Student Bodies and Minds

Jason E. Kaplan
Dufur school nurse Kamala Malcolm was the driving force behind creating the new facility.

School-based health clinics deliver much-needed care to one of our most vulnerable populations. Why doesn’t Oregon have more of them?

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Back-to-School Night will look a little different in Dufur — a Wasco County town whose population was 635 as of the 2020 census — this year. 

Along with meeting teachers and reconnecting with classmates, its students, parents and the rest of the community will celebrate the grand opening of the district’s brand-new School-Based Health Center. 

An examination room in the School-Based Health Center, a new building on the school campus in Dufur, Oregon. Photo by Jason E. Kaplan

The clinic represents a solid win for the town. Accessing health care in Oregon remains difficult, but it is especially challenging in rural and frontier areas. Desperately needed behavioral and mental health services are even harder to secure. But for kids in Dufur — there are 360 in grades pre-K through 12 — their immediate family and school staff will be able to address basic medical and mental health needs right on campus. 

The need for more physical and mental health services for youth is clear. Across the country, children are suffering from increased incidents of depression, anxiety and suicidal ideation. 

And they’re not the only ones struggling. The issue was even summed up in a “Saturday Night Live” sketch that aired in May this year, where a teacher, played by Maya Rudolph, laments working in a school filled with rampant behavior issues admits to the kids that “Y’all won.”

“COVID broke something we can’t fix,” Rudolph says wearily. 

While the sketch is more focused on teachers’ burnout than kids’ suffering, it’s not far from what advocates describe. 

“We work with school districts that are desperate for help with youth mental health,” says Maureen Hinman, executive director of the Oregon School-Based Health Alliance. “It’s impacting staff. We have teachers who are scared of the kids.” 

Clearly, this is a national phenomenon. But Oregon’s problem is particularly acute. The state has a  dismal record for absenteeism, the fourth highest in the nation, and ranks dead last in the country for mental-illness prevalence and access to care. So why doesn’t Oregon invest more school-based health clinics?

Dufur’s new facility brings the number of Oregon’s school-based health clinics to 89, meaning about 25% of school districts have one, according to Hinman. “That percentage may go up a bit now that Dufur’s clinic is online,” she says. 

Dufur School Superintendent Jack Henderson helped secure funding for the health center. Photo by Jason E. Kaplan

But securing a school-based health clinic takes a lot of work and coordination. Dufur’s resource became a reality after years of assessing needs, building community trust and finding funds. Grants came from the Oregon Health Authority, various foundations and a $50,000 chunk from the deep pockets of Google, which operates a data center nearby. 

“The people in Dufur were grant-writing machines,” remembers Kristen Nicolescu, medical provider and physician assistant for One Community Health. (One Community Health will provide the staffing and supplies for the clinic.)

So what will all of this work yield? Not intended to replace primary care, the clinic will offer vital supplemental services, designed to “increase seat time for students while keeping them focused and engaged,” according to Hinman. 

These services include providing sports physicals; offering preventive care; and diagnosing and treating illnesses and injuries like strep throat, sprained ankles, and ear infections. The clinic will be equipped with a small pharmacy and can administer free vaccines. That’s good news considering Oregon has the second highest nonmedical exemption rate for vaccines in the country at 9%. 

Kamala Malcolm, Dufur’s school nurse, worked with One Community Health to make the center happen. Photo by Jason E. Kaplan

These services promise to provide great relief for families where children are bused to school each day from points far and wide. “Our school district covers 500 square miles,” reports Dufur school nurse Kamala Malcolm, the driving force behind creating the new facility.  She also speaks to the student population’s great economic diversity. “We have everything from wheat and cow farmers to populations without running water or electricity.” 

This combination means that most everyone in Dufur faces some kind of barrier to timely health care. Some families have no insurance, many are on Medicaid. But even the wealthiest, most-resourced families still need to drive at least 15 miles to The Dalles for higher levels of care, resulting in school absences and lost workdays.

“Even if you have a primary care provider, it can take up to two months to get a doctor’s appointment,” laments Hinman. “This is an easy way to get a simple sports physical or quick appointment and not have to mess with getting seen by your primary care provider.” Hinman stresses that records will be seamlessly shared with those PCPs. 

Offering mental health supports will also be a big part of the clinic’s mandate. While logistics are still in the works, Malcolm is planning for one full-time behavioral-health consultant to be available one day a week. This counselor can provide talk therapy and coordinate with other providers and families to make sure kids, their families and staff have access to care. There will also be a nurse practitioner on staff who can prescribe anti-anxiety and anti-depression medication. 

It’s a big leap in the right direction. “We have strong evidence that students are more likely to go to a school-based health clinic for mental health care than any other kind of counselor,” reports Hinman, citing a 2018 study of Oregon schools. “It shows that adolescents are 10 to 21 times more likely to get mental health services at a school-based health center and youth that receive those services are 12%  less likely report depressive episodes, 16% less likely to report suicidal ideation and 18% less likely to report a suicide attempt.”

Dufur School is a pre-K through high school. Photo by Jason E. Kaplan

Dufur’s students are already ahead of the curve when it comes to important metrics for success. “Our graduation rate is 87%, and 64% of our students are present for 90% or more of the time,” reports Malcolm. “Both of these are above the Oregon average.” 

The school also has a history as a vital community hub, serving as a designated cooling center and providing a place for wildfire-smoke relief. Residents, whether they have kids or not, clearly value the school as a resource. But will students and their parents trust the clinic for their health care needs?

“It takes a while to build that trust,” admits Nicolescu. “If you are not offering services consistently, it’s hard to gain traction. The need is there, but if you’re not consistent, the demand is not high. They are just not used to seeing you.”

In answer, One Community Health has been operating a mobile medical unit at Dufur once a month to get students and parents used to the idea of accessing health care at school. “It’s been a great transition,” says Malcolm. “The parents have been welcoming and appreciative.”  Nicolescu is hoping to steadily grow participation, starting with “maybe 15 patients the first month and then growing 5% to 10% a month after that.”

Payment for this medical attention will come from private insurance providers, Medicaid or self-pay. “We use a sliding scale to determine the self-pay rate. If it’s an uninsured student, the visit is usually written off,” says Nicolescu. 

A $60,000 chunk of funding will also come from the state every year, a number that hasn’t changed since 2013. Efforts to pass Senate Bill 549A, allocating more money for these vital services, died during the last legislative session when Republican state legislators, including Dufur’s own representative, Bill Hansell, walked out on their jobs. 

House Bill 4070 — which would have invested some $18 million into school-based health clinics, $7.8 million for mental health and addiction programs, and another $10 million for new health centers — also failed in this year’s six-week short session. That draft bill would also make planning grants available to schools that want to create their own centers, as well as more funding for bonds to help with construction costs, according to Hinman in a November 2023 article from the Lund Report

Sad news for a state where kids are literally dying for lack of accessible health care. But Hinman and others remain hopeful that their next effort will be successful. She and others will push ahead with a similar bill that asks for more funding, including giving existing clinics a 10% bump and increases tied to inflation. 

Her goal is to keep the kids in Dufur and the rest of the state healthy, happy and thriving in school. 

Maureen Hinman, executive director of the Oregon School-Based Health Initiative. Photo by Jason E. Kaplan.

“In five years, I’d love to see a school-based health clinic in at least every high school or multi-level school,” she says. “Since we’ve seen them be successful in as small as a K-12 school of around 130 total students, I believe that is feasible.”

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