48% 
23% 
 
2% 
 
60% 
17% 
 
0% 

 
80% 
19% 
 
 
71% 
9% 

 
49% 
31% 
 
18% 
 
34% 
12% 
 
25% 

 
63% 
26% 
 
 
72% 
13% 

 
46% 
7% 
 
29% 
 
49% 
13% 
 
12% 

 
60% 
2% 
 
 
62% 
39% 

 
40% 
19% 
 
1% 
 
40% 
3% 
 
15% 

 

The State Policy Survey - Oversight and Support subscale. The Oversight and 

Support subscale explored external strategies in recommendations, guidelines, and public 

reporting provided to program office and staff to administer SBHCs. The subscale included the 

following variables: (1) absence/presence of a state program responsible for providing technical 

assistance to communities interested in developing and/or operating existing SBHCs; and (2) 

presence/absence of state government collecting data from SBHCs. Overall, more than 60% of 

 

41 

 

states reported a program responsible for providing technical assistance consistently from 2005-

2014. Further, more than half of states reported that their government collected data from SBHCs 

for performance measures throughout the time points (Table 9).   

The State Policy Survey - Policy and Standards subscale. The Policy and Standards 

subscale explored external mandates and governmental regulations that facilitate standards 

needed for SBHC programs. The subscale included the following variables: (1) state 

requirements for SBHC operating standards and (2) state requirements for data collection across 

the four time points. State requirements for SBHC operating standards included, “Yes, for state 

funded SBHCs only” and “Yes, for all SBHCs regardless of funding source.” Operating 

standards for SBHCs funded by the state was the most frequently reported from 2005-2014. State 

requirements for data collection were, “Mandatory for SBHCs funded by state,” “Mandatory for 

SBHCs funded and not funded by state,” and “Mandatory for SBHCs funded by state and 

voluntary for SBHCs not funded by state.” State requirements that were mandatory only for 

SBHCs funded by state were most frequently reported from 2005-2014 (Table 9). 

LMM Analyses: Inner Setting Variables & MH Services 

Screening & assessment services. Results from the intercept-only model showed that 

there was significant variation of services accounted for by state (F = 27.740, df = 40.302, p < 

.000). Results from the intercept-slope model showed that time also significantly accounted for 

variation of services (F = 71.896, df = 3, p < .000), with screening/assessment services 

significantly increasing from 2005 to 2014. To minimize confounding variables, time was 

controlled in the adjusted fixed effects model. Results from the adjusted model showed that 

geographic location, year of establishment, school enrollment, location of behavioral health 

 

42 

 

 

provider, hours open weekly, and agency sponsor were significantly associated with more 

screening/assessment services, when controlled for time (Table 10).

 

Table 10: LMM: Type III Test of Fixed Effects for Inner Setting Variables on Screening/Assessment Services, 
Controlled for Time 

Source 

Intercept 

Geographic Location 

Year Established 

School Enrollment 

Elementary School 

Middle School 

High School 

Days Open Weekly 

Hours Open Weekly 

Total MH Hours 

Behavioral Health Provider 

Title I 

Charter School 

Alternative School 

Category Vocational 

Category Magnet 

Public School 

Agency Sponsor 

Time 

 

Type III Tests of Fixed Effects 

Numerator df 

Denominator df 

1 

2 

5 

2 

1 

1 

1 

1 

2 

1 

3 

1 

1 

1 

1 

1 

1 

9 

3 

43.720 

3422.163 

3422.116 

3422.272 

3422.683 

3422.324 

3422.549 

3423.384 

3422.388 

3421.446 

3422.346 

3421.599 

3421.249 

3421.718 

3423.814 

3422.567 

3421.525 

3423.186 

3421.279 

F 

26.862 

11.590 

5.556 

9.682 

2.369 

1.241 

1.150 

1.607 

9.457 

.843 

4.110 

.013 

.186 

1.625 

.793 

6.670 

.241 

2.908 

202.103 

Sig. 

.000 

.000 

.000 

.000 

.124 

.265 

.284 

.205 

.000 

.359 

.006 

.911 

.666 

.202 

.373 

.010 

.624 

.002 

.000 

More specifically, sites in rural locations, with more recent year of establishment (i.e., 

2010+), school enrollment of 0-699 students, 31 or more hours open weekly, a behavioral health 

provider co-located within the center, school characterization reported as magnet school, and 

sponsorship with a mental health agency reported a significantly higher number of 

screening/assessment services than sites that did not report these factors from 2005 to 2014 

(Table 11).  

 

43 

 

 

Table 11: Estimated Marginal Means for Screening/Assessment by Inner Setting 
Variables 

Estimated Marginal Means 

 

Mean 

SE 

df 

95% 

Confidence 

Interval 

Lower  
Bound 

Upper  
Bound 

Geographic Location 
Rural 
Suburban 
Urban 
Year of Establishment 
1989-below 
1990-1994 
1995-1999 
2000-2004 
2005-2009 
2010+ 
School Enrollment 
0-699 
700-1999 
2000+ 
Behavioral Health Provider 
Not in school 
In school, but separate from center 

25.032  4.576  44.241  15.810  34.253 
22.812  4.569  43.959  13.604  32.020 
23.099  4.566  43.855  13.896  32.303 

 

 

 

 

 

23.069  4.595  44.990  13.813  32.324 
22.237  4.582  44.472  13.005  31.469 
23.142  4.570  44.012  13.931  32.353 
22.918  4.570  44.007  13.708  32.129 
24.357  4.576  44.233  15.136  33.578 
26.164  4.609  45.541  16.883  35.445 

24.586  4.561  43.658  15.391  33.780 
24.492  4.565  43.818  15.290  33.693 
21.866  4.597  45.048  12.607  31.125 

24.073  4.583  44.489  14.840  33.305 
23.718  4.563  43.721  14.521  32.915 

In school and co-locate within center 

24.625  4.576  44.221  15.405  33.846 

Hours Open Weekly 
8 or less hours 
9 to 30 hours 
31 or more hours 
Magnet School 
No 

22.306  4.585  44.586  13.069  31.543 
23.820  4.574  44.164  14.602  33.038 
24.817  4.568  43.920  15.610  34.023 

22.746  4.551  43.258  13.571  31.922 

Yes 
Agency Sponsor 
Local Department of Health 
Community Health System 
School System 
Hospital/Medical Center 
Mental Health Agency 
University 
Private, non-profit Organization 
a. Dependent Variable: ScreeningAssessment_cgt. 

24.549  4.601  45.219  15.283  33.816 

24.175  4.571  44.030  14.963  33.386 
23.676  4.559  43.595  14.485  32.867 
24.264  4.576  44.241  15.042  33.485 
24.215  4.557  43.514  15.027  33.402 
27.639  4.714  49.827  18.169  37.109 
21.914  4.640  46.739  12.579  31.249 
22.641  4.577  44.277  13.418  31.864 

 

 

Medication management services. Results from the first model showed that there was 

significant variation of services accounted for by state (F = 26.231, df = 40.227, p < .000). 

Results from the second model showed that time also significantly accounted for variation of 

services (F = 107.275, df = 3, p < .000), with medication management services increasing from 

 

44 

 

2005 to 2014. Similar to the previous outcome variable, time was controlled in the adjusted fixed 

effects model. Results from the adjusted model demonstrated that geographic location, year of 

establishment, school enrollment, grade level, location of behavioral health provider, hours open 

weekly, school characterization, and agency sponsor was significantly associated with more 

medication management services over time (Table 12).  

 

Table 12: LMM: Type III Test of Fixed Effects for Inner Setting Variables on 
Medication Management Services, Controlled for Time 

Type III Tests of Fixed Effects 

Source 

Numerator df 

Denominator df 

F 

51.138 

3425.851 

3425.746 

3426.093 

3427.139 

3426.221 

3426.854 

3428.905 

26.005 

6.689 

14.246 

3.629 

15.000 

.000 

1.009 

.267 

Sig. 

.000 

.001 

.000 

.027 

.000 

.986 

.315 

.606 

3426.170 

13.080 

.000 

3424.029 

3426.350 

1.099 

13.317 

3424.455 

3423.393 

3424.640 

3429.892 

3426.764 

3424.169 

3428.379 

3423.466 

.000 

2.845 

.047 

1.734 

.177 

4.784 

2.378 

285.980 

.294 

.000 

.989 

.092 

.829 

.188 

.674 

.029 

.011 

.000 

45 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intercept 

Geographic 

Location 

Year Established 

School Enrollment 

Elementary School 

Middle School 

High School 

Days Open 

Weekly 

Hours Open 

Weekly 

Total MH Hours 

Behavioral Health 

Provider 

Title I 

Charter School 

Alternative School 

Category 

Vocational 

Category Magnet 

Public School 

Agency Sponsor 

Time 

1 

2 

5 

2 

1 

1 

1 

1 

2 

1 

3 

1 

1 

1 

1 

1 

1 

9 

3 

 

More specifically, sites reported in urban locations, with year of establishment from 

2005-2009, school enrollment of 700-1999 students, serving elementary schools, 31 or more 

hours open weekly, no behavioral health provider in school, school characterization not reported 

as public school, and agency sponsorship with hospital/medical center reported a significantly 

higher number of medication management services than sites with other contexts from 2005 to 

2014 (Table 13). 

Table 13: Estimated Marginal Means for Medication Management by Inner Setting Variables 

Marginal Means Estimates 

 

Geographic Location 

Rural 

Suburban 

Urban 

Year of Establishment 

1989-below 
1990-1994 
1995-1999 
2000-2004 
2005-2009 

2010+ 

School Enrollment 

0-699 

700-1999 

2000+ 

Elementary School 

No 
Yes 

Behavioral Health Provider 

Not in school 

In school, but separate from center 
In school and co-locate within center 

Hours Open Weekly 

8 or less hours 
9 to 30 hours 

31 or more hours 

Public School 

No 
Yes 

Agency Sponsor 

Local Department of Health 
Community Health System 

School System 

Hospital/Medical Center 
Mental Health Agency 

University 

Private, non-profit Organization 

Mean 

 

SE 

 

16.266  3.366 
16.882 
18.104 

3.362 
3.357 

 

 

17.250  3.414 
14.318 
15.636 
16.956 
19.974 
18.370 

3.388 
3.365 
3.365 
3.376 
3.441 

 

16.874 
17.908 
16.470 

 

16.174 
17.994 

 

19.379 
17.340 
17.725 

 

15.017 
17.635 
18.599 

 

17.609 
16.559 

 

17.442 
18.132 
16.352 
19.190 
15.218 
19.002 
18.194 

 

3.347 
3.355 
3.417 

 

3.358 
3.358 

 

3.389 
3.350 
3.376 

 

3.394 
3.373 
3.360 

 

3.340 
3.377 

 

3.366 
3.344 
3.377 
3.339 
3.640 
3.499 
3.378 

df 
 

52.768 
51.886 
51.565 

 

55.139 
53.503 
52.047 
52.042 
52.740 
56.921 

 

50.949 
51.440 
55.332 

 

51.642 
51.640 

 

53.552 
51.138 
52.705 

 

53.879 
52.519 
51.755 

 

50.534 
52.804 

 

52.084 
50.753 
52.745 
50.478 
71.204 
60.766 
52.875 

95% Confidence Interval 

Lower Bound  Upper Bound 

 

9.493 
10.135 
11.366 

 

10.408 
7.524 
8.884 
10.204 
13.202 
11.479 

 

10.154 
11.173 
9.624 

 

9.434 
11.254 

 

12.583 
10.614 
10.953 

 

8.212 
10.869 
11.856 

 

10.902 
9.785 

 

10.688 
11.419 
9.579 
12.484 
7.960 
12.005 
11.417 

 

23.039 
23.629 
24.843 

 

24.091 
21.113 
22.388 
23.708 
26.747 
25.261 

 

23.593 
24.642 
23.317 

 

22.914 
24.734 

 

26.175 
24.065 
24.496 

 

21.822 
24.402 
25.343 

 

24.316 
23.333 

 

24.196 
24.846 
23.125 
25.896 
22.477 
25.999 
24.970 

 

46 

 

 

Table 13 (cont’d) 

a. Dependent Variable: MedManagement_cgt 

Substance use treatment services. Results from the first model showed that there was 

significant variation of services accounted for by state (F = 31.927, df = 41.451, p<.000). Results 

from the second model showed that time also significantly accounted for variation of services (F 

= 306.812, df = 3, p < .000), with substance use treatment services decreasing from 2005-2014. 

Results from the adjusted model demonstrated that geographic location, year of establishment, 

grade level, hours open weekly, school characterization, and agency sponsor was significantly 

associated with more services over time (Table 14).  

Table 14: LMM: Type III Test of Fixed Effects for Inner Setting Variables on Substance Use Treatment Services, 
Controlled for Time 

Source 

Intercept 

Geographic Location 

Year Established 

School Enrollment 

Elementary School 

Middle School 

High School 

Days Open Weekly 

Hours Open Weekly 

Total MH Hours 

Behavioral Health Provider 

Title I 

Charter School 

Alternative School 

Category Vocational 

Category Magnet 

Public School 

Agency Sponsor 

Time 

Type III Tests of Fixed Effects 

Numerator df 

Denominator df 

1 

2 

5 

2 

1 

1 

1 

1 

2 

1 

3 

1 

1 

1 

1 

1 

1 

9 

3 

57.155 

3428.425 

3428.294 

3428.713 

3430.130 

3428.885 

3429.796 

3432.509 

3428.638 

3425.975 

3429.124 

3426.584 

3424.983 

3426.714 

3433.693 

3429.531 

3426.100 

3431.730 

3425.086 

F 

17.241 

14.118 

5.366 

2.556 

8.899 

8.954 

12.207 

2.463 

7.903 

.480 

2.073 

2.626 

6.258 

.069 

4.125 

2.899 

14.847 

5.682 

611.703 

Sig. 

.000 

.000 

.000 

.078 

.003 

.003 

.000 

.117 

.000 

.489 

.102 

.105 

.012 

.793 

.042 

.089 

.000 

.000 

.000 

a. Dependent Variable: SubUseTreatment_cgt. 

 

47 

 

 

More specifically, sites reported in urban locations, with a more recent year of 

establishment (i.e., 2010+), serving all 3 grade levels (pre-k-5, elementary, and high school), 

school characterization reported as vocational, but not public or charter school, and agency 

sponsorship with private/nonprofit organizations reported a significantly higher number of 

services than sites with other contexts from 2005 to 2014 (Table 15). 

Table 15: Estimated Marginal Means of Substance Use Treatment Services by Inner Setting Variables 

 

Mean 

Std. Error 

Marginal Means Estimates 

Geographic Location 

Rural 

Suburban 

Urban 

Year of Establishment 

1989-below 
1990-1994 
1995-1999 
2000-2004 
2005-2009 

2010+ 

Elementary School 

No 
Yes 

Middle School 

No 
Yes 

High School 

No 
Yes 

Hours Open Weekly 

8 or less hours 
9 to 30 hours 

31 or more hours 
Charter School 

No 
Yes 

Vocational School 

No 
Yes 

Public School 

No 
Yes 

Agency Sponsor 

Local Department of Health 
Community Health System 

School System 

Hospital/Medical Center 
Mental Health Agency 

 

13.729 
14.066 
16.769 

 

12.974 
14.872 
12.797 
15.412 
15.583 
17.488 

 

13.969 
15.740 

 

14.030 
15.679 

 

13.771 
15.938 

 

16.009 
12.759 
15.796 

 

16.775 
12.934 

 

13.481 
16.228 

 

16.023 
13.686 

 

15.564 
15.217 
15.636 
14.271 
5.096 

 

3.617 
3.596 
3.588 

 

3.673 
3.634 
3.600 
3.599 
3.616 
3.713 

 

3.590 
3.590 

 

3.591 
3.585 

 

3.615 
3.567 

 

3.643 
3.611 
3.593 

 

3.495 
3.815 

 

3.522 
3.756 

 

3.563 
3.618 

 

3.601 
3.568 
3.617 
3.561 
4.005 

48 

df 
 

59.704 
58.328 
57.829 

 

63.445 
60.869 
58.574 
58.579 
59.660 
66.300 

 

57.947 
57.936 

 

58.016 
57.649 

 

59.558 
56.488 

 

61.479 
59.309 
58.115 

 

52.094 
73.860 

 

53.702 
69.363 

 

56.211 
59.769 

 

58.611 
56.559 
59.646 
56.106 
89.506 

 

95% Confidence Interval 

Lower Bound  Upper Bound 

 

6.493 
6.869 
9.586 

 

5.636 
7.604 
5.593 
8.208 
8.348 
10.075 

 

6.783 
8.554 

 

6.842 
8.502 

 

6.539 
8.794 

 

8.725 
5.533 
8.605 

 

9.761 
5.331 

 

6.418 
8.736 

 

8.887 
6.448 

 

8.358 
8.071 
8.400 
7.136 
-2.861 

 

20.965 
21.263 
23.951 

 

20.313 
22.140 
20.002 
22.616 
22.818 
24.901 

 

21.155 
22.926 

 

21.218 
22.856 

 

21.003 
23.082 

 

23.292 
19.984 
22.987 

 

23.788 
20.537 

 

20.544 
23.719 

 

23.159 
20.923 

 

22.770 
22.363 
22.871 
21.405 
13.053 

 

 

University 

Private, non-profit Organization 

a. Dependent Variable: SubUseTreatment_cgt. 

16.994 
17.698 

3.798 
3.620 

72.396 
59.868 

9.424 
10.457 

24.564 
24.939 

Referral services. Results from the first model showed that there was significant 

variation of services accounted for by state (F = 24.558, df = 40.510, p < .000). Results from the 

second model showed that time also significantly accounted for variation of services (F = 

567.985, df = 3, p < .000), with referrals services increasing from 2005-2014. Results from the 

adjusted model demonstrated that geographic location, school enrollment, hours open weekly, 

school characterization, and agency sponsor was significantly associated with more services over 

time, even after controlling for time (Table 16).  

Table 16: LMM: Type III Test of Fixed Effects for Inner Setting Variables on Referrals, Controlled for Time 

Source 

Intercept 

Geographic Location 

Year Established 

School Enrollment 

Elementary School 

Middle School 

High School 

Days Open Weekly 

Hours Open Weekly 

Total MH Hours 

Behavioral Health Provider 

Title I 

Charter School 

Alternative School 

Category Vocational 

Category Magnet 

Public School 

Agency Sponsor 

Time 

a. Dependent Variable: Referrals_cgt 

Type III Tests of Fixed Effects 

Numerator df 

Denominator df 

F 

1 

2 

5 

2 

1 

1 

1 

1 

2 

1 

3 

1 

1 

1 

1 

1 

1 

9 

3 

60.433 

3429.649 

3429.507 

3429.949 

3431.555 

3430.144 

3431.208 

3434.244 

3429.763 

3426.889 

3430.454 

3427.598 

3425.682 

3427.668 

3435.476 

3430.816 

3426.990 

3433.302 

3425.805 

20.348 

16.672 

2.141 

5.049 

.167 

2.638 

.959 

.232 

13.787 

.142 

.909 

7.780 

.010 

.781 

1.311 

6.337 

1.823 

2.789 

1356.301 

Sig. 

.000 

.000 

.058 

.006 

.683 

.104 

.328 

.630 

.000 

.707 

.436 

.005 

.921 

.377 

.252 

.012 

.177 

.003 

.000 

 

49 

 

 

More specifically, Table 17 reports that sites in rural locations, with school enrollment of 

more than 2010, 31 or more hours open weekly, school characterization reported as Title I or 

magnet school, and agency sponsorship with mental health agencies reported a significantly 

higher number of referral services than sites with other contexts from 2005 to 2014.

 

Table 17: Estimated Marginal Means of Referrals by Inner Setting Variables 

 

Marginal Means Estimates 

Mean 

Std. Error 

Geographic Location 

Rural 

Suburban 

Urban 

Year of Establishment 

1989-below 
1990-1994 
1995-1999 
2000-2004 
2005-2009 

2010+ 

School Enrollment 

0-699 

700-1999 

2000+ 

Hours Open Weekly 

8 or less hours 
9 to 30 hours 

31 or more hours 

Title I 

No 
Yes 

Magnet School 

No 
Yes 

Agency Sponsor 

Local Department of Health 
Community Health System 

School System 

Hospital/Medical Center 
Mental Health Agency 

University 

Private, non-profit Organization 

a. Dependent Variable: Referrals_cgt 

 

22.063 
17.858 
17.147 

 

19.911 
16.952 
19.086 
17.973 
18.937 
21.279 

 

20.444 
20.071 
16.554 

 

15.413 
20.439 
21.216 

 

18.005 
20.040 

 

17.339 
20.707 

 

18.512 
18.625 
18.981 
18.580 
27.412 
14.408 
16.433 

 

4.271 
4.242 
4.231 

 

4.346 
4.294 
4.247 
4.247 
4.270 
4.400 

 

4.211 
4.227 
4.352 

 

4.306 
4.263 
4.238 

 

4.232 
4.234 

 

4.168 
4.369 

 

4.248 
4.204 
4.270 
4.195 
4.791 
4.514 
4.274 

df 
 

63.524 
61.857 
61.253 

 

68.081 
64.947 
62.151 
62.166 
63.470 
71.588 

 

60.085 
60.997 
68.470 

 

65.701 
63.042 
61.593 

 

61.293 
61.380 

 

57.689 
69.570 

 

62.182 
59.713 
63.438 
59.148 
100.269 
79.027 
63.720 

95% Confidence Interval 

Lower Bound  Upper Bound 

 

13.531 
9.379 
8.687 

 

11.239 
8.376 
10.596 
9.484 
10.406 
12.506 

 

12.021 
11.618 
7.871 

 

6.816 
11.921 
12.744 

 

9.543 
11.576 

 

8.994 
11.993 

 

10.020 
10.214 
10.449 
10.186 
17.907 
5.423 
7.894 

 

30.596 
26.338 
25.607 

 

28.582 
25.528 
27.575 
26.461 
27.468 
30.051 

 

28.866 
28.523 
25.236 

 

24.011 
28.957 
29.688 

 

26.467 
28.505 

 

25.684 
29.421 

 

27.004 
27.035 
27.512 
26.974 
36.917 
23.392 
24.972 

LMM Analyses: Outer Setting Variables & MH Services 

 

50 

 

 

 Similarly, the same process used for inner setting variables and mental health services 

was carried out with the outer setting variables. Results showed that most outer context 

variables—with the exception of state general funds on substance use treatment and referrals—

were significantly related to the number of screening/assessment services, medication 

management services, substance use treatment services, and referral services reported by states, 

even after controlling for time (Table 18, 19, 20, 21). More specific results for the main effects 

of outer setting variables on each dependent variable (controlled for time) is reported in the 

following sections.  

Table 18: Type III Tests of Fixed Effects for Outer Context Variables on Screening/Assessment, Controlled for  
 

Time 

Type III Tests of Fixed Effects 

Numerator df 

Denominator df 

F 

State Requirements for Data Collection 

a. Dependent Variable: ScreeningAssessment_cgt 

Table 19: Type III Tests of Fixed Effects for Outer Context Variables on Medication Management, Controlled for 
 

Time. 

Source 

Intercept 

Time 

TechnicalAssistance 

State Agency 

SBHC Data 

SBHC Grant Program 

Title V MCH 

 

Type III Tests of Fixed Effects 

Numerator df 

Denominator df 

F 

21.062 

2641.836 

2649.135 

2644.021 

3231.054 

2638.676 

2648.588 

22.836 

419.327 

30.413 

91.816 

153.622 

17.818 

224.561 

1 

3 

1 

4 

1 

1 

1 

51 

Sig. 

.000 

.000 

.000 

.000 

.000 

.000 

.000 

 

Source 

Intercept 

Time 

TechnicalAssistance 

State Agency 

SBHC Data 

SBHC Grant Program 

Title V MCH 

State General Fund 

Tobacco Settlement 

Operating Standards 

1 

3 

1 

4 

1 

1 

1 

1 

1 

2 

2 

20.119 

2638.738 

2643.838 

2640.177 

3220.288 

2636.673 

2643.394 

2643.310 

2639.881 

2641.622 

2639.116 

61.275 

274.532 

58.682 

6.785 

44.533 

341.751 

51.708 

282.107 

937.849 

13.632 

215.651 

Sig. 

.000 

.000 

.000 

.000 

.000 

.000 

.000 

.000 

.000 

.000 

.000 

 

State General Fund 

Tobacco Settlement 

Operating Standards 

State Requirements for Data Collection 

a. Dependent Variable: Medmanagement_cgt 

1 

1 

2 

2 

2648.476 

2643.782 

2646.082 

2642.577 

59.613 

1360.565 

225.891 

562.686 

.000 

.000 

.000 

.000 

Table 20: Type III Tests of Fixed Effects for Outer Context Variables on Substance Use Treatment, Controlled for 
 

Time 

Type III Tests of Fixed Effects 

Numerator df 

Denominator df 

F 

State Requirements for Data Collection 
a. Dependent Variable: SubUseTreatment_cgt 

Table 21: Type III Tests of Fixed Effects for Outer Context Variables on Referrals, Controlled for Time 

Type III Tests of Fixed Effects 

Numerator df 

Denominator df 

F 

Sig. 

State Requirements for Data Collection 

a. Dependent Variable: Referrals_cgt. 

Screening & assessment services. For the funding sources subscale, sources from 

Tobacco Settlement demonstrated more services than state general fund or Title V MCH. 

 

52 

 

Source 

Intercept 

Time 

TechnicalAssistance 

State Agency 

SBHC Data 

SBHC Grant Program 

Title V MCH 

State General Fund 

Tobacco Settlement 

Operating Standards 

Source 

Intercept 

Time 

TechnicalAssistance 

State Agency 

SBHC Data 

SBHC Grant Program 

Title V MCH 

State General Fund 

Tobacco Settlement 

Operating Standards 

1 

3 

1 

4 

1 

1 

1 

1 

1 

2 

2 

20.659 

2640.641 

2647.251 

2642.567 

3224.664 

2637.865 

2646.718 

2646.612 

2642.274 

2644.436 

2641.229 

63.678 

735.734 

87.186 

55.277 

65.929 

4.631 

123.603 

.017 

2992.999 

908.646 

1443.066 

Sig. 

.000 

.000 

.000 

.000 

.000 

.031 

.000 

.896 

.000 

.000 

.000 

1 

3 

1 

4 

1 

1 

1 

1 

1 

2 

2 

25.652 

105.821 

.000 

2648.301 

1048.798 

.000 

2640.123 

2648.808 

3190.017 

41.820 

30.347 

14.650 

2646.836 

107.074 

2643.576 

2644.340 

2653.000 

2644.436 

7.718 

.014 

201.205 

908.646 

.000 

.000 

.000 

.000 

.006 

.905 

.000 

.000 

2641.229 

1443.066 

.000 

 

Notably, states with a grant program dedicated to SBHCs that did not report any agency as a 

funding source demonstrated lower services than those that did not. For the oversight and 

support subscale, states with a program unit to provide technical assistance and data collection 

reported more screening and assessment services than sites that did not have technical assistance  

over time. For the policy and standards subscale, states with requirements for SBHC data 

collection reported as mandatory for SBHCs funded by state and voluntary for SBHCs not 

funded by state demonstrated more services than any other criteria. States with any operating 

standard demonstrated less services than those without operating standards. See Table 22 for 

more results.

 

53 

 

 

Table 22: Estimated Marginal Means of Screening/Assessment by Outer Setting 
Variables 

Estimated Marginal Means 

95% Confidence 

 

Funding Sources Subscale 

Mean 

SBHC Grant Program 

 

Interval 

 

 

Std. 
Error 

 

df 

 

Lower 
Bound 

Upper 
Bound 

 

 

Grant Program Dedicated to 

43.608  7.099  19.739 

28.787 

58.429 

SBHCs 

No program available 

68.065  7.228  21.206 

53.043 

83.086 

Grant Program Funding 

 

 

 

 

 

Source 

Title V MCH Block Grant 

Tobacco Settlement 
State General Fund 

State Agency 

Public Health only 

Human Services only 

Public Health & Education 

Public Health & Human 

Services 

None 

53.593  7.139  20.190 
66.508  7.154  20.361 
61.099  7.147  20.282 

 

 

 

54.689  7.078  19.504 
57.581  7.190  20.766 
53.424  7.122  19.996 
49.457  7.210  20.995 

38.710 
51.601 
46.203 

 

39.901 
42.618 
38.568 
34.464 

68.476 
81.415 
75.995 

 

69.477 
72.543 
68.281 
64.451 

64.030  8.230  35.594 

47.332 

80.728 

Oversight & Support Subscale 

Technical Assistance 

 

 

 

 
 

 
 

Unit provides TA to SBHCs 

Does not provide TA 

SBHC Data 

State collects data 

State does not collect data 

60.755  7.127  20.055 
50.917  7.196  20.839 

45.890 
35.945 

75.620 
65.890 

 

 

 

 

 

28.610  3.872  42.611 
21.185  6.308  20.874 

20.800 
8.061 

36.420 
34.310 

Policy & Standards Subscale 

Operating Standards 

 

 

 

 
 

 
 

Yes, for state funded SBHCs 

53.894  7.159  20.412 

38.981 

68.808 

only 

Yes, for all SBHCs regardless 

54.265  7.159  20.418 

39.350 

69.180 

of funding source 

No operating standards 

59.349  7.143  20.238 

44.459 

74.239 

State requirements for data 

 

 

 

 

 

collection  

Mandatory for SBHCs funded 

50.936  7.137  20.165 

36.056 

65.816 

by state 

Mandatory for all SBHCs 

51.368  7.165  20.477 

36.445 

66.291 

regardless of funding source 
Mandatory for SBHCs funded 

by state & Voluntary for 

SBHCs not funded by state 

65.205  7.136  20.156 

50.326 

80.083 

a. Dependent Variable: ScreeningAssessment_cgt 

Medication management services. For the funding sources subscale, states with funding 

sources from public health and human agencies and Tobacco Settlement demonstrated more 

services than any other funding source. However, states with a grant program dedicated to 

 

54 

 

SBHCs demonstrated lower services than those that did not. For the oversight and support 

subscale, states with a program unit to provide technical assistance and collect data reported 

more medication management services than those that did not have technical assistance. For the 

policy and standards subscale, states with requirements for SBHC data collection reported as 

mandatory for SBHCs funded by state and voluntary for SBHCs not funded by state 

demonstrated higher number of services than any other criteria. However, states that reported 

presence of operating standards demonstrated lower services than those without operating 

standards. See Table 23 for more results. 

 

55 

 

 

 

Table 23: Estimated Marginal Means of Medication Management by Outer Setting 
Variables 

Estimated Marginal Means 

95% Confidence 

Interval 

 

Funding Sources Subscale 
Mean 

SBHC Grant Program 

 

Std. 
Error 

 

df 

 

 

Lower 
Bound 

 

Grant Program Dedicated to SBHCs 

No program available 

25.455  5.924  20.369 
31.644  6.112  23.073 

13.111 
19.002 

Grant Program Funding Source 

 

 

 

Title V MCH Block Grant 

Tobacco Settlement 
State General Fund 

State Agency 

Public Health only 

Human Services only 

Public Health & Education 

Public Health & Human Services 

None 

23.373  5.984  21.193 
42.790  6.006  21.506 
31.229  5.995  21.360 

 

 

 

37.955  5.893  19.944 
9.644 
6.057  22.247 
36.533  5.958  20.840 
41.944  6.086  22.677 
16.671  7.509  52.270 

Oversight & Support Subscale 

Technical Assistance 

 

 

 

 

10.936 
30.318 
18.773 

 

25.660 
-2.910 
24.136 
29.344 
1.605 

 
 

Unit provides TA to SBHCs 

Does not provide TA 

SBHC Data 

State collects data 

State does not collect data 

32.471  5.966  20.945 
24.628  6.067  22.388 

20.062 
12.059 

 

 

 

 

28.610  3.872  42.611 
21.185  6.308  20.874 

20.800 
8.061 

Policy & Standards Subscale 

Operating Standards 

 

 

 

 
 

 

Upper 
Bound 

 

37.799 
44.286 

 

35.809 
55.261 
43.684 

 

50.250 
22.198 
48.930 
54.544 
31.737 

 
 

44.880 
37.196 

 

36.420 
34.310 

 
 

Yes, for state funded SBHCs only 
Yes, for all SBHCs regardless of 

25.906  6.012  21.598 
17.161  6.013  21.609 

13.424 
4.678 

38.388 
29.644 

funding source 

No operating standards 

42.581  5.990  21.282 

30.135 

55.027 

State requirements for data 

 

 

 

 

 

collection  

Mandatory for SBHCs funded by state  29.737  5.980  21.147 
11.738  6.021  21.718 
Mandatory for all SBHCs regardless 

17.305 
-.757 

42.168 
24.233 

of funding source 

Mandatory for SBHCs funded by state 

44.173  5.979  21.131 

31.744 

56.603 

& Voluntary for SBHCs not funded 

by state 

a. Dependent Variable: Medmanagement_cgt 

Substance use treatment services. For the funding sources subscale, states with funding 

sources from public health and human agencies and Tobacco Settlement demonstrated more 

services than any other funding source. However, having a state grant program dedicated to 

 

56 

 

 

SBHCs demonstrated lower services than those that did not. For the oversight and support 

subscale, states with a program unit that provided technical assistance demonstrated more 

services than those that did not have technical assistance over time. However, states with a 

government unit to collect SBHC data reported less services than sites that did not. For the 

policy and standards subscale, states with requirements for SBHC data collection reported as 

mandatory for SBHCs regardless of funding source demonstrated higher number of services than 

any other criteria. States with operating standards only for state funded SBHCs demonstrated 

more services than those that did not have any operating standards. See Table 24 for more 

results.

 

57 

 

 

  

 

Table 24: Estimated Marginal Means of Substance Use Treatment by Outer Setting 
Variables 

Estimated Marginal Means 

 

Funding Sources Subscale 

Mean 

SBHC Grant Program 

 

Std. 
Error 

 

df 

 

95% Confidence 

Interval 

 

Lower 
Bound 

 

 

Upper 
Bound 

 

Grant Program Dedicated to 

48.960  6.282  20.095 

35.859 

62.060 

SBHCs 

No program available 

52.000  6.447  22.287 

38.640 

65.361 

Grant Program Funding 

 

 

 

 

 

Source 

Title V MCH Block Grant 

Tobacco Settlement 
State General Fund 

State Agency 

Public Health only 

Human Services only 

Public Health & Education 

Public Health & Human 

Services 

None 

46.778  6.334  20.765 
70.838  6.353  21.019 
50.524  6.345  20.901 

 

 

 

42.703  6.255  19.747 
52.283  6.399  21.622 
48.286  6.312  20.478 
60.656  6.424  21.968 

33.596 
57.626 
37.326 

 

29.645 
38.999 
35.139 
47.332 

59.959 
84.049 
63.722 

 

55.761 
65.567 
61.432 
73.980 

45.504  6.871  30.679 

31.485 

59.522 

Oversight & Support Subscale 

Technical Assistance 

 

 

 

 
 

 
 

Unit provides TA to SBHCs 

Does not provide TA 

SBHC Data 

State collects data 

State does not collect data 

56.881  6.319  20.564 
44.079  6.407  21.734 

43.724 
30.782 

70.038 
57.376 

 

 

 

 

 

12.137  4.074  39.076 
25.432  4.260  46.699 

3.898 
16.861 

20.376 
34.004 

Policy & Standards Subscale 

Operating Standards 

 

 

 

 
 

 
 

Yes, for state funded SBHCs 

66.696  6.359  21.094 

53.475 

79.917 

only 

Yes, for all SBHCs regardless of 

43.622  6.360  21.103 

30.400 

56.844 

funding source 

No operating standards 

41.122  6.339  20.837 

27.932 

54.312 

State requirements for data 

 

 

 

 

 

collection  

Mandatory for SBHCs funded 

31.733  6.331  20.728 

18.556 

44.910 

by state 

Mandatory for all SBHCs 

61.963  6.367  21.192 

48.730 

75.195 

regardless of funding source 
Mandatory for SBHCs funded 

by state & Voluntary for SBHCs 

not funded by state 

57.744  6.330  20.714 

44.569 

70.919 

a. Dependent Variable: SubUseTreatment_cgt 

 

58 

 

 Referral services. For the funding sources subscale, states with funding sources from 

human agencies only and Tobacco Settlement demonstrated more services than any other 

funding source. However, having a state grant program dedicated to SBHCs demonstrated lower 

services than those that did not. For the oversight and support subscale, states with a program 

unit to provide technical assistance and data collection demonstrated less services than those 

without a program unit. For the policy and standards subscale, states with requirements for 

SBHC data collection reported as mandatory for SBHCs regardless of funding source 

demonstrated higher number of services than any other criteria. States with operating standards 

for all SBHCs regardless of funding source demonstrated more services than those that did not 

have any operating standards. See Table 25 for more results.  

 

59 

 

 

 

 

Table 25: Estimated Marginal Means of Referrals by Outer Setting Variables 

Estimated Marginal Means 

Funding Sources Subscale 

 

Mean 

SE 

SBHC Grant Program 

 

 

df 

 

Grant Program Dedicated to SBHCs 

No program available 

Grant Program Funding Source 

Title V MCH Block Grant 

Tobacco Settlement 
State General Fund 

State Agency 

Public Health only 

Human Services only 

Public Health & Education 

Public Health & Human Services 

None 

51.609  6.210 
79.405 
6.793 

23.208 
33.169 

 

 

63.754 
6.397 
75.526  6.466 
65.431 
6.433 

 

26.132 
27.241 
26.687 

 

 

 

21.774 
59.423 
29.850 
83.623 
24.893 
66.843 
38.371 
31.587 
79.275  10.481  177.997 

6.110 
6.622 
6.318 
6.712 

Technical Assistance 

Oversight & Support Subscale 
 

 

 

Unit provides TA to SBHCs 

Does not provide TA 

SBHC Data 

State collects data 

State does not collect data 

57.110 
73.904 

6.342 
6.653 

25.224 
30.476 

 

 

 

17.555 
24.910 

3.985 
4.246 

39.206 
50.492 

Operating Standards 

Policy & Standards Subscale 
 

 

 

95% Confidence 

Interval 

 

Lower 
Bound 

 

38.770 
65.586 

 

50.608 
62.265 
52.224 

 

46.744 
70.096 
53.827 
24.691 
58.593 

 
 

44.055 
60.326 

 

9.497 
16.384 

 
 

 

Upper 
Bound 

 

64.449 
93.223 

 

76.901 
88.787 
78.639 

 

72.101 
97.150 
79.859 
52.051 
99.958 

 
 

70.165 
87.481 

 

25.613 
33.436 

 
 

Yes, for state funded SBHCs only 

Yes, for all SBHCs regardless of funding 

61.124 
76.550 

6.485 
6.487 

27.556 
27.569 

47.830 
63.252 

74.419 
89.848 

source 

No operating standards 

58.846 

6.417 

26.481 

45.667 

72.026 

State requirements for data collection  
Mandatory for SBHCs funded by state 
Mandatory for all SBHCs regardless of 

 

 

 

57.655 
74.929 

6.387 
6.511 

25.951 
27.998 

 

44.526 
61.591 

 

70.784 
88.267 

funding source 

Mandatory for SBHCs funded by state & 
Voluntary for SBHCs not funded by state 

63.937 

6.384 

25.923 

50.813 

77.061 

a. Dependent Variable: Referrals_cgt. 

 

 

 

 

 

 

60 

 

DISCUSSION 

The current study used descriptive analyses to explore the reported number of mental 

health (MH) services offered by SBHCs across the U.S. by conducting secondary analyses on the 

National Census SBHC Survey and the State Policy Survey. Further, the study used linear mixed 

modelling to explore the association between inner and outer setting variables (theorized within 

the CFIR framework) with SBHC mental health service delivery. Quantitative results from the 

current project may help promote understanding the role of structural characteristics and state 

level support in shaping MH service delivery over time. Interpretation of the data is presented by 

each research question in the following sections.  

RQ1. What is the number of mental health services reported to be delivered by state 

from 2005 to 2014?  

The first research question aimed to assess the number of MH services reported to be 

delivered by state from 2005 to 2014. Descriptive statistics demonstrated that there was variation 

in MH services reported by each state. Further analyses demonstrated that variation in the 

number of MH services reported to be delivered was significantly accounted for by state and 

time. Screening/assessment, medication management, and referral services significantly 

increased from 2005 to 2014, whereas, substance use treatment services significantly decreased 

over time. Given the significant variation of services, evaluating the inner and outer contextual 

variables that may support the capacity of some SBHCs to provide a greater number of MH 

services than other SBHCs is critically important.  

 

61 

 

RQ2. Which inner setting variables (structural characteristics and networks) are 

related to number of mental health services reported to be delivered from 2005 to 2014?  

The second research question aimed to explore the relationship between inner setting 

variables and MH services reported to be delivered from 2005 to 2014. Linear mixed modelling 

demonstrated an estimation, or estimated model, of the significance in the relationship between 

inner setting variables and delivery of MH services over time. Mean estimates allowed for 

comparison of reported number of services provided by sites at the state level. Overall, inner 

setting variables that were significantly associated with the number of MH services reported to 

be delivered over time included geographic location, year of establishment, school enrollment, 

hours open weekly, grade levels, school characterization, behavioral health provider, and agency 

sponsor. Total hours worked for MH staff and days open weekly were not significant for any 

MH service.  

The National Census Survey - Structural Characteristics subscale. Organizational 

level factors, such as size, location, and length of establishment are suggested to shape 

availability of resources and influence utilization of services (Greenhalgh et al., 2004; Wade et 

al., 2008). Results showed that school enrollment below 2000 was significantly associated with 

more screening/assessment, medication management, and referral services over time, but not 

substance use treatment. Findings support that the size of a student body can help shape delivery 

of services over time by directing the types of services necessary to meet student needs. This 

finding should be interpreted with caution because school enrollment of more than 2000 was the 

least reported characteristic over the four time points, which may have skewed mean estimates. 

Maturity was informed by the site’s reported year of establishment. Results showed that sites 

with a more recent year of establishment reported more screening/assessment, medication 

 

62 

 

management, and substance use treatment services over time, but not referral services. This 

finding could reflect trajectories SBHCs have undergone, with more recent establishments 

having more resources due to increased community support or recognition of impacts (Dreyfoos, 

1994; Flaherty et al., 1996; Swider & Valukas, 2004). 

Geographic location was significantly related to all four MH services over time. Sites in 

rural locations reported more screening/assessment and referral services than sites in urban or 

suburban locations. Sites in urban locations reported more medication management and 

substance use treatment services than sites in rural or suburban locations. These findings are 

inconsistent with previous studies asserting that geographic location was not found to have any 

effect on availability of MH services in SBHCs (Larson et al., 2017). Current findings suggest 

that there is potentially some interaction from geographic location in shaping delivery of MH 

services over time. For example, it is possible that sites in rural locations are more likely to refer 

students out to other sources because rural locations typically have less access to diverse 

services.  

Grade level was significantly related to medication management and substance use 

treatment services only. Sites that offered services to elementary schools reported more 

medication management services than those that did not. Sites that offered services to all grade 

levels reported more substance use treatment services than those that did not. This relationship 

was not observed for screening/assessment or referral services. These findings suggest that there 

are specific types of services more often to be provided for a given grade level. For example, it is 

possible that there is a higher need for medication management than any other service in 

elementary schools due to higher prevalence rates of mental health diagnoses, such as ADHD, at 

this age group that are often treated with medication (Baquiran, Webber, & Appel, 2002). 

 

63 

 

 

Findings are also inconsistent with previous research suggesting that higher grade levels 

predicted more services (Larson et al., 2017). Future research should assess the pattern of 

utilization among younger grade levels (elementary grade) that are suggested to direct an 

increase in medication management. 

Prior studies have found that SBHCs with a mental health component tended to have 

more “organizational resources,” such as more hours and days open weekly (Larson et al., 2017). 

The current study further assessed the direction of these relationships within sites with a MH 

component. Hours open weekly was significantly associated with the number of services 

reported to be delivered over time, but this relationship was not found significant with days open 

weekly. Sites with 31 or more hours open weekly reported more screening/assessment, 

medication management, and referral services over data collection time points than sites with 

less hours. These findings suggest that sites may need to accommodate for a higher demand of 

services with more hours open. Such information may support advocating for more SBHC 

organizational resources to operate sufficiently. Interestingly, sites that were open eight hours or 

less per week reported more substance use treatment services than sites open for more than eight 

hours per week. This finding might be influenced by prevention activities (which were not 

analyzed) targeting substance use behaviors that are taking place outside of SBHC MH services. 

Nonetheless, current findings offer more information on the direction of the relationship between 

health center operations and number of MH services reported to be delivered over time.  

As previously discussed, among schools with a SBHC, 30% still do not have a mental 

health provider on staff (School-Based Health Alliance, 2016; Larson et al., 2017). Moreover, 

mental or behavioral health providers on staff within SBHCs can be essential in expanding to 

more comprehensive MH care. In the current study, majority of sites reported having a 

 

64 

 

 

behavioral health (BH) provider either on staff (i.e., co-located within the center) or affiliated 

with the school (i.e., located in school, but separate from center). However, results found that 

location of a BH provider was only significantly associated with screening/assessment and 

medication management services, and not with referral and substance use services. Sites with a 

BH provider co-located within the center reported more screening/assessment services than any 

other provider location reported over time. Sites that did not have a BH provider on site reported 

more medication management services over time than sites with a BH provider. There is a 

discussion about how SBHCs are often concerned with issues related to duplicated services and 

coordinated care with school-employed health practitioners (Larson et al., 2017; Richardson, 

2007). Perhaps, certain services are coordinated with school-employed health practitioners 

outside of SBHCs and behavioral health providers, which may help to explain these results. 

 

There was limited variation of responses for school characterization across the four time-

points. Majority of schools were characterized as traditional public schools and/or title I.  There 

was a significant association between school characterization and type of MH services. Magnet 

schools reported more screening/assessment services than other school characterizations. Public 

schools were significantly less likely to offer medication management and substance use 

treatment services than other school characterizations. Charter schools were significantly less 

likely to offer substance use treatment services than other school characterizations. Vocational 

schools were significantly more likely to offer substance use treatment services than other school 

characterizations. Title I and magnet schools were significantly more likely to offer referral 

services than other school characterizations. It is important to note that interpreting these 

findings is difficult because schools could identify themselves with more than one school 

characterization, and school characterizations varied across the four time points for some schools 

 

65 

 

 

(i.e., a school may identify itself as a Title I school at time point 1 but identify itself as a public 

and Title I school at later time points). It remains unclear how school characterization may 

impact delivery and provision of services. It was beyond the scope of the current thesis project to 

explore clusters of school characterization. Further research would likely be needed to better 

understand the specifics of school type on provision of MH services offered through SBHCs over 

time.  

The National Census Survey - Networks Communications subscale. Networks and 

partnerships facilitate integration of services with increased sources for support, resources and 

funding (Armbruster, 2002; Dreyfoos, 1994; Swider & Valukas, 2004). Prior studies have 

observed that SBHCs with a mental health component are more likely to be sponsored by school 

and university departments than public health departments (Larson et al., 2017). In the current 

study, community health centers and hospital/medical centers were most frequently reported 

sponsors from 2005 to 2010.  Hospital/medical centers and school systems were most frequently 

reported sponsors in 2014. LMM results expanded on variations within these partnerships and 

demonstrated that sites with mental health agency sponsorships reported more 

screening/assessment and referral services than any other agency. Sites with hospital/medical 

center sponsorships reported more medication management services, following with university 

sponsorships. Sites with private/non-profit agencies reported more substance use treatment 

services than any other type of agency, following with university sponsorships. These findings 

suggest that collaboration with other service systems plays an important role in promoting 

delivery of mental health services within SBHCs over time. Given that these agencies are the 

most common sponsors reported for SBHCs with a mental health component, further research is 

 

66 

 

 

needed to understand the underlying differences within these partnerships that produce different 

outcomes in types of services offered.  

RQ3. Which outer setting variables (e.g., funding sources, policy and standards, 

oversight and support) are related to number of mental health services reported to be 

delivered from 2005 to 2014?   

The third research question aimed to explore the relationship between outer setting 

variables and mental health services reported to be delivered from 2005 to 2014. To our 

knowledge, prior studies have not assessed the relationship between outer context variables as 

collected within the Policy survey and delivery of MH services over time. Comparisons between 

SBHCs with different outer contextual factors – particularly, funding and state policy support –

are not well examined. Overall, most outer context variables, with the exception of state general 

funds on substance use treatment and referral services, were significantly associated with the 

number of reported MH services over time.    

The State Policy Survey - Funding Sources subscale. Implementation studies assert 

that the presence of dedicated and ongoing funding increases the likelihood of adopting, 

implementing and sustaining an innovation (Greenhalgh et al., 2008). Building on this concept, 

the current study assessed the relationship between state agencies reported as funding sources, 

having a SBHC grant program, SBHC funding sources and the number of MH services over 

time. Findings showed that states with a grant program dedicated specifically to SBHCs had 

fewer MH services being delivered than states that did not report a program unit. This could 

relate to the fact that many SBHCs have diverse sources for funding that may not be directly 

attributed to a state program unit. Moreover, it might be the case that states not reporting a 

program may not actually have access to a designated state program unit, making access to other 

 

67 

 

 

sources a priority for resources. Funding sources reported from tobacco settlement were 

associated with more screening/assessment, medication management, substance use treatment, 

and referral services than sources from Title V MCH or state general funds. Interestingly, state 

general funds were not significantly associated with the number of referral or substance use 

treatment services at any time point. Moreover, states that reported both public health agencies 

and human agencies as funding sources demonstrated more medication management and 

substance use treatment than states that reported other funding agencies. However, more referral 

services were found only among states that reported sources from human agencies alone. These 

findings help explain the variation of services accounted for by funding sources reported by 

SBHC policy-makers and may be useful to target for more funding opportunities.  

The State Policy Survey - Oversight and Support subscale. “Technical capacity” 

refers to an organization’s technical resources and technical potential (Greenhalgh et al., 2008). 

Prior studies have found technical capacity positively and significantly correlates to an 

organization’s willingness to utilize an innovation (Greenhalgh et al., 2008). Furthering this line 

of research, the current study assessed whether having a state program unit providing technical 

assistance for developing SBHCs or for data collection purposes was significantly related to the 

number of MH services reported over time. Results showed that states with a program unit to 

provide technical assistance reported more screening/assessment, medication management and 

substance use treatment services than those that did not have technical assistance over time. 

However, this relationship was not found for referral services. These findings suggest that having 

some type of technical assistance offered by state programs plays a role in facilitating the 

delivery of more treatment services. Since this was not observed for referrals, it might be the 

case that referrals are part of a coordinated care process (e.g., with a school psychologist or 

 

68 

 

 

school nurse) outside of the center. More research is needed to understand which types of 

technical assistance work best in promoting services within SBHC sites. Moreover, states with a 

program unit to collect data reported more screening/assessment and medication management 

services—but lower number of substance use treatment or referral services. It is possible that 

there are outside services, such as prevention activities or coordinate care services, that are 

influencing the direction of these relationships. More research should consider the overlap of 

services offered through multiple staff located within school settings, such as school 

psychologist, school nurse, and SBHC staff.  

The State Policy Survey - Policy and Standards subscale. External policy and 

incentives refer to changes influenced by external forces, such as mandates, regulations, and 

guidelines (Damschroder et al., 2009). These external forces can often shape the delivery of 

services and foster access to health care (Doll et al., 2017; Sprigg et al., 2017). Results from the 

current study demonstrated that operating standards, as defined by state, were significantly 

associated with an increase in substance use treatment and referral services over time—but not 

screening/assessment or medication management services. Moreover, the criteria for these 

operating standards varied. For example, more referrals were reported by states with operating 

standards for all SBHCs regardless of funding source, but more substance use treatment services 

were reported by states with operating standards only for state-funded SBHCs. The role of 

variations within these standards remains unclear. State requirements that are mandatory for 

SBHCs funded by the state demonstrated more screening/assessment, medication management, 

substance use treatment, and referral services over time. These findings suggest that state defined 

regulations can help promote services by developing frameworks to meet service quality 

standards.  

 

69 

 

 

Limitations  

There are several limitations to the current project that relates to the nature of secondary 

data. First, the project is limited to data that has already been collected by a third-party 

organization. Assessments and measures are then limited in scope, with some circumstances 

compromising the quality of the data collected. Moreover, missing data cases may have 

influenced the outcomes. For example, administrative errors in data collection may have yielded 

the observed missing data cases. Second, multicollinearity of the variables was not controlled for 

in the main analyses. These relationships, however, were noted in unadjusted models (bivariate 

analyses) and considered throughout the analyses and interpretation of results. Third, results 

from this study are not able to identify or explain causal relationships between inner and outer 

contexts with the provision of mental health services delivered through SBHCs. Results can only 

suggest the direction of relationships between inner contexts, outer contexts, and mental health 

services in SBHCs over time. In an attempt to minimize all these limitations, the study attempted 

to remain as transparent in procedures as possible for reproducibility with the secondary data set. 

Conclusion 
 

There remains a need to identify key factors in state level support that contribute to the 

delivery of mental health (MH) services in SBHCs over time and to understand variation of MH 

services across states. Results from the current study support significant variations in SBHC MH 

services among the 41 eligible U.S. states over the four time points. Findings from the current 

study suggest that there are significant relationships between structural characteristics, networks, 

and state level support and the delivery of MH services. Given the variation in the frequency of 

reported screening/assessment, medication management, substance use and referral services, it is 

 

70 

 

 

recommended that future research explore how these contextual variables influence the types of 

services made available to students.  

Importantly, this project has several important and innovative contributions to scientific 

knowledge and policy. First, the project is innovative in its theoretical approach. Using a 

contextualist perspective can address several limitations found in prior studies by accounting for 

the role of unique contexts for each state. Utilizing the contextualist approach allowed us to 

explore patterns in the structural characteristics and networks of SBHCs that had not been 

included in previous literature. The study results clearly emphasize that specific inner setting 

variables were significantly and positively related to more MH services being reported from 

2005 to 2014 but that the relations had differential impacts on which service was provided. Such 

patterns can be crucial to understand likelihood of specific mental health services within a given 

setting. Moreover, this project was innovative because, to our knowledge, it is the first study to 

include the State Policy Survey and evaluate associations between funding and policies at the 

state level with the number of mental health services delivered by SBHCs. Further, this study 

provides novel information by examining how these associations change over time. This 

information may be particularly useful for promoting facilitating factors that increase the use of 

specific types of mental health services to increase access to quality mental health treatment 

services, reducing the oft noted mental health disparities, and improve the lives of youth in the 

United States.  

 

 

 

71 

 

 

 

 

 

 

Figure 1: Stacked Bar Count (“Yes”) of School Characterization by Time 

 

 

 

72 

 

 

 

APPENDICES

73 

 

 

 

 

 

 

 

APPENDIX A: National SBHC Census Survey 

SCHOOL-BASED HEALTH CENTER CENSUS SCHOOL YEAR 2013-2014 

Welcome to the School-Based Health Alliance Census, School Year 2013-2014! 

Who should participate in the 2013-2014 School-Based Health Care Census? 
•  Partnerships between schools and community health organizations that deliver health care to students within a 

fixed site on school campus [SCHOOL-BASED] 

•  Health care programs that are formally or informally linked with schools to coordinate and promote health care for 

students on campus; clinical services are not provided on school site [SCHOOL-LINKED] 

•  Programs without a fixed site that rotate a health care team through a number of schools [MOBILE] 
•  Programs delivering school-based health services exclusively via telehealth technology [TELEHEALTH ONLY SITE]. 

For programs delivering some services by a provider who is physically onsite and some services via telehealth 
technology, respond to the census as a school-based, school-linked, or mobile health center and use the appropriate 
column in Section 3 to indicate which team members are accessible via telehealth. 

Who should complete the Census? 
The Census should be completed by the person who is most knowledgeable about the clinical care provided in the health 
center, such as the nurse practitioner or clinical director. 

Instructions: 
Please answer all questions. 
1.  If you are unable to complete every section, provide as much data as possible and return your incomplete form. We 

appreciate any amount of information you can provide. 

2.  If you are completing a paper version of the survey, please use a separate questionnaire for each fixed health center site 
you represent. For programs on campuses that serve several schools, complete one survey and provide information on all 
grades served within the immediate campus. Mobile programs may use one survey. 

3.  All questions refer to the school year 2013-2014, unless otherwise specified. 

If you are completing three or more censuses, the School-Based Health Alliance staff will offer you hands-on support. Please 
contact census@sbh4all.org and a member of the staff will schedule an appointment with you to complete the Censuses. 

You may use this printout to review the questions that are being asked beforehand to ensure collection of correct information. 

To complete the Census online, please visit: www.sbh4all.org/censussurvey. 

To complete a paper copy, please print and answer all items. Send a scanned copy or fax completed copy to: Mail: School-

Based Health Alliance, 1010 Vermont Avenue NW, Suite 600, Washington, D.C. 20005 Email: census@sbh4all.org
 

Fax: 202-638-5879 

Announcement: For the first time ever, we will have a publically accessible map of SBHCs across the country that will 
include basic health center demographic information and characteristics drawn from the census. 

74 

 

 

 

 
 

 

1.  HEALTH CENTER DEMOGRAPHICS 

A.  The health center I represent is (select one): 

o 

o 

o 

In a school building 

On school property, but not in a school building 

Beyond school property, but has formal or informal links with one or more schools in the community 

o  Mobile program serving several schools but with no fixed site 
o 

Telehealth only site (100% of services provided through telehealth technology) - If some services are provided by a 
provider onsite and some via telehealth technology, please select the location of the health 
center from the other options above. 

B.  How many schools are served by the health center? (For campuses with more than one school, such as a middle and high 

school, include all schools in your count.) 

o 

One school (i.e., Only the school where health center is located) 

o  Name of school:   

o  More than one school 

o  Names of schools:   

o 

o 

All schools in school district 

Do not know 

 

 

C.  Does your health center serve individuals other than students enrolled in your school (For school-linked programs, 

answer not applicable)? 

o 

o 

o 

o 

Yes 

No 

Not applicable 

Do not know 

D.  Which of the following populations are eligible to use the health center services (select all that apply) (For school-linked 

programs, describe populations served in “Other”)? 

Yes 

No 

Do not know 

Students from other schools 

Out-of-school youth 

Faculty/school personnel 

Family of students users (i.e., 
siblings, parents, or infants of 
students) 

Other people in the community 

Other, please specify: 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

75 

 

 

 

 

 

 
 

 

 

E. 

Indicate the type of agency that serves as the primary administrator and/or sponsoring health care organization 
for the health center (select one). 
o 

Federally Qualified Health Center (FQHC) or Look-Alike (an organization that receives funding under the Health 
Center Program as authorized under section 330 of the Public Service Act or a FQHC look-alike 
organization, which meets all of the Health Center Program requirements but does not receive a Health Center 
Program grant) 

o 

o 

o 

o 

Community health center (non-FQHC) 

Hospital/medical center 

Local health department 

School system 

o  Mental health agency 

o 

o 

o 

o 

Private, non-profit organization (not a community health center) 

University (i.e., school of medicine, nursing, public health) 

Tribal government 

Other, please specify:  

_ 

F.  The geographic location of the community served by the health center is described primarily as (select one): 

o 

o 

o 

Urban 

Rural 

Suburban 

2.  HEALTH CENTER OPERATIONS 

A. 

In what year was the health center first established?    

 

B.  During the 2013-14 school year, how many days each week was the health center open?   

C.  During the 2013-14 school year, how many hours per week was the health center open?   

 

 

D. 

Indicate when the health center was open during the 2013-14 school year (select all that apply): 

Yes 

No 

Do not know 

Before the school day begins 

After the school day ends 

During school hours 

During school vacations/ holiday breaks 
(i.e., Thanksgiving, winter, spring break) 

During summer months 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

E.  Does the health center have a prearranged source of after-hours care (i.e., on-call services provided by the sponsoring 

agency, health center staff, or external agency)? 

o  Yes 
o  No 

76 

 

 

 

 
 

 

 

 

3.  HEALTH CENTER CARE TEAM 

A.  This table is about your health center’s staffing. Include all staff, even those employed by other agencies. Do not include 

interns, volunteers, peer educators, etc. 

Total hours per week: For each staff person, write in the total clinical hours per week that person is physically at the health center or 
providing the service via telehealth technology. If a person serves many functions, select the position that describes the majority of 
their work at the health center. If more than one person fills a position, add together all the hours for that position. (For example, if two 
NPs each work 5 hours per week, write in 10 hours.) 

Total clinical hours per week 

Total clinical hours per week via 

on-site 

telehealth 

Nurse practitioner 

Physician 

Physician assistant 

Alcohol and drug counselor 

Licensed social worker/counselor/therapist 
Unlicensed social worker/counselor/therapist 

Psychiatric nurse practitioner 

Psychiatrist 

Psychologist 

Administrative assistant or receptionist 

Medical assistant or health aide 

Care coordinator 

Case manager/social services 

Dental assistant 

Dental hygienist 

Dentist 

Health educator 

Licensed practical or vocational nurse 

Nutritionist 

Ophthalmic tech 

Optometrist or ophthalmologist 

Outreach coordinator 

Registered dietician 

Registered nurse 

Other health center staff, please specify. 

 

 

 

 

 
 
 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please add any relevant comments concerning the health center staffing: 

 

 

 

 

 
 
 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

77 

 

 
 

 

 
 

 

 
 

 

 

 

B.  The following staff are (select one): 

School nurse 

School behavioral health provider 

Not in the 

school 

In the school but 

separate from 

the health center 

In school and co- 
located with the 

health center 

Do not know 

o 

o 

o 

o 

o 

o 

o 

o 

4. 

HEALTH CENTER PARTNERSHIPS 
A.  Does the health center have a memorandum of understanding (MOU) that includes any of the following components 

with the school and/or school district (select all that apply)? 

Formal outline of partner roles and responsibilities 

Expectations for services provided by each agency (i.e., in-kind space, 
janitorial support, etc.) 

Data sharing protocols as it relates to HIPAA and FERPA 

Other, please specify: 

Yes 

No 

Do not know 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

B. 

In what school teams/committees does your health center participate (select all that apply)? 

Curriculum development committee 

Crisis management or early intervention team 

Individuals with Disabilities Education Act (IDEA) team 

School improvement team 

School wellness committee (i.e., coordinated school health or other school wellness 
committee) 

School district wellness committee 

Other, please specify:   

 

5. 

PRIMARY CARE 

Yes 

No 

Do not 

know 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

A.  Do you provide primary care onsite, which includes comprehensive health assessments, diagnosis, and treatment of 

minor, acute, and chronic medical conditions, and referrals to, and follow-up for, specialty care? 

o 

o 

o 

Yes 

No 

Do not know 

78 

 

 

 
 

 

 

 
 

 

6.  VISION SERVICES 

A.  Does the health center offer vision services including screening, examination, and/or dispensing of  eye glasses (select all 

that apply)? 

Screening 

Examination 

Dispensing of eye glasses 

Provide onsite  Refer for services 
not provided at 
the health center 

Not provided or 

Do not know 

referred 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

7.  CHILD AND ADOLESCENT IMMUNIZATIONS 

A.  Do you provide any of the following immunizations (individually or in combination) to children or adolescents 

(select all that apply)? 

Provide onsite 

Refer for services 
not provided at 
the health center 

Not provided or 

referred 

Do not 
know 

Diphtheria/Tetanus/Acelluar Pertussis 
(DtaP, Tdap, or Td)) 

Haemophilus influenza tybe b (Hib) 

Hepatitis A 

Hepatitis B 

Inactivated Poliovirus (IPV) 

Influenza 

Human Papilloma Virus (HPV): male 

Human Papilloma Virus (HPV): female 

Measles-Mumps-Rubella (MMR) 

Meningococcal (MCV4) 

Pneumococcal (PCV, PPV) 

Rotavirus (Rota) 

Varicella (Varivax) 

Other, please specify: 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

79 

 

 

 
 

 

 
 

 

8. 

SEXUAL AND REPRODUCTIVE HEALTH 

A. 

Indicate which of the following sexual and reproductive health services are provided by the health center (select all that 
apply). 

Provide onsite 

Refer for services 
not  provided at the 

health center 

Not provided or   

Do not know 

referred 

Abstinence counseling 

Chlamydia testing and treatment 

STD diagnosis and treatment 

Counseling for contraceptive services 

Contraceptive (prescriptive) services 

Gynecological examinations 

HIV testing and counseling 

Papanicolaou (Pap) test 

Pregnancy testing 

Prenatal care 

Relationship violence (counseling/intervention) 

Sexual orientation education and counseling 

Testicular examinations 

Other, please specify: 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

B. 

Indicate which of the following contraceptive/barrier methods are provided to individual students (select all that apply). 

Provide 
onsite 

Prescribe onsite 

Refer for 

services not 
provided at 
the health 

center 

Not provided 
or   referred 

Do not 
know 

Barrier methods (i.e., male or female condoms, 
diaphragm) 

Hormonal methods (i.e., birth control pills, 
depo-provera, patch (OrthoEvra), ring 
(NuvaRing)) 

Implantable devices (i.e., implant (Nexplanon), 
intrauterine device (IUD)) 

Emergency contraception 

Other:   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

80 

 

 
 

 
 

 

 
 
 

 

C. 

Is the dispensing of prescribed contraceptives prohibited in the health center? 

o 

o 

o 

Yes 

No 

Do not know 

D.  By whom is this prohibition made (select all that apply)? 

State law/regulation 

State policy 

School district policy 

School policy 

Sponsor policy 

Health center policy 

Other, please specify: 

9.  BEHAVIORAL HEALTH 

Yes 

No 

Do not know 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.  Does the health center provide screening/assessment, referral, or treatment of any of the following behavioral 

health issues (select all that apply). 

Screening/ 
Assessment 

Treatment 

Refer for 

services not 

provided at the 

health center 

Not provided 
or referred 

Do not 
know 

Academic functioning 

Anxiety/nervousness/phobias 

Attention/concentration/ADD/ ADHD 

Depression/sadness 

Eating disorders 

Grief/loss/bereavement 

Identity issues 

Oppositional/defiant behavior/anger 

management 

Social skills/relationship issues/conflict 
(family, peers, partners) 

Strengths/resiliency factors 

Substance use (alcohol, tobacco and/or 
drugs) 

Suicidal ideation/attempt 

Trauma/abuse/exposure to 
violence/PTSD 

Other, please specify: 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

81 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

 

 
 
 

 

 

 
 

 

B.  Does the health center prescribe and/or manage behavioral health medications (select all that apply)? 

Prescribe 

Manage 

Co-manage 

10.  ORAL HEALTH 

Yes 

o 

o 

o 

No 

Do not know 

o 

o 

o 

o 

o 

o 

A. 

Indicate which of the following oral health services are provided to individuals by the health center (NOTE: 
Unless indicated, check off the services provided at your health center regardless of who provides the service) 
(select all that apply). 

Provide 
service 
onsite 

Provide service 
through mobile 

unit 

Refer for 

services not  

provided at the 

health center 

Not provided or 

referred 

Do not 
know 

Comprehensive dental 
examination and diagnosis by a 
dentist 

Comprehensive dental 
examination and diagnosis by a 
dental hygienist or therapist 

Dental screenings (i.e., visual 
inspection and assessment) 

Dental sealants 

Fluoride mouthrinse 

Fluoride varnish 

Fluoride supplements 

Fluoride gel/foam 

Dental cleaning 

General dental care (i.e., 
fillings, extractions) 

Oral health education 

Specialty care (i.e., 
orthodontics, oral surgery) 

Other, please specify: 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

82 

 

 
 
 

 

B.  Which of the following oral health services do primary medical care professionals provide at the health center (select all that 

apply)? 

Dental screenings 

Education 

Guidance/referral 

Prescribe fluoride supplements 

Preventive services: fluoride treatments 

Preventive services: sealants 

Risk assessment 

Other, please specify: 

Yes 

No 

Do not know 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

83 

 

 

 
 

 

Substance Use Prevention 

Tobacco, alcohol, drug use, 
and/or highly caffeinated 
beverages prevention) 

Injury and Violence Prevention 

General violence prevention 
(fighting, guns, gangs) 

Dating and intimate partner 
violence prevention 

Suicide prevention 

 

 

 

 

Sexual and Reproductive Health and Behaviors 

HIV/STD prevention 

Pregnancy prevention - 
abstinence only 

Pregnancy prevention - 
comprehensive 

Sexuality education (forming attitudes, 
values, and beliefs that support the 
sexual health of youth) 

Sexual orientation/gender 
identity differences (LGBTQ 
respect) 

Teen parenting classes 

Healthy Living 

Healthy eating/active 
living/weight management 

Chronic disease management (asthma, 
diabetes) 

Oral health education and 
promotion 

Interpersonal relationships (race 
relations, conflict resolution, healthy 
dating) 

Emotional health and well-being 
(social/emotional learning, stress 
management, hopefulness) 

School safety/climate 

Positive youth development (skills 
building, youth engagement, 
multiculturalism) 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.  HEALTH PROMOTION AND DISEASE PREVENTION 

A. 

Indicate which of the following prevention/education activities are provided by the health center staff and to whom (select 
all that apply). 

Individually with a 
child/adolescent (1 

on 1) 

With groups of 

children/adolescents in 
the clinic or classroom 

Not 
offered 

Do not 
know 

With 
parents 

or 

community 
members 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

84 

 

 

 

 

 
 

 
 

 

 

Successful Learning 
Dropout prevention, school/academic 
performance intervention, and/or school 
attendance 

Other, please specify 

 

 

12.  HEALTH INFORMATION TECHNOLOGY 

 

 

 

 

 

 

 

 

A. 

Is the health center able to access students’ individual educational data (i.e., attendance records, discipline 
action, grades)? 

o 

o 

o 

Yes 

No 

Do not know 

B. 

Indicate whether the health center uses any of the following (select all that apply): 

Yes 

No 

Do not know 

Electronic health/medical record (EHR/EMR) 

Management information system (MIS)/Practice 
management system 

Electronic billing system 

Electronic prescribing 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

C. 

Is there a common EHR/EMR used by primary care providers and behavioral health providers? 

o  Yes 
o  No 
o  Do not know 

D.  Has having an EHR/EMR allowed you to achieve any of the following stages of “meaningful use” as defined by the 

Centers for Medicare and Medicaid (CMS) (select all that apply): 

o 

o 

o 

o 

Stage one 

Stage two 

Health center does not have an EHR/EMR 

Do not know 

85 

 

 

 
 

 

 
 

 

 
 

 

 

 

13.  BILLING AND REIMBURSEMENT FOR STUDENTS 

A.  Does your health center bill any of the following entities for services provided to students (select all that apply)? 

Medicaid:  State agency 

Medicaid:  Managed Care Organization (MCO) 

Children’s Health Insurance Program (CHIP) 

Private/commercial insurance 

Tri-Care (military insurance program) 

State family planning programs 

State programs for the medically indigent 

Patients or families (self-pay) 

Other, please specify:   

 

Yes 

No 

Do not 
know 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

B.  What types of health insurance payment does the health center receive (select all that apply)? 

Fee for service 

Monthly or annual capitated payments for primary care 

Monthly or annual capitated payments for care coordination 

Supplemental payments for meeting performance standards 

Other, please specify:   

 

Yes 

No 

Do not 
know 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

C.  Who administers billing and collection for the health center (select all that apply)? 

SBHC Staff 

Medical sponsor staff 

Third-party billing service 

Other, please specify: 

Yes 

No 

Do not know 

 

 

 

 

 

 

 

 

 

 

 

 

D.  Estimate the percent of your total operational expenses that are covered by billing revenue. 

  

% 

E.  How does your health center assist in enrolling children/families in health insurance coverage (select all that apply)? 

o 

o 

o 

Enrollment completed onsite at health center 

Assistance completing forms provided by health center 

Referred to enrollment site outside of health center 

o  No assistance

86 

 

 
 

 

 

 
 

 

F.  Which of the following describes the SBHC’s relationship with any managed care organization (select all that apply)? 

SBHC serves as a PCP/preferred provider/ medical home 

SBHC serves as a specialty care provider (i.e., behavioral health, family 
planning) 

SBHC is not recognized as preferred provider, but is reimbursed for some 
services 

Other, please specify:   

 

14.  NON-BILLING SOURCES OF REVENUE/FUNDING 

Yes 

No 

Do not 
know 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

A.  What are the sources of revenue/funding that support the health center (do not include in-kind donations or billing 

revenue) (select all that apply)? 

Yes 

No 

Do not know 

Federal government 

State government 

County/city government 

Tribal government 

Private foundations 

Corporations/businesses 

Hospital 

School/school district 

Managed care organization or private insurer (a grant or 
donation, not patient revenue related) 

State network/association 

School-Based Health Alliance (formerly the National Assembly on 
School-Based Health Care) 

Other, please specify:   

 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

87 

 

 

 
 

 

 

B. 

If you receive support from the federal government, indicate the funding sources for your health center during the 
2013-14 school year (select all that apply): 

Federal Funding Sources: 

Yes 

No 

Do not 

know 

CDC Community Transformation grants 

CDC RFA-1308: Promoting Adolescent Health Through School-Based 
HIV/STD Prevention and School-Based Surveillance 

Indian Health Services 

Nurse-Managed Health Clinics T56 (Affordable Care Act) 

Substance Abuse and Mental Health Services Administration’s 
(SAMSHA) Centers for Substance Abuse Treatment and Prevention’s 
Safe School/Health Communities 

School-Based Health Center Capital Program (HRSA) 

Section 330 PHSA (community/migrant/rural health centers) 

TANF (Temporary Assistance to Needy Families) 

Teen Pregnancy Prevention programs 

Title I ESEA (Elementary Secondary Education Act) 

Title V SSA (Social Security Act-maternal and child health block 
grant) 

Title X PHSA (Public Health Service Act-family planning) 

Title XX SSA (social services block grant) 

Other, please specify:   

 

15.  HEALTH CENTER ACCESS POLICIES 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

A.  Do parents have the ability to restrict access to specific services? (For example, parents can cross off specific services 

on the consent form.) 

o 

o 

o 

Yes 

No 

Do not know 

B.  Most states allow minors to access sensitive services (i.e., reproductive health, behavioral health, and substance use 

prevention) without parental consent. Indicate which of the following best describes student access to sensitive 
services in your health center (select one). 

o 

In accordance with state law 

o  More restrictive than state law 

o 

Do not know 

88 

 

 

 
 

 

 
 

 

 

16.  HEALTHCARE QUALITY 

A. 

Indicate which of the following components of a quality assurance system are used by the health center (select all that 
apply): 

Yes 

No 

Do not know 

Chart audits 

Staff credential and training requirements 

Policies and procedures 

Standards for the physical environment 

Measures of patient knowledge 

Clinical Laboratory Improvement Act (CLIA) certification 

Measures of patient satisfaction 

Data reports from electronic medical record 

Review of claims data 

Other, please specify:   

 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

B.  Does the health center collect quality outcomes data based on (select all that apply): 

Healthcare Effectiveness Data and Information Set (HEDIS) measures 

Yes 

No 

Do not 
know 

Recommended core set of child health quality measures 
(CHIPRA/Medicaid) 

State-defined tool/measures 

Sponsor-specific tool/measures 

SBHC-developed tool/measures 

School-Based Health Alliance CQI for SBHC Tool 

School-Based Health Alliance Mental Health Program Evaluation Template 

Other, please specify:   

 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

C.  Does the health center use any of the following risk assessment screening tools (select all that apply)? 

o 

o 

o 

o 

o 

o 

o 

Bright Futures 

The CRAFFT screening tool 

Guidelines for Adolescent Preventive Services (GAPS) 

H.E.A.D.S.S. 

Patient Health Questionnaire (PHQ7, PHQ9, or PHQ15) 

Rapid Assessment for Adolescent Preventive Services (RAAPS) 

Screen for Child Anxiety Related Disorders (SCARED) 

o 

Other, please specify:   

89 

 

 
 
 

 

 
 

 

D.  Does the health center collect any data for quality improvement (i.e., % clients with BMI assessment; % clients with 

complete immunizations)? 

o  Yes 
o  No 
o  Do not know 

E.  Has your health center been accredited, directly or through your sponsoring agency, by any of the following (select all 

that apply): 

Yes 

No 

Plan to pursue in the 

next 12 months 

Do not know 

Joint Commission 

National Committee on Quality Assurance (NCQA) 

State certification (indicate type  

) 

Other, please specify: 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

F.  Has your health center been recognized as a patient-centered medical home by any of the following (select all that 

apply)? 

Joint Commission 

National Committee on Quality Assurance (NCQA) 

State-specific program (indicate 
type  
) 

Other patient-centered medical home 

recognition: 

Yes 

No 

Plan to pursue in the 

next 12 months 

Do not know 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

90 

 

 

 

 

 

 

17.  SCHOOL/CAMPUS DEMOGRAPHICS 

A. 

Indicate the grade levels served by the health center (select all that apply). (For campuses with more than one school 
served by the health center, include every grade. For school-linked programs, estimate grade levels served and describe in 
“Other”.) If you are uncertain about this answer, you can find the information at http://nces.ed.gov/globallocator/. 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

Pre-K 

K 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

Other, please specify:   

 

B.  What is the 2013-2014 academic year official school enrollment for the school/campus in which the health center is located? 

If your health center serves more than one school, list the official total enrollment of all the schools served. For school -linked 
programs, answer not applicable. (If you are uncertain about this answer, you can find the information at 
http://nces.ed.gov/globallocator/): 

  

 

C.  What  is  the  total  student  health  center  enrollment  for  2013-2014  academic  year  (students  with  consent  to  use  or 
registered to use the health center, although they do not have to be seen)? For school-linked programs, answer not applicable.  
 

D. 

In the 2013-2014 academic year, the ethnic/racial profile of the student population at the school/campus in which the health 
center is located was: (If you are uncertain about this answer, you can find the information at http://nces.ed.gov/globallocator) 
(For school-linked programs, provide an estimate based on patients served.): 

o 

o 

o 

o 

o 

Hispanic or Latino of any race  

% 

American Indian or Alaskan Native  

% 

Asian  

% 

Black or African-American  

% 

Native Hawaiian or other Pacific Islander  

% 

o  White  
o 
Two or 
more races  

% 

% TOTAL =100% 

E. 

In the 2013-2014 academic year, what percent of the student population at the school/campus in which the health center is 
located was eligible for the free- or reduced-price lunch program? (If you are uncertain about this answer, you can find the 
information at http://nces.ed.gov/globallocator/) (For school-linked programs, provide an estimate based on patients served.) 
  

% 

91 

 

 
 

 

 

 
 

 

F.  Can the school in which you are located be characterized as any of the following? (If there is more than one 

school in the building in which you are located and you provide services to those students include that type of 
school in your selection.) (For school-linked programs, answer not applicable.) Select all that apply. 

Yes 

No 

Not 

applicable 

Do not 
know 

Title I School (receives funding from US Dept. of Education to 
meet needs of at-risk and low-income students. If you are uncertain 
about this answer, you can find the information at 
http://nces.ed.gov/globallocator/) 

Charter School (public school operated independently of the local 
school board, often with a curriculum and philosophy different from 
the rest of the district) 

Parochial/Private School (funded by a religious organization, 
individuals, or corporation) 

Alternative School (offers nontraditional educational ideals, 
methods of teaching, or curriculum) 

Vocational School (often on the secondary level and offers 
instruction and practical experience in skilled trades) 

Magnet School (public school with specialized curriculum and 
student body representing a cross section of the community) 

Traditional Public School (supported by public funds and 
providing free education for children of a community or district) 

Community School (school with a school site leadership team 
including school staff, families, community members, and partner 
organizations with a designated coordinator responsible for 
coordinating partnerships focused on results, i.e., Beacon school, 
full-service school) 

Other, please specify:   

 

18.  YOUTH AND PARENT/GUARDIAN INVOLVEMENT 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

A.  Other than as patients, are students and parents/guardians involved in your health center in any of the 

following ways (select all that apply)? 

Students 

Parents/Guardians 

No involvement of 

students or 

parents/guardians 

Do 
not 
know 

Participate in organizing center-sponsored health 
education events (i.e., health fair) 

Participate in peer mentoring, counseling, or 
education 

Advocacy activities (local, state, or national) 

Participate in health center advisory council, 
committee, or board 

Participate in the design of health services 

Promote health services provided by health center 

Provide feedback to the health center 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

92 

 

 

 
 

 
 
 

 

 

 

 

Other, please specify:   

 

o 

o 

o 

o 

B.  Which of the following methods do you use to communicate with students and parents/guardians (select all 

that apply)? 

Students  Parents/Guardians 

Do not use this method with students or 

parents/guardians 

Do not 

know 

Email 

Social media (i.e., Twitter, Facebook) 

SBHC website or school website 

Blog 

Phone 

Text message 

Written material (i.e., brochure, 
newsletter) 

Other, please specify: 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

THANK YOU FOR COMPLETING THE 2013-14 CENSUS! 

 

93 

 

 

 

 
 
 

APPENDIX B: State Policy Survey 

FY 2014 School-Based Health Care (SBHC) Policy Assessment - 

State School-Based Health Center (SBHC) Program Office Survey 

 
1. 

 
2. 

 
3. 
 
4. 

 
5. 

The state school-based health care (SBHC) policy assessment should be completed by the person(s) most knowledgeable about 
state-level policies, funding, and program support related to SBHCs.  

For question #1, please provide the name and contact information for the primary respondent.  Please provide the contact 
information for secondary respondents at the end of this survey. 

It should take approximately 30 minutes to complete this survey.  

Please review instructions on how to “save and continue” at the top of the online survey page. 

If you are unable to complete every question, please forward the word document version of this survey (emailed to you) to the 
most appropriate person. 

 
6.  All questions refer to fiscal year 2014. 
 
7.  Deadline: November 7th, 2014 

Definitions. For the purpose of this survey, school-based health centers (SBHCs) are located in or near a school; are organized through school, 
community, and health provider relationships; are administered by a sponsoring facility such as a hospital, community health center, university, 
or public health department; and provide primary health care services to children in accordance with State and local law, including laws relating 
to licensure and certification. 

The term school-based health center does not refer to school health services identified in Individualized Education Plans (IEP) for special 
education students and delivered by Local Education Agencies (LEAs).   
 
About the Respondent 
 
1.  Respondent  #1: 
 

           

 

 

 

 

 

 

 

 
 

 
 

Title: 
Org: 
Street:        _______________________________________ 
City/State/Zip:  
Phone number:  
Email: 

 
 
 

 
 
 

 
 
 

 
 
 

 
 

 
 

 
 

 

 
 

 
 
 

 
 

 
 
 

 
 

 
 
 

 What is the total number of SBHCs in your state? ___________ 

 
SBHCs in Your State 
 
2. 
 
3.  Does your State define SBHCs in law or regulation? 
 
 
 

 Do not know  

 Yes 

 No 

     

 Other, please specify: __________________________________________ 

 

If yes, please provide a citation to this definition: ____________________________________________________________ 

 
4. 
 
SBHC Funding 
 
5.  Does the state fund or sponsor a grant program dedicated specifically to SBHCs? 

 

a) 

 

 

 Yes 

 

 No  

 

 

Please indicate the source and amount of funds granted to SBHCs in fiscal year 2014.  

Grant Program Funding Sources 
Title V MCH  
State General Fund 

Amount 
$           
$           

94 

 

 

 
 

 

 

Tobacco Settlement 
Preventative Services Block Grants 
Other (please specify):  
Total 

$           
$           
$           
$ 

b)  What is the total number of SBHCs that were funded by the state-directed grants in fiscal year 2014?             

 

6.  Which state agency is responsible for administration of grant program or funds to state’s SBHC program? Check all that apply.  
 
 
 
 
 
 
 
7. 

 Public Health 
 Mental Health 
 Education 
 Human Services 
 Do not know 
 Other, please specify: _______________________________ 

Is your state implementing patient-centered medical homes (PCMH) for their school-aged Medicaid populations?  

 Yes 

 No 
SBHC Oversight and Support).  

 

(skip to question 10 – SBHC Oversight and Support) 

 Do not know (skip to question 10 – 

8. 

 
9. 

 

 If yes, are SBHCs included and/or participating in the PCMH program? 

 Yes, all SBHCs 

 Yes, some SBHCs  

 No 

 

 Do not know 

  Do SBHCs qualify for any of the following enhanced Medicaid payments offered to     
  participating PCMH providers? Check all that apply. 

 Per member per month (PMPM) care coordination payment 
 Higher primary care payment levels 
 Pay for performance payments or bonuses 
 Other, please specify:__________ 
 Do not know 
 Not applicable 

 
SBHC Oversight and Support 
 
10. 

 Is there a state government program office or unit that is responsible for providing oversight and support to state-funded SBHCs? 

 Yes 

     

 No (skip to question 26 – Future Outlook for SBHCs)   

 Do not know (skip to question 13) 

 
11.  How many Full Time Equivalents (FTEs) staff this state program office?   
 
 
12. 

           FTEs 

 What are the top 3 most requested topics of technical assistance that this state program office provides? Please check 3 options only. 

 

 Planning/implementing an SBHC 
 Training for SBHC staff 
 Program evaluation 
 Financial sustainability 
 Quality assurance 
 Clinical guidelines  
 Coding and billing 
 Assistance with certification, licensing and accreditation 
 None 
 Do not know 
 Other, please specify: 

 

 

 

 

 

 

 

 Does the state government program collect data from SBHCs? 

 Yes 
 No (skip to question 18) 
 Do not know (skip to question 18) 

 
 

 If yes, what types of data are collected? Check all that apply.  

 Operations data (i.e., staffing, hours, policies) 
 Client/visit data 
 Risk assessment data 
 Quality improvement data 
 Finance data 
 Do not know 
 Other, please specify: 

 

 

 

 

 

 

 

 

 Describe state requirements for SBHC data collection. Check all that apply.  

 Mandatory for SBHCs funded by state 
 Mandatory for SBHCs not funded by state 
 Voluntary for SBHCs funded by state 

95 

 

 
 
 
 
 
 
 
 
 
 
 
13. 

 
14. 
 
 
 
 
 
 
 
 
15. 
 
 
 

 

 

 

 
 
16. 

 Voluntary for SBHCs not funded by state 
 Do not know 
 Other, please specify: 

 

 

 

 

 

 

 

 

 Which of the following performance indicators does the state government program use to assess SBHC performance/productivity?  Check 
all that apply.  

 Access measures (waiting times, etc.) 
 Annual risk assessments 
 Asthma care 
 BMI assessment 
 Chlamydia screening 
 Patient satisfaction 
 Depression screening 
 Diabetes care 
 HIV screening 
 Immunization status 
 Oral health assessment 
 Physical exams/well child visits 
 Pregnancy testing 
 Provider productivity 
 SBHC enrollment as percent of student body 
 Poor school performance 
 Substance use (alcohol and other drugs) screening 
 Tobacco use screening 
 Users as percent of SBHC enrollees 
 No performance indicators are tracked 
 Other, please specify:   ______________________ 

 Yes 

 

 No 

 

 Do not know 

 Does the state government program review SBHC Medicaid or CHIP claims data as part of assessing SBHC performance? 

 Yes, as a requirement for state grants 
 Yes, as a requirement for Medicaid billing 
 State does not certify or credential SBHCs 
 Do not know 

 
17. 
 
 
 
 
SBHC Policies and Standards 
 
18.  Does the state certify or credential SBHCs? Check all that apply.  
 
 
 
 
 
19. Does the state require SBHCs to adhere to state-defined operating standards? Examples of state standards can be found on the School-Based 
Health Alliance website. 
 
 
 
 
 
20.  How does the state monitor compliance with SBHC standards? Check all that apply.  
 
 
 
 
 
 
21.  What is the state’s response to SBHCs found to be out of compliance with state standards? Check all that apply.   
 
 
 
 
 
 
22.  Which of the following represent barriers for SBHCs to improving patient revenue collection? Check all that apply.   

 State funds are rescinded or revoked 
 SBHC issued warning or placed on probationary period 
 SBHC standards are not enforced 
 Do not know 
 Other, please specify: ____________________________________________ 

 Yes, for state funded SBHCs only 
 Yes, for all SBHCs regardless of funding source 
 No (skip to question 22) 
 Do not know (skip to question 22) 

 Site review by state government representative 
 Paper survey/report completed by site 
 State does not monitor its SBHC standards 
 Do not know 
 Other, please specify:  

 

 

 

 

 

 

 

 

 SBHCs lack administrative infrastructure to bill Medicaid 
 SBHCs cannot cover costs associated with Medicaid billing 
 SBHCs unable to manage complexity of Medicaid MCO contracts 
 SBHCs lack support for SBHC billing and collection from sponsor organization 
 SBHCs lack knowledge of proper Medicaid billing practices 
 Medicaid reimbursement does not provide enough financial incentive for SBHC to bill 
 SBHCs have inadequate information technology 

 

96 

 

 

 There are no SBHC practice-level barriers to Medicaid reimbursement in my state 
 Other, please specify in comments: _________________________ 

 

 
23.  Regarding Medicaid Managed Care organizations (MCOs) within your state, please indicate if any of the following represent barriers to 
SBHC Medicaid reimbursement. Check all that apply.   
 There are no Medicaid MCOs in our state 
 MCOs lack of knowledge of SBHC value  
 Contracting with multiple MCOs is burdensome to SBHCs 
 SBHCs inability to track MCO quality measures 
 Limited capacity of SBHCs to demonstrate its value to MCOs 
 SBHCs inability to meet MCO facility and/or provider requirements 
 Limited number of MCO enrollees served by SBHCs 
 SBHCs inability to exchange patient encounter information with MCOs 
 There are no MCO practice-level barriers to SBHC Medicaid reimbursement 
 Other, please specify: _________________________ 

 
 
 

24.  Does the state prohibit contraceptives from being dispensed in SBHCs? 

 Yes 

 
 

 No (skip to 26)  

 Do not know (skip to 26) 

25.  If yes, what is the source of the prohibition? Check all that apply.  

 State law 

 State regulation 

 Other, please specify: ___________________ 

 
Future Outlook for SBHCs 
 
26.  In the next three years, do you expect that state-level financial support for SBHCs will increase, decrease, or stay the same?  
 
 
27.  Of the issues below, which do you consider to be the top three concerns with regards to growing and sustaining SBHCs in your state? Please 
check 3 options only. 
 

 Stay the same   

 Do not know 

 Increase 

 

 Decrease 

 

 
 
 
 
 
 

 

Creating a sustainable financial model for SBHCs 
Ensuring continued support of SBHCs through public sector funding 
Establishing policies and mechanisms to maximize patient revenue streams 
Demonstrating the value and efficacy of SBHCs to health insurance and health care plans. 
Maintaining strong partnerships with schools and local health providers  
Effectively addressing complex health and behavioral health issues  
(mental health, substance abuse, school performance) of children and youth 
I am not concerned about growing or sustaining SBHCs in my state 

      _____  Other, please specify:____________ 
 
28.  Please rate the degree to which the following strategies affect SBHC funding:  

 

Not effective 

Some-what 
effective 

Effective 

Very 
effective 

Do not know 

 Grassroots advocacy  by providers, community 
leaders, consumers 
Support from state health agency leadership/ staff 
Support from state education agency leadership/ 
staff 
Political support from executive branch 

Political support from legislative branch 

Strong data or evidence of SBHC’s effectiveness 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

97 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

REFERENCES 

 

 

 
 
 

98 

 

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