Building sustainable health and education partnerships: stories from local communities.

BACKGROUND: Growing health disparities have a negative impact on young people's educational achievement. Community schools that involve deep relationships with partners across multiple domains address these disparities by providing opportunities and services that promote healthy development of young people, and enable them to graduate from high school ready for college, technical school, on-the-job training, career, and citizenship.
METHODS: Results from Milwaukie High School, North Clackamas, OR; Oakland Unified School District, Oakland, CA; and Cincinnati Community Learning Centers, Cincinnati, OH were based on a review of local site documents, web-based information, interviews, and e-mail communication with key local actors.
RESULTS: The schools and districts with strong health partnerships reflecting community schools strategy have shown improvements in attendance, academic performance, and increased access to mental, dental, vision, and health supports for their students.
CONCLUSIONS: To build deep health-education partnerships and grow community schools, a working leadership and management infrastructure must be in place that uses quality data, focuses on results, and facilitates professional development across sectors. The leadership infrastructure of community school initiatives offers a prototype on which others can build. Moreover, as leaders build cross-sector relationships, a clear definition of what scaling up means is essential for subsequent long-term systemic change.

The movement toward health equity, with its focus on community and the role of cross-sector leadership, nudges leaders, citizens, institutions, and organizations to examine linkages between educational success and health. Of particular concern are health disparities among youth across socioeconomic and racial/ethnic groups that can have a negative impact on educational achievement. High rates of chronic absence and suspensions from school, and low levels of third-grade reading scores, are often rooted in health issues.1 Research suggests correlations between academic success and vision challenges, asthma, teen pregnancy, aggression, violence, and lack of physical activity.2 From a healthy school community perspective, it is difficult to ignore the findings that high school graduates are far more likely to pursue a healthy lifestyle.3

Previous studies support the proposition that achieving health equity and education equity is not distinct challenges but rather demand a joint enterprise between education and health leaders. Such joint enterprises come together around the recognition of a strategic interdependence—healthy students are better learners and health providers can get better health outcomes by reaching children in schools.2,3 Accomplishing these intertwined goals can have even broader impact. In addition to educating students, schools can play a more central role in fostering healthy families and communities. Moreover, health organizations know that efforts to address the social determinants of health require the institutional commitment of schools.3

Schools that fit this mold are community schools, typically with full-time coordinators, where educators and community partners come together to ensure not only the healthy development of young people but also that they and their families have access to a broad array of opportunities that will support their learning and growth.4 Health agencies and institutions have a vital role to play in making this vision a reality.

Recent years have seen tangible progress in programmatic partnerships between health and education—health clinics, healthy eating and living programs, mental health services, and school gardens.2–4 Now, we need to move toward more systemic partnerships built on the vision of community schools. This article uses the experience of the Milwaukie High School (MHS) in Clackamas County Oregon; the partnership between the Alameda County Health Services Authority and the Oakland Unified School District (OUSD), which is becoming a full-service community school district; and the relationship between Cincinnati's Community Learning Centers (CLCs) and Growing Well, a health collaboration in the city, to illustrate key dimensions of systemic partnerships.

REVIEW OF LOCAL INITIATIVES

Milwaukie High School

Present, engaged, and moving toward graduation—these goals drive MHS in Clackamas County near Portland, Oregon. Milwaukie High School demonstrates that when health and education stakeholders work together, they can address the needs of a diverse student body and get results.

Attendance and achievement in reading, writing, and math have improved dramatically over the past 4 years at MHS. Family engagement is at an all-time high. Average daily attendance grew over the past 4 years, from 87 to 94%. Reading proficiency increased from 55 to 81%, math from 41 to 73%, writing from 48 to 62%, and the school's state rating moved from “Needs Improvement” to “Outstanding.”5 Principal Mark Pinder attributes these significant improvements “to the school staff and personnel of community partners who have come together to support Milwaukie students” (M. Pinder, personal communication, January 7, 2015).

Assistant Principal Michael Ralls was a key player in advocating the health focus. Together with Pinder, Ralls reached out to key individuals and convened a planning committee that included people from Clackamas County, the Meyer Memorial Trust, Outside In, Providence Health Services, and Trillium Family Services as well educators and students. The committee decided that focusing on partnerships to meet health and mental health needs and developing a more engaging curriculum was the path to increasing student attendance and engagement. This committee continues to function to review what is working, add services at MHS, and organize support at other schools to impact more students across the district.

Milwaukie High School now has alliances with 11 community partners. Ralls led the drive to raise over $600,000 in federal funds for a 2800 square foot, state-of-the-art, school-based health center. The center's medical sponsor, Outside In, provides free physical, emotional, and dental health services to all students based on self-referrals or referrals from the MHS Care Team.

The MHS CareTeam—school counselors, mental/physical health partners, social workers, and administrators—meets weekly to discuss students in need. Names come from attendance data, as well as directly from teachers. Looking at available data and information, the team develops an action plan with referrals to school staff and community partners to support the student. Milwaukie High School also has health support from University of Oregon Health Sciences' social work interns, an alcohol and drug abuse counselor from Volunteers of America, a food pantry in partnership with the local food bank, and a dental hygienist office is in the school on a weekly basis.

The District Attorney and Police Department support an on-site truancy program. The School Resource Officer of the Milwaukie Police Department works in tandem with the Dean of Students to deliver mandatory attendance meeting letters personally to parents. At these meetings, the parent, counselor, and Dean along with the student develop a plan to support attendance, which may include providing other community resources.

Active learning about health issues is also on the MHS agenda. Milwaukie partners with Oregon State University on classes discussing how to make healthy, cost-effective meals, and with the Rotary Club, to map food providers near the high school and calculate the nutritional value of foods in the area.

A social justice and equity thrust permeates MHS. All school personnel received equity training. Student groups such as the Students of African American and African Heritage Association, Latino Focus, and the Multicultural Club address equity issues. The school's HOPE (Help Our People Exceed) group advocates for the Student Health Center. Pamela Rook, HOPE's advisor states: “This equity focus has driven the student advocacy group for our School-Based Health Center. Affordable, accessible health care is, we believe, an important aspect of success in school. This is the message we have taken to our state legislators and county commissioners” (P. Rook, e-mail communication, March 9, 2015).

Community activism is part of the MHS engagement strategy. Students support the Red Cross the American Cancer Society, and Habitat for Humanity. Science classes participate in wetland restoration and salmon hatching. Students also participate in Community 101, an Oregon Community Foundation program, where students give grants to nonprofits and volunteer in the community.

A school-wide priority is to help incoming students and their families understand and access available services that support their children's learning and development. The focus is on helping students improve their reading, writing, and math skills and access health and other available supports.

Family engagement activities include 2 parent meetings a month, 1 in English and 1 in Spanish, and biyearly academic honors awards with only standing room available in MHS' auditorium. MHS also hosts Milwaukie Cares Carnival to support homeless families, a multicultural pot luck dinner, and Noche Latina (a Hispanic heritage celebration), all to draw families in to support their school and students.

Active engagement is also at the heart of the North Clackamas School District's framework for teaching and learning. The framework helps students build academic language, access background knowledge, demonstrate learning, and check for understanding. Milwaukie High School instructional leadership team assists teachers to design and modify curriculum and instruction through weekly Professional Learning Community meetings, using diagnostic, formative, and summative assessments. The Instructional Leaders Team guides professional development that focuses on student engagement and individualized instruction.

Students also can learn firsthand through internships and practicums in coordination through the district's Sabin Schellenberg Professional Technical Center. Students in the Health Sciences course, for example, participate in 4-week rotations depending on their career choice in physical therapy, surgical technology, diagnostic imaging, dentistry, nursing, obstetrics, veterinary medicine, and respiratory therapy at multiple hospital sites.

Principal Pinder sums up what makes MHS tick this way: “we work together to do what our kids need…we get volunteers and partners to support teachers, keep students voice in the mix, and keep our faculty in the loop. All of this has helped increase our graduation rates from 60% to over 73%. Our largest demographic subgroup of Hispanic students has graduation rate equal to that of white students” (M. Pinder, personal communication, January 7, 2015).

Alameda County Health Services Authority and Oakland Unified School District

The deep partnership between the Alameda County Health Care Services Authority (ACHCSA) and the OUSD seeks to attain health equity and education equity. The Health Authority always has been involved with the OUSD, however, that partnership moved to a new level when OUSD committed to becoming a full-service community schools district.

The leadership challenge facing Alameda County is daunting. Children, youth, and families still live, attend schools, and work in low-opportunity neighborhoods that have profound and long-term impacts on their health, education, and economic well-being. The data are stark: compared to a Caucasian child in the affluent Oakland Hills, an African American born in West Oakland is 1.5 times more likely to be born premature or with low birth weight; 7 times more likely to be born into poverty; 4 times less likely to read at grade level; 5 times more likely to be hospitalized for diabetes, and twice as likely to die of heart disease. The life expectancy differential is 15 years.6

Alameda County Health Care Services Authority's Center for Healthy Schools and Communities has been working since 1996 to address these challenges. The Center helps to build school-based, school-linked health and wellness programs that are built on local wisdom and aligned with nationally recognized, research-driven frameworks. Its work extends beyond simply placing health services on school sites; it is rooted in purposeful, culturally responsive collaborations with youth, families, schools, and surrounding institutions.

Recognizing the inseparable link between health and education, the Center defines its works in this way:

Together with our partners, we work to create a continuum of supports and opportunities in schools and neighborhoods that supplement schools' core instructional programs by promoting student wellness and removing barriers to learning. As schools focus on developing a strong curriculum, effective teaching, and an environment conducive to learning, our programs complement and strengthen this foundation by increasing student resilience and decreasing risk factors of school failure.7(p8)

The center is a unique entity within local public health departments with a staff of 11 people who provide capacity-building and program-development support. It has built partnerships with the county's 18 school districts by focusing on health indices most closely related to school success, such as attendance and teen pregnancy. By linking health, education, and communities, the Center leverages knowledge and expertise to build a quality education foundation for all youth, with community schools as the underlying framework.

The Center's work is funded within ACHCSA through the general fund, local tax measures, Medi-Cal administrative activities billing, and philanthropy. The Center's assets and expertise are vital to implementing the comprehensive community schools approach to transforming OUSD schools into centers of community that create the conditions for all children and their families to thrive.

Oakland Unified School District is in its seventh year of working to become a full-service community school district. Former Superintendent Tony Smith, now Illinois Chief State School Officer, lead a strategic planning process toward this goal. With an eye to eliminating historical inequity, OUSD's mission is to develop thriving students who are college, career, and community ready. A community schools leadership council, co-chaired by the district and the Center, guides the overall enterprise, mobilizes resources, and aligns public and private partners around shared results. Top leaders of major agencies sit on the council including OUSD, ACHCSA, the city of Oakland, the Alameda County Social Service Agency, First Five Alameda County, and local community-based organizations and institutions of higher education.

All schools in Oakland are moving along a continuum to become community schools. Twenty-four of the district's 86 schools now have a full-time community school manager employed by local community-based organizations or the school district. Each community school works to supports students in these areas: academic and social emotional learning, health and wellness, youth leadership, school culture and climate, family engagement and support, school readiness and transitions, and expanded learning. Alameda County Health Care Services Authority invests over $25,000,000 annually in a continuum of school health supports in OUSD, including 16 school health centers, site and district level behavioral health clinicians in 65 schools, 16 public health programs, 3 youth and family opportunity hubs, many youth development activities, the Central Family Resource Center as part of a district-wide eligibility and enrollment initiative, and special equity-focused projects, primarily supporting boys and young men of color (J. Harris, e-mail communication, March 17, 2015).

The Center develops creative finance strategies that leverage private and public funds to support youth and families. Services are financed by blending a mix of funding streams including county appropriated funds, OUSD dollars, Medicaid, the State Children's Health Insurance Program (SCHIP), and private dollars. It focuses on securing long-term commitments and shared investments with partners.

Coordination at OUSD community schools is the responsibility of a dedicated site manager who works with school staff and community partners to ensure that student and family opportunities and supports are well-integrated and connected to the school's instructional program. This individual supports a school site team of parents, educators, and community partners that is responsible for leadership, vision, programming, and oversight of major components of the community school. Data and a sharp focus on improving results drive the work at each site. Schools and partners have agreements and processes in place to share and use data to these ends. Staff members of the health partners supported by the Center are members of these teams, affording them an opportunity to be more deeply connected to the whole school and to other partners.

The synergy in the relationship between OUSD and ACHCSA is evidenced in comments of key leaders. “ACHCSA is the best kind of partner to have. Not only do they put real resources into our schools, but they are thinking partners, always challenging us to find new ways to address the difficult equity issues in Oakland together,” says Curtiss Sarikkey, Deputy Chief of Community Schools and Student Services in OUSD (e-mail communication, March 9, 2015).

Tracey Schear, Director of the Center for Healthy Schools and Communities, echoes Sarikkey:

Through our partnership with OUSD and the community partners, we have taken to scale a comprehensive school health initiative, and have made incredible progress toward our goal of creating universal access to health supports through schools. The emergence of the community school approach in OUSD brought more coherence to the work, and fortified our shared commitment to sustain critical health and education supports for children and families. (T. Schear, e-mail communication, March 12, 2015)

Cincinnati: Growing Well in CLCs

The Growing Well health collaborative in Cincinnati is embedded in Cincinnati's CLCs—a community schools initiative that started with a school construction and rehabilitation program in 2001.8 The CLC model has had major impact on the expansion of physical, dental vision, and mental health services for students and their families by creating a community-wide culture of collaboration. It also has played an important role in helping Cincinnati become the highest performing urban school district in Ohio.9

Community Learning Centers serve as hubs of educational, recreational, cultural, health, and civic partnerships, which optimize the conditions for learning and catalyze the revitalization of the community. Community Learning Centers emerged from the planning process associated with a major construction and rehabilitation program that involved deep community engagement.10 There are now 35 CLCs in Cincinnati and a school board policy envisioning that all 55 city schools will become CLCs. Resource coordinators in each school are responsible for mobilizing and integrating community partnerships into the life of the school. Community partners participate on school-based planning teams that set priorities for the CLC, monitor progress, and pursue continuous improvement.

The CLCs Institute, a nonprofit intermediary, was organized by local leadership to provide program development and capacity-building support to the CLCs. The emergence of the CLCs led Interact for Health, previously The Health Foundation of Greater Cincinnati, Chief Executive Officer Jim Schwab to fund a planning effort in 2005 to design infrastructure for meeting the broad health care needs of Cincinnati's students.10 Led by Marilyn Crumpton of the Cincinnati Department of Public Health, Growing Well emerged from this planning. Its mission is to embed its 30 health partners into the CLCs by bringing them into the schools with sustainable funding streams.11

Growing Well takes existing services delivered independently and braids them together into a system of care with public schools as the focal point for service delivery. It leverages public and private dollars from multiple sources, including billing services through Medicaid, SCHIP, private insurance, and funding for start-up from local foundations.

Today, primary care (21 school-based health clinics), dental clinics (3 serving multiple schools), a vision center serving the district and beyond, and mental health services, as well as wellness opportunities, are being provided. Vision and mental health services are of particular note.

MindPeace is a Mental Health Collaborative whose purpose is to align the partners, infrastructure, and processes for children's mental health solutions, with a focus on increasing access to quality mental health services at public schools. Mental health practitioners in schools not only provide direct services to students but also work with administration, faculty, and staff to create a positive culture and climate in the school.

The OneSight Vision Center at Oyler School is the first self-sustaining comprehensive vision center at a public school in the nation.12 The Cincinnati Health Department, Growing Well, the Ohio and American Optometric Associations, the Cincinnati Eye Institute, and Cincinnati Public Schools, as well as OneSight, a leading global vision care charity, planned the center. The team provided optometric expertise, design, business expertise, and training to ensure success. The Cincinnati Health Department operates the Vision Center as part of their federally qualified health center, and ongoing financing comes from billing for services.

More recently, based on an assessment of health needs in Cincinnati, Growing Well has focused on 3 key indicators: asthma, vision, and dental health. For asthma, access to Asthma Control Tests, used to determine need for controller medication, has increased to 75% of the 4400 students with asthma. The vision program has expanded the number of students receiving glasses by 70% from 1239 in 2009–2010 to 2015 in 2014–2015.13

The opening of 3 full-time dental centers with 3–4 chairs in CLCs in the past 3 years, with transportation between schools, has increased preventive and restorative services for students. Expanding screening to high school students has doubled the number of students identified with dental needs from 2117 in 2009–2010, to 4114 for 2014–2015 (M. Crumpton, e-mail communication, March 7, 2015).

Presently, 4 sites serve school staff, family members, and community members. Plans to add services for adults in 2 other locations are in development. The decision on whom to serve is made at each CLC.

Growing Well is also part of a broader infrastructure of partnership networks that support the CLCs. Organized by the CLCs Institute, networks such as MindPeace, the Cincinnati After School Network, the Adopt-A-Class Foundation (business mentors), College Access, Leave No Child Inside (nature and environmental), Growing Well, and others have come together as a Cross-Boundary Leadership Team. The team weaves together the work of partner organizations at individual CLC sites so they operate collaboratively, ensuring interdisciplinary services that respond to the whole child. Speaking about the secret to getting diverse groups such as physicians, dentists, teachers, and parents, to work together for a common goal, Crumpton says: “The secret of a successful collaborative is in valuing and leveraging the investment of every member.” Despite her success, she adds: “It has been challenging to effectively communicate the value of school-based health services. Many people don't understand that children experiencing poverty have such poor health outcomes and that academic success is affected by a child's health.”13

IMPLICATIONS FOR SCHOOL HEALTH

The stories of MHS, Oakland, and Cincinnati, as well as experience with community school initiatives and other community collaborative groups, suggest a set of important lessons for health and education leaders seeking to align the assets of their organizations and institutions to help young people succeed.

Focus on Results That Cut Across Systems

The push toward results-driven planning and accountability is a fact of life in the education and health communities.14 For partnerships to deepen, finding results that matter to both sectors is essential. If health leaders put themselves in the shoes of educators, they will see that asthma management, vision services, and mental health services are precursors to better attendance, fewer suspensions, better reading, and ultimately higher graduation rates. Working together on results that matter to both will deepen relationships and lead to system change.

Data Must Be at the Center of Conversations to Build Bridges Based on Results

Even before considering a partnership, health and education leaders should look at data important to one another. Knowing what matters to a potential partner is vital to relationship building. It is like any negotiation where you start by looking at one another's interests.

Build a Working Infrastructure

Sustainable collaborative efforts require that leaders build a viable infrastructure that facilitates the work of leaders and practitioners toward their shared vision. The stories suggest infrastructure at 3 levels.

Community-wide leadership

The Community Schools Leadership Council in Oakland and the collaborative structure of Growing Well are vital for setting an overall vision, aligning and re-aligning resources to get desired results, and changing policy so that changes can be embedded in systems and agencies. The planning group at MHS has now become a vehicle for expanding partnerships between schools and health agencies across the North Clackamas district. These cross-sector collaborative groups help address the challenges of leadership transition because multiple stakeholders have an investment in sustaining the joint enterprise.

School-site leadership teams

The school site committees at MHS, and in Oakland, and Cincinnati, are key entities for planning, implementation, and continuous improvement of health and education partnerships. These groups are focused on a set of results that they see as interconnected in terms of the types of services and supports that students and their families need. The teams may incorporate working groups on wellness or after school, for example, because it is the integration of the assets and expertise of different sectors that are vital at the school site. A coordinator at each school site supports the principal and the site leadership team and coordinates the work of educators and community partners.

An intermediary entity

Planning, coordination, and management support are vital to the work of multisector leadership. There is no right agency for this role. For Growing Well, the Cincinnati Health Department is the intermediary while a separate non-profit, the CLCs Institute, coordinates the work of the Cross Boundary Leadership Team and the CLCs. In Alameda, the Center for Health and Health in Schools, together with the OUSD Office of Family School Community Partnerships, supports Oakland's Full-Service Community School effort. Elsewhere, United Ways, local government, and higher education institutions play this role. Intermediary leadership powers the work performing these key functions by ensuring communication between community-wide and school-site leaders, facilitating use of data to drive results, evaluating impact, aligning and integrating programs and services, financing and resource development, promoting supportive policy, providing professional development and technical assistance, and engaging the broader community.15

Know Your Territory; Build on Strengths

In numerous communities across the county, there are partnerships between school and health institutions. As health and education leaders think about how to work together more systemically, it is essential to look at what has happened, what has worked, and what has not. What relationships—organizational and personal—are in place to build on? What mistakes in the past might influence new efforts? An asset-based approach is vital to finding ways to expand health and education partnerships and have them become more systemic and get results.

Systemic Change Happens in Stages

In 1993, a study group commissioned by the US Departments of Health and Human Services and Education produced a guide, Together We Can: Crafting a Pro-family System of Education and Human Services, which laid out a 5-stage spiraling process of change moving from getting started, building trust, strategic planning, implementation, and moving to scale.16 We later realized that there was another stage before getting to scale—deepening and broadening the work. You can see this phenomenon at Milwaukie, as MHS and its partners continue to strengthen ties between the school and health partners, and as community stakeholders consider how to take the Milwaukie approach to other schools. Cincinnati's project began with only a few CLCs and expanded to 35, and the Cross-Boundary Leadership Team emerged over time. In each case, the infrastructure was in place to move the enterprise forward.

Know What Scale Up Means

Finally, as health and education leadership seeks to scale up systemic relationships between their sectors, they should keep in mind the importance of these factors. Shared ownership of the enterprise is essential; allies must share resources, information, and accountability for results with the intention of fundamentally transforming their relationship. Innovations must spread so that more and more students have the benefits of quality health services and experiences at school. There must be deep change in the attitudes, behaviors, assumptions, and expectations of health and education leaders and practitioners about the relationships between health and education—within classrooms, health clinics, after school programs, and other health partners and programs. Health and education partnerships must be sustainable; sustainability grows not only from financing strategies but also from out of an infrastructure that supports a collaborative decision-making process based on a long-term vision, and that continually measures progress against a clear set of benchmarks.

Human Subjects Approval Statement

The preparation of this paper did not require original research involving human subjects.