Tackling Economic Inequality WE ARE NEW YORK’S LAW SCHOOL www.nyls.edu/impact

www.nyls.edu/impact
WE ARE NEW YORK’S LAW SCHOOL
Tackling Economic Inequality
FRIDAY, APRIL 17, 2015
9:00 a.m. – 9:15 a.m. (Auditorium)
WELCOMING REMARKS
Anthony Crowell, Dean and President,
Professor of Law, New York Law School (NYLS)
Ross Sandler, Professor of Law and Director,
Center for New York City Law, NYLS
11:30 a.m. – 12:45 p.m. (Auditorium)
HOME AND COMMUNITY
(This session is accredited for 1.5 CLE hours
in Areas of Professional Practice)
Moderator: Andrew Scherer, Policy Director,
Impact Center for Public Interest Law, NYLS
Andrew Scherer, Policy Director, Impact
Center for Public Interest Law, NYLS
Panelists:
Vicki Been, Commissioner, New York City
Department of Housing, Preservation, and
Development
9:15 a.m. – 10:00 a.m. (Auditorium)
BREAKFAST ROUNDTABLE
Benjamin Dulchin, Executive Director,
Association for Neighborhood and Housing
Development
Moderator: Errol Louis, Political Anchor,
NY1 News, and host of “Inside City Hall”
Panelists:
Eric Alterman, Author, Inequality and One City
Richard Buery, Deputy Mayor for Strategic
Policy Initiatives, City of New York
Maya Wiley, Counsel to the Mayor, City of
New York
10:15 a.m. – 11:30 a.m. (Auditorium)
INCOME AND WEALTH
(This session is accredited for 1.5 CLE hours
in Areas of Professional Practice)
Moderator: Carlin Meyer, Professor of Law,
Emeritus, NYLS
Panelists:
Steven Banks, Commissioner, New York
City Human Resources Administration/
Department of Social Services
Andrew A. Beveridge, Ph.D., President and
CEO of Social Explorer; Professor of Sociology
at Queens College and the Graduate School
and University Center of the City University of
New York
Lance Freeman, Professor, Graduate School
of Architecture, Planning and Preservation,
Columbia University Rachel D. Godsil, Eleanor Bontecou
Professor of Law, Seton Hall Law School;
Chair, New York City Rent Guidelines Board
1:00 p.m. – 2:00 p.m. (Events Center)
LUNCH
Keynote Speaker: Governor Howard Dean
Introduction: Deborah N. Archer, Associate
Dean for Academic Affairs; Professor of Law;
Co-Director, Impact Center for Public Interest
Law; and Director, Racial Justice Project,
NYLS
2:15 p.m. – 3:30 p.m. (Auditorium)
FAMILY AND CHILDREN
(This session is accredited for 1.5 CLE hours
in Areas of Professional Practice)
Moderator: Lisa F. Grumet, Director, Diane
Abbey Law Institute for Children and Families,
NYLS
Panelists:
Gladys Carrión, Commissioner, New York
City Administration for Children’s Services
Melanie Hartzog, Executive Director,
Children’s Defense Fund—New York
Sophia Pappas, Chief Executive Officer,
Division of Early Childhood Education,
New York City Department of Education
Kim Sweet, Executive Director, Advocates for
Children of New York
3:30 p.m. – 4:45 p.m. (Auditorium)
ADMINISTRATION OF JUSTICE
(This session is accredited for 1.5 CLE hours
in Areas of Professional Practice)
Moderator: Deborah N. Archer, Associate
Dean for Academic Affairs; Professor of Law;
Co-Director, Impact Center for Public Interest
Law; and Director, Racial Justice Project,
NYLS
Panelists:
Elizabeth Glazer, Director, Mayor’s Office of
Criminal Justice, City of New York
Hon. Jenny Rivera, Associate Judge, New
York Court of Appeals
Nicholas Turner, President and Director,
Vera Institute of Justice
David Udell, Executive Director, National
Center for Access to Justice; Visiting
Professor from Practice, Cardozo Law School 4:45 p.m. – 5:45 p.m. (Fifth Floor Café)
RECEPTION
Saskia Sassen, Robert S. Lynd Professor of
Sociology, Columbia University
Paul Sonn, General Counsel and Program
Director, National Employment Law Project
001
Tackling Economic Inequality
Economic Inequality in New York City: Causes and Solutions
TABLE OF CONTENTS
CHILDREN AND FAMILIES PANEL ....................................................................................................... 3
CHILDREN’S DEFENSE FUND, ENDING CHILD POVERTY NOW REPORT EXCERPTS ...................................... 3
CHILDREN’S DEFENSE FUND, SCHOOL-BASED HEALTH CENTERS IN NEW YORK STATE EXCERPTS............ 31
NEW YORK CITY ADMINISTRATION FOR CHILDREN’S SERVICES, FLASH REPORT EXCERPTS ...................... 59
NEW YORK CITY ADMINISTRATION FOR CHILDREN’S SERVICES, FOSTER CARE PLACEMENTS BY
BOROUGH STATISTICS .................................................................................................................................. 64
NEW YORK CITY ADMINISTRATION FOR CHILDREN’S SERVICES ABUSE/NEGLECT INVESTIGATIONS BY
COMMUNITY DISTRICT STATISTICS .............................................................................................................. 66
ADMINISTRATION FOR CHILDREN AND FAMILIES, MEMORANDUM ON WELLBEING .................................... 68
NEW YORK STATE EDUCATION LAW SECTION 3602-EE, STATEWIDE UNIVERSAL FULL-DAY PREKINDERGARTEN PROGRAM .......................................................................................................................... 89
OFFICE OF EARLY CHILDHOOD EDUCATION, A PARENT’S GUIDE TO UNIVERSAL PREKINDERGARTEN ....... 93
ADVOCATES FOR CHILDREN OF NEW YORK, POLICY AGENDA .................................................................... 95
ADVOCATES FOR CHIILDREN OF NEW YORK, SIXTEEN GOING ON SEVENTH GRADE REPORT ...................... 105
ADDITIONAL RESOURCES ............................................................................................................................. 141
002
ENDING
C H I L D P O V E RT Y N O W
a
n
CHILDREN’S DEFENSE FUND
003
CDF MISSION STATEMENT
The Children’s Defense Fund Leave No Child Behind® mission is to ensure every child a Healthy
Start, a Head Start, a Fair Start, a Safe Start and a Moral Start in life and successful passage to
adulthood with the help of caring families and communities.
CDF provides a strong, effective and independent voice for all the children of America who
cannot vote, lobby or speak for themselves. We pay particular attention to the needs of poor
children, children of color and those with disabilities. CDF educates the nation about the needs
of children and encourages preventive investments before they get sick, drop out of school, get
into trouble or suffer family breakdown.
CDF began in 1973 and is a private, nonprofit organization supported by individual donations,
foundation, corporate and government grants.
ACKNOWLEDGEMENTS
CDF gratefully acknowledges the generous support of the Northwest Area Foundation, which
underwrote a substantial part of this project. We also thank the Technical Advisory Committee
members Helen Blank of the National Women’s Law Center, Elizabeth Lower-Basch and Hannah
Mathews of the Center for Law and Social Policy, David Riemer of the Community Advocates
Public Policy Institute, Barbara Sard and Arloc Sherman of the Center on Budget and Policy
Priorities, and Ellen Teller of the Food Research and Action Center, for providing crucial technical
expertise and feedback.
This report draws from the results of an analysis conducted by the Urban Institute under
contract for CDF. A full technical report of the analysis is available on CDF’s website. CDF
thanks the Urban Institute staff who worked on this project, Linda Giannarelli, Kye Lippold,
Sarah Minton, Laura Wheaton and Sheila Zedlewski, for their thorough thoughtful approach to
the project.
© 2015 Children’s Defense Fund. All rights reserved.
Cover photo © Dean Alexander Photography
Inside photos © Dean Alexander Photography, Julia Cass, Steve Liss and Alison Wright Photography
004
HOW TO REDUCE CHILD POVERTY
BY 60 PERCENT
Create
subsidized jobs
Expand housing
subsidies
EITC
Increase SNAP
benefits
%
Make Child
Tax Credit fully
refundable
CHILD TAX
CREDIT
606.6
$10.10
Increase Earned
Income Tax Credit
Raise
minimum wage
million
Expand child care
subsidies
Pass through
and disregard
child support
Make Child and
Dependent Care Tax
Credit refundable
6
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OVERVIEW
or the first time, this report shows that by investing an additional 2 percent of the federal budget into existing
programs and policies that increase employment, make work pay, and ensure children’s basic needs are
met, the nation could reduce child poverty by 60 percent and lift 6.6 million children out of poverty.
F
The United States has the second highest child poverty rate among 35 industrialized countries despite having the
largest economy in the world. A child in the United States has a 1 in 5 chance of being poor and the younger she
is the poorer she is likely to be. A child of color, who will be in the majority of U.S. children in 2020, is more than
twice as likely to be poor as a White child. This is unacceptable and unnecessary. Growing up poor has lifelong
negative consequences, decreasing the likelihood of graduating from high school and increasing the likelihood of
becoming a poor adult, suffering from poor health, and becoming involved in the criminal justice system. These
impacts cost the nation at least half a trillion dollars a year in lost productivity and increased health and crime
costs. Letting a fifth of our children grow up poor prevents them from having equal opportunities to succeed in
life and robs the nation of their future contributions.
The U.S. can end child poverty by investing more in programs and policies that work. Substantial progress in
reducing child poverty has been made over the past 50 years, despite worsening income inequality and increased
unemployment and low-wage work. Child poverty dropped over a third from 1967 to 2012 when income from in-kind
benefits like nutrition and housing assistance and tax credits are counted. Without these federal safety net programs
child poverty would have been 68 percent higher in 2013, and 8.2 million additional children would have been
poor. Despite this progress, 12.2 million children were poor in 2013 even after taking into account federal safety
net programs because good jobs are still too scarce and safety net programs are stretched far too thin.
Recognizing the harms child poverty causes and building on progress already made in reducing child poverty, the
Children’s Defense Fund contracted with the Urban Institute to estimate the impact on child poverty if the nation
invested more in proven poverty reduction strategies. Focusing on policies and programs that improve families’
current economic well-being, CDF targeted changes in nine existing programs and policies that help make work
pay, increase employment, and meet children’s basic needs.
Using the Supplemental Poverty Measure (SPM) that best accounts for the impact of government benefits and tax
policy, and 2010 data, the most recent available when research began, the Urban Institute found that these
changes would:
• Reduce child poverty 60 percent — lifting 6.6 million children, 0.5 million of them extremely poor,
above the poverty line.
• Improve the economic circumstances of another 4 million poor children, although not enough to lift
them above the poverty line.
• Reduce child poverty among children under 3 by 64 percent.
• Reduce poverty among Black children, who suffer the highest child poverty rates, 72 percent.
• Reduce poverty among single-parent households 64 percent.
• Reduce poverty among children in non-metropolitan areas 68 percent.
In all, 97 percent of poor children would experience improvements in their family’s economic circumstances.
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Policy Improvements To Reduce Child Poverty By 60 Percent
Increasing employment and making work pay more for adults with children
• Increase the Earned Income Tax Credit for lower-income families with children.
• Increase the minimum wage from $7.25 to $10.10.
• Create subsidized jobs for unemployed and underemployed individuals ages 16-64 in families
with children.
• Make child care subsidies available to all eligible families below 150 percent of poverty.
• Make the Child and Dependent Care Tax Credit refundable with a higher reimbursement rate.
Ensuring children’s basic needs are met
• Base SNAP benefits on USDA’s Low-Cost Food Plan for families with children.
• Make the Child Tax Credit fully refundable.
• Make housing vouchers available to all households with children below 150 percent of poverty for
whom fair market rent exceeds 50 percent of their income.
• Require child support to be fully passed through to TANF families, fully disregarded for TANF benefits,
and partially disregarded for SNAP benefits.
Reducing child poverty 60 percent with these improvements was estimated to cost $77.2 billion in 2010, only
2 percent of U.S. government spending that year, 0.5 percent of the 2010 U.S. gross domestic product (GDP),
and 15 percent of the estimated $500 billion the nation spends every year for the costs of children growing up
poor. By reducing child poverty now the nation would reduce these children’s chances of becoming poor adults
and reduce child poverty in the next generation.
Our nation can easily afford it. There are multiple ways to increase investments in children without increasing the
deficit, from reducing military spending — the U.S. accounts for less than 5 percent of the world’s population but
37 percent of the world’s military spending — to closing tax breaks and loopholes that cost the nation hundreds
of billions while fueling the nation’s alarming income and wealth gaps (see tradeoff details on p. 31).
The Urban Institute’s analysis for CDF is clear: by investing more in existing programs the U.S. could substantially
decrease child poverty immediately. Shrinking child poverty by 60 percent and improving economic circumstances
for 97 percent of poor children would improve the life chances of millions of children, bring child poverty in the
U.S. in line with rates in other high-income countries, and help prevent poverty in the future. As the wealthy and
powerful nation we are, it is way past time we commit to ensuring all children’s basic needs are met. This report
shows for the first time that solutions to child poverty in our rich nation already exist if we are willing to invest in
them. Let’s create that public will and take action for our children — they cannot wait.
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CHAPTER 1
POVERTY HURTS CHILDREN AND OUR NATION’S FUTURE
Child poverty destroys dreams and opportunities.
Nearly 15 million children in America lived below the official poverty level — $23,834 for a family of four — in
2013, based only on cash income. Over 40 percent of these children lived in extreme poverty, at less than half
the poverty level. The youngest children were most likely to be poor, with more than 1 in 5 children under age 5
living in poverty during the years of rapid brain
development.
U.S. Ranks Second to Last in Child Poverty
America’s child poverty rate is one of the
highest among industrialized nations.
The United States, with the world’s largest economy,
has the shameful distinction of having the second
highest relative child poverty rate among 35
industrialized nations.1 With a rate more than six
times higher than in Finland, the country with
the lowest child poverty rate, the U.S. beat out
only Romania, while lagging behind the rest of
Europe, Australia, Canada, Japan, and New
Zealand. Many countries with fewer resources
have lower poverty rates, including the U.K.,
New Zealand, the Czech Republic and Hungary,
a clear indication the U.S. could do much more
to reduce child poverty.
Child poverty robs children of their future.
Reducing child poverty would yield incalculable
benefits for millions of children and the country
as a whole.
Child poverty creates gaps in cognitive skills
in babies.
3.6
Finland
Netherlands
Denmark
Cyprus
Iceland
Norway
Slovenia
Sweden
Austria
Ireland
Germany
Switzerland
Malta
France
Czech Republic
Hungary
United Kingdom
Belgium
Australia
New Zealand
Luxembourg
Estonia
Slovakia
Poland
Canada
Japan
Portugal
Greece
Italy
Lithuania
Spain
Latvia
Bulgaria
United States
Romania
5.9
6.3
6.5
6.5
6.6
7.2
7.3
7.8
8.5
9.4
9.4
9.5
9.5
9.7
10.0
10.0
10.3
10.9
11.7
11.8
11.9
13.2
13.9
14.0
14.9
15.2
15.3
17.0
17.9
19.7
20.5
21.6
23.1
23.6
0
5
10
15
20
25
Percent of Children Aged 0-17 Living in Households with Incomes
Below 50% of National Median Income
Poor parents have fewer financial resources and
Source: Unicef, 2013
often experience more stress, and as a result
their young children are less likely to be read to,
spend less time talking to adults, and hear many fewer words each week than children from more affluent families.2
One study found that by age 4, high-income children had heard 30 million more words than poor children.3 Poor
preschoolers are also less likely to be able to recognize letters, count to 20, or write their first names.4 Incomerelated gaps in cognitive skills can be observed in babies as early as 9 months old and often widen with age.5
These disparities create an early disadvantage that is often hard to overcome.
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Childhood toxic stress can negatively impact brain functioning for life.
When children experience strong, frequent, or prolonged adversity — such as physical or emotional abuse, chronic
hunger and neglect, caregiver substance abuse or mental illness, exposure to violence, or the accumulated burdens
of family poverty — the stressful environment can become toxic. If this so-called “toxic stress” continues and is
not mitigated by adequate adult support it can literally rewire children’s brains, disrupting their social competence
and ability to succeed in school and in life and increasing the likelihood of low educational achievement, unstable
employment, adult poverty, and involvement in the criminal justice system.6
No Food, No Water, No Light
remember not eating sometimes. I mean, the only time that
“I
we actually had food is when we went to my grandmother’s,”
Carmen Griffith says bluntly. Her parents divorced when she was
five, and her school teacher mother descended into alcoholism
and depression. After one drunken episode when Carmen’s mother
was arrested for breaking and entering, she lost her teaching job.
Although she got sober and worked hard to turn her life around,
the tough economic times got worse. Carmen and her younger
sister had to go to grandma’s house to take baths, because there
was no running water at their house. Sometimes there was no
electricity. The family has struggled to eat and keep a roof overhead.
Carmen never gave up and knows education will open doors
for her future, and is pursuing her dream of becoming a child
psychiatrist so she can help children struggling to overcome
severe challenges, just as she has had to do.
Child hunger jeopardizes children’s health and ability to learn.
Poor children are more likely to experience hunger. In 2013, more than 45 percent of poor children lived in
homes where not everyone had enough food.7 Food insecurity is associated with lower reading and math scores,
greater physical and mental health problems, higher incidence of emotional and behavioral problems, and a
greater chance of obesity.8
Poor children experience worse health outcomes.
Poor children are less likely to have access to affordable quality health coverage. Nearly 1 in 6 poor children lacks
health insurance compared to about 1 in 12 non-poor children.9 Children in poor families are five times as likely
to be in fair or poor health as children in non-poor families.10 They have more severe health problems than higherincome children, and fare worse than higher-income children with the same problems. For example, a poor child
with asthma is more likely to be reported in poor health, spend more days in bed, and have more hospital episodes
than a high-income child with asthma.
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Traumatic experiences in childhood — often called adverse childhood experiences — also impact health throughout
life. The more adverse experiences in childhood, the greater the likelihood of health problems in adulthood
including heart disease, diabetes, substance abuse, and depression.11
Poor children are less likely to graduate from high school.
Poor children are less likely to enter school ready to learn and to graduate from high school than their non-poor
peers. One study found children who were poor for half their childhood were nearly 90 percent more likely to enter
their 20s without completing high school than those who had never been poor.12 And the younger the children
were when they experienced poverty, the worse the impacts. Poor infants and toddlers — from birth to age 2 —
were nearly 30 percent less likely to complete high school than children who first experienced poverty later in
childhood.
Child poverty fuels the intergenerational cycle of poverty.
In one study, people who experienced poverty at any point during childhood were more than three times as likely
to be poor at age 30 as those who were never poor as children.13 The longer a child was poor, the greater the risk
of adult poverty.
Child poverty has substantial economic costs.
Costs of Child Poverty
Lost Productivity
$170 billion
Increased Crime
$170 billion
Worse Health
$160 billion
$500 billion
According to one study, the lost productivity and extra health and
crime costs stemming from child poverty add up to roughly half a
trillion dollars a year, or 3.8 percent of GDP.14 Another study found
eliminating child poverty between the prenatal years and age 5
would increase lifetime earnings between $53,000 and $100,000
per child, for a total lifetime benefit of $20 to $36 billion for all
babies born in a given year.15 And we can never measure the countless
innovations and discoveries that did not occur because children’s
potentials were stunted by poverty.
It doesn’t have to be this way. Child poverty can be reduced.
Child poverty is not immutable. Poverty rates change with the economy and changes in government policies.
Child poverty, based just on earnings and cash benefits, declined 49 percent during the economic expansion of
the 1960s and 29 percent during the economic boom of the late 1990s, but grew 59 percent from 1969 to
1983 as the economy faltered.16
The U.S. has made substantial progress in reducing poverty over the past 50 years despite worsening inequality
and increased unemployment. Child poverty dropped over a third between 1967 and 2012 when income from tax
credits and in-kind benefits like nutrition assistance are counted.17 This is all the more remarkable given that
unemployment and income inequality more than doubled during this period.
The United Kingdom provides a modern example of how a concerted effort to reduce child poverty can succeed,
even during economic recession.18 In 1999, Prime Minister Tony Blair’s government committed to ending child
poverty (see text box on p.14). Through a multi-pronged approach, the British government under Blair and his
successor Gordon Brown managed to reduce child poverty by more than half over 10 years, and reductions persisted
during the Great Recession. Many families with children benefited, but poorer children benefited most: Average
incomes for families with children increased $3,200, and incomes for families in the bottom fifth of the income
range increased $7,200.
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The U.K.’s Three-Pronged Approach to Ending Child Poverty
1. Increased employment through a mostly voluntary welfare-to-work program, the first national minimum
wage, and tax reductions and tax credits for workers and employers.
2. Increased incomes among families with children regardless of parental employment through increases
in a universal child benefit and means-tested income supports for low-income families with children
and through a new child tax credit.
3. Reduced the intergenerational transmission of poverty through investments in early childhood and
primary and secondary education including improvements to maternal and paternal leave policies,
the introduction of universal preschool for 3- and 4-year-olds, and expansions of child care assistance
for working families.
Ending child poverty permanently first requires boosting resources of poor families with children.
A recent Washington Post article reported that if the U.K. suddenly decided to join the U.S. as a state, it would
be the second-poorest state, as measured by GDP per capita, behind Alabama and just ahead of Mississippi.19 If
the U.K. can reduce child poverty, so can the U.S. In fact, given the U.S. has the world’s largest economy and given
the high costs the U.S. incurs from child poverty every year, the nation cannot afford not to end child poverty.
The quickest way to reduce child poverty is to improve the economic circumstances of poor children. This would
alleviate child suffering and is a key step toward ending childhood poverty permanently, since growing up in
poverty increases the likelihood of being poor as an adult and a parent.
Current income support and safety net programs and policies help millions of children every year. Child care assistance
and the Earned Income Tax Credit (EITC) help parents work and boost the value of work. Programs like nutrition
and housing assistance help ensure children eat and have a roof over their heads when jobs for their parents are
scarce or do not pay enough.
1 IN 5 CHILDREN LIVES IN POVERTY
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Safety net investments provide long-term benefits.
Not only do these programs help ensure children are fed and housed, federal safety net programs like the EITC
and the Supplemental Nutrition Assistance Program (SNAP) are investments that improve children’s long term
outcomes. Children from families receiving income boosts from the EITC or similar programs have been found to have
better birth outcomes, higher test scores, higher graduation rates and higher college attendance.20 Such outcomes
translate into increased economic security later in life. One study found children in low-income families that
received an additional $3,000 dollars a year between the child’s prenatal year and fifth birthday earned on average
17 percent more as adults than similar children whose families did not receive the added income.21 Studies of
the federal nutrition programs found needy children who received food assistance before age 5 were in better
health as adults and were more likely to complete more schooling, earn more money, and not rely on safety net
programs as adults.22
The nation could reduce child poverty now.
Despite evidence of both short- and long-term benefits, millions of poor children do not receive the assistance
they need because of limited eligibility and benefits and lack of funding.
The Children’s Defense Fund wanted to answer a basic question: “How close could the nation get to ending poverty
for today’s children by simply investing more in approaches that work?” To answer this question, CDF contracted
with the Urban Institute, a leading nonpartisan research organization, to estimate the impact on child poverty of
changes to nine existing federal programs and policies. The Urban Institute found the nation could reduce child
poverty by a striking 60 percent by implementing these nine policy changes, demonstrating that the nation currently
has the tools to significantly reduce child poverty. There can no longer be any excuse for our country not living up
to its creed that all children should have the same opportunity to succeed.
Homeless in High School
n the summer of 2012, Craig Phillips was looking forward to his
I
junior year at Boys and Girls High School in Brooklyn, New York.
But after Craig tried to protect his mother from his father in a violent
domestic confrontation, his father kicked them out of the house. Craig
said, “Ever since that point, life has just never been the same.” Craig,
his mother and older brother ended up in a homeless shelter for his
junior and senior years of high school. His mother continued to work
as a habilitation aide for Cerebral Palsy of New York. His brother and
Craig worked too. But their combined salaries were not sufficient to
afford an apartment in the city of New York. Finally, Craig and his
family were able to move into their own home, a state-subsidized
apartment, in the spring of 2014. Craig beat the odds of homeless
high school students by graduating from high school and entering his
freshman year of college.
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CHAPTER 2
HOW TO REDUCE CHILD POVERTY
RIGHT NOW
o identify policy improvements that could reduce child poverty and alleviate its harmful impacts immediately
the Children’s Defense Fund started from two premises. The first is that the best anti-poverty strategy is to
ensure parents and caregivers who are able to work can find jobs that pay enough to support a family. CDF
sought policy improvements that would increase employment and make work pay for adults with children. The
Earned Income Tax Credit (EITC), child care subsidies, and the Child and Dependent Care Tax Credit have all
been shown to help increase employment. Increasing the reach and value of these benefits could help reduce
child poverty. Similarly, increasing the availability of publicly funded jobs could reduce child poverty by providing
jobs for parents who are hard to employ. However, a job does not necessarily guarantee a livable income; nearly
1 in 3 poor children lives in a family with an adult who works full-time year-round.1 No family with a parent working
full-time year-round should live in poverty. Increasing the value of the minimum wage would reduce child poverty
by increasing income for families with minimum wage workers.
T
The second premise is that all of society benefits if children’s basic needs are met when the economy contracts,
disaster hits or parents lose their jobs. Children’s chances of reaching successful, productive adulthood are strongly
influenced by their experiences growing up. If children go hungry, suffer homelessness or experience prolonged
stress from economic hardships, their opportunities in life will be diminished. CDF identified policy improvements
that would ensure children’s basic needs are met when families fall on hard times. In 2013 our nation’s safety
net programs and refundable tax credits lifted 8.2 million children from poverty,2 but many children in need did
not benefit. Housing subsidies only reach 1 in 4 needy families with children.3 While the Supplemental Nutrition
Assistance Program (SNAP) reaches a large percent of poor families, millions of children are hungry because
benefits are not enough to ensure adequate nutrition. The Child Tax Credit is a valuable benefit for many families
with children, but the poorest families benefit the least. Finally, child support payments collected by states don’t
always reach the children for whom they were intended. Increasing the reach and impact of these crucial programs
would help reduce child poverty.
In seeking to strengthen the economic circumstances of poor children, CDF focused on improving existing policies
and programs that work, rather than creating new programs. CDF sought to assist poor children but did not limit
improvements to families below 100 percent of poverty for two reasons. First, CDF recognizes that families living
a few thousand dollars above the poverty line still struggle to meet their children’s needs. Second, many of the
programs included in the analysis phase out benefits to families above poverty gradually to avoid disincentives to
increase earnings.
After identifying policy improvements that could reduce child poverty, CDF contracted with the Urban Institute to
model the effects of these changes on child poverty using the Supplemental Poverty Measure (SPM) and 2010
Census and administrative data, the most recent available when this project began (for more information see
“How the Urban Institute Assessed Impacts of Policy Improvements” on p. 26). This chapter describes the policy
improvements and the impact each would have had on child poverty in 2010 had it been in place for that year.
The combined impact of implementing all the policy improvements at the same time is presented in Chapter 3.
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It is important to note that the Urban Institute’s analysis only assessed the changes to families’ resources in
2010 if the policy changes had been in place for that one year. The analysis did not capture any of the longer
term impacts of increased economic resources on children’s educational and life outcomes and on child poverty in
future generations.
Increasing employment and making work pay for adults with children
Earned Income Tax Credit increase
Why this Policy — The Earned Income Tax Credit (EITC) is one of the nation’s most effective tools for reducing
child poverty among working families. This refundable tax credit kept 3.2 million children out of poverty in 2013.4
It is only available to those with earnings and it increases with higher earnings up to a maximum, providing an
incentive to work and to work more hours. Expansion of the EITC has been shown to be the most important reason why
employment among single mothers increased in the 1990s, more than the booming economy or welfare reform.5
Improvements — CDF asked the Urban Institute to model improving the EITC by increasing its value for the lowestincome families with children (see Appendix 1 for details). The analysis assumed a higher EITC made working
worthwhile for some single parents who previously did not work.6
Child Poverty Impact — The Urban Institute’s analysis found that these EITC improvements would reduce child
poverty nearly 9 percent and lift 1 million children above poverty. Nearly half of the anti-poverty impact would
come from 463,000 single parents starting to work, earning on average $11,761 more annually and receiving an
EITC worth on average $4,699. The rest of the child poverty drop would come from 7.6 million families receiving
a credit that was on average $990 larger.7 The anti-poverty effect of the EITC expansion may even have been
underestimated because the Urban Institute’s model underestimated the number of families receiving the EITC
by 26 percent compared to IRS data.8
Cost — The cost of these EITC improvements and associated secondary changes in other benefits and taxes in
2010 would be $8.2 billion.9
Expansions of SNAP and Refundable Tax Credits
Kept 1.55 Million Children Out of Poverty
During the recession, Congress, as part of the American Recovery and Reinvestment Act (ARRA),
increased the value of the maximum SNAP benefit 13.6 percent, and expanded the reach of the Child
Tax Credit (CTC) and the Earned Income Tax Credit (EITC) by lowering the CTC’s refundability income
limit from over $12,000 to $3,000, reducing the EITC marriage penalty, and increasing the EITC for
families with three or more children.
The Urban Institute found these changes substantially decreased child poverty in 2010. Without the
SNAP benefit boost, child SPM poverty would have been 7.6 percent higher, with 831,000 more children
in poverty. Without the SNAP increase and the CTC and EITC changes, child poverty would have been
14.2 percent higher, and 1.55 million additional children would have been poor. Despite the fact that
child poverty in 2013 was 11 percent higher than before the recession, Congress terminated the SNAP
benefit increase in November 2013. Unless Congress takes action, the changes to the CTC and the EITC
will expire at the end of 2017.
18
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Dying on Minimum Wage
aria Fernandes struggled to survive, working three minimum-wage jobs at three different
M
Dunkin’ Donuts shops. Five days a week she worked the afternoon shift in Newark, the
overnight shift in Linden, and then weekends shifts in Harrison. She earned just over $8.25
an hour, New Jersey’s minimum wage, but sometimes fell behind on the $550 monthly rent
for her garden apartment. She dreamed of moving to Pennsylvania and sharing a life with her
boyfriend Glen Carter. According to The New York Times, since her death from gas fumes
while sleeping in her car between shifts in August 2014, Fernandes has become a symbol of the
hardships facing the nation’s army of low-wage workers.
Minimum wage increase
Why this Policy — A parent with two children working full time at the federal minimum wage of $7.25 an hour
currently earns $4,700 below the poverty level. Nearly 70 percent of the 14.7 million poor children in America,
according to the official poverty measure, live with an adult who works, and 30 percent live with an adult who
works full-time year-round.10 The current federal minimum wage is worth 24 percent less in inflation-adjusted
terms than at its peak in 1968.11 If it had grown at the same rate as productivity, the minimum wage would be
$18.42 today.12 The Congressional Budget Office (CBO) estimated in February 2014 that increasing the minimum
wage to $10.10 by 2016 would lift 900,000 people above the official poverty threshold.13
Improvements — CDF asked the Urban Institute to model an increase in the federal minimum wage from $7.25
an hour to $10.10 for workers and an increase to 70 percent of that level ($7.07) for tipped workers, as proposed
in the Harkin-Miller Fair Minimum Wage Act of 2013. The Urban Institute’s model assumed employers would also
raise wages for non-covered workers earning just under the original minimum wage and for workers just above the new
minimum wage to maintain relative wages — so-called “spillover effects.”14 The Urban Institute conservatively
assumed an increase in the minimum wage would lead to small job losses of the same magnitude assumed by the
CBO.15 Since the Urban Institute used 2010 data for the analysis, the new minimum wages were deflated from
2014 dollars to 2010 dollars, resulting in a wage of $9.30 for most workers and $6.51 for tipped workers.16
Child Poverty Impact — This minimum wage increase would reduce child poverty by 4 percent and move
400,000 children out of poverty. Children living with a full-time year-round worker would see an 8.1 percent
poverty reduction. An estimated 11.4 million workers in families with children would see an average increase in
earnings of $1,557, while 89,000 people would lose their jobs.17 The impacts of the minimum wage on poverty
were limited by the fact that 82 percent of the 27.6 million affected workers (with and without children) would be
above the SPM poverty threshold and increased earnings would be partially offset by increased taxes and to a
lesser extent by decreased benefits.18
Cost — The minimum wage increase was projected to generate revenue rather than cost governments, because
families with higher wages owed more in taxes and were eligible for fewer benefits.19 The total increase in new tax
revenue and savings from decreased benefits would equal $15.2 billion.
E N D I N G
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015
Subsidized jobs program
Why this Policy — Publicly funded (or subsidized) jobs are effective for providing income and building skills
among the unemployed and underemployed.20 Subsidized jobs programs were most recently deployed during the
2008-2009 Great Recession through funding from the Temporary Assistance for Needy Families Emergency Fund.
These programs were shown to benefit the long-term unemployed the most and increase employment and income
even after participation ended.21
Improvements — CDF asked the Urban Institute to model a subsidized jobs program that would provide minimum-wage
jobs to unemployed or underemployed individuals ages 16-64 in families with children for 30 weeks at a time,
with a possibility of renewal after four weeks searching for unsubsidized employment.22 Since not everyone
offered a subsidized job would take one, we assumed that at most 25 percent of those who were unemployed
would sign up.23 Take-up rates were assumed to be lower for individuals at higher income levels, working in part-time
jobs, and for students, early retirees, and people with disabilities. Funds were assumed to be available to provide
child care subsidies to families who became eligible because of a subsidized job.
Child Poverty Impact — This subsidized jobs program would reduce child poverty by nearly 11 percent and lift 1.2
million children out of poverty. A total of 2.5 million people in families with children would work through the program
and each would earn on average an additional $10,630 for the year, although some of the additional income
would be offset by increased taxes and decreased government benefits.
One Step Forward, Two Steps Back
n Cincinnati, Ohio, Christopher Rogers, 13, sometimes used the
$3 an hour he earned cutting grass and working on a candy truck
to pay the phone and electric bills when money ran short. He and his
mother, Ana Cohen, were occasional welfare recipients, with Ana
going off welfare when she finds work and then back on again when
the jobs end or the hours and pay don’t add up to a livable income.
“The way they have it now, the system is based on work but when
there isn’t any work, it doesn’t work,” Ana said.
I
For more than a year, she worked close to full time doing security at
a CVS store. She was paid $11 an hour. When she was laid off, she
received unemployment insurance. That lasted through March 2011.
At that point, she had no income — just food stamps and subsidized
housing — and was not able to find another job. This was when Christopher’s earnings paid some of
the bills. In 2011, Ana said that she had never “made enough money not to be on food stamps, and
I’ve had to use welfare as a fall back. There’s just not enough jobs that pay enough for me to get over
that hump.”
20
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016
Cost — Providing 2.5 million new subsidized jobs would cost $22.9 billion after taking into account associated
changes in benefits and taxes.
Child care subsidy expansion
Why this Policy — To work, parents need access to affordable high-quality
child care. Center-based care for infants in 2013 cost more than in-state
college tuition in 31 states and the District of Columbia.24 To assist
low-income families with child care costs, the federal government and
states provide child care subsidies to some families with children under
13 through the Child Care and Development Fund (CCDF) and related
government funding streams.25 But because of limited funding, demand
for subsidies far exceeds supply. In fiscal year 2009 only 18 percent of
federally eligible children benefited from child care subsidies in an
average month.26
Fewer than 1 in 5
eligible children
benefited from
child care subsidies
in an average
month in fiscal
year 2009 due to
funding restrictions.
Improvements — CDF asked the Urban Institute to model expanding the
CCDF child care subsidy program to provide assistance to all needy poor
and near-poor families. Although eligibility varies by state, to simplify the
analysis CDF selected a uniform income limit of 150 percent of poverty.
The use of 150 percent of poverty acknowledged that 100 percent of
poverty, $23,850 for a family of four, is often far below what families and children need. Income limits in the
35 states with limits higher than 150 percent of poverty were assumed unchanged. In addition to expanding the
availability of subsidies, the analysis assumed a small fraction of adults with children would start working because
of increased availability of subsidies.27 Not all eligible families would choose to use assistance, so only families
paying child care expenses in 2010 were selected to begin receiving a subsidy.28
Child Poverty Impact — The child care subsidy expansion would reduce child poverty by 3 percent or 300,000 children.
Three-quarters of that reduction would come from affordable child care helping 358,000 adults gain employment;
child poverty in those families would be reduced by 11 percent. Overall, the number of families receiving the subsidy
would nearly double from an average of 989,000 a month to 1,948,000.
Of note, the child poverty impact of this change was likely underestimated compared to the impact of housing and
nutrition assistance because the Supplemental Poverty Measure only captures changes in families’ out-of-pocket child
care costs instead of the value of the subsidy. In addition, by limiting the subsidy expansion to families previously
paying for care, the simulation may have underestimated the families who would use this subsidy if available.
Cost — This expansion and associated secondary changes in benefits and taxes would cost a total of $5.3 billion.
Child and Dependent Care Tax Credit expansion
Why this Policy — The Child and Dependent Care Tax Credit (CDCTC) is a nonrefundable tax credit that reimburses
families for a portion of their child or dependent care expenses, thereby increasing families’ economic resources
and helping them work. In 2010, 6.7 million taxpayers received a total of $3.55 billion through the CDCTC.29
Because the CDCTC is a nonrefundable credit, families with no tax liability — usually families with low earnings —
cannot benefit from it. Furthermore, the credit only reimburses a maximum of 35 percent of child or dependent care
costs. As a result, in 2010, families who made $20,000 or less received less than 1 percent of CDCTC benefits.30
E N D I N G
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017
Improvements — To increase the impact of this credit, CDF asked the Urban Institute to model two changes:
• Making the credit fully refundable to enable all families, regardless of tax liability, to benefit from it.
• Increasing the maximum percent of costs reimbursed from 35 to 50 percent for lower-income families
(see Appendix 1 for details).
As with the child care subsidy expansion, the Urban Institute simulated that a small fraction of those who
received a larger CDCTC would start working due to lower child care costs.31
Child Poverty Impact — These improvements would reduce child poverty by 1 percent, lifting 146,500 children
out of poverty. More than half of the impact would result from 101,000 parents who would begin to work because
of lower child care costs. The average credit would increase by $124. The anti-poverty impact of the CDCTC is likely
limited by the fact that many poor families cannot afford to spend large amounts on child care.
Cost — These changes to the CDCTC and associated secondary changes in benefits and taxes would cost a total
of $1.6 billion.
Ensuring children’s basic needs are met when families fall on hard times
SNAP benefit increase
Why this Policy — The Supplemental Nutrition Assistance Program (SNAP) is a crucial safety net program for
children. SNAP helped combat hunger among 20.5 million children in fiscal year 2012, over a quarter of all children
in the nation, and kept 2.1 million children from poverty in 2013.32 However, SNAP benefits average less than
$1.40 per person per meal, which is inadequate for low-income families
who often lack access to affordable nutritious food.33 In 2013, 54 percent
SNAP benefits
of families receiving SNAP were still food insecure, clear evidence that
current SNAP benefits are insufficient to meet families’ food needs.34
average less than
During the recession, Congress recognized that SNAP benefits were too low
$1.40 per person per
for many and increased the value of the maximum benefit by 13.6 percent.35
The impact was powerful: 831,000 children were kept out of poverty in
meal — not enough
2010 as a result of this change (see box on p. 18). Congress terminated that
for low-income families
increase in November 2013.
who often lack
access to affordable
nutritious food.
Improvements — To increase the anti-poverty and anti-hunger impact of
SNAP for families with children, CDF asked the Urban Institute to model
SNAP benefits based on the U.S. Department of Agriculture’s Low-Cost
Food Plan, which is approximately 30 percent higher in value than the
Thrifty Food Plan, on which benefits are currently based.36
Child Poverty Impact — Basing the SNAP benefit on the Low-Cost Food Plan would reduce child poverty by 16
percent, lifting 1.8 million children out of poverty. This change would affect the largest number of people: all of the
existing 11.1 million SNAP families with children and an additional 1.5 million families with children who would
begin participating because of the benefit increase, for a total of 12.6 million families. On average, households
would receive an additional $722 each year.
Cost — The SNAP expansion would cost $23.2 billion.
22
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Shoes Say It All
hoes tell the story of the McKee family’s descent into
S
poverty. Those of Skyler, 10, and Zachery, 12, were
falling apart in 2011. Their sister, then 14 years old, wore
the varsity coach’s shoes when she played on her school’s
volleyball team. Less visible was hunger. The children and
their parents, Tonya and Ed McKee, of Dowagiac, Michigan,
sometimes went without food after Ed lost his job in 2009
and the unemployment insurance ran out, before the family
started receiving Supplemental Nutrition Assistance Program
benefits. Skyler said he gave the birthday money he got at
church to his mom for groceries “and I told her she didn’t
have to pay me back.” Skyler confided that sometimes his
stomach growled. “It’s hard, not easy like it was before
where we had money and could do stuff. Now we don’t
go anywhere … Sometimes we don’t have food and we just
don’t eat.”
Child Tax Credit expansion
Why this Policy — The partially refundable Child Tax Credit (CTC) provides families a $1,000 credit for each child
under 17 to help families offset the costs of raising a child. It is an important tool for reducing child poverty,
keeping 1.7 million children out of poverty in 2013.37 However, the poorest families cannot receive the full
amount of the credit because families have to earn more than $3,000 per year to qualify for a refund that is limited
to only 15 percent of what they earn above $3,000. For example, a family with two children has to earn at least
$16,333 to be eligible for the full $2,000 credit.38 As a result, only 13 percent of the funds spent on the credit
go to the lowest 20 percent of earners.39
Improvements — To increase the anti-poverty impact of the CTC, CDF asked the Urban Institute to model a fully
refundable CTC so the poorest families could benefit from the full $1,000 credit for each qualifying child regardless
of earned income.
Child Poverty Impact — Making the CTC fully refundable would reduce child poverty by nearly 12 percent and
lift 1.3 million children out of poverty. A total of 4.4 million would start receiving a refund from the CTC. In all
8.2 million families would each receive on average $1,497 more for their CTC.
Cost — Making the Child Tax Credit fully refundable would cost $12.4 billion.
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019
Housing subsidies expansion
Why this Policy — Housing is the single largest expense for most families and is growing increasingly out of reach.
The number of homeless public school students was 85 percent higher in 2012-2013 than before the recession.40
The number of families with worst-case housing needs increased from 6 million in 2007 to 8.5 million in 2011,
including 3.2 million families with children.41 Homelessness and housing instability can have detrimental
consequences on children’s emotional, cognitive and physical development, academic achievement and success
as adults.42 Federal rental assistance, including public housing and vouchers for private rentals, help approximately
5 million of the neediest low-income households afford a place to live.43 Because of funding limitations only
about 1 in 4 needy families with children receives assistance.44
Because of funding
limitations only
1 in 4 eligible
families with children
receives housing
assistance.
Improvements — CDF asked the Urban Institute to model an expansion of the
housing voucher program to better meet the need among poor and near-poor
families with children. The expansion was limited to families below 150 percent
of the official poverty guidelines who were not already receiving housing
assistance and for whom the fair market rent exceeded 50 percent of their
income.45 The analysis assumed 70 percent of eligible families would be able
to use the vouchers based on challenges families face in finding housing
within program time limits.46
Child Poverty Impact — This housing subsidy expansion would have the largest
impact among the nine policy improvements, reducing child poverty by 20.8
percent and lifting 2.3 million children out of poverty. The number of households receiving a subsidy, worth an average
of $9,435, would increase by 2.6 million, a 53 percent increase.
Cost — The cost of this expansion and associated secondary changes in other benefits would be $23.5 billion.
Child support pass-through increase and disregard
Why this Policy — Child support payments represent on average 40 percent of income for poor custodial families
who receive them, and kept 740,000 children out of poverty in 2013.47 For families who receive Temporary
Assistance for Needy Families (TANF), the state collects child support from non-custodial parents and keeps most
of the payments received to reimburse the cost of assistance. States have the option to pass through child support
payments to the custodial parent and child and to disregard the child support payment when determining eligibility
for TANF benefits and benefit value. A pass-through does not financially benefit a family unless it is also disregarded.
As of July 2013, 22 states passed through and disregarded at least some of the child support collected.48 The SNAP
program does not include a disregard for child support income.
Improvements — CDF asked the Urban Institute to model a full pass-through of all child support collected on
behalf of TANF families, along with a disregard of the child support income in the calculation of TANF benefits.
In addition, up to $100 of child support collected per month per child was disregarded for SNAP eligibility and
benefit calculations.
Child Poverty Impact — These changes would have the smallest impact of the nine policy changes because of the
small number of families affected, reducing child poverty by less than 1 percent, or approximately 89,300 children.
In aggregate TANF families would receive $477 million more in passed-through child support, $97 million more
in TANF benefits from the TANF disregard, and $608 million more in SNAP benefits from the SNAP disregard.
Cost — The child support pass-through improvements and associated secondary changes in benefits would cost
$1.1 billion.
24
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Child SPM Poverty in 2010
Prior to the policy changes there were 10.9 million poor children in 2010 according to the Urban Institute’s
SPM calculations, resulting in a child poverty rate of 14.6 percent. This child SPM estimate is lower than
the Census’ SPM estimate of 18.2 percent because TRIM3 corrects for under-reporting of certain surveyreported resources, including receipt of SNAP, subsidized housing, Supplemental Security Income and
TANF, and because TRIM3 uses a different methodology to impute taxes paid. Characteristics of poor
children based on Urban Institute’s model are presented in Appendix 2.
For more details about the Urban Institute’s methods please refer to the Urban Institute’s technical report
on CDF’s website.53
by age 4 poor children have
heard 30 million fewer words
than well-off children
child poverty increases
the risk of unemployment
and adult poverty
POVERTY
HURTS
poor children are more
likely to be hungry and
less likely to have affordable
quality health coverage
poor children are
less likely to graduate
from high school
E N D I N G
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021
CHAPTER 3
COMBINED IMPACTS AND COSTS
Policy improvements selected by the Children’s Defense Fund would reduce child poverty by 60 percent.
Ninety-seven percent of poor children would benefit.
According to the Urban Institute’s analysis, the nine policy improvements described in Chapter 2 together would
reduce child poverty as measured by the Supplemental Poverty Measure (SPM) by 60.3 percent, lifting 6.6 million
children out of poverty in 2010 (see Table 3.1). Among these 6.6 million children would be 540,000 extremely
poor children, nearly one quarter of all extremely poor children. An additional 4 million poor children would see
their family’s economic resources increase, although not enough to lift them above the poverty line. In all, 10.6
million poor children, or 97 percent of all poor children, would experience increases in economic resources; only
305,000 poor children would not benefit.
Child poverty would decline substantially for children of all ages, races and ethnicities, and in all regions of the
country. Although all groups would experience significant child poverty reductions, some would experience greater
declines:
• 64 percent for children under 3, who are the most vulnerable to poverty’s harmful effects.
• 72 percent for Black children, who have the highest child poverty rates; the Black-White child poverty
gap would shrink by 30 percent.
• 64 percent for single-parent families with children.
• 68 percent for children in non-metropolitan areas.
• 63 percent for children in the Midwest.
TABLE 3.1 Children Who Would Benefit From Policy Changes
Family SPM poverty
range prior to
policy changes
Less than 100% poverty
Less than 50%
From 50% to <100%
Number who
are lifted
above
poverty
(millions)
Percent
who are
lifted
above
poverty
Total
number with
increases in
resources
(millions)
6.6
0.5
6.0
60%
24
68
10.6
2.0
8.5
97%
97
97
16.0
9.0
7.5
90
66
23
43.3
58%
From 100% to <150%
From 150% to <200%
200% or higher
Among all children
6.6
60%
Percent
with
increases
in
resources
Average
annual family
resources
pre-policy
changes
Average
increase
in
family
resources
$18,983
6,933
22,041
$10,087
11,407
9,895
33,433
44,466
84,002
5,512
3,348
1,945
$41,109
$5,580
Note: Number may not sum to totals because of rounding.
E N D I N G
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022
A total of 43.3 million children would benefit.
In addition to helping poor children, the policy changes would also improve the economic well-being of 32.7 million
children above 100 percent of SPM poverty — half of them in families with incomes between 100 and 150 percent
of poverty — but to a lesser extent than for children below poverty (see Table 3.1). Increases in family resources
for poor children would average $10,087 a year compared to $1,945 for children at or above 200 percent of
poverty. A total of 43.3 million children, 58 percent of all children in America, would see their family’s economic
resources increase as a result of these nine policy improvements.
Although the focus of the analysis was reducing child poverty, these policy changes would also reduce poverty among
working-age adults by 26 percent and among the elderly by 4 percent. Overall, the proposed policy improvements
would reduce poverty in the entire population by 31.5 percent. A net total of 3.1 million people in families with
children would gain jobs from the combined impacts of new subsidized jobs and improvements to the Earned
Income Tax Credit, child care subsidies, minimum wage, and the Child and Dependent Care Tax Credit.1
Although 4.3 million children would remain poor despite the policy changes, 93 percent of them would still be
helped by one or more of the changes, including 902,000 children who would be lifted above 50 percent of poverty.
Not surprisingly, those who would remain poor started out deeper in poverty: 38 percent were extremely poor compared to 8 percent of the children lifted above poverty. Legal status may also explain why some children would
remain poor. Thirty percent of these children lived in households headed by an undocumented immigrant (although
89 percent of the children in these families were citizens) as compared to 14 percent of children who would be
lifted above poverty. Many policies and programs included in this analysis restrict benefits to citizens and authorized
immigrants who have been in the U.S. for a minimum of five years.
Lifting 60 percent of poor children out of poverty and increasing resources for a total of 43.3 million
children in 2010 was estimated to cost federal and state governments $77.2 billion.2
The cost to reduce child poverty by 60 percent represents
only 2 percent of the $3.5 trillion spent by the federal
government in 2010 and only 0.5 percent of the country’s
gross domestic product (GDP) that year.3 It is only 69 percent
of the $112 billion the U.S. has spent on average every
year since 2001 on the wars in Iraq and Afghanistan.4 Our
national security depends as much on a healthy, educated
citizenry as it does on military strength. Furthermore this
investment could be made without increasing the deficit
by eliminating tax breaks for corporations and wealthy
individuals or redirecting a small fraction of our military
spending.
30
C H I L D R E N ’ S
FIGURE 3.1 – Cost of Proposed Policy
Changes Relative to Costs of Child Poverty,
Federal Spending, and GDP
$16,000
$14,958b
14,000
12,000
10,000
Billions
Just over half of the $77.2 billion (54 percent) would go
to families below 100 percent of SPM poverty, and 84
percent would go to families with incomes below 150 percent
of poverty. Reducing child poverty by 60 percent would
make an enormous difference in the lives and futures of
those children and begin to reduce the estimated half a
trillion dollars the U.S. spends every year for the lost
productivity and extra health and criminal justice costs of
adults who grew up poor.
8,000
6,000
$3,457b
4,000
2,000
D E F E N S E
0
$77b
$500b
All Policy
Changes
Child
Poverty
2010
Federal
Spending
2010
GDP
F U N D
023
Tradeoffs: Paying to End Child Poverty
The Nation Can Easily Afford to Invest $77.2 Billion in Children
Any one of the following could pay for a 60 percent reduction in child poverty:
• Closing tax loopholes that allow U.S. corporations to dodge $90 billion in federal income taxes each
year by shifting profits to subsidiaries in tax havens;5
or
• Eliminating tax breaks for the wealthy by taxing capital gains and dividends at the same rates as
wages, saving more than $84 billion a year;6
or
• Closing 23 tax loopholes included in former House Ways and Means Chairman Dave Camp’s Tax Reform
Act of 2014, which would free up an average of $79.3 billion per year;7
or
• Cutting only 14 percent of the nation’s FY2015 $578 billion in military spending.8 The U.S. houses less
than 5 percent of the world’s population but accounts for 37 percent of the world’s military expenditures;
or
• Scrapping the F-35 fighter jet program, already several years behind schedule and 68 percent over
budget and still not producing fully functioning planes. For the $1.5 trillion projected cost of this program,
the nation could reduce child poverty by 60 percent for 19 years.9
Alternatively the nation could:
Increase the value of SNAP benefits for families
with children by 30 percent and reduce child
poverty by 16 percent (cost = $23.2 billion).
by Eliminating tax breaks for corporate meals
and entertainment (savings = $14 billion);10
Ensuring high-income households don’t pay
less in taxes than middle income families
($7 billion);11 and
Closing the Gingrich-Edwards S-corporation
loophole that allows professionals such as lawyers
and doctors who work for themselves to avoid
payroll taxes by characterizing much of their
income as business profits rather than wages or
salaries ($2.5 billion).12
Provide housing subsidies for poor and near-poor
families with children, reducing child poverty by
21 percent (cost = $23.5 billion) and provide
subsidized jobs to unemployed or underemployed
people in families with children, reducing child
poverty by 10.7 percent (cost = $22.9 billion).
E N D I N G
by Making common sense reforms to corporate
accounting tax rules (savings = $58 billion).13
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024
Make the Child Tax Credit fully refundable
and reduce child poverty by 12 percent
(cost = $12.4 billion).
by
Returning estate and gift taxes to 2009 levels,
(savings = $13.1 billion).14
Increase the value of the Earned Income Tax
Credit and reduce child poverty by 9 percent
(cost = $8.2 billion).
by
Closing tax loopholes that allow speculators who
trade risky investments called derivatives to avoid,
defer, or reduce taxes (savings = $2.9 billion);15
Preventing tax-preferred retirement accounts, which
were designed to help middle-class families save for
retirement, from being used by the wealthy to shelter
income from taxes (savings = $2.8 billion);16 and
Closing the corporate stock options tax loophole
that allow companies to deduct stock options
cashed in by an employee at the inflated current
market value, rather than the original cost to the
corporation (savings = $2.5 billion).17
Provide access to child care subsidies for poor
and near-poor families and reduce child poverty
by 3 percent (cost = $5.3 billion).
by
Closing the tax loophole that allows corporations
to write-off unlimited amounts of compensation
for corporate executives as long as it’s
“performance based” (savings = $5 billion)18 and
Eliminating tax giveaways for corporate jets
(savings = $0.37 billion).19
Increase the value of the Child and Dependent
Care Tax Credit and reduce child poverty by
1 percent (cost = $1.6 billion).
by
Closing the ‘carried interest’ tax break for hedge
fund managers by requiring that their earnings
be taxed as ordinary income rather than capital
gains (savings = $1.7 billion).20
Pass through and disregard child support
and reduce child poverty by 1 percent
(cost = $1.1 billion).
by
Eliminating the mortgage interest deduction
for vacation homes and yachts
(savings = $1.5 billion).21
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Reducing child poverty by 60 percent would require a combination of policy changes.
No single policy change on its own would reduce child poverty by more than
21 percent. Reaching 60 percent reduction in child poverty would require the
combined impacts of multiple policy changes. Nonetheless, some single policy
changes would have large impacts. The largest reduction in child poverty from a
single policy change was seen with the expansion of housing subsidies, which
would cut child poverty by 20.8 percent (see Table 3.2). Increasing the value of
SNAP benefits would have the second largest impact, with a 16.2 percent
reduction, and making the Child Tax Credit fully refundable would result in the
third largest reduction (11.6 percent). Because in some cases the same child
would be lifted above poverty by more than one policy improvement, the impact of all
policy changes together would be slightly smaller than the sum of the impacts of
the individual policy changes (60.3 vs. 77.3 percent).
61 percent of the
children benefiting
would be in families
below 150 percent of
poverty but 84 percent
of the costs would go
to these families.
TABLE 3.2 Impacts and Costs of Individual Policy Changes
Percent
change in SPM
child poverty
Number of
poor children
lifted out
of poverty
(millions)
Net new federal
and state
government
costs
(billions) ^
$77.2b
Percent of net
new costs going
to families below
100%
of
SPM
150%
of
SPM
54%
84%
Combined impact*
-60.3%
6.6m
Housing
-20.8
2.3
23.5
75
98
SNAP
-16.2
1.8
23.2
37
83
Child Tax Credit
-11.6
1.3
12.4
50
86
Subsidized jobs
-10.7
1.2
22.9
55
66
EITC
-8.8
1.0
8.2
37
78
Minimum wage
-4.0
0.4
-15.2
n/a
n/a
Child care subsidies
-3.1
0.3
5.3
35
77
CDCTC
-1.3
0.15
1.6
25
66
Child support
-0.8
0.09
1.1
30
72
*The combined impact is less than the sum of the impacts of the individual policy changes because in some cases the same child
would be lifted above poverty by more than one policy improvement. Similarly the cost of the nine changes together is less than the
sum of the costs of the individual changes.
^ This includes spending going to all children, including those not lifted above poverty and those already above poverty.
n/a: Not available because the minimum wage increase does not result in government costs.
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EITC and minimum wage changes and the subsidized jobs program together reduce child poverty
by nearly a quarter.
There is great interest across the political spectrum in policies that make work pay more, including pairing an
increase in the minimum wage with an improved EITC since the two policies amplify and complement each
other.22 Increasing the minimum wage would boost the value of the EITC for low-income workers, and increasing
the value of the EITC for lower-wage workers would increase incentives to work more. The anti-poverty impacts of
subsidized jobs programs would also be amplified by minimum wage and EITC changes.
The Urban Institute examined the combined impacts of these three policy changes and found that the EITC and
minimum wage increases together would decrease child poverty by 12.4 percent. Combining the EITC, minimum
wage and the subsidized jobs program would reduce child poverty by 23.4 percent, at a cost of $18.5 billion
(see Appendix Table A3.1 for details).
Impacts differ by race/ethnicity.
The policy improvements combined would result in a
larger poverty reduction for Black children than for White
and Hispanic children and children of other races. Child
poverty for Black children would go from being 2.7 times
as high as for White children to 1.9 times, a 30 percent
decrease in the Black/White gap. Black children would
experience the largest impacts with six of the nine individual
policy improvements (see Appendix Table A3.2).
Impacts differ by age.
The youngest children would benefit most from the child
poverty reductions. Currently this is the poorest age group
and the group poverty hurts most, as the first few years
of life are crucial for healthy brain development
(see Appendix Table A3.3).
Child Poverty Reductions Differ by
Race, Age, Urbanicity, and Region
Race
White
Hispanic
Black
Other
- 60%
- 56%
- 72%
- 56%
Age
≤2
3-5
6-12
13-17
- 64%
- 61%
- 61%
- 56%
Urbanicity
Non-Metro
Metro
- 68%
- 59%
Region
Impacts differ by urbanicity, region, and state.
Midwest
South
The policy improvements together would reduce child
- 63%
- 61%
poverty more in non-metropolitan than metropolitan areas,
likely because of lower housing costs and therefore lower
SPM poverty thresholds in non-metropolitan areas. Seven
of the nine individual policy changes followed this pattern (see Appendix Table A3.4).
Northeast
West
- 61%
- 58%
As a whole, the improvements also had slightly different impacts on child poverty in different regions of the country,
with the largest reduction in the Midwest and the smallest in the West. These variations are likely due to lower
housing costs, and therefore lower SPM thresholds, in the Midwest and South compared to the Northeast and
West, although not all policy changes followed the same regional pattern (see Appendix Table A3.4).
In sum, while there were small differences based on race/ethnicity and geography, child poverty would fall by
more than half in all subsets of children examined. Overall, these nine policy improvements would reduce child
poverty by 60 percent, lifting 6.6 million children out of poverty and increase economic resources for a total of
43.3 million children, at a cost the nation can well afford.
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Impacts of Policy Improvements in Select States
The Urban Institute was able to compute impacts of the policy improvements in California, Florida,
New York, and Texas, which together are home to 36 percent of poor children based only on cash income.
Although large reductions in child poverty would occur in all four, projected impacts were more than 20
percent higher in New York than in the three other states. All policy changes except those to the minimum
wage, the Child and Dependent Care Tax Credit and child support would have the largest impact in New
York (see Appendix Table A3.5). Increasing access to housing subsidies would have a particularly large
impact in New York, reducing child poverty by nearly 40 percent. It would also have a large impact in
California, with a 30 percent reduction. The larger impacts projected for New York may be partly a result of
the state having a lower prevalence of undocumented immigrants — who may not be eligible for benefits
— compared to the three other states (3.2 percent in New York vs. 4.5 percent in Florida, 6.7 percent in
Texas, and 6.8 percent in California 23).
Number and percent of
poor children prior to the
policy changes
Child poverty reduction
CA
FL
NY
TX
2.2 million
23.5%
0.8 million
20.2%
0.6 million
13.7%
1.2 million
17.4%
-57.6%
-59.7%
-72.7%
-57.8%
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CHAPTER 4
CONCLUSION AND RECOMMENDATIONS
he results are clear. For the first time, this report shows how child
poverty in the United States could be substantially reduced. By making
work pay more, supporting employment for those who can work, and
expanding safety net supports to ensure children’s basic needs are met, the
nation could reduce child poverty by 60 percent — lifting 6.6 million children
out of poverty immediately.
T
For the first time, this
report shows how we
could reduce child
poverty in the United
Lifting 6.6 million children above poverty for a year and improving
circumstances for 97 percent of poor children through the policy changes
States by 60 percent.
described in this report would cost $77.2 billion. That is just 2 percent of the
$3.5 trillion spent by the federal government in 2010 and half of 1 percent
of the country’s 2010 gross domestic product, a cost our rich nation can well afford. This investment would
eventually pay for itself since protecting children against the lifelong consequences of poverty would improve their
life incomes and outcomes and reduce child poverty in future generations. The nation would benefit from a larger
tax-paying and healthier workforce which would build a stronger economy and gradually reduce the half a trillion
dollars our nation spends each year on child poverty.
The U.S. has long been an outlier among high-income countries for its high rates of child poverty. This report
shows this is in no way inevitable. By investing more in protecting children from poverty the U.S. could rejoin the
ranks of peer nations. Shrinking the U.S. relative child poverty rate by 60 percent would cut child poverty in the
U.S. from 23.1 to 9.2 percent, placing the U.S. in line with countries like Germany and Switzerland.1
Most importantly, lifting 6.6 million children out of poverty would mean children like Christopher Rogers, pictured
earlier, could focus on homework rather than on trying to make money to supplement their parents’ income.
Ensuring children don’t go hungry in our rich nation would mean children like Skyler McKee wouldn’t have to
go without the food they need to be healthy and able to learn. Making sure children have a stable place to live
would mean that children like Tristan would not be exposed to the toxic stress of growing up in a homeless shelter.
Providing jobs and making work pay more would mean parents like Ana Cohen can do what they most want to do:
earn enough through work to care for their children. Ultimately, protecting children from the harms of poverty
means ensuring all children have an opportunity to reach their full potential.
Although essential, improving the economic circumstances of poor families with children is not enough. To reduce
poverty long-term, children also need access to affordable comprehensive health care, affordable high-quality early
development and learning opportunities, high-performing schools and colleges, families and neighborhoods free
from violence, and economic opportunities as young adults. Ensuring today’s children are protected from poverty
is only part of the nation’s obligation to its children. But as this report shows, it’s a goal the nation can achieve
right now with the right investments.
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The nation has a choice. We can continue to let millions of children grow up in poverty, which destroys hope, robs
children of their future and fuels an intergenerational cycle of poverty. Or we can make the smart and compassionate
choice and ensure children are protected from poverty by investing more in programs and policies we already know
work. We can let children’s opportunities be determined by the circumstances of their birth or be true to our
nation’s bedrock principle that all children should have an equal opportunity to succeed.
The right choice is obvious. Our wealthy and powerful nation must commit to ensuring all children have the
opportunity to reach their full potential. For the millions of children who are hungry or homeless or hopeless about
their future we cannot afford to wait. The future of our children and our nation depends on it.
CDF therefore recommends the following improvements, which together could reduce child poverty by 60 percent
and improve economic circumstances for 43.3 million children:
1. Increase investments in housing assistance for poor families with children so all eligible families can afford
a safe and stable place to raise their children. In our analysis this expansion alone would reduce child
poverty by 21 percent.
2. Increase the value of SNAP benefits to cover a larger portion of the nutrition needs of children. We found
that increasing the value of SNAP benefits by 30 percent would decrease child poverty by 16 percent.
3. Make the Child Tax Credit fully refundable. Our analysis found this would reduce child poverty by 12 percent.
4. Expand subsidized jobs programs for older teens and adults to meet the demand for jobs. The best solution
to poverty remains a job that pays enough to raise a family. We found that subsidized minimum-wage jobs
would reduce child poverty by 11 percent, and by 29 percent among children living with adults who aren’t
currently working.
5. Increase the value of the Earned Income Tax Credit. Moderately increasing the value of the federal EITC for
low-income workers with children would reduce child poverty by 9 percent. While CDF tested an expansion
of the federal EITC, expansions of state and local EITCs would likely also help reduce child poverty.
6. Raise the minimum wage to $10.10 or higher. Raising the federal minimum wage to $10.10 decreased
child poverty by 4 percent, and by 8 percent among children living with a full-time year-round worker.
The minimum wage could be increased at the federal, state or local levels.
7. Expand access to child care subsidies to all poor and near-poor families. Such an expansion would reduce
child poverty by 3 percent overall. Among families without working adults, it would reduce child poverty
by 11 percent by making work possible.
8. Make the Child and Dependent Care Tax Credit refundable and increase its value. This change would
reduce child poverty by 1 percent and enable 101,000 parents to work.
9. Require a full pass-through and disregard of child support for TANF families, along with a $100 disregard
for SNAP benefit calculation. These changes would reduce child poverty just under 1 percent and help
families fully benefit from child support intended to benefit their children.
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School-based Health Centers in New York State:
Ensuring Sustainability and Establishing
Opportunities for Growth
FEBRUARY 2014
031
Acknowlegements
Acknowlegements
he principal author of this report was Lorraine Gonzalez-Camastra of the Children’s Defense Fund –
New York. Sections of the report detailing fiscal analyses of the school-based health center program
were provided by Peter Epp and Scott Morgan at CohnReznick. Amy Shefrin and David Sandman at
the New York State Health Foundation provided significant guidance and feedback.
T
Support for this work was provided by the New York State Health Foundation (NYSHealth). The mission of
NYSHealth is to expand health insurance coverage, increase access to high-quality health care services,
and improve public and community health. The views presented here are those of the authors and not
necessarily reflect those of the New York State Health Foundation or its directors, officers, or staff.
The Children’s Defense Fund – New York also acknowledges New York State’s School-based Health
Alliance — a coalition of school-based health center providers in New York State — for their support and
feedback on this critical issue. Additionally, the following individuals contributed to the report by facilitating
workgroup meetings, participating in in-depth phone interviews, or providing written feedback on drafts of
the report:
David Appel, M.D.
Medical Director,
School Health Program
Montefiore Medical Center
Beverly Grossman
Senior Policy Director,
Community Health Care Association
of New York State
Michele Strasz
Executive Director,
School-Community Health
Alliance of Michigan
Susan Beane, M.D.
Vice President & Medical
Director,
Healthfirst
Mary Jo Harris, RN, MS
Health Specialist, Maryland
State Department of Education
Jogesh Syalee, M.D.
Medical Provider & Administrator,
Jamaica Hospital Medical
Albert Einstein College of Medicine,
Montefiore Medical Center
Doug Berman
Former Sr. Vice President, Formerly
of Harlem United
Kate Breslin
President and CEO,
Schuyler Center for Analysis &
Advocacy
Beverly Colon, R-P.A.
Vice President, Health &
Wellness Division
The Children’s Aid Society
Adria Cruz
Director of School-based Health
Centers and Special Initiatives
The Children’s Aid Society
Janet Garth, MPH
Manager, Center for
Community Health & Education
New York Presbyterian Hospital
ii
Lara Kassel
Coalition Coordinator,
Medicaid Matters New York
Katherine Lobach, M.D.
Professor Emerita, Department
of Pediatrics
Albert Einstein College of Medicine,
Montefiore Medical Center
Tosan Oruwariye, M.D.
E.V.P. & Chief Medical Officer,
Morris Heights Health Center
John Schlitt
Vice President, Policy and
Government Affairs
School-Based Health Alliance
Andrea Smyth
Chief Executive Officer,
A.Smyth Advocacy
Wendy Stark
Sr. Vice President for Special
Populations & Administration,
Lutheran Family Health Centers
Lauren Tobias
Policy Director,
Schuyler Center for Analysis
& Advocacy
Kim Urbach
Nurse Practitioner,
University of Rochester
Medical Center
Former Board Chair,
New York State School-based
Health Alliance
Elie Ward
Director of Policy & Advocacy,
American Academy of
Pediatrics
Deborah Zahn, MPH
Principal,
Health Management Associates
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
032
A
significant opportunity currently lies before us in New York State — to ensure that the important role of
school-based health centers (Centers) in serving many of our most at-risk children is sustained, while
also strategically achieving the goals established by the Medicaid Redesign initiative.
School-based health centers are invaluable service providers to children and youth in their communities. They
provide cost-effective primary medical, dental, mental health and reproductive health care and education services
to low-income communities. Additionally, Centers are a vehicle for eliminating racial and ethnic health disparities
in the communities that they serve. In New York State, approximately 25% of Centers serve communities where
more than one-third of the population lives below 100% of the Federal Poverty Level and 79% percent of students
in schools with Centers are non-white with more than 30% identified as Black or African-American.1 2
Executive Summary
Executive Summary
Furthermore, Centers lead to educational advancement and economic development for youth who are poor and
underserved. In addition to being instruments for accessible, comprehensive primary care services that foster
health equity for poor and minority youth, Centers have a proven record of impacting the health and education
of children/youth in a profound way, improving classroom attendance and graduation rates. One study notes
that children with asthma in elementary schools without Centers missed three more days on average compared
to those in a school with a Center.3 Another Bronx study showed that children with asthma in schools without a
Center were 50% more likely to be hospitalized than those who attended a school with a Center.4 Those students
1
http://factfinder2.census.gov/faces/nav/jsf/pages/community_facts.xhtml#none
2
http://www.health.ny.gov/statistics/school/skfacts.htm
3
McCord, M.T., Klein, J.D., Joy, J.M. and Fothergill, K. (1993). School-based Clinic Use and School Performance, Journal of
Adolescent Health, 14, 1-98.
4
Webber MP, Carpinellos KE, Oruwariye T, Lo Y, Burton WB, Appel DK. (2003). Burden of Asthma in inner-city Elementary Schoolchildren:
Do School-Based Health Centers Make A Difference?” Arch. Pediatric & Adolescent Medicine, 157, 125-129.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
033
1
Executive Summary
who used their Center were more likely to graduate or be promoted than those who did not. They were less
likely to be dismissed from school early due to illness and had three times less loss of academic seat time
when compared to students not enrolled in a Center.5 In this time of competitive learning, school attendance
matters significantly. Centers are an important way of ensuring students can easily access comprehensive care
without missing significant amounts of class time.
Medicaid Redesign — instituted by Governor Andrew Cuomo’s Administration in 2010 — was created to
develop a system of care that would improve health outcomes of Medicaid recipients in New York and, in turn,
reduce the costs of care long-term. The concept of “coordinated care” via managed care organizations is the
methodology upon which the administration plans to revise health care administration for Medicaid recipients
and, ultimately, improve health outcomes. The redesign of Medicaid has birthed the need to determine how to
fully transition all New York State Medicaid dollars to managed care organizations and, in turn, reimburse
health care providers in a carefully crafted way that ensures adequate Medicaid payment levels and the
sustainability of programs and services. Specifically, for school-based health centers (Centers) in New York, this
is an enormous challenge. Over the past twenty years, Centers’ financing has become significantly reliant on the
program because their base consumers are children covered by Medicaid. Currently, Medicaid is the leading
third-party payer, accounting for 89% of third-party revenue. Therefore, with the implementation of Medicaid
Redesign, transitioning from a fee-for-service payment methodology to one involving managed care can impact
whether or not Centers remain viable in New York State. Center viability is crucial to ensuring that children and
youth in New York’s high need areas have a secure means of comprehensive health care.
In comparing current Medicaid reimbursements received by Centers to those issued by managed care organizations
for primary care services, it is projected that the transition from a fee-for-service to a managed care payment
structure could result in program revenue loss of up to $16.2 million statewide. Collectively, among all Center
providers, this represents 50% of current Medicaid revenues and 25% of the $63.3 million statewide program
budget. It is important to note that this projection includes a reduction for federally-qualified health center
(FQHC) sponsored centers, not taking into account the wraparound payment they receive. Excluding the FQHC
rate reduction nets a statewide loss of $8.9 million.
This projected loss of up to $16.2 million is scheduled to take place on top of the existing statewide deficit of
$1.5 million. Historically and currently, Centers have operated on a skeletal budget. The $1.5 million deficit is
presently filled through the support of organizational sponsors. However, it is important to note that organizational
sponsorship is not limited to $1.5 million in annual financing. Rather, it totals approximately $5.2 million a
year, including in-kind revenue.6 The actual amount of Centers’ sustainability has been the result of piecing together
a myriad of funding sources to create a budget that supports crucial services for children living in the poorest
communities of New York State.
Given this projected revenue loss of up to $16.2 million, it is imperative that New York State construct a
methodology for Medicaid managed care financing that guarantees a stable fiscal environment for Centers, in
turn, providing continuity of care to school-aged children at existing sites and an opportunity for expansion.
The goal of this report is to provide concrete, workable financing solutions and implementation methodologies
for Centers in the environment of Medicaid managed care and beyond. New York State is a leader and innovator
in providing children with access to health services. Committing to the sustainability of school-based health
centers as providers for children and youth is necessary for New York to continue its dedication to the health
and well-being of its youngest residents.
2
5
Van Cura M. (2010). The Relationship between School-Based Health Centers Rates of Early Dismissal from School and Loss of Seat
Time. Journal of School Health, 80 (8) 371-78.
6
Data source for financing. Financial Expenditure Data gathered from the State Department of Health for Year 2011.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
034
Methodologies for Research and Analysis
To accurately assess the financing structure of New York’s school-based health center program, quantitative
and qualitative analyses were completed. Quantitative financing data was amassed from 196 (of 223*)
school-based health centers in New York State. Data was gathered cross-regionally and among the three
existing sponsorship models — namely, hospitals, federally qualified health centers, and independent
diagnostic and treatment centers. This data was examined by CohnReznick — a national firm with expertise
in health center fiscal analysis and third-party reimbursement.
Qualitative data was collected and examined by the Children’s Defense Fund – New York (CDF–NY).
CDF-NY conducted individual interviews and convened two stakeholder forums, engaging more than sixty
participants — twenty-five percent of whom were Center providers and administrators. Other interviewees and
participants of stakeholder forums included government administrators, elected officials, and other veterans of
school and children’s health.
Examining Other States
Through data gathering on programs in California, Maryland, and Michigan, as well as from the National
School-based Health Alliance, CDF-NY was able to gather valuable information that influenced the construction
of policy recommendations in this report. For a summary on financing models in other states, see Appendix A.
All data representing the financial landscape of Centers in New York State is collectively and anonymously
reported in this document.
Findings
The overarching findings from the research and analyses conducted were as follows:
• Transitioning Medicaid reimbursements from a fee-for-service to a managed care method could result in
a statewide program loss of up to $16.2 million.
In comparing current Medicaid reimbursements received by Centers to those issued by managed care
organizations for primary care services, it is projected that the transition from a fee-for-service to a
managed care payment structure could result in program revenue loss of up to $16.2 million statewide.
This is because managed care organizations reimburse providers at lower rates than fee-for-service
payments. The loss of $16.2 million is projected on top of an existing statewide program deficit of
$1.5 million.
Executive Summary
Surveying New York Providers
• The $16.2 million in Center revenue loss will become the profit of New York State and/or managed care
organizations.
A total of $16.2 million will either be kept by New York State or newly acquired by managed care
organizations once Medicaid reimbursements to Centers transition to a system that involves managed
care organizations.
• Medicaid is the leading third-party payer to Centers in New York State, accounting for 89% of
third-party revenue.
Of all children and youth who visit school-based health centers statewide, 44% of them are confirmed to
have Medicaid as their health insurance. While only 44% of the membership uses Medicaid, the revenue
gained by Centers is 89% of total third-party revenue.
* This number is based on data from December 2013.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
035
3
Executive Summary
Centers can accept health insurance other than Medicaid, however, these payers are not the primary
sources of third-party revenue. This is true for a few reasons. Principally, the schools where Centers are
placed have a large population of students who are publicly insured on Medicaid.7 Secondly, Centers in
New York are often precluded from receiving primary care reimbursement for children covered by Child
Health Plus (CHPlus) and private health insurance plans. This is because payment is funneled through
managed care organizations, which will not pay for primary care services to providers who are not
designated providers for their patients.
While Medicaid beneficiaries who receive services at school-based health centers also need to enroll in
managed care as part of their health insurance, Center providers are paid directly by the State for rendered
services without managed care involvement due to an established waiver. This waiver does not apply for
services rendered to beneficiaries of CHPlus and private health insurance.
• Medicaid reimbursements to Centers vary according to sponsorship.
The Medicaid reimbursement rate – either the ambulatory patient group (APG) rate methodology or the
FQHC prospective payment system (PPS) rate – determines each program’s Medicaid payment level.
All centers are eligible to receive APG rates which are designed to take into account the amount and
type of resources used in an ambulatory visit. Only Federally Qualified Health Centers (FQHCs) are eligible
to receive PPS rates, which are generally higher than the APG rates and most FQHCs have “opted-out”
of APGs. Hospitals and DTCs, by default, accept the APG rate. FQHCs receive, on average, reimbursements
that are 14% higher than those received by hospitals and independent DTCs. Diagnostic and treatment
centers fare the worst with respect to Medicaid reimbursements.
When transitioning to managed care with payment rates below these traditional rate systems, Hospitals
and DTCs stand the most to lose as FQHCs are “held harmless” through a supplemental payment paying
up to the PPS rate.
• Independent diagnostic and treatment centers (DTCs) are most vulnerable to adverse consequences of a
Medicaid carve-in to managed care.
Among the three Center models, independent diagnostic and treatment centers are the most at risk for
financial hardship upon implementation of the carve-in to managed care. This is due to the fact that
they are not eligible for the same enhanced Medicaid reimbursement received by FQHCs, nor do their
sponsoring organizations have resources to backfill programs that fall at a deficit, as may be true with
larger hospitals. Additionally, DTCs are sponsored by nonprofit organizations, which are already heavily
reliant on government funding. This is most concerning given that New York’s DTCs offer services in
communities where 30%-41% of residents live below the poverty level.8
Recommendations
Based on the findings of CDF-NY’s research and research and analyses, the following recommendations explicitly
provide a concrete method for adequate reimbursement to Centers upon implementation of Medicaid Redesign
and also provide mechanisms for financing outside of the realm of Medicaid managed care. These recommendations
are made in the interest of preserving a system of health care that has proven effective for children and youth
in New York State and nationally.
4
7
http://ww2.nasbhc.org/RoadMap/Public/Funding_IB_MedicaidReimbursement.pdf.
8
www.usa.com
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
036
• Transitioning Centers to receive Medicaid reimbursements via managed care should be phased in prior to
full implementation.
Handling the transition of Medicaid reimbursements from a fee-for-service model to a managed care
model with great precision and accuracy is paramount to securing that Center doors remain open in the
months and years ahead. Centers, for the first time, will need to implement a completely new
reimbursement system. Phased-in implementation will afford an opportunity for assessment and
identification of any errors and systemic glitches that can be effectively addressed and rectified on a
smaller scale. This will, ultimately, aid in ensuring ultimate success for the “carve in” methodology —
a common goal of the State Administration and Center providers in the interest of uninterrupted services
to children and youth.
• Workgroup meetings among the State Department of Health, Center providers, and managed care
organizations should commence prior to and continue through the implementation process.
As experienced by other populations undergoing the transition from a fee-for-service reimbursement
methodology to one involving managed care, it is expected that situations will arise that will negatively
impact the utilization of Centers by children and youth. Workgroup meetings inclusive of the State
Department of Health, Center providers, and managed care organizations would serve a critical purpose —
to ensure effective planning and negotiation for implementation of the “carve in” with the ultimate goal
of sustaining an effective health care model for children and youth. Prior to implementation, it is critical
for all parties to agree to specific dollar amounts for financing Centers via managed care organizations.
Ongoing workgroup meetings would monitor trends concerning managed care recognition and
reimbursement, effectively resolving systemic issues that impact utilization — ultimately, guaranteeing
uninterrupted services to children and youth dependent on Centers’ care.
• After being carved in to managed care, school-based health centers should receive Medicaid financing
inclusive of a per-member-per-month rate.
Reinvesting additional Medicaid savings — acquired via managed care involvement — back into schoolbased health centers is the only way that the program can survive and continue to offer optimal care to
low-income families. This PMPM payment would cover the cost of school-based enabling and support
services not covered by traditional payment models and rates. Re-investing this additional Medicaid
savings back into Centers can be done using a methodology that pays Center providers per member on a
monthly basis.
Executive Summary
Within the Medicaid Managed Care Environment:
• School-based health centers should not be required to complete credentialing and automatically be
recognized by managed care organizations as designated providers for specified services.
Completing non-standardized credentialing applications for various managed care entities to ensure
third-party insurance reimbursement is a process that would add administrative burden and costs
on Centers. Non-standardized credentialing is a cumbersome, overwhelming, and costly process for
organizations with low administrative capacity. In order to successfully complete the process,
organizations would need to add to administrative overhead costs that would create further deficit.
Instead, as in the state of Michigan, Centers should be automatically recognized by managed care as
designated providers to avoid excess expenditure on the credentialing process.
• School-based health centers should have a specified designation in managed care that permits them to
receive reimbursement.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
037
5
Executive Summary
In order for school-based health centers to receive Medicaid dollars administered by managed care
organizations, they need to have a specified, recognized designation in the managed care system. Other
states — namely, Michigan and Maryland — have arranged for school-based health centers to have a
recognized designation and, in turn, are entitled to Medicaid reimbursements administered via managed
care. This eliminates unnecessary competition for reimbursement between community providers and
school-based health centers, allowing each to have a designated role and recognized status within
managed care.
This designation would require Center providers to:
n
meet specific standards for comprehensive service provision to children/youth;
n
report on quality outcome measures pre-determined via negotiations with managed care
organizations; and
n
effectively integrate with community providers to ensure quality health care.
• School-based health centers need to use a streamlined, centralized billing system.
In order to create a fluid process for reimbursement to providers that optimizes the potential for
expeditious processing and revenue generation, New York State needs to create and support a
simplified, streamlined, and centralized system that Centers can use to bill managed care organizations.
Given the skeletal budget by which Centers operate, ensuring timely, adequate reimbursement is
necessary to guaranteeing program viability and sustainability.
Additionally, such a system could serve as a clearinghouse of information for the State Administration.
Data gathered through this tool could provide critical information on how the program can be
administered moving forward to ensure optimal, cost-effective care to children and youth.
Beyond Medicaid Managed Care
• School-based health centers should receive funding for specialized care and public health
education services.
Currently, New York State operates federally-subsidized programs that offer interventions and support for
areas related to reproductive health, childhood obesity, substance abuse and mental health. Allocating
some of the public funds used to finance these programs to Centers that currently offer these services
will allow for a new opportunity to enhance program revenue and services to the same target population.
• School-based health centers should designate clinic hours to serve the community, at large.
Making Centers available to the community, at large, for primary care services would optimize the
potential of the facility to serve patients beyond the limitations of school hours, which would create
additional revenue and guarantee sustainability. Additionally, creating community access would
also meet a growing demand in New York State for expansion of primary care services given the
implementation of the Affordable Care Act.
6
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
038
Introduction
Introduction
ccess to affordable primary health care has posed one of the most difficult challenges in our health
care system. Specifically, for low-income communities, residents are often medically disenfranchised, not
having access to affordable, comprehensive, and quality health services. Lack of access leads to other
consequences — namely, disproportionate health outcomes for low-income individuals — that can hamper
quality of life and opportunities for advancement.
A
School-based health centers — facilities housed in schools that provide on-site primary care, ancillary care,
reproductive health care and education, and mental health services — offer a means for remediating the shortage of medical service provision for children and youth, particularly in low-income communities.9 Securing
these facilities as critical access points for care is essential to creating a fastened pathway for children and
youth to have a healthy start in life.
The Current Challenge
At this time, New York State’s school-based health centers are facing an enormous challenge. As providers that
have become heavily reliant on Medicaid dollars, they have been sustainable due to a fee-for-service financing
methodology. However, as of October 2014, Centers are being directed by the state’s administration to involve
managed care organizations as an intermediary for issuing Medicaid reimbursements. This shift in financing is
part of the Medicaid Redesign initiative issued by Governor Andrew Cuomo in 2010. This initiative has birthed
the need to determine how to fully transition Medicaid reimbursements from a fee-for-service methodology to
one that involves managed care organizations for various beneficiaries and providers. For school-based health
centers, guaranteeing their continued viability means crafting a Medicaid reimbursement methodology that
offers adequate levels of payment, ultimately ensuring the sustainability of programs and services.
9
http://ww2.nasbhc.org/RoadMap/PUBLIC/Advocacy_SBHCdefinition.pdf.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
039
7
History
Providing medical services in schools to achieve both child health and school performance objectives has a
deep and long history in the United States. The first school-based health centers (Centers) emerged in
Cambridge, MA in the 1960s, following President Lyndon B. Johnson’s War on Poverty, which acknowledged
the need to focus on health issues among impoverished school-age children.10 Since 1970, school-based
health centers have grown from just a handful to more than 1,900 in 45 states. Currently, New York State,
which houses 223 centers statewide, is one of three states — along with California and Florida — with the
greatest volume of centers.
Who and Where Centers Serve
Nationally, Centers serve all school levels, but have the greatest presence in high schools at 30 percent, followed
by elementary schools (20%), middle schools (15%), elementary with middle schools (14%), schools offering
K-12 (14%), and middle with high schools (7%). The majority are co-located in school buildings in urban
communities (59%), followed by rural (27%) and suburban (14%) communities. Seventy percent of the students
in schools with Centers are non-White. They include Hispanic/Latino (36%), Black non-Hispanic/Latino (26%),
Asian/Pacific Islander (4%), Native American/Alaskan Native (1%), and “Other” (1%).11
In New York State, almost 25% of Centers serve communities where more than one-third of the population
lives below 100% of the Federal Poverty Level.12 Additionally, 79% percent of students in schools with Centers
are non-white with more than 30% identified as Black or African-American.13
Parallel to the premise on which Centers were birthed — to focus on addressing health issues among poor
children — they remain critical in providing health care for school-age children living in poverty who are racial
and ethnic minorities.
Service Provision and Staffing
School-based health centers provide a range of primary care and ancillary care services. Namely, these include:
first aid; diagnosis and treatment for pediatric and adolescent health needs; assessments and examinations for
sports physicals and working papers; chronic disease monitoring and treatment; laboratory testing; reproductive
health services; STI/HIV testing, treatment, and counseling; vaccinations; mental health services; and dental care.
Centers are staffed by a multi-disciplinary team of licensed health care professionals and support staff.
By and large, they are staffed by Nurse Practitioners (NPs) or Physician Assistants (PAs). One NP or PA is
designated to serve between 700 and 1,500 students. A supervising physician from the center’s sponsoring
agency is required to be accessible to the NP or PA at all times during operating hours. Mental health needs
may be addressed at the school site or by referral. If services are provided on-site, one full-time licensed mental
health provider should be available for every 700-1,500 students enrolled in the program. Lastly, all Centers
have a medical or health assistant on site who schedules appointments, conducts data entry, and assists the NP
and PA in patient care. Centers that offer expanded services may have additional staff on-site which may include
a health educator, a community outreach worker, registered nurses, or a nutritionist. If dental services are provided
8
10
Wolfe, B. (2012). The Legacy of the War on Poverty. Retrieved from
http://npc.umich.edu/news/events/war-on-poverty-june-conference/wolfe.pdf.
11
Zimmerman et. al. (December 2011). The School-Based Health Care Policy Program: Capstone Program, Center for School,
Health, and Education. Retrieved from http://www.schoolbasedhealthcare.org/wp-content/uploads/2011/01/SBHCPP-Capstone-Evaluation-ATTACHMENTS-Dec-20111.pdf.
12
http://factfinder2.census.gov/faces/nav/jsf/pages/community_facts.xhtml#none
13
http://www.health.ny.gov/statistics/school/skfacts.htm
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
040
on-site, a dental assistant, a dental hygienist, and a supervising dentist will be part of the center’s staff. One full
time dental hygienist can provide services for approximately 2,500 enrollees.
It is required that all staff are trained in child abuse, infection control, emergency care, including general first
aid, basic life support, and in the use of an automated external defibrillator. Centers are also required to have a
presence during all normal school hours.14
Facility Requirements
The school space designated to the Center must include adequate space to provide services. Space is needed for
exam room(s), counseling room(s), a reception area, professional office space, a storage area and locked space
for medical records and pharmaceuticals, bathroom(s), an infirmary area, clean and dirty prep areas, hand
washing sinks, and a laboratory area. Approximately 1,500 to 2,000 square feet is recommended by the New
York State Department of Health (NYSDOH), School Health Program for a site with an enrollment of 700 students.
However, typically, space allocation is determined by availability and resources within the school building.15
Invaluable Service at Minimal Cost: Implications on Public Health
and Academic Performance
By providing accessible, quality health education and services for high-need children and youth, school-based
health centers provide an enormous benefit to communities and greater society, as compared with their low
expense. Primarily, their benefit outweighs cost due to their “one-stop shop” approach to prevention and early
detection/treatment for children and youth who are most at risk. Costs, as well as administrative burdens experienced
by providers and families, are dramatically reduced given their capacity to have multi-disciplinary teams serve
school-age youth without the need for referrals and outsourcing of services. This is most relevant to Centers with
robust models of care that offer primary and ancillary care services. Centers save money for the taxpayer and
for low-income families by offering children access to health care — ultimately fostering disease prevention
and early detection/treatment.16
Centers also serve as a vehicle for eliminating racial and ethnic health disparities in preventive primary, dental,
mental health and reproductive health care and education. Geographic placement of school-based health centers
in communities where the demographic make-up consists of racial and ethnic minorities who are at or below
133 percent of the federal poverty level (FPL) gives opportunity for minority children in low-income families to
access primary and specialty care prevention and treatment services. History and data have shown that access
to such care in schools by qualified professionals is a fundamentally effective model to guarantee disease
prevention and service intervention.17
Moreover, Centers lead to educational advancement and economic development for youth who are poor and
underserved. Studies have shown improved school attendance, grades and graduation rates as a result of Center
intervention.18 Improving the health of a child in poverty enhances his or her chance of educational achievement
and advancement out of poverty.19
14
Horton, J.M. and Lima-Negron, J. (2009). School-based Health Centers: Expanding the Knowledge and Vision. Retrieved from
http://www.nystatesbhc.org/images/stories/CHFWCNY%20FINAL%20DOCUMENT%208.5.pdf.
15
Horton, J.M. and Lima-Negron, J. (2009). School-based Health Centers: Expanding the Knowledge and Vision. Retrieved from
http://www.nystatesbhc.org/images/stories/CHFWCNY%20FINAL%20DOCUMENT%208.5.pdf.
16
Webber et. al. (2005). Impact of Asthma Intervention in Two Elementary School Based Health Centers in the Bronx.
Pediatric Pulmonology: 40 (6), 497-493.
17
Jeff J. Guo, Terrance J. Wade, Wei Pan, and Kathryn N. Keller (2010). School-Based Health Centers: Cost–Benefit Analysis and Impact
on Health Care Disparities. American Journal of Public Health: 100 (9), 1617-1623.
18
http://www.eric.ed.gov/PDFS/ED539815.pdf.
19
Webber MP, Carpinellos KE, Oruwariye T, Lo Y, Burton WB, Appel DK. (2003). Burden of Asthma in inner-city Elementary
Schoolchildren: Do School-Based Health Centers Make A Difference?” Arch. Pediatric & Adolescent Medicine, 157, 125-129.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
041
9
Financing and Sponsorship
School-based health centers are financed by myriad sources. Government grants and subsidies, organizational
sponsorship, and third-party reimbursements all support the 223 centers throughout New York State.
New York State’s school-based health center program costs $63.3 million. This cost includes direct and indirect
expenses. Of the $63.3 million budget: 42% is covered by state grants; 54% is covered by third-party revenue;
and, the balance is covered by in-kind support from sponsor organizations.
Government Grants
In the initial years of the program, public financing for centers across the United States began with local and
state investments of the federal maternal and child health (MCH) block grant. Between the years 1994-2004,
funding through the Public Health Services Act appropriation featured the first-ever federal grant program
dedicated exclusively to Centers: the Healthy Schools/Healthy Communities (HSHC) program. The program,
operated by the Health Resources and Services Administration (HRSA), a division of the U.S. Department of
Health and Human Services, funded 80 Centers across the country, including nine in New York. By the late
1990s, financing by MCH block grant began to diminish because of federal budget cuts, and the HSHC funding
was consolidated with other federal health care safety net program funds, forcing states to determine other
means for center viability and sustainability. In addition to continued funding by the MCH block grant, New
York State carved out public monies via tax dollars from the Health Care Reform Act (HCRA). These monies
provided financial support for a number of public health programs, including school-based health centers, from tax
dollars levied from the Tobacco Settlement. Currently, government grants comprise 42% of the Center program
budget statewide.
Sponsors
Over the past twenty years, organizations establishing school-based health center programs in their designated
communities have become critical entities for sponsorship and financial support. These organizations include:
hospitals, public health departments, federally-qualified health centers (FQHCs), and nonprofit healthcare and
social service agencies. In New York State, school-based health centers are identified according to sponsorship
as hospital-sponsored Centers, federally-qualified health center-sponsored centers, or independent diagnostic and
treatment centers (sponsored by public health departments and non-profit agencies). Implications for financial
support vary based on the organizational sponsorship designation. Larger and wealthier institutions are in the
position to allot more finances to centers, ensuring program sustainability independent of government financing.
Less affluent institutional sponsors, like federally-qualified health centers and non-profit agencies, are more
reliant on government financing and third-party reimbursements in order to maintain services. See Appendix B
for a listing of Centers and sponsors in New York State.
Third-Party Payments
Third-party payments via health insurance reimbursements (including Medicaid) have become significant sources
of income for centers since the 1990’s. Originally, Centers began to bill health insurances for service reimbursement
to supplement their revenue stream. Currently, these third-party reimbursements constitute 54% of revenues
generated by Centers in New York.20
Additionally, since school-based health centers are strategically located in impoverished communities, students who
receive care at these facilities are largely insured by Medicaid, making it the primary third-party payer. As a
result, Centers are heavily reliant on Medicaid financing for program sustainability. More specifically, in New
20
Fiscal Data gathered from the State Department of Health for Year 2011.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
042
11
York State, Medicaid reimbursements supply 89% of third-party revenue, making it the most significant third-party
payer for the program.21
Reliance on the Medicaid program for financial support is significant for New York State’s School-based Health
Center program, overall. However, Center sponsorship and geographic location also influence the degree by
which a program is reliant on Medicaid funding. For example, diagnostic and treatment centers (DTCs) in
downstate New York are the most reliant on Medicaid financing, making them significantly more susceptible to
program closure if state Medicaid funding is adversely impacted.
In addition to center payer mix varying by sponsorship and region, Medicaid reimbursement levels to centers in
New York State also differ by sponsorship and region. From a geographic rate-setting perspective, New York State
Medicaid rates are segregated between upstate and downstate, with differing rates established taking into account
the differences in the cost of living and other factors by region. The sponsoring entity’s identity also affects the
Medicaid rate. Hospital outpatient clinics, FQHCs and free-standing diagnostic and treatment centers each have
differing reimbursement rates. Centers sponsored by FQHCs receive the prospective payment system (PPS) rate.
This rate was created by federal legislation — the Consolidated Appropriations Act of 2001, and includes a provision
establishing a minimum Medicaid per visit rate for FQHCs using a specific methodology.23 Through the PPS
methodology, an enhanced Medicaid reimbursement rate to FQHCs is established to cover the cost of federallymandated services. Centers sponsored by all other entities are reimbursed under the ambulatory patient group
(APG) rate methodology, which is designed to take into account the amount and type of resources used in an
ambulatory visit. While FQHCs can qualify to receive APG reimbursement, they often opt for the PPS rate since
it offers higher compensation, reflective of the actual cost of care.
Medicaid Redesign in New York State: The Impact on School-based Health Centers
In 2010, Governor Andrew Cuomo issued an executive order, instituting Medicaid Redesign — an initiative
purposed to provide “care coordination” for all program beneficiaries in New York and avoid duplication in
expenditures. This, in turn, is expected to reform the Medicaid system and reduce costs. The Governor’s action
was taken to address the uptick in Medicaid expenditures within the past five years. The reconfiguration of
Medicaid spending in New York is a necessary step towards preserving the program long-term. However, it is
critically important that careful planning and administration ensue in the overhaul of a program that provides
critical health services for underserved children and other populations.
“Care coordination” for all Medicaid beneficiaries will entail eliminating the fee-for-service payment structure by
re-allocating $26 billion in fee-for-service spending to managed care organizations that will coordinate patient
care for all Medicaid beneficiaries.23 The reallocation of spending through managed care organizations will require
that school-based health centers transform the way they acquire Medicaid reimbursement dollars. To date, New
York State has implemented a “carve out” methodology for Medicaid reimbursement to Centers. The “carve out”
was authorized via a waiver in the Pataki Administration in 1998 and allowed Center providers to directly bill
New York State for services provided to children on Medicaid.24 The “carve out” has offered Center providers
a streamlined, simplified billing methodology that allowed reimbursements to occur expeditiously and at
an adequate rate, as approved by the State Department of Health.
Shifting to a billing method that would involve processing claims through a large pool of managed care
organizations will involve a more complex structure and may not guarantee reimbursement rates at a level that
12
21
Fiscal Data gathered from the State Department of Health for Year 2011.
22
Koppen, C. (2001). Understanding the Medicaid Payment Prospective System for Federally Qualified Health Centers. Retrieved
from http://www.nachc.com/client//IB69%20PPS%20Complete.pdf.
23
http://www.health.ny.gov/health_care/medicaid/redesign/docs/care_manage_for_all.pdf.
24
State Department of Health (letter to school-based health centers, April 22, 2004).
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
043
will sustain Centers. This is true for two reasons: (1) managed care reimbursements to providers are contracted on
a payment schedule that is negotiated between the provider and managed care organization, often not allowing
the provider much flexibility in rate determination; (2) managed care organizations have organized payment
rates that are lower than the existing rates that Center providers receive via the fee-for-service payment
methodology.
Since Medicaid reimbursements comprise more than 89% of Centers’ third-party revenue in New York, ensuring that
reimbursements to Center providers are timely and do not decline is crucial to their sustainability moving forward.
Without a thoughtful plan that accounts for operating costs, Centers will close.
An Analysis: The Financial Performance of Centers – Current and Prospective
Surveying New York Providers
In order to accurately assess the financing structure of New York’s school-based health center program for this
report, quantitative and qualitative analyses were completed. The quantitative analysis was completed by
CohnReznick — a national firm with expertise in health center fiscal analysis and third party reimbursement.
Quantitative financing data was amassed from 196 (of 223) school-based health centers in New York State.
Of the 196 sites, 72 are located in the Upstate Region and 124 in the Downstate Region. Fifty percent are
hospital-sponsored; 35% are FQHC-sponsored; and 15% are DTC-sponsored.
Qualitative data was collected and examined by the Children’s Defense Fund – New York (CDF–NY). CDF–NY
conducted individual interviews and convened two stakeholder forums, engaging more than sixty participants.
Interviewees and participants of stakeholder forums included Center providers, government administrators,
elected officials, and other veterans of school health.
Looking at Other States
An important step in the development of this report’s recommendations for sustainability and growth of schoolbased health centers included researching and examining models from other states. Through research and a host
of communications with other state and program officials, as well as the National School-based Health Alliance,
we were able to gather valuable information that influenced the construction of the policy recommendations in
this report. For a summary on financing models in other states, see Appendix A.
All data representing the financial landscape of Centers in New York State is collectively and anonymously
reported in this document.
Findings
Initial research and assessment of Center financing in New York State revealed the following:
• Medicaid is the leading third-party payer to Centers in New York State, accounting for 89% of
third-party revenue.
Of all children and youth who visit school-based health centers statewide, 44% of them are confirmed to
have Medicaid as their health insurance while the remainder of the population consists of children/youth:
with private coverage (10%), with Child Health Plus (4%), without insurance (29%), and with an unknown
insurance status (13%). See Table with Graph A. Of the subgroups identified as “uninsured” or “unknown”,
it is likely that a large portion of these members have Medicaid, yet this information is not recorded by
Centers based on the fact that the visits represent confidential encounters for reproductive health or
mental health services. However, while only 44% of the membership uses Medicaid, the revenue gained
by Centers is 89% of total third-party revenue. See Table with Graph B.
12
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
044
13
• Medicaid reimbursements to Centers vary according to sponsorship.
Based on fiscal and year end data reports for the school-based health center program in New York State,
Medicaid reimbursements cover 89% of the cost per visit, on average. Medicaid reimbursements range
from covering 44% to 123% of a visit cost. Diagnostic and treatment centers fare the worst with respect
to Medicaid reimbursements. Data shows that Medicaid reimbursements cover 44% to 63% of a visit
cost, on average. The balance is covered by grant dollars and in-kind organizational support.
New York State’s school-based health centers currently accept Medicaid reimbursements for services
provided to enrolled consumers. The payment is issued directly from New York State to the Center.
Rates vary according to sponsorship type. FQHCs receive, on average, reimbursements that are 14%
higher than those received by hospitals and independent DTCs. By statute, the PPS reimbursement
methodology offers FQHCs protection by providing a guaranteed baseline for payment regardless of
whether the Medicaid beneficiary is covered under fee-for-service or enrolled in managed care.
Table with Graph A.
NYS Center Statewide Third Party Enrollment
Third Party Payer Type
% Enrollment by Center Membership
Medicaid
44
Private Insurance
10
Uninsured
29
Unknown
13
CHP
4
Medicaid
Private Insurance
Uninsured
Unknown
CHP
14
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
045
Table with Graph B.
Distribution of Statewide Center Revenue Generated by Third Party Payer
Medicaid
Upstate Hospital
Downstate Hospital
Upstate FQHC
Downstate FQHC
Upstate DTC
Downstate DTC
TOTAL
CHP
Private
Uninsured/
Unknown
TOTAL
$
5,583,577.00
296,570.00
1,700,299.00
None
7,580,446.00
%
74
4
22
None
100%
$
12,002,756.00
58,177.00
482,106.00
None
12,543,039.00
%
96
0
4
None
100%
$
1,495,446.00
184,113.00
546,263.00
None
2,225,822.00
%
67
8
25
None
100%
$
9,200,032.00
230,789.00
105,900.00
None
9,536,721.00
%
96
2
1
None
100%
$
573,139.00
47,473.00
275,118.00
None
895,730.00
%
64
5
31
None
100%
$
1,697,459.00
2,957.00
37,816.00
None
1,738,232.00
%
98
0
2
None
100%
$
30,552,412.97
820,079.20
3,147,502.83
None
34,519,995.00
%
89
2
9
None
100%
100%
80
60
Uninsured
40
CHP
Private
Medicaid
20
0
Upstate
Hospital
Downstate
Hospital
Upstate
FQHC
Downstate
FQHC
Upstate
DTC
Downstate
DTC
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
046
15
For Medicaid patients enrolled in managed care, FQHCs receive a supplemental payment from the State
for the difference between their Medicaid PPS rate and the payment they receive from the managed care
plan. This rate protection is rooted in the essential safety net provider status of FQHCs. The legislative
history of the FQHC Medicaid program notes:
The role of [health centers] . . . is to deliver comprehensive primary care services to underserved populations
or areas without regard to ability to pay. To the extent that the Medicaid program is not covering the
cost of treating its own beneficiaries, it is compromising the ability of the centers to meet the primary
care needs of those without any public or private coverage whatsoever. See Table with Graph C.
To ensure that Federal PHS Act grant funds are not used to subsidize health center or program services
to Medicaid beneficiaries, States would be required to make payment for these [FQHC] services at 100
percent of the costs which are reasonable and related to the cost of furnishing these services. [H.R.
Rep. No. 101-247, at 392-93, reprinted in 1989 U.S.C.C.A.N. 2118-19 (emphasis added)]
Therefore, given this Federal protection, any potential reductions in state financing of Medicaid do not
adversely impact the reimbursement rates received by FQHCs. See Table with Graph D.
16
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
047
Table with Graph C.
Average Medicaid Reimbursement Rate for Centers Per Claim
Sponsorship Type
Average Medicaid Reimbursement Rate
for SBHCs Per Claim
FQHCs (PPS Rate)
$160.86
Hospitals (APG Rate)
$153.97
DTCs (APG Rate)
$130.54
Average Medicaid Reimbursement Rate for SBHCs Per Claim
$200
150
100
50
0
FQHCs (PPS Rate)
Hospitals (APG Rate)
DTCs (APG Rate)
Table with Graph D.
Average Medicaid Reimbursement Rate for Centers Per Claim
Region
DTC
SBHC Sponsor
FQHC
Hospital
Downstate
$137.52
$180.49
$175.68
Upstate
$106.22
$112.80
$141.07
Grand Total
$130.64
$160.18
$165.18
CY 2012 Average Paid Per Claim by Sponsor Type per NYSDOH
$200
150
100
50
0
DTC
FQHC
Hospital
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
048
17
• Independent diagnostic and treatment centers are most vulnerable to adverse consequences of a
Medicaid carve-in to managed care.
Additionally, when examining the payer mix by sponsorship and region for all Centers, diagnostic and
treatment centers (DTCs) in downstate New York demonstrate to be the most reliant on Medicaid financing.
DTCs show through financial reporting that Medicaid visits comprise 73% of all patient visits. Meanwhile,
the range of percentages by which Medicaid finances the other sponsors and regions stretched from
32% to 49%, making downstate DTCs significantly more susceptible to program closure if state
Medicaid funding is adversely impacted. See Table with Graph E.
Table with Graph E.
Payer Mix for Visits (by region and sponsorship)
Upstate
Hospital
Downstate
Hospital
Upstate
FQHC
Downstate
FQHC
3%
14%
7%
13%
1%
6%
Uninsured
12%
21%
11%
31%
11%
8%
Private Insurance
33%
11%
27%
7%
26%
10%
Child Health Plus
7%
3%
7%
3%
7%
2%
43%
32%
49%
44%
33%
73%
Unknown
Medicaid
Upstate
DTC
Unknown
Private Insurance
Uninsured
Child Health Plus
Downstate
DTC
Medicaid
100%
90
80
70
60
50
40
30
20
10
0
Upstate
Hospital
18
Downstate
Hospital
Upstate
FQHC
Downstate
FQHC
Upstate
DTC
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
Downstate
DTC
049
The implementation of Medicaid Redesign and the “carve in” of Medicaid dollars to managed care will,
however, adversely affect non-FQHC providers by causing reductions in their reimbursement rates.
An illustration of how providers are projected to fare with the institution of the “carve in” is provided in
Table 1. Data is organized by geography (Upstate, Downstate) and sponsorship type (Hospital, FQHC,
and DTC).
Table 1. Estimated Medicaid Revenue Impact Post- Medicaid Redesign
Implementation
Existing
Medicaid
Rate
Per Visit
Estimated
Average
Medicaid
Managed Care
Rate Per Visit**
Number of
Annual
Projected
Rate
Medicaid
Differential Visits***
Medicaid
Revenue
Impact
Estimated
Prospective
Payment
Rate Per
Visit****
Medicaid
Revenue
Generated
by Prospective
Payment Rate
Medicaid
Revenue
Impact
Upstate
Hospitalsponsored
$141.07
$77.44
($63.63)
8,567
($545,118)
FQHCsponsored
$112.80
$77.44
($35.36)
26,378
($932,726)
D&TCsponsored
$106.22
$77.44
($28.78)
5,343
($153,772)
($153,772)
40,288
($1,631,616)
($698,890)
($7,168,969)
Total Upstate
($545,118)
$35.36
$932,726
$0
Downstate
Hospitalsponsored
$175.68
$81.38
($94.30)
76,023
($7,168,969)
FQHCsponsored
$180.49
$81.38
($99.11)
64,594
($6,401,911)
D&TCsponsored
$137.52
$81.38
($56.14)
18,614
($1,044,990)
($1,044,990)
Total Downstate
159,231
($14,615,870)
($8,213,959)
Grand Total
199,519
($16,247,486)
($8,912,849)
$99.11
$6,401,911
$0
* Per SDOH 2/28/2013 – Statewide Average Payment
** Per SDOH 3/4/2013 – Based on 2011 FQHC MCVRs
***Per SDOH 2/28/2013 – Paid visits 2011
****Applies to Federally-Qualified Heath Centers only
The data shows that the “carve in” is projected to bring a loss of $0 to FQHCs, $7.7 million to
Hospitals, and $1.2 million to DTCs. While the projected loss to DTCs is less than the loss to
Hospitals, DTCs do not have the monetary backing in-house to fill the gap loss, making them most
vulnerable to closing. In turn, this would impact communities with more than one-third of their
population living below the poverty level.25
Further analysis of Center financing elicited the following additional findings:
• Transitioning Medicaid reimbursements from a fee-for-service to a managed care method could result in
a statewide program loss of up to $16.2 million.
25
www.usa.com
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
050
19
It is projected that the transition from a fee-for-service to a managed care payment structure could result
in a program revenue loss of up to $16.2 million statewide, most adversely affecting Centers in the
downstate region. Since FQHCs are protected by statute to receive federal dollars that would subsidize
state Medicaid financing and guarantee payment levels at a rate comparable to the average cost per visit
(pre-determined by data from the previous fiscal year), we conducted an analysis (see Table 1) to show
the impact on Medicaid revenue statewide. The projected net loss for Medicaid is reduced to $8.9 million
when FQHCs are excluded. This is still a significant dollar amount and would, ultimately, unfavorably
impact program viability throughout New York State.
With managed care organizations serving as the intermediary between New York State and school-based
health centers, Center providers are slated to lose Medicaid revenue. The remaining revenue lost by Centers
becomes savings to New York State and/or managed care organizations. See Table 2 for more details.
Table 2. Estimated Medicaid Savings by Managed Care Organizations PostMedicaid Redesign Implementation
Existing
Medicaid
Rate
Per Visit
Estimated
Average
Medicaid
Managed Care
Rate Per Visit**
Rate
Differential
Number of
Annual
Projected
Medicaid
Visits***
Current
Medicaid
Cost
Medicaid
Managed
Care Cost
Total
Medicaid
Savings by
Managed Care
Upstate
Hospitalsponsored
$141.07
$77.44
($63.63)
8,567
$1,208,547
$663.43
$545,118
FQHCsponsored
$112.80
$77.44
($35.36)
26,378
$2,975,438
$2,042,712
$932,726
D&TCsponsored
$106.22
$77.44
($28.78)
5,343
$567,533
$413,762
$153,722
40,288
$4,751,519
$3,119,903
$1,631,616
Total Upstate
Downstate
Downstate
Hospitalsponsored
$175.68
$81.38
($94.30)
76,023
$13,355,721
$6,186,752
$7,168,969
FQHCsponsored
$180.49
$81.38
($99.11)
64,594
$11,658,571
$5,256,660
$6,401,911
D&TC-sponsored
$137.52
$81.38
($56.14)
18,614
$2,559,797
$1,514,807
$1,044,990
Total Downstate
159,231
$27,574,089
$12,958,219
$14,615,870
Grand Total
199,519
$32,325,608
$16,078,122
$16,247,486
* Per SDOH 2/28/2013 – Statewide Average Payment
** Per SDOH 3/4/2013 – Based on 2011 FQHC MCVRs
***Per SDOH 2/28/2013 – Paid visits 2011
****Applies to Federally-Qualified Heath Centers only
20
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
051
• The $16.2 million in Center revenue loss will become the profit of New York State and/or managed
care organizations.
A total of $16.2 million will either be kept by New York State or newly acquired by managed
care organizations. Simultaneously, Centers will be adversely impacted by this new structure of
management, losing up to 50% ($16.2 million) of their current Medicaid revenues. Centers are
expected to provide the same level of service with a 50% average reduction in their reimbursement. This
not only threatens their viability, but clearly disincentivizes them from providing comprehensive services
to a vulnerable population.
Ensuring Sustainability
Recommendations for the Managed Care Environment
Preserving the $16.2 million loss of Medicaid revenues to Centers post the carve-in to managed care is critical
to maintaining program viability and ensuring fiscal sustainability. This section addresses how the $16.2 million
can remain in the school-based health center system and be used to support comprehensive services provided
by the program for children and youth who benefit from these services.
Recommendation: Transitioning Centers to receive Medicaid reimbursements via managed care should be
phased in prior to full implementation.
Managed care organizations will embark on a massive undertaking in becoming responsible for the effective
administration of Medicaid dollars to Centers. Given that Medicaid is the primary source of revenue for Centers,
the program cannot sustain systemic glitches in the forthcoming administration of Medicaid dollars. Handling the
Medicaid “carve in” with great precision and accuracy is paramount to securing that center doors remain open
in the months and years ahead.
As is sensible with most vast undertakings, the “carve in” should be phased in prior to full implementation.
The phase-in is needed because Centers, for the first time, will need to implement a completely new
reimbursement system. This will afford an opportunity for assessment and identification of any errors and
systemic glitches that can be effectively addressed and rectified on a smaller scale. This will, ultimately, aid in
ensuring ultimate success for the “carve in” methodology.
There is precedent for the phased in approach in how previous populations have transitioned into managed care.
The homeless population, for instance, was transitioned into managed care over a six month period, beginning
in April 2012. This transition impacted 206 sites that served 50,000 people statewide. The phased in approach
was found to be necessary in order to minimize decreases in productivity and utilization of health services by
this population. Given that there are 223 school-based health centers statewide that serve close to 200,000
children and youth, there is all the more cause for there to be a phased in transition from a fee-for-service
reimbursement methodology to one that involves managed care organizations.
Recommendation: Workgroup meetings among the State Department of Health, Center providers, and managed
care organizations should commence prior to and continue through the implementation process.
Anticipating that the transition from fee-for-service to managed care will, inevitably, lead to situations that
could negatively impact the utilization of Centers by children and youth, workgroup meetings among the State
Department of Health, Center providers, and managed care organizations should commence prior to implementation
to set a baseline for contracted payments to Centers from managed care organizations. Post-implementation,
ongoing workgroup meetings should occur to monitor trends concerning managed care recognition of Centers
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
052
21
and adequate reimbursement. The transition to managed care for the homeless population included ongoing
workgroup meetings through the conversion period, which afforded the opportunity to track and monitor
systemic glitches that, in turn, could be rectified expeditiously by the State Department of Health.
Recommendation: After being carved in to managed care, school-based health centers should receive
Medicaid financing inclusive of a per-member-per-month rate.
The analysis completed in this report clearly demonstrates that of the $32 million currently allotted for Medicaid
reimbursement to school-based health centers, it is estimated that lower reimbursement rates issued by managed
care organizations to providers would result in a 50% ($16.2 million) reduction in Medicaid revenue statewide.
This savings of $16.2 million by managed care organizations can be reinvested back to school-based health centers
to ensure that providers across New York State remain whole, in turn, allowing for critical health services —
namely, first aid; diagnosis and treatment for pediatric and adolescent health needs; assessments and examinations
for sports physicals and working papers; chronic disease monitoring and treatment; laboratory testing; reproductive
health services; STI/HIV testing, treatment, and counseling; vaccinations; mental health services; and dental
care — to be covered for children and youth in high need communities. The reinvested payment would be for
services provided not covered in traditional payment models issued per patient member of the center on a
monthly basis. Table 3 illustrates how monthly payments for members can be configured and issued to providers.
Using a total reinvestment amount of $16.2 million for 65,441 patient members, the monthly reinvestment to
Centers per patient member per month equals $20.69. Table 4 illustrates how reinvesting $20.69 per patient
member per month will result in keeping centers fiscally whole.
Table 3. Configuring How to Reinvest Medicaid Savings into School-based
Health Centers
Number of
Annual
Visit***
Current
Medicaid
Cost
Medicaid
Managed
Care Cost
Total
Medicaid
Savings by
Managed
Care
Reinvestment
Number
Per Patient
of Patient
Member
Members**** Per Year
Reinvestment
Patient
Member
Per Month
Upstate
Hospital-sponsored
8,567
$1,208,547
$663.43
$545,118
9,874
FQHC-sponsored
26,378
$2,975,438
$2,042,712
$932,726
3,484
D&TC-sponsored
5,343
$567,533
$413,762
$153,722
1,748
40,288
Downstate
$4,751,519
$3,119,903
$1,631,616
15,106
Total Upstate
Hospital-sponsored
76,023
$13,355,721
$6,186,752
$7,168,969
23,724
FQHC-sponsored
64,594
$11,658,571
$5,256,660
$6,401,911
17,671
D&TC-sponsored
18,614
$2,559,797
$1,514,807
$1,044,990
8,940
Total Downstate
159,231
$27,574,089
$12,958,219
$14,615,870
50,335
Grand Total
199,519
$32,325,608
$16,078,122
$16,247,486
* Per SDOH 2/28/2013 – Statewide Average Payment
** Per SDOH 3/4/2013 – Based on 2011 FQHC MCVRs
***Per SDOH 2/28/2013 – Paid visits 2011
****Applies to Federally-Qualified Heath Centers only
22
Total
Amount to
Reinvest
/
65,441
Divided by
No. of
Patient
Members
$248.28
=
Annual
Amount to
Reinvest Per
Patient
Member
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
$20.69
Monthly
Amount to
Reinvest Per
Patient
Member
053
Table 4. Demonstrating Reinvestment of Medicaid Savings Per Member
Per Month
Number of Annual
Projected
Medicaid
Visits
Number of
Patient
Members
Reinvestment
of $20.69
Per Member
Per Month
Total Medicaid
Savings by
Managed
Reimbursement
Medicaid
Managed Care
Reimbursement
+ PMPM
Add On
Upstate
Hospital-sponsored
8,567
9,874
$2,251,486
$663,428
$3,114,914
FQHC-sponsored
26,378
3,484
$864,997
$2,042,712
$2,907,709
D&TC-sponsored
5,343
1,748
$433,988
$413,762
$847,750
40,288
15,106
$3,750,470
$3,119,903
$6,870,373
Hospital-sponsored
76,023
23,724
$5,890,120
$6,186,752
$12,076,872
FQHC-sponsored
64,594
17,671
$4,387,300
$5,256,660
$9,643,960
D&TC-sponsored
18,614
8,940
$2,219,595
$1,514,807
$3,734,402
Total Downstate
159,231
50,335
$12,497,016
$12,958,219
$25,455,235
Grand Total
199,519
65,441
$16,247,486
$16,078,122
= $32,325,608
Total Upstate
Downstate
+
* Per SDOH 2/28/2013 – Statewide Average Payment
** Per SDOH 3/4/2013 – Based on 2011 FQHC MCVRs
***Per SDOH 2/28/2013 – Paid visits 2011
****Applies to Federally-Qualified Heath Centers only
The per-member-per-month add-on methodology is currently being used in other health sub-sectors in New York
State. Namely, Patient-Centered Medical Homes receive payment incentives in this form for Medicaid patients
covered by managed care.26 Given that Centers provide valuable and critical services for children/youth, they should
be granted permission to receive per-member-per-month payment add-ons, as well.
Recommendation: School-based health centers should not be required to complete credentialing and
automatically be recognized by managed care organizations as designated providers for specified services.
New York City counties have a total of 21 managed care organizations that can act as third-party payers for
medical care. While this variation exists to a lesser extent in upstate counties, completing non-standardized
credentialing applications for various managed care entities to ensure third-party insurance reimbursement
is a cumbersome, overwhelming, and costly process for organizations with low administrative capacity.
Furthermore, beyond the initial process, credentialing requires maintenance beyond the scope of what is
reasonable for Centers’ slim administrative staffing.
In the state of Michigan, Centers are reimbursed by managed care organizations for services without
individualized credentialing and contracts with managed care organizations or prior authorization. Instead,
Centers are automatically recognized as designated providers that should be reimbursed for specific services
after completing a simplified certification form. This was done for two reasons: (1) to alleviate administrative
burden on Centers already contending with low administrative support; and, (2) to ensure that Center providers
26
http://www.pcdc.org/resources/patient-centered-medical-home/.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
054
23
could receive reimbursement via managed care for services rendered. For these same reasons, New York State
should create a system that mirrors the Michigan model.
Further, New York State could require plans to reimburse Center providers under a fee-for-service methodology.
Doing so would avoid potential instances of duplicate payments. Under this system, Center providers would
offer care that falls in to two broad categories — services requiring prior authorization, and presumptively authorized
services. Preventive and primary care services would require authorization from the patient’s plan. Since these
services can be scheduled in advance, providers would have sufficient time to obtain authorization before offering
care. Ancillary and specialty services, such as reproductive health, dental and urgent care services would not
require pre-authorization. Center providers could offer these services to students with confidence that they
would be reimbursed by managed care. Such a system would retain the care coordination aspects of managed
care that eliminate inefficiencies, while preserving the SBHC comprehensive model of care that has been
shown to improve access to and quality of care.
Recommendation: School-based health centers should have a specified designation in managed care
that permits them to receive reimbursement.
In order for school-based health centers to receive Medicaid dollars administered by managed care
organizations, they need to have a specified designation in the managed care system. Given that they currently
receive Medicaid reimbursement outside of managed care, Center providers do not have a designation within
managed care that permits reimbursement.
The new designation would be warranted by Center providers meeting specific criteria in order to ensure quality
care to children and youth. Namely, Centers would:
• meet specific standards for comprehensive service provision to children/youth;
• report on quality outcome measures pre-determined via negotiations with managed care organizations; and
• effectively integrate with community providers to ensure quality health care.
Other states — namely Michigan and Maryland — with school-based health centers have arranged for Centers
to be recognized as designated providers who are entitled to Medicaid reimbursements administered via managed
care. This eliminates unnecessary competition for reimbursement between community providers and school-based
health centers, allowing each to have a designated role and recognized status within managed care.
Recommendation: School-based health centers need to use a streamlined, centralized billing system.
In order to create a fluid process for reimbursement to providers that optimizes the potential for expeditious
processing and revenue generation, New York State needs to create and support a simplified, streamlined,
and centralized system that Centers can use to bill managed care organizations. Such a model is successfully
used in the state of Michigan and financed by The Kellogg Foundation and the state’s Department of Health.
This investment by the Kellogg Foundation and the Department of Health is based on the understanding that
Centers can better thrive when mechanisms for financing are streamlined and simplified to ensure timely
payment and fluid administration.
Given the skeletal budget by which Centers operate, ensuring reimbursements that are timely and adequate
is necessary to guaranteeing program viability and sustainability. Such a system could be dual-purposed and
also serve as a clearinghouse of information for the State Administration. Data gathered through this tool
could provide critical information on how the program can be administered moving forward to ensure optimal,
cost-effective care to children and youth.
24
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
055
Recommendations beyond Managed Care
The transition to managed care not only comes fraught with the possibility that Centers could close if steps are
not taken to ensure sustained funding streams; it also represents an opportunity to consider how we can use
Centers in new and practical ways, ultimately benefitting children, youth, and families in their communities.
Recommendation: School-based health centers should receive funding for specialized care and public health
education services.
In addition to offering primary care services, Centers have been long-standing providers of reproductive health
services and education, mental health services and dental care. Currently, New York State operates federallysubsidized programs that offer interventions and support for areas related to reproductive health, childhood
obesity, substance abuse and mental health. Blending public funds used to finance these programs with the
existing monies allocated for Center providers would enhance the statewide budget for these services and
create opportunities for Centers and the specialized services to remain viable and whole. Additionally,
channeling these specialized services through school-based providers in high need/risk areas achieves the goals
of these programs. This model is used in the state of California, whereby government funding for ancillary and
specialized care is allocated to Centers that offer the corresponding services.
Recommendation: School-based health centers should designate primary care clinic hours to serve the
community, at large.
With the implementation of the Patient Protection and Affordable Care Act (ACA), it is estimated that
approximately 1.1 million New Yorkers will be newly insured in Year 2014 and will be seeking medical care.27
Therefore, it is timely for primary care access points to grow and expand across New York State.
Historically, school-based health centers have provided services to school-aged youth within specified hours
and days of the week. Center facilities are typically not used during hours when the school building is closed.
Making Centers available to the community, at large, for primary care services would optimize the potential of
the facility to serve patients beyond the limitations of school hours, which would create additional revenue and
guarantee sustainability. Additionally, creating community access would also meet a growing demand in New
York State for expansion of primary care services.
Examining Opportunities for Growth
In 2011, the Patient Protection and Affordable Care Act (ACA) authorized a new program and appropriated
$200 million in funding from 2010 – 2013 to address significant and pressing capital needs to improve delivery
and support expansion of services at school-based health centers. The U.S. Department of Health and Human
Services awarded these funds under the School-Based Health Center Capital (SBHCC) Program in fiscal years
(FYs) 2011, 2012 and 2013 to 470 school-based health center programs to create new school-based health
center sites in medically underserved areas; and expand preventive and primary health care services at existing
school-based health center sites.28 This investment is intentionally targeted to increase children’s access to
health services offered at school-based health centers.
27
Blavin et. al. (2012). The Coverage and Cost Effects of Implementation of the Affordable Care Act in New York State. Retrieved
from http://www.urban.org/UploadedPDF/412534-Affordable-Care-Act-in-New-York-State.pdf.
28
http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
056
25
These funds are projected to expand services by more than 50 percent and allow for the establishment of new
centers and improved infrastructure. Thus far, forty-seven Centers across New York State have been awarded
approximately $17 million in such capital expenses.29 Stakeholders of children’s health celebrate action taken by
the Obama Administration to invest in Center infrastructure and technology. While these funds are time-limited,
they offer an opportunity for investment in infrastructure and new systems that will help the expansion of services
statewide.
There is opportunity to leverage these capital investments further. As recommended earlier in this report, Center
facilities could be qualified to serve the greater community with primary and ancillary care services during
non-school hours (i.e. evenings and weekends). Doing so would not only sustain Centers’ viability, it would
create a means for growth and expansion. Financing opportunities available to organizations that are working to
expand primary care in communities could be blended with school-based health center financing mechanisms
to establish more sites across New York State.
Conclusion
In order for school-based health centers to successfully grow and expand, they must first be sustained. Making
certain that New York’s Centers are financially viable under a Medicaid Redesign is paramount to ensuring that
they remain critical access points for children and youth receiving primary and preventive care. Taking the
steps necessary to do the following in the environment of managed care will enable Center sustainability:
• Phase in Center transition to managed care;
• Convene workgroup meetings among the State Department of Health, Center providers, and managed
care organizations through the implementation process;
• Reinvest Medicaid savings back into Centers;
• Give Centers a specified provider and reimbursement designation within managed care;
• Require that managed care organizations automatically recognize Centers as designated providers;
• Develop a simplified, streamlined billing system.
Beyond the scope of managed care, Centers can generate additional revenue that would further enhance their
sustainability by:
• Receiving funding for specialized care and public health education services;
• Designating clinic hours to serve the community, at large.
Funding allotted for capital expenses by the Patient Protection and Affordable Care Act (ACA) is a great
example of how investments made to Centers provide the opportunity for improved and expanded facilities,
which, in turn, lead to service growth. With continuing investments designated for Centers, there can be more
growth and program development.
It is important to note, however, that administering funds to achieve expansion is a pointless act without first
securing program viability post-implementation of Medicaid Redesign. Securing funds for operating and program
expenses needs to be a top priority. For existing Centers, this needs to be done by ensuring adequate reimbursement
for services. For newly established Centers, this can be done by relying on FQHC sponsors to develop new programs
in untouched communities across New York State given their existing sustainable model.
26
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
057
CDF–NY firmly stands on the notion that all children deserve the right to affordable, quality, and comprehensive
health care. School-based health centers are a mechanism for children’s access to such care. Therefore, their
sustainability and growth is priority in order to ensure that youth in communities are provided with the resources
to be healthy and productive students who can thrive academically and socially.
We encourage all stakeholders of children’s health to endure and stand in support of school-based health centers
as they face this crossroads in financing. As stakeholders, we have a responsibility to support valuable services
and programs that enrich the lives of our children and promote their well-being.
School-based Health Centers in New York State: Ensuring Sustainability and Establishing Opportunities for Growth
058
27
Flash
February 2015
059
Child Protection
Article 10 Total Filings & Filing Outcomes, CY 2012 - CY 2014 and January 2015
59%
9.2%
9.8%
10.1%
28.9%
27.7%
34.7%
14.2%
31.5%
61.3%
62.2%
56.2%
54.3%
CY 2012
CY 2013
CY 2014
Court Ordered Supervision
CY
2012
Art.10
Filings
8,913
CY
2013
9,318
Removal
CY
2014
9,900
Jan-15
Other/Unspecified
Jan
2015
812
Notes: 1) The category “Other/Unspecified” includes released with no supervision, no order issued and no outcome specified.
Outcomes of cases heard the next day are not captured in this report. 2) Percentage change is January 2014 vs. January 2015.
060
8
Preventive Services
New Preventive Cases*
January 2012 – January 2015
1400
New Cases
1200
1000
800
983
814
17%
600
CY 2012 Total = 10,830
400
CY 2013 Total = 11,235
CY 2014 Total = 12,325
200
CY 2015 YTD =
814
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2012
2013
2014
2015
*Notes: 1) New preventive cases do not include cases transferred from one preventive program to another. 2) Percentage change is
January 2014 vs. January 2014. 3) See Pages 36 and 37 of the Appendix for supporting data.
13
061
TABLE 2 - SCR Intakes by Reporter Group, NOV 13 – JAN 14 and NOV 14 – JAN 15
Year
Child Care/
Substitute
Care
Personnel
Educational
Personnel
Anonymous
Friends/
Neighbors/
Other
Relatives
NonMandatedOther
Parent
Foster Parent
Total
2013/2014
2014/2015
% Change
49
56
14.3%
1,462
1,457
-0.3%
435
340
-21.8%
424
407
-4.0%
25
21
-16.0%
Bronx
963
954
-0.9%
330
330
0.0%
352
368
4.5%
594
560
-5.7%
193
188
-2.6%
0
1
--
4,827
4,682
-3.0%
2013/2014
2014/2015
% Change
44
45
2.3%
1,349
1,289
-4.4%
376
392
4.3%
394
348
-11.7%
30
27
-10.0%
Brooklyn
828
705
-14.9%
400
321
-19.8%
390
336
-13.8%
519
460
-11.4%
182
168
-7.7%
0
0
--
4,512
4,091
-9.3%
2013/2014
2014/2015
% Change
24
27
12.5%
494
532
7.7%
248
306
23.4%
233
274
17.6%
13
14
7.7%
Manhattan
455
507
11.4%
166
174
4.8%
178
207
16.3%
303
283
-6.6%
103
103
0.0%
0
0
--
2,217
2,427
9.5%
2013/2014
2014/2015
% Change
26
31
19.2%
1,076
981
-8.8%
284
269
-5.3%
271
266
-1.8%
22
11
-50.0%
Queens
559
602
7.7%
212
168
-20.8%
216
216
0.0%
302
290
-4.0%
121
104
-14.0%
1
0
--
3,090
2,938
-4.9%
2013/2014
2014/2015
% Change
2
9
350.0%
276
299
8.3%
57
45
-21.1%
77
79
2.6%
4
2
-50.0%
Staten Island
105
108
2.9%
77
74
-3.9%
66
69
4.5%
56
52
-7.1%
37
58
56.8%
0
0
--
757
795
5.0%
2013/2014
2014/2015
% Change
24
18
-25.0%
43
45
4.7%
17
23
35.3%
29
36
24.1%
6
6
0.0%
OSI
78
74
-5.1%
30
33
10.0%
18
15
-16.7%
78
83
6.4%
52
48
-7.7%
1
2
--
376
383
1.9%
2013/2014
2014/2015
% Change
7
4
-42.9%
38
29
-23.7%
87
71
-18.4%
56
40
-28.6%
3
2
-33.3%
Other
121
114
-5.8%
24
11
-54.2%
32
26
-18.8%
39
29
-25.6%
38
28
-26.3%
0
2
--
445
356
-20.0%
2013/2014
2014/2015
% Change
176
190
8.0%
4,738
4,632
-2.2%
1,504
1,446
-3.9%
1,484
1,450
-2.3%
103
83
-19.4%
Citywide
3,109
3,064
-1.4%
1,239
1,111
-10.3%
1,252
1,237
-1.2%
1,891
1,757
-7.1%
726
697
-4.0%
2
5
150.0%
16,224
15,672
-3.4%
Medical/
Law
Mental Health
Enforcement
Personnel
MandatedOther
Social
Service
Personnel
33
062
Figure 3: SCR Allegations, NOV 14 – JAN 15
Total Allegations = 38,989
34
063
Foster Care Placements by Borough/CD of Origin CY 2014 and 2013*
CY 2014
Number of
Placements
BRONX
BX01 Mott Haven/Melrose
BX02 Hunts Point/Longwood
BX03 Morrisania/Crotona
BX04 Highbridge/Concourse
BX05 Fordham/University Heights
BX06 Belmont/East Tremont
BX07 Kingsbridge Heights/Bedford Pk
BX08 Riverdale/Fieldstone
BX09 Parkchester/Soundview
BX10 Throgs Neck/Co-op City
BX11 Morris Park/Bronxdale
BX12 Williamsbridge/Baychester
Unknown CD
BRONX TOTAL
BROOKLYN
BK01 Greenpoint/Williamsburg
BK02 Fort Greene/Brooklyn Heights
BK03 Bedford Stuyvesant
BK04 Bushwick
BK05 East New York/Starrett City
BK06 Park Slope/Carroll Gardens
BK07 Sunset Park
BK08 Crown Heights
BK09 South Crown Heights/Prospect
BK10 Bay Ridge/Dyker Heights
BK11 Bensonhurst
BK12 Borough Park
BK13 Coney Island
BK14 Flatbush/Midwood
BK15 Sheepshead Bay
BK16 Brownsville
BK17 East Flatbush
BK18 Flatlands/Canarsie
Unknown CD
BROOKLYN TOTAL
MANHATTAN
MNO1 Financial District
MNO2 Greenwich Village/Soho
MNO3 Lower East Side/Chinatown
MNO4 Clinton/Chelsea
MNO5 Midtown
MNO6 Stuyvesant Town/Turtle Bay
MNO7 Upper West Side
MNO8 Upper East Side
MNO9 Morningside Height./Hamilton
MN10 Central Harlem
MN11 East Harlem
MN12 Washington Heights/Inwood
Unknown CD
MANHATTAN TOTAL
CY 2013
% of
Rank Placements
Number of
Placements
% of
Rank Placements
126
114
99
186
140
75
85
26
124
22
47
133
2
1,179
10
13
15
4
7
21
16
43
12
47
28
8
3.1%
2.8%
2.5%
4.6%
3.5%
1.9%
2.1%
0.6%
3.1%
0.5%
1.2%
3.3%
142
89
103
188
105
105
88
29
128
22
57
130
16
1,202
9
21
19
1
15
15
22
41
12
49
27
11
3.4%
2.1%
2.5%
4.5%
2.5%
2.5%
2.1%
0.7%
3.0%
0.5%
1.4%
3.1%
44
28
164
81
221
14
33
72
39
8
23
22
38
42
17
212
85
61
18
1,222
32
42
6
18
1
51
38
22
34
53
44
48
35
33
50
3
17
24
1.1%
0.7%
4.1%
2.0%
5.5%
0.3%
0.8%
1.8%
1.0%
0.2%
0.6%
0.5%
0.9%
1.0%
0.4%
5.3%
2.1%
1.5%
30
48
158
131
167
23
26
99
46
9
19
19
55
66
18
158
107
57
22
1,258
40
31
5
10
3
46
43
20
33
56
51
51
29
26
53
5
13
27
0.7%
1.1%
3.8%
3.1%
4.0%
0.5%
0.6%
2.4%
1.1%
0.2%
0.5%
0.5%
1.3%
1.6%
0.4%
3.8%
2.5%
1.4%
2
3
75
36
17
2
51
5
70
124
132
49
12
578
58
57
20
37
49
59
26
55
23
11
9
27
0.0%
0.1%
1.9%
0.9%
0.4%
0.0%
1.3%
0.1%
1.7%
3.1%
3.3%
1.2%
6
2
105
44
23
22
70
11
76
146
164
68
14
751
57
59
15
35
46
49
24
54
23
8
4
25
0.1%
0.0%
2.5%
1.0%
0.5%
0.5%
1.7%
0.3%
1.8%
3.5%
3.9%
1.6%
Page 1 of 2
064
Foster Care Placements by Borough/CD of Origin CY 2014 and 2013*
CY 2014
Number of
Placements
QUEENS
QN01 Astoria
QNO2 Woodside/Sunnyside
QNO3 Jackson Heights
QN04 Elmhurst/Corona
QN05 Ridgewood/Maspeth
QN06 Rego Park/Forest Hills
QN07 Flushing/Whitestone
QN08 Hillcrest/Fresh Meadows
QN09 Ozone Park/Woodhaven
QN10 South. Ozone Park/Howard Beac
QN11 Bayside/Little Neck
QN12 Jamaica/Hollis
QN13 Queens Village
QN14 Rockaway/Broad Channel
Unknown CD
QUEENS TOTAL
STATEN ISLAND
S101 Saint George/Stapleton
S102 South Beach/Willowbrook
S103 Tottenville/Great Mils
Unknown CD
STATEN ISLAND TOTAL
Outside of NYC
Unknown Borough
NYC Total
CY 2013
% of
Rank Placements
Number of
Placements
% of
Rank Placements
46
13
38
60
29
6
32
46
32
46
4
218
77
109
8
764
29
52
36
25
41
54
39
30
40
31
56
2
19
14
1.1%
0.3%
0.9%
1.5%
0.7%
0.1%
0.8%
1.1%
0.8%
1.1%
0.1%
5.4%
1.9%
2.7%
46
24
53
23
39
10
31
28
48
34
4
150
106
105
2
703
33
45
30
46
37
55
39
42
31
38
58
7
14
15
1.1%
0.6%
1.3%
0.5%
0.9%
0.2%
0.7%
0.7%
1.1%
0.8%
0.1%
3.6%
2.5%
2.5%
175
23
23
3
224
32
29
4,028
5
45
46
4.3%
0.6%
0.6%
169
40
25
2
236
38
15
4,203
2
36
44
4.0%
1.0%
0.6%
*Excludes youth who were in JD placements at any time during their foster care spell.
Prepared by ACS, Division of Policy, Planning and Measurement, Management and Outcome Reporting Unit
Data Source: CCRS
Page 2 of 2
065
Abuse/Neglect Investigations by Community District, 2009-2013
2009
Consolidated
Investigations
Number
Borough/Community District*
BRONX
BX01 Mott Haven/Melrose
1,930
BX02 Hunts Point/Longwood
1,188
BX03 Morrisania/Crotona
1,691
BX04 Highbridge/Concourse
2,570
BX05 Fordham/University Heights
2,347
BX06 Belmont/East Tremont
1,839
BX07 Kingsbridge Heights/Bedford Pk
1,753
BX08 Riverdale/Fieldstone
501
BX09 Parkchester/Soundview
2,438
BX10 Throgs Neck/Co-op City
721
BX11 Morris Park/Bronxdale
852
BX12 Williamsbridge/Baychester
1,898
Unknown CD
437
BRONX TOTAL
20,165
BROOKLYN
BK01 Greenpoint/Williamsburg
685
BK02 Fort Greene/Brooklyn Heights
555
BK03 Bedford Stuyvesant
2,115
BK04 Bushwick
1,355
BK05 East New York/Starrett City
2,502
BK06 Park Slope/Carroll Gardens
501
BK07 Sunset Park
689
BK08 Crown Heights
1,025
BK09 South Crown Heights/Prospect
661
BK10 Bay Ridge/Dyker Heights
426
BK11 Bensonhurst
596
BK12 Borough Park
545
BK13 Coney Island
736
BK14 Flatbush/Midwood
1,140
BK15 Sheepshead Bay
570
BK16 Brownsville
1,665
BK17 East Flatbush
1,368
BK18 Flatlands/Canarsie
1,083
Unknown CD
430
BROOKLYN TOTAL
18,647
Rank
Children
Indication
Rate
2010
Consolidated
Investigations
Indication
Rate
Number Rank Children
2011
Consolidated
Investigations
Number
Rank
Children
Indication
Rate
2012
Consolidated
Investigations
Number Rank
Children
Indication
Rate
2013
Consolidated
Investigations
Indication
Rate
Number Rank Children
6
17
11
1
4
8
10
44
3
32
25
7
3,039
1,949
2,766
4,275
3,815
2,990
2,714
736
3,948
1,080
1,323
3,067
713
32,415
47.8%
1,638
48.7%
1,003
45.4%
1,402
48.2%
2,047
45.5%
1,841
48.7%
1,560
44.3%
1,500
40.7%
466
44.1%
2,018
37.6%
700
41.0%
865
43.8%
1,634
43.0%
436
45.5% 17,110
9
23
14
3
6
12
13
48
5
35
28
10
2,658
1,659
2,306
3,293
2,948
2,492
2,378
672
3,298
1,016
1,284
2,621
676
27,301
40.2%
43.0%
43.2%
39.8%
39.6%
41.8%
38.7%
36.1%
39.9%
34.7%
37.5%
36.6%
40.1%
39.7%
1,790
974
1,463
1,861
1,723
1,614
1,498
435
2,035
694
903
1,711
271
16,972
7
24
13
5
8
11
12
48
3
34
27
9
2,823
1,532
2,437
2,926
2,748
2,706
2,364
608
3,305
979
1,348
2,778
384
26,938
38.5%
1,584
42.3%
1,045
40.2%
1,432
38.2%
1,895
37.6%
1,706
38.8%
1,479
35.3%
1,342
31.3%
501
39.8%
1,960
34.0%
641
33.2%
816
33.4%
1,628
33.2%
400
37.4% 16,429
10
17
13
4
5
11
15
43
3
36
26
7
2,538
1,763
2,316
3,194
2,722
2,507
2,062
733
3,149
931
1,216
2,681
627
26,439
38.2%
1,658
41.4%
1,058
38.3%
1,382
38.9%
1,848
39.9%
1,714
41.0%
1,474
36.4%
1,473
37.3%
417
37.4%
1,935
31.8%
627
33.3%
788
33.6%
1,589
38.2%
168
37.7% 16,131
6
18
15
4
5
12
13
48
3
34
28
9
2,590
1,827
2,223
2,886
2,699
2,409
2,257
593
2,978
856
1,112
2,498
271
25,199
41.6%
42.0%
35.7%
38.3%
37.2%
38.3%
34.1%
37.6%
37.1%
33.2%
29.4%
35.1%
29.2%
37.0%
35
42
5
14
2
45
33
22
36
50
40
43
30
19
41
12
13
21
1,109
872
3,531
2,257
4,147
780
1,014
1,694
976
681
868
852
1,157
1,758
825
2,963
2,120
1,629
730
29,963
46.0%
589
44.9%
496
52.5%
2,046
42.4%
1,267
42.7%
2,485
40.5%
435
40.8%
664
47.0%
912
43.3%
643
31.9%
352
38.1%
596
40.4%
484
41.7%
704
41.8%
1,050
38.9%
536
42.5%
1,724
39.8%
1,327
39.0%
1,016
39.5%
435
42.9% 17,761
40
45
4
18
1
49
36
25
37
51
39
46
34
21
42
8
15
22
931
746
3,375
2,109
4,093
694
925
1,429
964
503
855
774
1,185
1,681
778
2,987
2,075
1,460
685
28,249
50.1%
47.0%
52.9%
45.8%
43.9%
42.5%
39.8%
43.8%
44.3%
40.1%
32.6%
37.0%
42.8%
40.6%
39.4%
46.0%
42.4%
38.4%
41.4%
43.9%
614
459
1,918
1,091
2,486
385
614
929
613
373
611
451
767
1,003
492
1,683
1,341
1,076
212
17,118
36
46
4
18
1
49
36
26
39
50
40
47
32
22
44
10
15
19
937
702
3,191
1,749
4,117
580
922
1,455
902
526
872
682
1,283
1,606
721
2,862
2,055
1,563
289
27,014
48.7%
486
43.8%
470
51.6%
1,669
45.0%
1,013
45.2%
2,284
39.2%
349
42.0%
580
42.5%
799
36.7%
529
32.7%
359
33.7%
616
38.6%
450
41.5%
649
37.2%
955
37.6%
516
44.9%
1,595
41.4%
1,205
38.4%
969
34.9%
373
42.7% 15,866
44
45
6
19
1
50
38
28
40
49
37
47
35
22
41
8
16
21
746
763
2,757
1,695
3,748
558
884
1,232
810
513
913
703
1,014
1,451
767
2,863
1,804
1,459
552
25,232
50.6%
540
47.9%
447
49.3%
1,580
48.3%
942
45.8%
2,252
41.0%
340
43.3%
540
46.6%
817
40.5%
539
35.7%
327
39.0%
576
41.6%
451
41.9%
650
38.8%
935
37.0%
498
48.2%
1,622
41.1%
1,269
42.0%
1,009
39.2%
193
44.2% 15,527
38
47
10
23
1
49
38
26
40
51
36
46
33
24
42
8
16
19
796
723
2,592
1,476
3,598
511
822
1,259
791
489
815
616
1,047
1,421
675
2,821
1,899
1,442
313
24,106
56.7%
45.6%
53.1%
43.7%
42.1%
40.0%
43.2%
45.5%
42.6%
39.8%
36.3%
41.6%
46.3%
41.2%
35.5%
46.4%
39.5%
38.5%
40.4%
43.7%
066
Abuse/Neglect Investigations by Community District, 2009-2013
2009
Consolidated
Investigations
Number
Borough/Community District*
MANHATTAN
MN01 Financial District
97
MN02 Greenwich Village/Soho
75
MN03 Lower East Side/Chinatown
796
MN04 Clinton/Chelsea
263
MN05 Midtown
89
MN06 Stuyvesant Town/Turtle Bay
107
MN07 Upper West Side
475
MN08 Upper East Side
243
MN09 Morningside Height./Hamilton
687
MN10 Central Harlem
1,144
MN11 East Harlem
1,296
MN12 Washington Heights/Inwood
903
Unknown CD
194
MANHATTAN TOTAL
6,369
QUEENS
QN01 Astoria
775
QN02 Woodside/Sunnyside
349
QN03 Jackson Heights
799
QN04 Elmhurst/Corona
820
QN05 Ridgewood/Maspeth
658
QN06 Rego Park/Forest Hills
198
QN07 Flushing/Whitestone
627
QN08 Hillcrest/Fresh Meadows
474
QN09 Ozone Park/Woodhaven
731
QN10 South. Ozone Park/Howard Beach
626
QN11 Bayside/Little Neck
220
QN12 Jamaica/Hollis
1,815
QN13 Queens Village
962
QN14 Rockaway/Broad Channel
1,124
Unknown CD
228
QUEENS TOTAL
10,406
STATEN ISLAND
SI01
Saint George/Stapleton
1,327
SI02
South Beach/Willowbrook
490
SI03
Tottenville/Great Kills
442
Unknown CD
62
STATEN ISLAND TOTAL
2,321
Outside of NYC/Unknown
1,341
NYC Total
59,249
Rank
Indication
Rate
Children
57
59
28
52
58
56
47
53
34
18
16
24
133
104
1,265
359
115
154
709
339
1,017
1,782
2,055
1,258
301
9,591
29
51
27
26
37
55
38
48
31
39
54
9
23
20
15
46
49
2010
Consolidated
Investigations
Indication
Rate
Number Rank Children
50.5%
41.3%
43.3%
40.7%
38.2%
43.0%
42.3%
35.8%
40.0%
42.1%
42.2%
44.2%
37.6%
42.0%
2011
Consolidated
Investigations
Number
Rank
Indication
Rate
Children
2012
Consolidated
Investigations
Number Rank
Indication
Rate
Children
2013
Consolidated
Investigations
Indication
Rate
Number Rank Children
93
76
922
269
128
156
542
262
803
1,323
1,564
1,084
235
7,457
58
59
24
52
57
56
41
53
29
16
11
20
126
91
1,462
384
166
211
793
365
1,165
2,115
2,443
1,532
344
11,197
38.7%
25.0%
47.8%
38.3%
46.9%
31.4%
44.1%
36.6%
45.7%
40.4%
46.6%
36.5%
46.4%
42.6%
122
60
950
278
119
149
513
216
751
1,329
1,441
1,018
188
7,134
57
59
25
52
58
56
42
54
33
17
14
21
185
82
1,479
415
147
193
737
295
1,045
1,947
2,187
1,405
252
10,369
28.7%
36.7%
42.2%
37.4%
39.5%
39.6%
42.5%
26.9%
40.3%
39.1%
45.7%
34.7%
53.2%
40.4%
83
73
840
263
120
156
507
268
745
1,356
1,457
975
247
7,090
58
59
25
53
57
56
42
52
31
14
12
20
117
94
1,431
394
148
196
746
349
1,068
1,969
2,130
1,362
331
10,335
30.1%
35.6%
43.7%
42.2%
46.7%
26.9%
44.8%
34.7%
39.6%
38.6%
46.1%
40.4%
40.5%
41.3%
97
72
806
281
139
144
471
185
743
1,418
1,487
978
125
6,946
58
59
27
52
57
56
45
55
30
14
11
21
118
89
1,212
382
172
188
656
246
1,023
2,033
2,147
1,339
210
9,815
32.0%
22.2%
41.7%
41.3%
48.6%
32.6%
41.2%
40.0%
40.6%
41.0%
43.9%
37.4%
49.6%
41.0%
1,179
478
1,156
1,150
953
267
931
689
1,135
946
327
2,832
1,425
1,953
373
15,794
40.4%
776
35.8%
404
40.7%
887
44.1%
800
36.2%
795
24.7%
189
36.7%
597
24.7%
527
37.3%
899
35.0%
728
30.0%
230
38.1%
2,155
38.0%
1,165
33.8%
1,320
29.4%
319
36.7% 11,791
32
50
27
30
31
55
38
43
26
33
54
2
19
17
1,158
568
1,290
1,131
1,197
257
881
772
1,382
1,113
322
3,441
1,737
2,220
520
17,989
39.2%
38.1%
41.3%
42.6%
34.0%
25.4%
34.0%
24.7%
33.8%
31.0%
25.7%
40.6%
38.1%
38.8%
34.2%
36.9%
788
343
981
850
777
227
614
513
775
683
179
2,206
1,058
1,332
214
11,540
29
51
23
28
30
53
36
42
31
35
55
2
20
16
1,194
483
1,372
1,250
1,182
302
831
794
1,215
1,044
247
3,561
1,555
2,160
307
17,497
36.7%
737
32.9%
322
39.3%
919
41.1%
752
36.8%
751
21.1%
178
33.2%
657
25.7%
552
31.5%
802
28.8%
659
27.4%
194
34.3%
1,983
33.0%
933
36.7%
1,045
34.6%
172
34.4% 10,656
32
51
24
29
30
55
34
39
27
33
54
2
23
17
1,058
456
1,299
1,102
1,074
235
904
813
1,164
979
255
3,103
1,364
1,727
231
15,764
34.5%
685
36.0%
332
37.1%
961
36.8%
766
30.1%
718
15.2%
202
33.6%
545
27.7%
476
35.5%
820
33.5%
614
29.4%
200
36.2%
2,024
34.3%
996
36.8%
1,123
50.0%
157
30.2% 10,619
32
50
22
29
31
53
37
44
25
35
54
2
20
17
1,010
452
1,311
1,119
1,041
279
751
719
1,241
874
278
3,041
1,409
1,751
241
15,517
36.0%
36.2%
37.7%
36.8%
27.3%
19.8%
35.7%
31.7%
32.4%
27.6%
32.3%
31.5%
31.1%
35.7%
32.5%
32.8%
2,339
752
759
98
3,948
2,277
93,988
35.9%
1,818
30.2%
524
27.6%
481
25.8%
90
32.8% 2,913
37.1% 2,578
42.1% 59,610
7
44
47
3,246
805
726
177
4,954
4,144
93,834
38.9%
32.4%
31.6%
44.4%
36.7%
35.7%
40.4%
1,792
529
479
61
2,861
2,956
58,581
6
41
45
3,134
811
723
97
4,765
4,131
90,714
36.6%
1,592
33.1%
450
28.0%
461
41.0%
94
34.6% 2,597
32.6% 2,798
38.3% 55,436
9
47
46
2,618
675
690
136
4,119
3,870
85,759
37.9%
1,629
31.1%
519
31.5%
493
34.8%
36
35.5% 2,677
32.2% 3,179
39.0% 55,079
7
41
43
2,720
763
744
55
4,282
4,781
83,700
36.2%
36.2%
28.8%
27.8%
34.8%
34.0%
38.3%
*These are the CD of the residence of the children in the investigation. If children in the same investigation live at different addresses, the address of the oldest child was used to designate the CD of the report.
Prepared by The Division of Polocy, Planning and Measurement, Management and Outcome Reporting Unit
Data Source: Connections
067
ACF
Administration
for Children
and Families
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Administration on Children, Youth and Families
1. Log No: ACYF-CB-IM-12-04
2. Issuance Date: 04/17/2012
3. Originating Office: Children’s Bureau
4. Key Words: Social and emotional well-being, trauma, screening and
assessment, evidence-based and evidence-informed practices
INFORMATION MEMORANDUM
TO: State, Tribal and Territorial Agencies Administering or Supervising the Administration of
Titles IV-B and IV-E of the Social Security Act, Indian Tribes and Indian Tribal Organizations
SUBJECT: Promoting Social and Emotional Well-Being for Children and Youth Receiving
Child Welfare Services
PURPOSE: To explain the Administration on Children, Youth and Families priority to promote
social and emotional well-being for children and youth receiving child welfare services, and to
encourage child welfare agencies to focus on improving the behavioral and social-emotional
outcomes for children who have experienced abuse and/or neglect.
LEGAL AND RELATED REFERENCES: Titles IV-B and IV-E of the Social Security Act;
Child Abuse Prevention and Treatment Act; Child and Family Services Improvement and
Innovation Act
INFORMATION:
I.
Overview
The Administration on Children, Youth and Families (ACYF) is focused on promoting the social
and emotional well-being of children and youth who have experienced maltreatment 1 and are
receiving child welfare services. To focus on social and emotional well-being is to attend to
children’s behavioral, emotional and social functioning – those skills, capacities, and
characteristics that enable young people to understand and navigate their world in healthy,
positive ways. While it is important to consider the overall well-being of children who have
experienced abuse and neglect, a focus on the social and emotional aspects of well-being can
significantly improve outcomes for these children while they are receiving child welfare services
and after their cases have closed. ACYF is organizing many of its activities around the
promotion of meaningful and measurable changes in social and emotional well-being for
children who have experienced maltreatment, trauma, and/or exposure to violence.
1
The terms “abuse and neglect” and “maltreatment” are used synonymously in this Information Memorandum.
1
068
The child welfare system has made significant strides in recent years. Today, there are 27%
fewer children in foster care than there were in 1998 (USDHHS, ACF, ACYF, 2002-2011).
There are fewer children entering foster care and more exiting to permanency through
reunification, adoption, and guardianship. The system’s integration of knowledge about the
importance of family connections and stable, nurturing relationships, as well as collaborative
efforts among child welfare and other child-serving systems, made these advances possible.
However, there is a growing body of evidence indicating that while ensuring safety and
achieving permanency are necessary to well-being, they are not sufficient. Research that has
emerged in recent years has suggested that most of the adverse effects of maltreatment are
concentrated in behavioral, social, and emotional domains. The problems that children develop
in these areas have negative impacts that ripple across the lifespan, limiting children’s chances to
succeed in school, work, and relationships. Integrating these findings into policies, programs,
and practices is the logical next step for child welfare systems to increase the sophistication of
their approach to improving outcomes for children and their families.
There is also an emerging body of evidence for interventions that address the behavioral, social,
and emotional impacts of maltreatment. By (a) anticipating the challenges that children will
bring with them when they enter the child welfare system, (b) rethinking the structure of services
delivered throughout the system, and (c) de-scaling practices that are not achieving desired
results while concurrently scaling up evidence-based interventions, meaningful and measurable
improvements in child-level and system-level outcomes are possible.
Increasing the focus on well-being is not a move away from the child welfare system’s essential
emphasis on safety and permanency; rather an integrated approach is needed. Policies,
programs, and practices can improve children’s social and emotional functioning while
concurrently working towards goals of reunification, guardianship, or adoption. Addressing the
social and emotional elements of functioning for children in foster care can even improve
permanency outcomes. For example, a study of adoption recruitment services demonstrated that,
in addition to intensive recruitment efforts, ensuring that children receive effective behavioral
and mental health services is critical to facilitating a smoother transition to an adoptive home,
and can decrease the chances of a disruption of an adoption (Vandivere, Allen, Malm,
McKindon, & Zinn, 2011).
II.
A Well-Being Framework
There are many frameworks for understanding well-being of children and youth. While these
frameworks differ in minor ways, they generally identify similar domains and definitions of
well-being. In an effort to understand what well-being looks like and how to support it for young
people who have experienced maltreatment, ACYF has adapted a framework by Lou, Anthony,
Stone, Vu, & Austin (2008). The framework identifies four basic domains of well being: (a)
cognitive functioning, (b) physical health and development, (c) behavioral/emotional
functioning, and (d) social functioning. Aspects of healthy functioning within each domain are
expected to vary according to the age or developmental status of children or youth. 2 The
2
Within each developmental category, refinement is possible; for example, for older youth, job readiness and
independent living skills are markers of well-being during the transition to adulthood.
2
069
framework also takes into account contextual factors, both internal and external to children, that
may influence well-being. These include environmental supports, such as family income and
community organization, as well as personal characteristics, such as temperament, identity
development, and genetic and neurobiological influences. ACYF’s framework for well-being is
presented in Appendix 1.
Within each domain, the characteristics of healthy functioning relate directly to how children and
youth navigate their daily lives: how they engage in relationships, cope with challenges, and
handle responsibilities. For example, self-esteem, emotional management and expression,
motivation, and social competence are important aspects of well-being that are directly related to
how young people move through the world and participate in society.
As was stated above, it is important to attend to the overall well-being of children and youth who
have experienced maltreatment. By focusing on social and emotional well-being in particular,
ACYF is not de-emphasizing other aspects of well-being. Rather, ACYF is prioritizing social
and emotional well-being because: (a) the challenges that children face in these domains are
great, (b) there are resources and policies that can be leveraged to improve child functioning in
these areas, (c) effective practices and programs for promoting social and emotional well-being
are available, and (d) outcomes for children and child welfare systems can significantly improve
with an emphasis on social and emotional well-being.
III.
Emerging Evidence on the Impact of Maltreatment
Researchers have extensively documented the impacts of abuse and neglect on the short- and
long-term health and well-being of children. Emerging evidence demonstrates that these
biological and psychological effects are concentrated in behavioral, social, and emotional
domains. These effects can keep children from developing the skills and capacities they need to
be successful in the classroom, in the workplace, in their communities, and in interpersonal
relationships. As a result, this can hinder children’s development into healthy, caring, and
productive adults and keep them from reaching their full potential. The following points
describe some of the impacts of abuse and neglect on children’s behavioral, social, and
emotional functioning. These findings argue that many of the children involved with child
welfare have a set of complex challenges; these challenges may not be addressed by the system
and services as they are currently designed. Integrating these recent findings into the design of
systems and services will enhance child welfare’s ability to improve outcomes for these children
and their families.
•
Neurological Impact: Early childhood is a time of rapid and foundational growth. During
this time, the neurological development taking place is building the architecture for the skills
and capacities that children will rely on throughout life (National Research Council and
Institute of Medicine, 2000).
Neglect and abuse have distinct effects on the developing brain. During early childhood,
neurons are created, organized, connected, and pruned to form the complex workings of the
brain. These actions depend, in large part, on the environment in which a young child grows.
Neglect (physical, emotional, social, or cognitive) hinders these neurological activities such
that the brain does not develop along a normal healthy trajectory towards its full potential.
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070
This negatively impacts a young person’s capacity for optimal social and emotional
functioning (Perry, 2002).
Abuse has a different, though still harmful impact on neurobiology. Experiences of mild or
moderate stress in the context of a secure caregiving environment, such as being temporarily
separated from a reliable caregiver or frustrated by the inability to complete a task, support
children’s development of adaptive coping. Chronic or extreme stress, however, such as
maltreatment, has a different result. Children who experience abuse or neglect have
abnormally high levels of cortisol, a hormone associated with the stress response, even after
they are removed from maltreating caregivers and placed in safe circumstances. Such
continuously high cortisol levels adversely affect stress responsiveness, emotion, and
memory (National Scientific Council on the Developing Child, 2005). Studies have also
shown that heightened stress impairs the development of the prefrontal cortex, the brain
region that is critical for the emergence of abilities that are essential to “autonomous
functioning and engagement in relationships” (Cook, Blaustein, Spinazzola, & van der Kolk,
2003, p.11). These “executive functions” include planning, focusing, self-regulation, and
decision-making. Executive functions are necessary to successfully managing school, work,
and healthy relationships.
•
Traumatic Impact: Traumatic events can elicit mental and physical reactions in children,
including hyperarousal and dissociation. If these acute “states” are not treated after children
experience trauma, they can become chronic, maladaptive “traits” that characterize how
children react in everyday, nonthreatening situations (Perry, 1995).
Maltreatment is distinct from other types of trauma because it is interpersonal in nature. A
caregiver who is supposed to be a secure base-the source of attachment, safety, and securityis also the source of hurt and harm. This creates a confused and ineffective attachment and
serves as the model for other significant attachments (Bloom, 1999). Often referred to as
“chronic interpersonal trauma” or “complex trauma,” maltreatment’s impact spans multiple
domains, and its severity is further complicated depending on a child’s developmental stage.
Chronic interpersonal trauma can result in difficulties regulating emotional responses,
accurately interpreting the cues and communications of others, managing intense moods
(particularly rage and anxiety), regulating arousal states (resulting in dissociation), and
accurately forming perceptions of self and others (Terr, 1991). Among children entering
foster care in one State, a comprehensive assessment revealed that one in four exhibited
trauma symptoms necessitating treatment, including traumatic grief/separation, adjustment
reactions, avoidance, re-experiencing, numbing, and dissociation (Griffin, Kisiel,
McClelland, Stolback, & Holzberg, 2012).
•
Behavioral Impact: Whether or not children enter foster care, the prevalence of behavior
problems rising to a clinical level 3 is high among children who have experienced
maltreatment. The National Survey of Child and Adolescent Well-Being (NSCAW), a
longitudinal study of children who were the subject of child protective services reports,
provides data to demonstrate this: twenty-two percent of children who remain in their homes
3
“Rising to the clinical level” describes problems that have been assessed to be severe enough to warrant clinical
behavioral health services.
4
071
after a report of abuse or neglect have clinical-level behavior problems–the same rate as
children who are removed and living with kin. Rates rise to 32% for children living in foster
homes and nearly 50% for children in group homes or residential care (Casaneuva,
Ringeisen, Wilson, Smith, & Dolan, 2011a).
•
Relational Competence: Maltreatment also affects the way in which children and youth
engage in social interactions and participate in relationships. NSCAW findings indicate that
children who are the subject of child protective services reports are twice as likely as children
in the general population to have significant challenges in the area of social competence
(Casaneuva, Ringeisen, Wilson, Smith, & Dolan, 2011a). The effects of maltreatment can
influence relationships across a person’s lifetime, impacting the ability to form a new
attachment to a primary caregiver, make friends, and engage in romantic or marital
partnerships (Mikulincer & Shaver, 2007).
•
Mental Health: Studies have demonstrated that rates of mental illness are high among
children who have experienced maltreatment and have been in foster care. Posttraumatic
Stress Disorder (PTSD), Attention Deficit/Hyperactivity Disorder (ADHD), Major
Depressive Disorder (MDD), and Conduct Disorder (CD)/Oppositional Defiant Disorder
(ODD) are the most common mental health diagnoses among this population. As McMillan,
et al. (2005) demonstrated, many children meet diagnostic criteria for these disorders before
entering foster care, indicating that it is frequently the experience of maltreatment rather than
participation in foster care that predicates mental health problems. By the time they are
teenagers, 63% of children in foster care have at least one mental health diagnosis; 23% have
three or more diagnoses (White, Havalchack, Jackson, O’Brien, & Pecora, 2007). 4
•
Psychotropics: According to a 2010 study of Medicaid-enrolled children in thirteen States,
children in foster care, who represent only three percent of those covered by Medicaid, were
prescribed antipsychotic medications at nearly nine times the rate of children enrolled in
Medicaid who were not in foster care (MMDLN/Rutgers CERTs, 2010). Over three years,
22% of children in foster care will have taken a psychotropic drug at some point (Leslie,
Raghavan, Zhang, & Aarons, 2010). Data from NSCAW show that rates of psychotropic
medication use are comparable for children receiving in-home child welfare services
(10.9%), children in kinship care (11.8%), and children in foster care (13.6%) (Casaneuva,
Ringeisen, Wilson, Smith, & Dolan, 2011a). Although numerous studies have demonstrated
that rates of psychotropic medication prescription are comparatively high, these rates, at least
in part, reflect increased levels of emotional and behavioral distress necessitating treatment
among this group. More information about the use of psychotropic medications among
children in foster care can be found in a related IM issued by the Children’s Bureau, ACYFCB-IM-12-03.
These scientific findings clearly demonstrate the profound impact that maltreatment has on social
and emotional well-being. As such, focusing on ensuring safety and permanency alone for
children who have experienced abuse or neglect is unlikely to resolve these complex biological
4
It is important to note that there is significant overlap between mental health and trauma symptoms, and that
symptoms of trauma are often mistaken for mental health symptoms (Griffin, Kisiel, McClelland, Stolback, &
Holzberg, 2012).
5
072
and psychosocial issues. For this reason, child welfare policies, programs, and practices should
give greater consideration to explicit efforts to reduce young people’s impairment and improve
their functioning.
IV.
Requirements and Policy Opportunities
Titles IV-B and IV-E of the Social Security Act and the Child Abuse Prevention and Treatment
Act (CAPTA) have historically included provisions that promote the well-being of children.
Title IV-B programs are intended to enhance the safety, permanence, and well-being of children
who are in foster care or are being served in their own homes. The title IV-E foster care program
includes requirements to address a child’s well-being, such as in the areas of health and
education. CAPTA provides funding for prevention, assessment, and treatment programs to
increase the well-being and safety of children who have been abused or neglected. Some policy
requirements and opportunities in existing policies related to social and emotional well-being are
listed below:
•
State Plan for Child Welfare Services (Section 422 of the Social Security Act) Section
422(b)(15) requires child welfare agencies to develop, in coordination and collaboration with
the State title XIX (Medicaid) agency and in consultation with pediatricians, other experts in
health care, and experts in and recipients of child welfare services, a plan for the ongoing
oversight and coordination of health care services, including mental health services, for any
child in a foster care placement.
o Mental Health Services: These health care oversight plans must include a description of
how States will provide necessary mental health services to children in foster care.
Additionally, States may address the mental health of children who have experienced
maltreatment according to provisions elsewhere in statute. For instance, time-limited
family reunification services under Promoting Safe and Stable Families explicitly include
mental health services (431(a)(7)(B)(iii) of the Social Security Act).
o Early and Periodic Diagnosis, Screening, and Assessment (EPSDT): Many States
incorporate EPSDT, a standard Medicaid benefit for children and youth, into their health
care plans. EPSDT ensures that children get appropriate medical, vision, hearing, and
dental check-ups to identify and treat any problems as soon as possible. EPSDT also
includes mental health assessments and services. Because they are categorically eligible
for Medicaid, all children in foster care who are eligible for title IV-E reimbursement are
entitled to EPSDT.
o Trauma Screening and Treatment: 2011’s Child and Family Services Improvement
and Innovation Act requires States to include in their health care oversight plans a
description of how they will screen for and treat emotional trauma associated with
maltreatment and removal for children in foster care (section 422(b)(14)(A)(ii) of the
Social Security Act). Identifying the trauma-related symptoms displayed by children and
youth when they enter care is critical for the development of a treatment plan. It is also
important to have a complete trauma history for each child. Although children come to
the attention of the child welfare system as a result of a specific allegation of
maltreatment, abuse and neglect are chronic in nature. Child welfare workers should
6
073
have an understanding of the multiple types and incidences of trauma children have
experienced, beyond just the event that precipitated child welfare involvement.
Conducting comprehensive functional assessments according to a standardized schedule
(e.g., every six months, or every time a child moves to a more restrictive placement
setting) can help caseworkers and administrators gauge whether or not treatment
strategies are working to decrease children’s symptoms. States could consider integrating
trauma screening into the regular screening activities taking place under EPSDT in order
to meet the new requirement.
o Psychotropic Medication Oversight and Monitoring: The Child and Family Services
Improvement and Innovation Act also requires States to submit as part of the health care
oversight plans a description of the protocols in place or planned to oversee and monitor
the use of psychotropic medications among children in foster care (section
422(b)(14)(A)(v) of the Social Security Act). ACYF, in partnership with the Substance
Abuse and Mental Health Services Administration (SAMHSA) and the Centers for
Medicare & Medicaid Services (CMS), is currently providing technical assistance to
States to support the development of their plans. The recent IM, ACYF-CB-IM-12-03,
describes strategies for strengthening systems of oversight and monitoring of
psychotropic medications.
Because use of psychotropic medication with children has not been as extensively tested
as use with adults, and because these drugs can have complicated side effects, they
should be prescribed with care. When they are prescribed, their use should be justified
by clinical evidence identified in EPSDT, trauma screenings, and children’s treatment
plans. As States develop their plans for prescription psychotropic medication
management, there is also work to be done to identify effective psychosocial
interventions that can improve behavioral and mental health outcomes of children
receiving child welfare services.
•
Child Abuse Prevention and Treatment Act (CAPTA) State Grants: In order to receive
CAPTA funds, States are required to submit a plan that describes how they will support and
enhance interagency collaboration among public health agencies, agencies in the child
protective service system, and agencies carrying out private community-based programs to
improve the health outcomes, including mental health outcomes, of children identified as
victims of child abuse or neglect. This includes supporting prompt, comprehensive health
and developmental evaluations for children who are the subject of substantiated child
maltreatment reports.
o Early Intervention: States receiving CAPTA funds are required to refer children under
the age of three with a substantiated case of maltreatment to early intervention services
funded under Part C of the Individuals with Disabilities Education Act
(§106(b)(2)(B)(xxi)). Children with substantiated cases of maltreatment are assured
timely, comprehensive, and multidisciplinary screenings, and, if a developmental
disability is identified, they are entitled to ongoing early intervention services. In many
States, child-serving systems have worked in collaboration to support early intervention
referrals, evaluations, and services for children who have experienced abuse or neglect
(Child Welfare Information Gateway, 2007).
7
074
Maltreatment impacts how young people form relationships with others throughout their lives.
For many maltreated children, nurturing and supportive parental behavior was inconsistent or
unavailable, leaving children lacking confidence to explore new environments and relationships
(Bretherton, 2000; Sorce & Emde, 1981). States should consider how these policies might best
be linked and carried out to support healing and recovery and promote healthy functioning of
children and youth.
Other Federal child welfare policies also address elements of well-being, including policies
related to kinship care, family connections, sibling placements, monthly parent visits, placement
stability, and school stability. When implemented in a purposeful way, these policies all
contribute to improving social and emotional well-being, repairing ruptured relationships, and
enhancing relational skills.
V.
Current State and County Investments
Currently, state and county child welfare systems are investing significant funds in providing
services intended to improve well-being outcomes for children and their families. Three of the
most common services purchased by states and counties are counseling, parenting classes, and
life skills training. However, a number of studies suggest that some of these services are not
grounded in the best available evidence and may be provided to children without sufficient
attention to their specific maltreatment and trauma histories.
In a study of children receiving mental health services, McCrae, Guo, and Barth (2010) found
that children who got typical mental health services had more behavioral problems over time
than those who received none. “The study should not be understood to indicate that all [mental
health services] for children involved with [child welfare services] are ineffective; rather, it
indicates that children [in child welfare] do not predictably receive services that are sufficient to
help them overcome their behavioral difficulties” (p.358).
Another study examined interventions to improve caregivers’ parenting skills and found “that
most of the parent focused interventions currently delivered to families in child welfare and most
foster family training do not use treatment strategies with solid empirical support” (Horwitz,
Chamberlain, Landsverk, Mullican, 2010, p.28).
Child welfare systems also work to provide youth who are exiting foster care to emancipation
with the skills and resources they will need to function as adults. Often this takes the form of
programs that teach basic life skills, budgeting and financial management, and health and
nutrition. In an evaluation of outcomes for youth in foster care participating in four youth
development programs around the country, researchers determined that the life skills training
programs studied resulted in no statistically significant improvement on any of the key outcomes
measured (Koball, et al., 2011). 5
5
These outcomes included: High school completion, current employment, earnings, net worth, economic hardship,
receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal
documents, any bank account, and sense of preparedness in 18 areas of adult living.
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VI.
Screening and Functional Assessment
Functional assessment is a central component of promoting social and emotional well-being for
children who have experienced abuse or neglect. Traditionally, child welfare systems use
assessment as a point-in-time diagnostic activity to determine if a child has a particular set of
symptoms or requires a specific intervention. Functional assessment, however, provides a more
holistic evaluation of children’s well-being and can also be used to measure improvement in skill
and competencies that contribute to well-being. Functional assessment—assessment of multiple
aspects of a child’s social-emotional functioning (Bracken, Keith, & Walker, 1998)—involves
sets of measures that account for the major domains of well-being. Rather than using a “one size
fits all” assessment for children and youth in foster care, systems serving children receiving child
welfare services should have an array of assessment tools available. This allows systems to
appropriately evaluate functioning across the domains of social-emotional well-being for
children across age groups (O’Brien, 2011). They capture children’s strengths, including skills
and capacities, as well as potential difficulties (Humphrey, et al., 2011; Roeser, Strobel, &
Quihuis, (2002) in a developmentally-appropriate manner, accounting for the trauma- and mental
health-related challenges faced by children and youth who have experienced abuse or neglect.
Similarly, some assessment tools can be used to measure parenting capacities and improvements
over time.
Screening for symptoms related to trauma, specifically how experiences of trauma may impair
healthy functioning, is an essential element of functional assessment. Trauma screening involves
universal administration of a brief tool(s) to: (1) estimate the prevalence of trauma symptoms
and/or traumatic experiences and (2) identify children who may require further assessment and
intervention. Examples of trauma screening tools include the Child and Adolescent Needs and
Strengths (CANS) Trauma Version, the Childhood Trauma Questionnaire (CTQ), and the
Pediatric Emotional Distress Scale (PEDS).
Functional assessment tools can be used to inform decisions about the appropriateness of
services. They can be useful tools, for example, for informing the design of outcomes-oriented
case plans (Wotring, Hodges, & Xue, 2005). Functional assessments can also track progress
toward social-emotional well-being outcomes. Several valid and reliable tools used to measure
domains of social-emotional functioning with children and adolescents have been tested and
normed with representative samples of children from the general population. 6 Data from these
assessments allow States and programs to measure a child’s level of functioning and monitor
how it compares with general populations of the same age group. In other words, assessment
helps systems to determine not only whether a child meets the threshold for a particular concern
but also how the child fares relatives to the expected developmental trajectory for child
functioning. This allows States and programs to better understand whether interventions are
moving each child back on track developmentally within the well-being domains.
Additionally, the universal administration of these types of functional assessment tools to all
children in a system at entry and at key follow-up periods can help systems track changes in
children’s social-emotional functioning compared to their own baseline during and after the
6
Examples include the Strengths and Difficulties Questionnaire (SDQ), the Child Behavior Checklist (CBCL), the
Social Skills Rating Scale (SSRS), and the Emotional Quotient Inventory Youth Version (EQ-i:YV).
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delivery of services. This allows systems to generate data that help them understand whether
their services are making a positive difference for children and youth. Continuously monitoring
progress using these functional assessment tools also helps decision-makers reassess the
appropriateness of the service array over time for individual children. Broader analyses of the
aggregate data from assessments can help decision-makers at the program and systems levels to
identify the best and most effective practices for all children in the target population and for
particular subgroups (Wotring, Hodges, & Xue, 2005).
VII.
Effective Interventions
Recent research has expanded the knowledge base regarding interventions that treat the
behavioral, social, and emotional problems that are common among children who have
experienced maltreatment. While generic counseling is not consistently effective in reducing
mental health symptoms for children in foster care, several evidence-based treatments have been
successful when delivered with fidelity to the model; the same is true for parenting interventions
and programs for youth. Many of these interventions have been rigorously tested and shown to
reliably improve child functioning by targeting the impact of maltreatment and developing skills
and competencies that help children navigate their daily lives. The emergence of promising and
effective interventions at multiple levels – at the child level related to trauma and
behavioral/mental health; at the older youth level related to relational health and social and
emotional –well-being; and at the caregiver level related to increasing capacity to care for their
children – provides an opportunity to impact the life circumstances of families as a whole.
Child welfare and mental health systems can develop the capacity to install, implement, and
sustain these evidence-based and evidence-informed interventions by using research to identify
effective and promising interventions that meet the needs of the specific population to be served;
making needed adaptations to bring the interventions to scale within the child welfare system,
developing an awareness of principles of evidence-based practices among staff at all levels; and
reorganizing infrastructure to support implementation fidelity and further evaluations of these
practices and interventions.
Evidence-based and evidence-informed practices have been developed to address the most
common mental health diagnoses, trauma symptoms, and behavioral health needs of children and
show measurable improvements or promising results. 7 These interventions show measurable
improvements or promising results in decreasing emotional/behavioral symptoms; diminishing
depression, anxiety; increasing the ability to self-regulate; improving physical health; and
helping traumatized children and youth form and maintain healthy attachments. There are also
evidence-based and evidence informed interventions geared toward improving outcomes related
to youth skill development, education, and employment. (Job Corps and Big Brothers/Big Sisters
are examples.) Many of these practices are available but have not been brought to scale or
targeted to the foster care population even though they have been shown to improve functioning.
Others have shown promising results, and should be evaluated more broadly as they are
implemented more widely.
7
Evidence-based and evidence-informed practices such as Trauma-focused Cognitive Behavioral Therapy,
Multisystemic Therapy, and Parent-Child Interaction Therapy are examples. There are also evidence-based and
evidence informed interventions geared toward improving outcomes related to youth skill development, education,
and employment; Job Corps and Big Brothers/Big Sisters are examples.
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It is important to note that many of the evidence-based interventions that improve child
functioning require the involvement of caregivers and specifically target their behaviors for
change as well. Caregivers need support in managing the behaviors of children who have
experienced maltreatment and in providing a nurturing environment in which healing can occur.
In such supportive contexts, children can learn “the value, purpose and safety of relationships”
(Rees, 2010). In order to achieve better outcomes for children who have experienced
maltreatment, it is essential to engage families, whether biological, foster, or adoptive, in the
process of healing and recovery.
VIII. Maximizing Resources to Achieve Better Results
By leveraging current policies and requirements and shifting existing resources to promote social
and emotional well-being, child welfare systems can begin to align policies, practices, and
programs to achieve significantly better results, both for individual children and for the system as
a whole.
•
Better Child and Family Outcomes: Focusing on social and emotional well-being means
attending to the specific skills, capacities, and characteristics that children and youth need to
develop while they are young in order to be autonomous, healthy adults. Although the
impact of maltreatment is pernicious, the experience of abuse and neglect does not guarantee
that children will develop the behavioral, psychological, and social-emotional problems listed
above. Neither does it mean that children with behavioral concerns, trauma symptoms,
and/or mental health disorders cannot heal and recover and become happy, successful adults.
By integrating evidence-based and evidence-informed services and supports to promote
social and emotional well-being, child welfare systems can help children develop healthy
coping mechanisms, relational skills, and the other capacities that they need to succeed in
school, to participate in the workforce and their communities, to care for their own children,
and to have positive relationships with others.
•
Better System Outcomes: With services and supports to promote children’s social and
emotional well-being, system-level outcomes, such as length of stay, congregate care
placements, exits to permanency, and reentries, can be expected to improve as well. Children
may spend less time in foster care before exiting to reunification, adoption, or guardianship,
and reentries into foster care may become less common. While children and youth are
certainly not to blame when they do not exit to permanency quickly or when they reenter
foster care, children’s behavioral problems, when unaddressed, often contribute to placement
changes, adoption disruptions, and returns to foster care.
IX.
Focusing on Social and Emotional Well-Being
Focusing the work of a child welfare system on well-being, particularly social and emotional
well-being, requires a concerted effort on behalf of all staff and stakeholders, from directors, to
managers, to supervisors, to caseworkers, to foster parents. It entails (a) understanding the
challenges that children who have experienced maltreatment bring with them when they come to
the attention of the child welfare system, (b) considering how services are structured and
delivered at each point along children’s trajectory through the child welfare system, and (c) descaling practices that are not improving outcomes while simultaneously installing and scaling up
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effective approaches. ACYF recognizes that it is not simple to transform a system in this way
and that these processes take time. As the logical next step in reforming the child welfare
system, it requires the careful development of capacity to integrate new research and implement
new practices without compromising ongoing efforts to achieve safety and permanency for
children who have experienced maltreatment.
Understanding Impact of Maltreatment and Anticipating Challenges: As discussed above,
maltreatment leaves a particular traumatic fingerprint on the development and functioning of
children and youth. Often the behavioral, social-emotional, and mental health problems that
children in foster care have are assumed to be the result of their experience with the child welfare
system. McMillan, et al. (2005) and Griffin, Kisiel, McClelland, Stolback, & Holzberg (2012)
have shown that children and youth frequently display these challenges before they enter foster
care. 8 An understanding of the impact maltreatment has had on children when they come to the
attention of the child welfare system allows providers to be more proactive, knowing what to
look for and anticipating the services that may be needed. This capacity is necessary at the
caseworker-level, but also at the level of administrators who are making decisions about the
array of services needed internally or through contracts.
Responding and Intervening along the Child Welfare Continuum: Focusing child welfare on
improving social and emotional well-being requires careful consideration of how services are
structured and delivered throughout the system. For example, a child welfare system with a
focus on social and emotional well-being might be characterized by the following:
•
•
•
•
•
•
Assessment tools used with children receiving child welfare services are reviewed to ensure
that they are valid, reliable, and sensitive enough to distinguish trauma and mental health
symptoms.
Children are screened for trauma when their cases are opened.
In-home caregivers receive services that have been demonstrated to improve parenting
capacities and children’s social-emotional functioning.
Child welfare staff and foster parents receive ongoing training on issues related to trauma and
mental health challenges that are common among the children and youth being served by the
system.
Assessments take place at regular or scheduled intervals to determine whether services being
delivered to children and youth are improving social and emotional functioning.
Independent living and transitional living programs implement programs to support youth’s
development of self-regulation and positive relational skills.
De-Scaling and Scaling Up: When child welfare systems make changes, new programs and
practices are often added onto the already existing array of services. Ongoing contracts and the
need to provide continuous services make it difficult to discontinue or downsize programs that
are not improving outcomes for children and youth. Transforming the array of services, rather
than simply augmenting it, requires “de-scaling” programs that are not reliably enhancing child
functioning by divesting funds and simultaneously shifting resources to support proven practices.
8
This is not to say that foster care is never detrimental to the well-being of children and youth. However, the fact
that children display problems before they come to the attention of the child welfare system indicates that the
experience of maltreatment often predicates their difficulties.
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Additional dollars may be necessary initially to support installation of evidence-based practices.
However, de-scaling programs that are not working and reallocating resources ensures that
effective services can be sustained without requiring new, ongoing funding.
Transforming child welfare services by de-scaling and/or converting interventions that are not
working while scaling up evidence-based treatments is unquestionably complex and difficult
work. Other systems have grappled with this challenge; for example, as mental health services
are increasingly provided in community-based settings, the role of residential treatment facilities
has been widely reexamined. As new research emerges and the population receiving services
changes, it is necessary to reevaluate the way those services are delivered. To start, States can
conduct an inventory of the services they are currently providing to children with child welfare
involvement and gather information about how effective these services are in improving
children’s functioning. This information can help drive decision-making about the steps that are
necessary to align State, county, and local resources to improve outcomes.
Child welfare agencies that coordinate efforts within and across departments to innovatively retool the complement of services available to youth and families in the child welfare system are
more likely to achieve sustainable change. Service coordination at the State and local level can
benefit from the growing effort across Federal agencies, including the Substance Abuse and
Mental Health Services Administration, National Institutes of Mental Health, National Institute
on Drug Abuse, Department of Justice, Department of Education, and others, to promote
improved well-being outcomes and the use of effective practices.
X.
Strategies for Shifting the System to Promote Social and Emotional Well-Being
There are many ways that child welfare systems can begin to embed a focus on social and
emotional well-being in their work. A few specific examples are listed below.
Services. This IM has shown that children who have experienced abuse or neglect have
significant behavioral, social, and emotional challenges; it has also shown that there are
evidence-based practices and interventions that can improve outcomes for children and their
families. Delivering effective services is the most critical component of a focus on promoting
social and emotional well-being.
•
Screening and Functional Assessment: Conduct high quality and regular trauma
screenings and functional assessments of children, youth, and families to determine exposure
to and impacts of maltreatment and other forms of complex interpersonal trauma. The
American Academy of Child and Adolescent Psychiatry and the Child Welfare League of
America have developed guidelines for screening and assessment to help inform child
welfare systems (AACAP & CWLA, 2002). Valid and reliable mental and behavioral health
and developmental screening and assessment tools should be used to understand the impact
of maltreatment on vulnerable children and youth. Screens and assessments should be
sensitive enough to distinguish symptoms of trauma reactions and mental health disorders.
The use of such tools is important in fulfilling child welfare agencies’ responsibility for
ensuring the well-being of children and youth who have been exposed to complex
interpersonal trauma (Levitt, 2009). Conducting assessments as early as possible when
children become involved with the child welfare system and regularly thereafter allows
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caseworkers to know how children are doing initially and whether or not they are getting
better with the services provided.
•
Evidence-Based Interventions: Deliver evidence-based and evidence-informed
interventions for the treatment of trauma and mental health disorders. When evidence-based
screening and assessment indicates that children are suffering from trauma and/or mental
health symptoms, it is necessary to provide treatments that effectively improve functioning.
Child welfare systems will need to collaborate with mental health and Medicaid systems to
build an array of evidence-based or evidence-informed interventions to improve trauma and
mental health-related outcomes for children who have experienced maltreatment.
In recent years, public and private sector organizations have produced extensive, publically
available lists and databases of evidence-based and evidence-informed interventions for
improving well-being outcomes for vulnerable children (See “Resources,” below). These
include, among others, SAMHSA’s National Registry of Evidence-Based Programs and
Practices (NREPP) and the U.S. Department of Justice’s CrimeSolutions.gov. The Agency
for Healthcare Research and Quality is currently conducting an evidence review of
“Interventions Addressing Child Exposure to Trauma: Child Maltreatment and Family
Violence,” which will be available later in the year. Additionally, many institutions,
including SAMHSA and organizations funded by HHS, including the National Child
Traumatic Stress Network (NCTSN) and the National Early Childhood Technical Assistance
Center (NECTAC), have published publically-accessible reviews of valid and reliable
instruments for screening and assessing various aspects of social-emotional well-being with
different populations and age groups. As such, it is now more feasible than ever to identify
and implement evidence-based and evidence-informed interventions.
•
Services within Child Welfare: Consider restructuring services that are the sole
responsibility of child welfare. Some services fall completely within the purview of the child
welfare system. For example, services provided by Independent Living and Transitional
Living Programs are often dictated by the child welfare agency. Others include
investigations, case management, and foster parent training. Without requiring the
coordination or collaboration of other systems, it may be possible to change the way these
services are delivered. Child welfare agencies could redesign programs and modify contracts
to require that Independent Living and Transitional Living Programs deliver services that are
trauma-informed and evidence based.
Workforce. It is essential to develop a workforce strategy that supports an emphasis on
promoting social and emotional well-being. Administrators and staff of child welfare and other
systems that affect children receiving child welfare services, including Medicaid, mental health,
and the courts must understand the rationale for the focus and have the capacity to implement
changes.
•
Capacity around Evidence-Based Practices: Build the capacity of child welfare and
mental health systems’ staff to understand, install, implement, and sustain evidence-based
practices. This includes: using research to identify effective interventions that improve
outcomes for the population; developing an awareness of principles of evidence-based
practice among staff at all levels; and reorganizing infrastructure to support implementation
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fidelity. While child welfare staff may not be responsible for delivering these interventions,
they should be able to appropriately assess and refer children and families to evidence-based
treatment providers and determine whether or not the interventions being delivered are
having positive effects on child and family functioning. Child welfare workers should also
have regular access to learning tools and communities to remain up-to-date on the latest
developments in relevant evidence-based practices.
•
Training on Specific Populations: Train staff to more effectively serve specific populations
of children and youth and specific populations of prospective foster and adoptive families
served by the child welfare system. While the social and emotional issues of each child
differ, certain populations will share common challenges. Lesbian, gay, bisexual,
transgender, and questioning (LGBTQ) youth are often overrepresented in the child welfare
system, and they have a set of unique challenges to overcome (ACYF, 2011). In an earlier
IM, States were encouraged to “claim available title IV-E reimbursement for costs associated
with training staff to increase their capacity to serve young people who identify as LGBTQ
and to consider how the title IV-E agency can best serve young people and keep them safe”
(ACYF, 2011, p.2). Additionally, LGBT families can be an untapped resource for
placement, and agencies are often working to improve their skills and competencies in
serving these families. States may use IV-E training dollars at an enhanced reimbursement
rate (75 percent) to improve workers’ competency in serving both LGBTQ youth in care and
prospective LGBT foster and adoptive families.
•
Training for Professionals Outside of Child Welfare: Provide training on the impact of
maltreatment, trauma, and the social and emotional well-being of children who have been
abused or neglected. Under the Fostering Connections to Success and Increasing Adoptions
Act of 2008, States may use title IV-E training dollars at an enhanced reimbursement rate (75
percent) for training staff of personnel outside of the public child welfare system. Eligible
personnel include: staff of private agencies contracted to perform services for the child
welfare agency, court personnel, attorneys, guardians ad litem, court appointed special
advocates, and prospective relative guardians, as well as foster and adoptive parents.
•
Engaging the Judiciary and the Courts: The Courts play a critical role in promoting the
social and emotional well-being of children known to child welfare. The oversight role of
the Courts could be enhanced by providing training on the core components of social and
emotional well-being and trauma and effective screening, assessment and intervention
approaches that can improve functioning. Judges are well situated to ask questions, ensure
effective services are delivered, and track well-being outcomes for their individual cases and
at the system level.
System. Promoting social and emotional well-being requires a careful analysis of the way the
child welfare system is currently structured and the systemic changes that are necessary.
•
Program Inventory: Examine current spending to understand where resources can be
shifted to support evidence-based programs and practices. Many states are currently
purchasing services that are not reliably yielding the desired results, such as generic
counseling, parenting classes, and life skills training for emancipating youth. By identifying
resources that are being used to support these types of services, child welfare systems can
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begin planning to de-scale them and repurpose funds for evidence-based interventions.
Ideally, administrators will combine this work with an analysis of data describing the needs
of the population of children receiving child welfare services in order to identify areas in
which de-scaling and installation of new practices can improve child and family outcomes.
•
Measure Outcomes, Not Services: It is common for child welfare systems to gauge their
success based on whether or not services are being delivered. One way to focus attention on
well-being is to measure how young people are doing behaviorally, socially, and emotionally
and track whether or not they are improving in these areas as they receive services. At the
system level, data from trauma screenings and functional assessments can help administrators
understand how successful their child welfare systems are in achieving positive outcomes for
children and youth. This understanding can inform decisions about the array of services that
is currently available and the procurement of services going forward.
Building a child welfare system that responds effectively to the traumatic impact of maltreatment
and promotes social and emotional well-being is complex work. Multiple, complementary
strategies must be employed in order to create systematic changes that improve outcomes for
children. The progress that the child welfare system has made in recent years has been the result
of ongoing and evolving collaborations across multiple child-serving systems, including mental
health, Medicaid, education, early childhood, and more. Together, these systems integrated
knowledge about the importance of permanency and family connections and structured
themselves to deliver services that keep young people safer; keep children with their families
more often; and ensure reunification, adoption, and guardianship for more of the children who
come into foster care.
As child welfare systems continue to improve and refine their work to promote safety and
permanency for children, a strengthened focus on the social and emotional well-being of children
who have experienced maltreatment is the logical next step in reforming the child welfare
system. Children who have been abused or neglected have significant social-emotional,
behavioral, and mental health challenges requiring attention, and treating them with a traumafocused and evidence-based approach can improve outcomes throughout child welfare. This
approach can result in increased placement stability; greater rates of permanency through
reunification, adoption, and guardianship; and greater readiness for successful adulthood among
all children who exit foster care, especially those youth who leave foster care without a
permanent home. Most importantly, it will enable children who have experienced maltreatment
to look forward to bright, healthy futures.
XI.
Resources
Additional information on the importance of promoting social and emotional well-being and
responding to trauma can be found through a number of Federally-funded sources. For example,
the National Child Traumatic Stress Network (NCTSN) is a collaboration of academic and
community-based centers whose mission is to raise the standard of care and increase access to
services for children and their families across the country. NCTSN develops and disseminates
evidence-based interventions, trauma-informed services, and educational resources. Additional
information on the work of NCTSN can be found on their website: http://www.nctsn.org/.
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Several listings include a range of evidence-based and evidence-informed practices to inform
child-serving systems about interventions that may be effective in reducing the impact of
maltreatment and/or trauma on children in the child welfare system. States should weigh the
strength of available evidence in support of the interventions considered.
•
SAMHSA’s National Registry of Evidence-Based Programs and Practices:
http://nrepp.samhsa.gov
•
Interventions for Disruptive Behavior Disorders Evidence-Based Practices (EBP) KIT:
SAMHSA’s toolkit includes tools to assist in developing mental health programs that help
prevent or reduce aggressive behavioral, emotional, and development problems in children
by enhancing the knowledge of parents, caregivers, and providers:
http://store.samhsa.gov/product/Interventions-for-Disruptive-Behavior-Disorders-EvidenceBased-Practices-EBP-KIT/SMA11-4634CD-DVD
•
Interventions Addressing Child Exposure to Trauma: Part 1-Child Maltreatment: This
comparative evidence review of interventions for children who have experienced
maltreatment will be released in summer, 2012 from the Agency for Healthcare Research and
Quality (AHRQ). For more information on the project, visit:
http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-andreports/?pageaction=displayproduct&productid=846#amendments
In addition, the Child Welfare Information Gateway connects child welfare and other
professionals to information and resources to help strengthen families. Information, resources,
and tools covering topics within child welfare, out-of-home care, risk and protective factors, and
impacts of trauma are readily available through the Gateway for professionals and other
individuals wishing to learn more about and improve services for children, youth, and families
with child welfare involvement. The Gateway can be accessed through the following website:
http://www.childwelfare.gov/.
Inquiries to: Children’s Bureau Regional Program Managers
/s/
Bryan Samuels
Commissioner
Administration on Children, Youth and Families
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childhood neglect tells us about nature and nurture. Brain and Mind. 3:79.
Rees, CA. (2010). All they need is love? Helping children to recover from neglect and abuse.
Archives of Diseases in Childhood. 96:969.Roeser, R. W., Strobel, K. R., & Quihuis, G.
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(2002). Studying Early Adolescents' Academic Motivation, Social-Emotional
Functioning, and Engagement in Learning: Variable- and Person-Centered Approaches.
Anxiety, Stress & Coping, 15(4), 345-368.
Sorce, JF & Emde, RN. (1981). Mother’s presence is not enough: Effect of emotional availability
on infant exploration. Developmental Psychology. 17(6):737.
Terr, LC. (1991). Acute responses to external events and Posttraumatic stress disorders. In
Lewis, M (Ed.). Child and adolescent psychiatry: a comprehensive textbook New Haven,
CT: Williams & Wilkins.
U.S. Department of Health and Human Services (USDHHS); Administration for Children and
Families (ACF); Administration on Children, Youth and Families. (2002-2011) Adoption
and Foster Care Analysis and Reporting System (AFCARS) Reports Nos. 10-18.
Washington, DC: Author. Accessed on February 29, 2012, at
http://www.acf.hhs.gov/programs/cb/stats_research/index.htm#afcars
Vandivere, S., Allen, T., Malm, K. McKindon, A., and Zinn, A. (2011) Technical Report #2:
Wendy’s Wonderful Kids Program Impacts, Child Trends, Washington, D.C. Retrieved
from:http://www.davethomasfoundation.org/about-foster-care-adoption/research/readthe-research/technical-report-2/
White, CR; Havalchack, A; Jackson, L; O’Brien, K; & Pecora, P. (2007). Mental Health,
Ethnicity, Sexuality, and Spirituality among Youth in Foster Care: Findings from the
Casey Field Office Mental Health Study. Seattle, WA: Casey Family Programs.
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Use of Outcome Data, Stakeholder Involvement, and Evidence-Based Practice. The Behavior
Therapist. 28(7):150-157.
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Appendix 1: ACYF Well-Being Framework
Well-Being Outcome Domains
Physical Health and
Emotional/Behavioral
Development
Functioning
Normative standards for
Self-control, emotional
growth and development,
management and
gross motor and fine
expression, internalizing
motor skills, overall
and externalizing
health, BMI
behaviors, trauma
symptoms
Social Functioning
Temperament, cognitive
ability
Family income,
family social capital,
community factors (e.g.,
institutional resources,
collective socialization,
community organization,
neighborhood SES)
Temperament, cognitive
ability
Language development,
pre-academic skills (e.g.,
numeracy), approaches to
learning, problem-solving
skills
Normative standards for
growth and development,
gross motor and fine
motor skills, overall
health, BMI
Self-control, self-esteem,
emotional management
and expression,
internalizing and
externalizing behaviors,
trauma symptoms
Social competencies,
attachment and caregiver
relationships, adaptive
behavior
Family income,
family social capital,
social support,
community factors (e.g.,
institutional resources,
collective socialization,
community organization,
neighborhood SES)
Identity development,
self-concept, self-esteem,
self-efficacy, cognitive
ability
Academic achievement,
school engagement,
school attachment,
problem-solving skills,
decision-making
Normative standards for
growth and development,
overall health, BMI, riskavoidance behavior
related to health
Emotional intelligence,
self-efficacy, motivation,
self-control, prosocial
behavior, positive
outlook, coping,
internalizing and
externalizing behaviors,
trauma symptoms
Social competencies,
social connections and
relationships, social
skills, adaptive behavior
Family income,
family social capital,
social support,
community factors (e.g.,
institutional resources,
collective socialization,
community organization,
neighborhood SES)
Identity development,
self-concept, self-esteem,
self-efficacy, cognitive
ability
Academic achievement,
school engagement,
school attachment,
problem solving skills,
decision-making
Overall health, BMI, riskavoidance behavior
related to health
Emotional intelligence,
self-efficacy, motivation,
self-control, prosocial
behavior, positive
outlook, coping,
internalizing and
externalizing behaviors,
trauma symptoms
Social competence, social
connections and
relationships, social
skills, adaptive behavior
Adolescence (13-18)
Middle Childhood (6-12)
Family income,
family social capital,
community factors (e.g.,
institutional resources,
collective socialization,
community organization,
neighborhood SES)
Language development
Infancy (0-2)
Cognitive Functioning
Early Childhood
(3-5)
Intermediate Outcome Domains
Environmental Supports
Personal Characteristics
Social competencies,
attachment and caregiver
relationships, adaptive
behavior
Social and Emotional Well-Being Domains
21
088
New York State Education Law section 3602-ee
Statewide Universal Full-Day Pre-Kindergarten Program
§ 3602-ee. Statewide universal full-day pre-kindergarten program. 1.
The purpose of the universal full-day pre-kindergarten program is to
incentivize
and
fund state-of-the-art innovative pre-kindergarten
programs and to encourage program creativity through competition.
2. All universal full-day pre-kindergarten programs shall
quality on the following elements:
(a) curriculum;
(b) learning environment, materials and supplies;
(c) family engagement;
(d) staffing patterns;
(e) teacher education and experience;
(f) facility quality;
(g) physical well-being, health and nutrition; and
(h)
partnerships
with
non-profit,
community
and
institutions.
demonstrate
educational
3. (a) The universal full-day pre-kindergarten program shall make
awards to (i) consolidated applications submitted by school districts
which include pre-kindergarten programs offered by schools, non-profit
organizations, community-based organizations, charter schools, libraries
and/or museums, which shall demonstrate geographic diversity within the
area to be served as well as diversity of providers; and (ii) non-profit
organizations, community-based organizations, charter schools, libraries
and museums, which may apply individually to the extent allowed under
paragraph (b) of this subdivision. Any consolidated application must
include, but is not limited to, the names of individual locations and
providers, applicable licenses, facility lease information, and intended
staffing plans and certifications.
(b) Prior to submission of a consolidated application, a school
district shall widely solicit non-profit organizations, community-based
organizations, charter schools, libraries and museums located within the
school district to be included in its application. The school district
shall notify any applicant who has been denied for inclusion in the
consolidated application no later than two weeks prior to submission of
such application. Such eligible providers denied for inclusion may apply
individually as provided in paragraph (a) of this subdivision.
(c) The department shall establish two application periods in advance
of a school year.
(d) Providers awarded slots under this section that they actually
utilized would continue to have such slots renewed in subsequent years
provided
the program meets quality standards and all applicable
requirements.
4. Programs that provide more stimulation, enhance child development
and demonstrate creative approaches to improve early childhood education
will have a competitive advantage in the application process.
5. The department shall develop a scoring system, which it shall use
to evaluate which applications shall be funded on a competitive basis
based on merit and factors including but not limited to the criteria
listed above and student and community
need.
Upon
review
of
089
applications, if the program is oversubscribed in any region or regions
of the state, the department shall notify the division of the budget,
which shall develop a plan for distribution of available slots within
any oversubscribed region. The subscription for the New York city region
is three hundred million dollars. The department shall allocate full-day
pre-kindergarten conversion slots and new full-day pre-kindergarten
slots
based
on available funding and shall make payments upon
documentation of eligible expenditures in the base year, which shall be
limited to the actual number of slots operated and paid on a per-pupil
basis pursuant to subdivision fourteen of this section.
6. The department shall develop a statewide inspection protocol, which
shall provide for annual inspections of all
universal
full-day
pre-kindergarten providers, and shall develop a quality assurance
protocol and physical plant review protocol for such reviews.
7. Statewide universal full-day pre-kindergarten slots shall only be
awarded to support programs that provide instruction for at least five
hours per school day for the full school year and that otherwise comply
with the rules and requirements pursuant to section thirty-six hundred
two-e of this part except as otherwise provided in this section.
8. All teachers in the universal full-day pre-kindergarten program
shall meet the same teacher certification standards applicable to public
schools. Pre-kindergarten teachers providing instruction through this
section shall possess:
(a) a teaching license or certificate valid for service in the early
childhood grades; or
(b) a teaching license or certificate for students with disabilities
valid for service in early childhood grades; or
(c) for eligible agencies as defined in paragraph b of subdivision one
of section thirty-six hundred two-e of this part that are not schools, a
bachelor's degree in early childhood education or a related field and a
written plan to obtain a certification valid for service in the early
childhood grades as follows:
(i) for teachers hired on or after the effective date of this section
as the teacher for a universal full-day pre-kindergarten classroom,
within three years after commencing employment, at which time such
certification shall be required for employment; and
(ii) for teachers hired by such provider prior to the effective date
of this section for other early childhood care and education programs,
no later than June thirtieth, two thousand seventeen, at which time such
certification shall be required for employment.
9. The process by which applicants submit proposals to collaborate
with the school district or individually to the department, and the
renewal process for such providers, shall take into account any record
of
violations
of
health and safety codes and/or licensure or
registration requirements. In addition, any agency that is cited for a
violation classified as an "imminent danger" by the office of children
and family services or as a "public health hazard" by the New York city
department of health and mental hygiene which is not immediately
corrected and which is not of a life threatening or of a grave and
serious nature shall be suspended from the program and, upon final
determination of such violation by the regulating agency, suspended or
terminated from participating in the program under this section based on
the severity of the violation. Provided further, that eligible agencies
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090
with a record of other serious or critical and/or repeated violations
that pose a risk to health or safety shall, upon final determination of
such violations, be suspended or terminated from participating in the
program under this section, and the office of children and family
services shall establish statewide standards for determining such
grounds for such suspension or termination based on violations issued by
the applicable regulatory agency.
10. Notwithstanding any provision of law to the contrary, a universal
full-day pre-kindergarten provider shall be inspected by the department,
the school district with which it partners, if any, and its respective
licensing, permitting, regulatory, oversight, registration or enrolling
agency or entity no fewer than two times per school year, at least one
inspection of which shall be performed by the eligible agency's
respective licensing, permitting, regulatory, oversight, registration or
enrolling agency, as applicable.
11. Facilities providing universal full-day pre-kindergarten under
this section shall meet all applicable fire safety and building codes
and any applicable facility requirements of a state or local licensing
or registering agency and at all times shall maintain building and
classroom space in a manner that ensures and protects the health and
safety of students in all programs statewide, notwithstanding any
changes in such applicable codes or requirements.
12. Notwithstanding paragraph (a) of subdivision one of section
twenty-eight hundred fifty-four of this chapter and paragraph (c) of
subdivision two of section twenty-eight hundred fifty-four of this
chapter, charter schools shall be eligible to participate in universal
full-day pre-kindergarten programs under this section, provided that all
such monitoring, programmatic review and operational requirements under
this section shall be the responsibility of the charter entity and shall
be consistent with the requirements under article fifty-six of this
chapter. The provisions of paragraph (b) of subdivision two of section
twenty-eight hundred fifty-four of this chapter shall apply to the
admission
of
pre-kindergarten
students,
except
parents
of
pre-kindergarten children may submit applications for the two thousand
fourteen--two thousand fifteen school year by a date to be determined by
the charter school upon selection to participate in the universal
full-day pre-kindergarten program. The limitations on the employment of
uncertified teachers under paragraph (a-1) of subdivision three of
section twenty-eight hundred fifty-four of this chapter shall apply to
all teachers from pre-kindergarten through grade twelve.
13. Apportionments under this section shall only be used to supplement
and not supplant current local expenditures of federal, state or local
funds on pre-kindergarten programs and the number of slots in such
programs from such sources. Current local expenditures shall include any
local expenditures of federal, state or local funds used to supplement
or extend services provided directly or via contract to eligible
children enrolled in a universal pre-kindergarten program pursuant to
section thirty-six hundred two-e of this part.
14. (a) The award per pupil for an eligible entity pursuant to
subdivision three of this section shall equal: (i) for each new full-day
pre-kindergarten placement the lesser of the full-day pre-kindergarten
per pupil amount or the total approved expenditures per pupil and (ii)
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091
for each existing half-day pre-kindergarten placement converted into a
full-day pre-kindergarten placement the lesser of (A) the positive
difference of the full-day pre-kindergarten per pupil amount minus the
district's selected aid per pre-kindergarten
pupil
pursuant
to
subparagraph (i) of paragraph b of subdivision ten of section thirty-six
hundred two-e of this part or (B) the positive difference of the total
approved expenditures per pupil minus the district's selected aid per
pre-kindergarten pupil pursuant to subparagraph (i) of paragraph b of
subdivision ten of section thirty-six hundred two-e of this part. Each
participating eligible entity pursuant to subdivision three of this
section shall provide its expenses under this provision in a format
prescribed by the commissioner.
(b) For the purposes of this section, "full-day pre-kindergarten per
pupil amount" shall mean (i) for pupils enrolled in programs where the
teacher of record for such pupil holds a teaching certificate issued by
the commissioner in an appropriate certificate title, ten thousand
dollars, and (ii) for pupils enrolled in programs where the teacher of
record for such pupil does not hold a teaching certificate issued by the
commissioner in an appropriate certificate title, seven
thousand
dollars.
(c) For the purposes of this section, "teacher of record" shall mean
the teacher who is primarily and directly responsible for a student's
learning
activities, as reported to the department in a manner
prescribed by the commissioner.
15. Definitions. For the purpose of this section, the following
definitions shall apply:
(a) "regions of the state" shall mean:
(i) Capital Region: Includes Albany, Columbia, Greene, Rensselaer,
Saratoga, Schenectady, Warren, and Washington counties.
(ii) Central New York Region: Includes Cayuga, Cortland, Madison,
Onondaga and Oswego counties.
(iii) Finger Lakes Region: Includes Genesee, Livingston, Monroe,
Ontario, Orleans, Seneca, Wayne, Wyoming and Yates counties.
(iv) Long Island Region: Includes Nassau and Suffolk counties.
(v) Mid-Hudson Region: Includes Dutchess, Orange, Putnam, Rockland,
Sullivan, Ulster and Westchester counties.
(vi) Mohawk Valley Region: Includes Fulton, Herkimer, Montgomery,
Oneida, Otsego and Schoharie counties.
(vii) New York City Region: Includes Bronx, Kings, New York, Queens
and Richmond counties.
(viii) North Country Region: Includes Clinton, Essex, Franklin,
Hamilton, Jefferson, Lewis and St. Lawrence counties.
(ix)
Southern Tier Region: Includes Broome, Chemung, Chenango,
Delaware, Schuyler, Steuben, Tioga and Tompkins counties.
(x) Western New York Region:
Includes
Allegany,
Cattaraugus,
Chautauqua, Erie and Niagara counties.
(b) "community-based organization" shall mean a provider of child care
and early education, a day care provider, early childhood program or
center, approved preschool special education program, Head Start or
other such community-based organization.
16. The authority of the department to administer the universal
full-day pre-kindergarten program shall expire June thirtieth, two
thousand sixteen; provided that the program shall continue and remain in
full effect.
4
092
Sophia E. Pappas, Executive Director
A Parent’s Guide to Universal Prekindergarten
Helping you understand what to expect in pre-k is crucial. More than 85 percent of the brain is
developed before the age of 5. The preschool years are the time in which the brain begins to maximize
efficiency.1 The most important goal of pre-k is to help your child develop the knowledge, skills, and
approaches to learning needed to be ready for school. Below are typical pre-k activities with suggestions
of what you can do at home to reinforce and extend your child’s learning. Working together, we can give
your child a great start for school.
Gross and Fine Motor
In Pre-k Children play outside every day, weather permitting. Playing outside
helps develop children’s muscles, improves coordination, and reinforces healthy
habits. The playground is a great place for children to learn social skills such as
taking turns, talking to others, making friends, and getting along.
At Home Take your child to the playground to explore all kinds of movements. Play outdoor games like
hopscotch, jump rope, red light, green light, and drawing with sidewalk chalk. Play games that you
played when you were a child.
Read Aloud
In Pre-k Children listen to stories every day. They ask questions, learn new
words, and discuss different parts of books. During this time, children develop
listening, reading, writing, speaking, and critical thinking skills. They get excited to
hear what will happen next and what they will learn each time the teacher turns the
page.
At Home Read different kinds of books with your child. Visit the library and take out storybooks and
non-fiction books about animals, people, places, and things. Let your child take “picture walks” by telling
you what the story is about by looking at the pictures. Ask questions about what may come next or why
a person did something in the story.
Center/ Choice Time
In Pre-k Children make decisions about where they will explore, discover, and
learn each day. They learn independence by working by themselves or with other
children during center/choice time activities. They read and write, build, cut, paint,
and pretend. They practice planning, doing and reviewing what they did in centers.
Building these skills is critical in a child’s social-emotional development.
1
National Research Council and Institute of Medicine.2000, From Neurons to Neighborhoods: The Science of Early Childhood Development.
Washington, D.C.: National Academy Press.
093
Sophia E. Pappas, Executive Director
At Home Allow your child to make decisions about what to wear to school, which game to play, or
which color towel to use. Ask your child to make a plan (e.g. decide what equipment they will play on in
the playground or which games they want to play with a friend) and execute it. Then, help them reflect
on how it went by talking about it with them and asking them how they think their plans went.
Class Meeting
In Pre-k
Children come together and become a community of learners,
explorers, and friends. They discuss the plan for the day. They build language
skills by listening and responding to stories as well as singing songs and
reciting nursery rhymes. They practice counting, look for patterns, and
explore other math concepts.
At Home Sing songs, share stories, and recite poems that you learned as a child. Tell stories about
your family and what you did when you were young. Talk about the weather each day and why people
wear different clothes depending on the weather.
Small Group
In Pre-k Children spend focused time with the teacher and other students
when they are in small groups. They develop new knowledge and practice
what they learn with support from the teacher and other students.
At Home Spend time with your child one-on-one when possible. Have
conversations about what they learned at school. During bath time, talk
about the day, favorite activities and friends.
Meal Time
In Pre-k Children have a role in getting ready for meal time. Meals are often
set up in family style so children can serve themselves and continue learning
social skills as they engage in rich conversations during meals. Teachers often
eat with children, modeling manners and conversation.
At Home Develop routines for meal times. Let your child prepare for meal time
by setting the table. Sit at the table and allow your child to serve himself. Let him help with clean up by
clearing the table, putting dishes in the sink or placing utensils in drawers.
Pre-k is the first step toward preparing your child for college and future careers.
Brought to you by The Office of Early Childhood Education
www.nyc.gov/schools/earlychildhood
Tel: 212-374-0351
Was this helpful? Send us your feedback.
Email: [email protected]
You can find information on pre-K sites on our website.
http://schools.nyc.gov/ChoicesEnrollment/PreK
094
POLICY AGENDA
Overview
AFC’s mission is to promote the best education New York can provide for all students, especially students
of color and students from low-income families. At a minimum, this education must allow all students to
become literate, develop social-emotional competence, and prepare for successful adult lives. In working
toward these goals, parents must have the opportunity to play a meaningful role in their children’s
education.
AFC focuses on assisting the students who need the most support to overcome barriers and succeed in
school. Each year, we help thousands of individual students and parents navigate the New York City
education system. Our on-the-ground experience allows us to identify systemic problems and solutions,
driving our policy priorities.
We advocate for policies that promote:
►
Improved educational programs, opportunities, and outcomes for students from low-income
families, students of color, students with disabilities, English Language Learners, students living in
temporary housing, LGBTQ students, and students involved in the child welfare or the juvenile or
criminal justice systems.
►
Positive approaches to discipline that reduce disparities in suspension rates based on race and
disability and keep students in school.
►
School stability for students, particularly students experiencing homelessness and students in foster
care so they can remain in their school even if their living situation changes.
►
Access to high-quality early childhood education programs and services that prepare zero-to-fiveyear-old children for kindergarten.
►
Multiple pathways to high school graduation, including paths that do not rely on high-stakes
standardized testing, so that more students can graduate and access college or employment.
►
Parent engagement so all parents, including parents with Limited English Proficiency and parents of
students with disabilities, can participate meaningfully in their children’s education.
►
Protection from discrimination for students in traditional public schools and charter schools.
Our Policy Agenda includes specific proposals (attached) regarding the School-to-Prison Pipeline, Students
with Disabilities, English Language Learners, Students in Temporary Housing or Foster Care, Charter
Schools, Early Childhood Education, and Pathways to a Diploma.
March 2014
095
SCHOOL-TO-PRISON PIPELINE
The school-to-prison pipeline is a phrase used to describe the disproportionate application of exclusionary
school discipline practices to youth of color and youth with disabilities, leading to over-representation of
these youth in the juvenile and criminal justice systems. Youth who fall along the school-to-prison pipeline
are often academically and behaviorally underserved and subjected to overly harsh and discriminatory
discipline policies.
During the 2012-2013 school year, there were more than 53,000 out-of-school-suspensions from NYC
traditional public schools. Seventy-eight percent of these suspensions were for lower-level infractions of
the Discipline Code, for conduct such as defying authority or talking back. Students of color and students
with disabilities were disproportionately suspended. Suspensions force students to miss valuable
instructional time while failing to address underlying behaviors. There is no evidence that the regular use
of suspensions improves school safety and clear evidence that suspensions negatively impact student
outcomes.
We advocate for positive approaches to discipline that maintain safety while improving school climate,
increasing learning, and reducing the overreliance on exclusionary discipline practices such as suspensions,
arrests, summonses, and unnecessary removals by Emergency Medical Services (EMS).
►
Convene a Mayoral-Led Leadership Team:
This interagency, multidisciplinary Team should be charged with re-designing school discipline to keep
students safely in school while avoiding suspensions, arrests, summonses, and inappropriate removals by
EMS. The Team should set targets such as reducing the number of suspensions and should publicly report
its progress. The Team should include leaders from key City agencies and other stakeholders, such as
parents, youth, and advocates, as well as representatives from the fields of education, justice, child welfare,
and mental health.
►
Initiate and Fund a Restorative Practices Pilot School Initiative:
Despite the demonstrated success of positive and restorative responses to student misbehavior in school
districts around the country, only a handful of NYC schools are engaged in this work. Implementing a pilot
in ten schools would require an estimated $1.5 to $1.75 million.
►
Revise the DOE’s Discipline Code:
The Discipline Code should mandate the use of guidance interventions, such as counseling, mediation,
positive behavioral supports, and restorative justice, prior to imposing suspensions in most cases. The
Discipline Code should also prohibit the use of suspensions for minor infractions.
►
Expand Training and Professional Development Opportunities:
The DOE must provide ongoing professional development to ensure that all school personnel, School
Safety Agents, and school-based police officers are trained in behavior management and de-escalation
techniques that are based on culturally-competent understandings of child development and age-appropriate
positive approaches to school discipline. An investment of $700,000 would allow the DOE to train an
additional fifty schools in restorative justice or to expand the Institute for Understanding Behavior’s
successful Therapeutic Crisis Intervention system to twenty-five high-needs schools.
2
096
►
Expand Student Support Services:
The City must increase the number of school social workers and guidance counselors and increase access to
mental health services in schools for students with significant social emotional needs. Hiring enough social
workers and guidance counselors to fully staff a targeted group of high-needs schools would represent a
modest increase in the DOE’s budget and could have a big impact on suspension rates citywide. The DOE
should increase access to mental health services through school-based mental health clinics and schoolbased health clinics offering mental health services, mobile models that serve schools without school-based
clinics, and school-based partnerships that facilitate rapid referral of students in crisis to community mental
health clinics.
►
Increase Use of Functional Behavioral Assessments (FBAs) and Behavior
Intervention Plans (BIPs):
In response to a complaint filed by AFC, the State recently ordered the DOE to revamp the procedures for
conducting evaluations of student behavior (FBAs) and developing behavior plans (BIPs) for students with
disabilities whose behavior interferes with their learning. The DOE must mandate training and provide
support in developing FBAs and BIPs that provide individualized behavioral support and hold schools
accountable for using these tools.
►
Amend the NYC Student Safety Act:
The current Act permits the DOE to redact significant portions of suspension data. With such limited data,
the number of suspensions issued to Black students or students with disabilities, or even the total number of
suspensions issued citywide, is unknown. Closing loopholes in the Student Safety Act to promote greater
transparency is essential to the creation of a more positive and progressive discipline system.
►
Revise the Memorandum of Understanding (MOU) between the DOE and NYPD:
In 1998, the City transferred school safety responsibilities from the DOE to the NYPD. The current MOU
is outdated and incomplete. The revised MOU should emphasize graduated, measured responses to
different levels of misbehavior and school-based, rather than court-based, resolutions to school disciplinary
matters.
►
Provide youth with quality education while they are in detention, in placement,
or incarcerated:
An overwhelming number of students who are court-involved are academically behind, and roughly 50
percent are students with disabilities, most of who have emotional and/or learning disabilities. The DOE,
ACS, and the New York State Office of Children and Family Services (OCFS) must ensure that all students
in detention, in placement, or incarcerated receive quality education, including remedial literacy, special
education services and supports, credit-bearing coursework, preparation for Regents exams, and behavioral
health services and supports.
►
Provide uninterrupted, quality education for youth transitioning from detention,
placement, or incarceration back to the community:
The DOE, ACS, OCFS, and facilities contracted to care for court-involved youth must work together to
ensure that all youth discharged from court-ordered settings get seamlessly re-enrolled in school, referred to
appropriate school placements, and expeditiously awarded credits for work done while in detention, in
placement, or incarcerated. These agencies must also work together to transition students back to schools
that are welcoming and nurturing and can provide mental health services, remedial literacy programs, and
robust special education services.
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097
STUDENTS WITH DISABILITIES
More than 17 percent of students in NYC public schools are classified as students with disabilities. On the
2013 state exams, only six percent of these students were proficient in reading and only eight percent were
proficient in math. We hear from hundreds of families each year who are struggling to get their students
with disabilities the specialized support required to meet their individual needs.
We advocate for improved educational programs, opportunities, and outcomes for students with disabilities
and improved parent engagement.
►
Articulate a Multi-Year Plan for System-Wide Capacity Building and Report Data
Publicly:
The DOE must create a strategic multi-year plan to improve educational outcomes for students with
disabilities and must report quarterly to the Mayor and the public on varied indicators of progress.
►
Build Capacity to Teach Literacy to Students with Disabilities:
The DOE must build systems to train and support teachers in using research-based methodologies to
support reading and writing development for students who are struggling, including students with
disabilities. This approach may include hiring literacy coaches with expertise in research-based
methodologies for students with disabilities, providing ongoing professional development to general
education and special education teachers, and expanding best practices.
►
Make the Curriculum Accessible to Students with Disabilities:
The DOE must ensure that schools are properly prepared to offer challenging academic curriculum in a
variety of formats to reach all learners, including students with disabilities, by designing curriculum and
classrooms using Universal Design for Learning, purchasing fully accessible instructional materials that are
aligned to the common core standards, digitalizing commonly used texts throughout the system so students
can access the materials using a variety of modalities, and increasing the use of technology to support
students with disabilities.
►
Replicate Current Successful Specialized Community School Programs and
Create New Ones:
The DOE should replicate models such as those used in ASD NEST/Horizon, Manhattan School for
Children, The Children’s School, and D.75 inclusion, programs that specialize in serving certain
populations of students, such as students with autism, in community schools. The DOE should use data to
determine the need for new specialized community school programs, including programs for students who
need intensive research-based reading instruction and students with autism or behavioral needs who need
small classes in community schools with specialized support. In addition, the DOE should invest in
specialists such as literacy coaches and behavioral coaches to work with students with disabilities in
community schools.
►
Change the Tenor of Interaction with Families to Develop Cooperative
Relationships Instead of Adversarial Ones:
Revisit the practices of the DOE’s Office of Legal Services. Take steps to increase the use of alternative
methods of dispute resolution, including mediation and facilitated IEP meetings. Strengthen and publicize
the process for parents to obtain assistance with special education issues that require them to seek help
outside their child’s school.
We also support the recommendations of the ARISE Coalition, which AFC leads, to the new Mayor. These
recommendations are available at http://www.arisecoalition.org.
4
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ENGLISH LANGUAGE LEARNERS & LANGUAGE ACCESS
More than 40 percent of students in New York City public schools speak a language other than English at
home and more than 14 percent of students in New York City public schools are classified as English
Language Learners (ELLs). More than 20 percent of English Language Learners are also classified as
students with disabilities. On the 2013 state exams, only three percent of English Language Learners were
proficient in reading and 11 percent were proficient in math. We often hear from parents whose English
Language Learner students are not in appropriate placements that will meet their language needs. We also
hear from Limited English Proficient parents who are unable to participate meaningfully in their children’s
education because they cannot understand the school documents they receive or meetings they attend about
their child.
We advocate for improved educational programs, opportunities, and outcomes for English Language
Learners and improved translation and interpretation for Limited English Proficient parents.
►
Improve Enrollment and Placement Practices:
DOE enrollment offices must inform immigrant families of their options of schools that can serve their
students appropriately. The DOE should also create a transfer option for ELLs placed at schools that
cannot meet their language needs.
►
Create Additional Programs for ELLs:
The DOE must create additional bilingual general education and special education programs to serve ELLs.
The DOE also must create programs to serve different populations of ELLs including Students with
Interrupted Formal Education (SIFE) and long-term ELLs. The DOE should create additional dual
language programs and ensure that these programs are accessible to ELLs.
►
Make the Full Range of Educational Options Accessible to ELLs:
The DOE should make the full range of educational options, including Universal Pre-K, transfer schools,
and Career and Technical Education (CTE) programs, accessible to ELLs.
►
Improve Interpretation and Translation for Families:
The DOE must ensure that general education and special education documents are translated for Limited
English Proficient families and that families have access to high-quality interpretation at school meetings
and events.
5
099
STUDENTS IN TEMPORARY HOUSING OR FOSTER CARE
During the 2012-2013 school year, nearly 80,000 NYC students experienced homelessness and more than
13,000 children spent time in foster care. Students in temporary housing and students in foster care often
face frequent school transfers, which are linked to increased absenteeism and suspensions, higher grade
retention, higher drop-out rates, and disruption of social and emotional supports.
We advocate for increased school stability for students experiencing homelessness and students in foster
care so they can remain in their school even if their living situation changes.
►
Place Students Near their Schools:
The City should set aggressive targets for increasing the number of children placed in shelters or foster care
placements located in the same community school district as the children’s schools and publicly report
these outcomes on a regular basis. As a first step, the City must ensure that the proper school information
is being entered into the computer system at PATH for all children when families enter the shelter system
and in the Connections computer system when children enter foster care. In addition, for families not
initially placed in shelters close to their children’s schools, education-based shelter transfers must be made
available for families who wish to transfer shelters so their children can remain in their original schools.
►
Improve Transportation:
For most children in temporary housing or foster care, transportation is critical to keeping them at their
original schools. The DOE should work with DHS and ACS to develop and implement written protocols
for responding to yellow bus requests for students in temporary housing and students in foster care. Such
protocols should ensure that these requests are processed within five days in a consistent, transparent
manner, and that hardship cases are prioritized for yellow bus service so that students can maintain school
stability consistent with the federal McKinney-Vento Act and Fostering Connections to Success and
Increasing Adoptions Act. As a first step, the DOE should implement a web-based busing request platform
for students in temporary housing or foster care, an improvement that has been under consideration for over
a year.
►
Increase Access to Early Childhood Education:
The City should set targets and report outcomes for increasing the number of children in family shelters and
with child welfare involvement enrolled in early childhood programs such as EarlyLearn or UPK. The City
should conduct outreach at family shelters, encourage inter-agency collaboration, and prioritize enrolling
these children in preschool programs.
►
Fund Education Specialists at Foster Care Agencies:
Education specialists are needed at each foster care agency to ensure that children in foster care have their
educational needs met. ACS should provide training for all education specialists, an initiative ACS has
been exploring for several years. ACS should also incorporate information about education into the core
trainings it offers all agency case planners.
►
Improve Inter-agency Collaboration with Oversight by the Mayor’s Office:
To implement these priorities, city agencies (e.g., DOE, DHS, ACS, HRA) must collaborate, revise
policies, and prioritize educational success in the culture of their agencies. A Deputy Mayor-level official
should oversee such inter-agency collaborative efforts.
6
100
CHARTER SCHOOLS
Approximately 70,000 students in NYC attend charter schools. Despite state law requiring charter schools
to serve students with disabilities and English Language Learners in comparable numbers to other schools
in their community school districts, recent studies have shown that charter schools are failing to serve
comparable numbers of these students. Furthermore, charter schools have their own discipline policies,
which do not always meet the requirements of state and federal law and are often more punitive than the
DOE Discipline Code.
We advocate for students, including students with disabilities, English Language Learners, and students
with behavioral challenges, to receive the programs and supports they need to succeed at charter schools
when their parents choose this option.
►
Review and Revise Discipline Policies:
The three charter school authorizers, including the DOE, should review and revise their charter schools’
discipline policies so that they comport with federal and state law, promote research-based positive
approaches to address behavior, and require full-time alternative instruction. Authorizers should also
ensure that the discipline policies are posted online, require charter schools to report annually on
suspension/expulsion data, and hold schools accountable that fail to follow state and federal laws when
suspending or expelling students.
►
Amend State Law on Discipline:
Charter schools have argued that the State’s school discipline law does not apply to them. State law should
be amended to make clear that all charter schools must abide by state discipline law.
►
Create a Variety of Programs for Students with Disabilities and ELLs:
With the support of charter school authorizers, charter schools must invest in professional development,
technical assistance, and evidence-based practices so they can offer a range of programs, supports, and
services to serve a diverse array of learners.
►
Hold Charter Schools Accountable for Serving Students with Disabilities and
ELLs:
Charter school authorizers must hold charter schools accountable for recruiting, retaining, and serving
students with disabilities and ELLs at comparable rates to community schools.
7
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EARLY CHILDHOOD EDUCATION
The first five years of children’s lives have a profound impact on their education and future. Studies show
that children from low-income backgrounds who participate in high-quality preschool programs are
dramatically less likely to be retained a grade in school, be placed in special education classes, drop out of
high school, or depend on public benefits.
We advocate for access to high-quality early childhood education programs and services that prepare zeroto-five-year-old children for kindergarten.
►
Expand High-Quality Early Childhood Education Programs:
Ensure that every three- and four-year-old child has access to a full-day, high-quality pre-kindergarten
program. Start by passing Mayor de Blasio’s plan to provide full-day Universal Pre-K to every four-yearold child. Expand high-quality early childhood education programs for infants and toddlers from lowincome families.
►
Increase the EarlyLearn Rate:
The City must increase the per-child rate for EarlyLearn to ensure that programs can meet the required
quality standards and provide compensation and benefits necessary to attract and retain qualified teachers.
►
Coordinate NYC’s Early Childhood Programs:
The City should appoint a high-level leader or office within the DOE to coordinate early childhood
programs, including EarlyLearn, Universal Pre-K, Early Intervention, preschool special education, and
home visiting programs. Particular attention should be paid to the transition between Early Intervention
and preschool special education services, as well as the provision of special education services at Universal
Pre-K and other public preschool programs.
►
Increase Access for Special Populations:
As preschool programs increase, the City should set targets and report on outcomes for increasing the
number of preschoolers with disabilities, English Language Learners, and preschoolers in temporary
housing or with child welfare involvement participating in early childhood education programs.
We also support the recommendations in the Campaign for Children’s Transition Plan, available at
http://bit.ly/1eQ1Uwv.
8
102
PATHWAYS TO A DIPLOMA
Approximately 35 percent of New York City’s high school students fail to graduate within four years. For
English Language Learners, students with disabilities, and students from low-income backgrounds,
graduation rates are even lower. In order to graduate, students must pass five exams: English, Math,
Science, Global Studies, and United States History. We believe that schools should have high standards for
student achievement to ensure students are prepared for careers and post-secondary education
opportunities. However, New York State’s assessment structure is more onerous than other states, and its
focus on high-stakes standardized exit exams creates unnecessary barriers to graduation for some students.
We advocate for multiple pathways to high school graduation, including paths that do not rely on highstakes standardized testing, so that more students can graduate and access college or employment.
►
Reduce the Number of Required Exit Exams:
Reduce the number of exit exams required to graduate with a high school diploma from 5 to 3, in line with
other states. The English Regents, one Math Regents, and one Science Regents would still be required for
graduation.
►
Develop a Pathway to Graduation Based on Performance-Based Assessment:
In lieu of Regents exams, New York should offer performance-based options, which allow students to
demonstrate attainment of standards by completing a series of tasks or projects.
►
Build Flexibility and Support into the Current System:
New York should make its current set of graduation requirements accessible to more students by providing
alternative options for assessing students in Career and Technical Education (CTE) programs; ensuring that
appropriate transition planning, accommodations, and supports are provided to students with disabilities
and English Language Learners; expanding the Regents exam appeal process; and providing an array of
programmatic options and supports for students who have difficulties moving through a given pathway.
►
Communicate and Monitor Multiple Pathways:
Students, families, and schools must receive clear information on all alternative pathways that are available
to students to receive a high school diploma. The City and State must collect and report to the public
detailed outcomes data, including usage of the specific diplomas and pathways that students have taken to
earn a high school diploma, and comparisons of outcomes across multiple student groups.
We also support the recommendations of the Coalition for Multiple Pathways to a Diploma, led by AFC,
available at http://www.advocatesforchildren.org/policy_and_initiatives/pathways_to_a_diploma.
9
103
ADDITIONAL RECOMMENDATIONS
While AFC does not have projects focused on the following areas, we support the following
recommendations:
►
Protect the Rights of LGBTQ Students:
The DOE must provide all students, including lesbian, gay, bisexual, transgender, and queer or questioning
(LGBTQ) students, with a safe and supportive environment free from discrimination, harassment, and
bullying.
►
Expand Programs for Overage Middle School Students:
The DOE should expand age-appropriate program options for overage middle school students.
►
Expand Programs for Overage High School Students:
The DOE should create additional small, alternative programs with accelerated credit and vocational
options for high school students who are overage and under-credited. These alternative programs must be
age-appropriate and must provide students with the special education, behavioral, and language support
they need.
►
Increase Arts Education:
Ensure that every student has a complete education that includes comprehensive, high-quality instruction in
the arts.
►
Increase After-School Programs:
Increase the number of students who have access to high-quality after-school programs.
►
Provide Adequate and Equitable Education Funding:
The State should provide NYC with additional funding to meet the promise of the Campaign for Fiscal
Equity lawsuit.
►
Improve Family Engagement:
The DOE and the State should improve family engagement. The State should adopt the National Standards
for Family-School Partnerships and require pre-service and in-service training for teachers and school
leaders on culturally competent family engagement practices.
10
104
DRAFT – NOT FOR DISTRIBUTION
“I felt so stupid, doing eighth grade over again,
still not getting it with all these little kids.”
—
Third-time eighth grader
SEPTEMBER 2014
105
Acknowledgements
We would like to thank and
acknowledge Ashley Grant for her
work as the primary author of this
report as well as Christian Villenas,
Aiyana Mourtos, Bianca Cabrera, and
Sarah Part for their significant
contributions. We would also like to
thank the students, families,
community organizations and
NYCDOE staff who shared their
experiences and recommendations
and Liza Pappas and the New York
City Independent Budget Office, who
provided us with quantitative data.
This report would not have been
possible without funding from Equal
Justice Works and the Arnold &
Porter Foundation. We are grateful for
their support.
2 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
106
Table of Contents
I.
EXECUTIVE SUMMARY ....................................................................................................................... 4
II.
OVER-AGE STUDENTS IN NEW YORK CITY MIDDLE SCHOOLS: THE SCOPE
OF THE PROBLEM ................................................................................................................................ 8
The Definition of “Over-Age”........................................................................................................... 8
Demographics of Over-Age Middle School Students .................................................................... 9
Concentration of Over-Age Middle School Students in High-Needs Communities ............... 11
Status at Point of Entry to Middle School...................................................................................... 15
Relevance of Disruptions in Schooling ........................................................................................... 15
Impact on Individual Students ......................................................................................................... 16
III.
PROMOTION POLICIES IN NEW YORK CITY: A BRIEF HISTORY ....................................19
Promotional Gates ............................................................................................................................. 19
Bloomberg-Era Policies..................................................................................................................... 20
Eight-Plus Program............................................................................................................................ 21
Current Regulatory Framework ....................................................................................................... 22
IV.
CURRENT PROGRAM OPTIONS FOR OVER-AGE MIDDLE SCHOOL STUDENTS .....25
V.
RECOMMENDATIONS .....................................................................................................................28
Standardize the definition of over-age. Gather and publically report data about over-age
middle school students in New York City...................................................................................... 28
Review and revise promotional policies at all grade levels to reduce the number of
students who end up over-age.......................................................................................................... 29
Make the promotion appeals process more accessible to families .............................................. 30
Establish central-based supports for schools serving over-age students ................................... 31
Expand alternative options for over-age middle school students. .............................................. 32
Provide over-age students with opportunities to interact with age-appropriate peers and
earn high school credit. ..................................................................................................................... 34
VI.
CONCLUSION ....................................................................................................................................35
VII. APPENDIX .............................................................................................................................................36
September 2014 | 3
107
Executive Summary
When we met Eric,1 he was a sixteen-year-old eighth grader who had repeated the eighth
grade twice after failing the state math tests. His family had relocated to a shelter in the Bronx
after his family’s apartment in Queens burned down. When Eric tried to enroll in a school closer
to the shelter, staff told him that he was too old to attend their school. Determined, Eric and his
family solicited the help of an advocate, and he was allowed to re-enroll in middle school.
However, Eric felt extremely out of place among thirteen- and fourteen-year-olds; he
desperately wanted to find a school where he could learn with students his own age. Eric
decided to search for an alternative. First, he visited a program for over-age middle school
students in Richmond Hill, Queens, but realized the long commute would be too difficult to
manage. Next, Eric learned about a charter school that served over-age youth, but found out he
was too old to apply to that program and too young to enroll in a high school equivalency
program. Eventually, Eric grew so uncomfortable at his community middle school that his
mother decided to homeschool him until he was old enough to enroll in a GED program the
following school year. Although he has a lot of catching up to do, Eric is now eighteen years old
and hoping to obtain his high school equivalency diploma. He never made it to high school.
● ● ●
Eric is not alone. He is one of seventy over-age middle school students assisted by Advocates for
Children of New York (AFC) during the 2013-14 school year. The term “over-age students” refers
to those young people who are above the traditional school age for their grade level. In New York
City, more than 50,000 middle school students are at least one year over-age.2 These students
represent 23% of the city’s middle school population.3 The New York City Department of
Education (NYCDOE) reports that 4.1% of middle school students are at least three years over-age;
this represents more than 8,500 young people.4 Despite these high numbers, New York City
provides fewer than 450 seats in alternative programs for these students.5 The vast majority of these
seats are available only to eighth-grade students, leaving sixth and seventh graders with few, if any,
1
All student names have been changed.
New York City Department of Education (NYCDOE) data for school year 2011-2012 provided by the New York
City Independent Budget Office (IBO) in response to the authors’ request. Data from the 2011-12 school year was
the most recent available at the time of the request in December 2013. This data captures all students in grades 6
through 8 who were enrolled for at least 1 day during the 2011-12 school year. It includes students in District 79
and charter schools, but not students in District 75 (the citywide special education district).
3
Ibid.
4
NYCDOE “Overage for Grade Report (ROAG),” 2013-14 (8,644, 4.1% of registered NYCDOE middle school
students, were at least 3 years over-age in 2013-14). The NYCDOE provided this information for school years
2009-10 through 2013-14 in response to an October 2013 Freedom of Information Law request by Advocates for
Children of New York (AFC). Data reflects over-age students enrolled in all DOE middle schools on October 31 st
of each school year. It includes students in District 75 and District 79, but not students in charter schools.
5
See Table 1. All three schools that serve 6th- and 7th grade students have eligibility criteria that exclude some
over-age students.
2
4 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
108
alternative options.6 Most of the charter schools, transfer schools, and
high school equivalency programs designed to get over-age students back
on track target only students ages sixteen to twenty-one, and many serve
only students who have actually made it to the ninth grade. Plainly, more
programs and services are needed to meet the needs of over-age middle
school students.
An analysis of these over-age students and the middle schools they attend
reveals several significant trends.7 Key findings include an
overrepresentation of Black students, Hispanic students, and students
with disabilities and a concentration of over-age students in high-need
communities in Brooklyn and the Bronx. In addition, a correlation exists
between over-age status and school attendance: after the sixth grade, even
one-year over-age students have lower attendance rates than their on-track
peers, and attendance rates continue to decrease as students drop further
and further behind. Moreover, educators report a strong correlation
between significant disruptions in schooling and over-age status.
Most over-age middle school students in New York City have been
retained at least once before they entered sixth grade.8 Retained students
have lower self-esteem and more negative attitudes toward school than
comparable students who were promoted,9 and they are significantly less
likely to pursue post-secondary education.10 A large body of research
indicates that dropout rates are two to eleven times higher among
previously-retained students than their on-track peers.11 Not surprisingly,
Nearly 1 in 4 middle
school students in NYC
is a year or more
over-age.
8,644 middle school
students were three or
more years over-age
during the 2013-14
school year.
86% of over-age middle
school students identify as
Black or Hispanic.
Over-age middle
schoolers are twice as
likely to have special
education needs as
their on-track peers.
Over-age students are at
least twice as likely to
drop out of school.
6
Ibid.
See Section II, Demographics of Over-Age Middle School Students
8
See Section II, Status at Point of Entry to Middle School.
9
Holmes, C. & K. Matthews (1984, Summer). “The Effects of Nonpromotion on Elementary and Junior High
School Pupils: A Meta-Analysis.” Review of Educational Research 54(2): 225-236.
10
Brooks-Gunn, J., G. Guo, & F. F Furstenberg (1993). “Who Drops out of and Who Continues Beyond High
School? A 20-Year Follow-Up of Black Urban Youth.” Journal of Research on Adolescence 3(3).
11
Rumberger, R. W. & K. A. Larson (1998). “Student mobility and the increased risk of high school drop out.”
American Journal of Education 107: 1-35 (students retained before eighth grade are 4 times more likely to drop out);
National Center for Education Statistics (1992). Characteristics of At-Risk Students in NELS: 88. (Contractor Report
NCES 92-042). Washington, D.C.: U.S. Department of Education, Office of Educational Research and Improvement
(students retained in grades K-4 are 5 times more likely to drop out than those who were never retained; students
retained in grades 5 through 8 are 11 times more likely to drop out than students who were not retained; overage 8th-grade students are 8 times more likely to drop out); Barro, S.M. & A. Kolstad (1987). Who Drops Out of
High School? Findings from High School and Beyond. Report no. CS 87-397c. Washington, D.C.: U.S. Department of
Education (over-age students were 2 to 3 times more likely to drop out than non-retained peers); Jimerson, S.R.
(2001). “Meta-analysis of Grade Retention Research: Implications for Practice in the 21st Century.” School
Psychology Review 30: 313-330 (Being one year behind makes students 50% more likely to drop out.); NYCDOE
Office of Multiple Pathways (2006). Multiple Pathways Research and Development: Summary Findings and Strategic
Solutions for Overage, Under-Credited Youth. New York, NY: Author. Retrieved from
7
September 2014 | 5
109
the more times a student is retained, the less likely it becomes that he or she will finish high school.12
Given the strong connection between retention and the likelihood of not completing high school,
we need new strategies to address the needs of students struggling to meet grade-level standards.
Repeatedly over the last thirty years, New York City has attempted to use grade retention as a means
for boosting student achievement.13 Despite the failures of the Promotional Gates program in the
1980s, the Bloomberg-Klein administration in 2004 began a similar retention-based program
requiring students to pass year-end assessments in order to be promoted to the next grade level.
After nearly a decade of reliance on these high-stakes examinations, 2013-14 marked a dramatic shift
in the NYCDOE’s promotion policy. This summer, schools used multiple measures — otherwise
known as promotion portfolios — to make promotion decisions for students in grades three
through eight. At the time of publication, retention data was not yet available for the 2013-14 school
year. However, thousands of students became over-age under the promotion policies of the last
decade, and many of those students remain in New York City middle schools.
We recommend that the NYCDOE take the following steps to reduce the number of
over-age students and to better serve those over-age students still stuck in middle school:






Standardize the definition of over-age and publicly report data on over-age students;
Review and further revise promotion policies at all grade levels to reduce the number of
students who end up over-age in middle and high schools;
Make promotion appeals more accessible to families by creating an appeals form and
designating central-based staff to assist in difficult cases;
Foster innovation and information-sharing by establishing central-based supports for
schools serving over-age students;
Expand alternative options for over-age middle school students; and
Create opportunities for over-age students to interact with age-appropriate peers and earn
high school credits.
http://schools.nyc.gov/NR/rdonlyres/B5EC6D1C-F88A-4610-8F0F-A14D63420115/0/FindingsofOMPG.pdf
(“Overage and under-credited students fall behind early, and once they become off-track, leave the system rapidly.
84% of students who are 16 years old with fewer than 8 credits end up leaving the system”). See also Allensworth,
E.M. (2005). “Dropout Rates after High-States Testing in Elementary School: A study of the Contradictory Effects
of Chicago’s Efforts to End Social Promotion.” Educational Evaluation and Policy Analysis 27(4): 341-364; Holmes &
Matthews, 1984.
12
FairTest (2007). Testing and Grade Retention. Cambridge, MA: Author (Students “retained once have a 40% higher
chance of dropping out and a 60% higher chance if retained twice.”); Janosz, M., M. LeBlanc, B. Boulerice, & R.E.
Tremblay (1997). “Disentangling the Weight of School Dropout Predictors: A Test on Two Longitudinal Samples.”
Journal of Youth and Adolescence 26(6): 733-762; Louisiana Department of Education (2011). Grade Retention is Not
an Intervention. Baton Rouge, LA: Author (On-track students’ likelihood of graduating is 81%. This likelihood drops
to 48% for once-retained students, to 19% for twice-retained students, and to 7% for students retained more than
twice.). Hammond, C. (2007) Dropout Risk Factors and Exemplary Programs: A Technical Report. Clemson, SC at 12.
Retrieved from http://www.dropoutprevention.org/sites/default/files/uploads/major_reports/
DropoutRiskFactorsandExemplaryProgramsFINAL5-16-07.pdf (multiple retentions dramatically increase the odds
that a student will drop out).
13
See Section III.
6 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
110
The information in this paper is derived from the experiences of AFC’s over-age clients,
conversations with community-based organizations and educators, published studies, and
NYCDOE data. As the individual stories of young people illustrate, a host of factors contribute to
students becoming over-age. As such, the NYCDOE must expand its current alternative programs,
look to its own experts, and learn lessons from the past to come up with creative solutions to this
problem. Doing so is critical to ensuring that over-age students do not become dropouts before
they even reach the ninth grade.14
The purpose of this paper is to bring attention to the over-age middle school crisis in New York
City. The following section presents the available data on over-age middle school students and the
experiences of AFC’s clients to describe the scope and nature of the problem. We next review New
York City’s past and present promotion policies as well as previous programs targeted to over-age
middle school students, and lay out the current options. Finally, we offer several recommendations
to help prevent future students from becoming over-age and to help current over-age middle school
students get back on track.
14
Iver, M.A.M. (2010). Gradual Disengagement: A Portrait of the 2008-09 Dropouts in the Baltimore City Schools.
Baltimore, MD: Baltimore Education Research Consortium.
September 2014 | 7
111
Over-Age Students in New York City Middle Schools:
The Scope of the Problem
In New York City, on-track students turn eleven, twelve, and thirteen by December 31st of their
sixth, seventh, and eighth-grade years, respectively. The term “over-age students” is used in this
paper to refer to those young people who are at least a year over the traditional school age for their
grade level. The New York City Independent Budget Office reports that 23% of New York City
middle school students are at least one year over-age.15
The NYCDOE does not have a consistent definition of what it means to be over-age. In the
context of high school, it defines over-age students as those who are at least two years off-track
relative to expected age and credit accumulation.16 When it comes to its middle schools, however,
the NYCDOE does not clearly define what it means to be over-age and does not release data on the
number of students who are over-age. Though it does publish the percentage of students who enter
sixth grade two or more years over-age, the Department does not provide guidance on how this
figure is calculated.17 Through a Freedom of Information Law (FOIL) request, AFC obtained the
NYCDOE’s internal Overage for Grade Report (ROAG) figures for each NYCDOE middle school.
In this report, the NYCDOE defines as “over-age for their grade level” only those students who are
at least three years older than on-track peers.18 Using this definition, The NYCDOE reports that
4.1% of New York City middle school students, more than 8,600 young people, are over-age.19
15
AFC calculation (2014) using IBO data, 2011-12. See Footnote 2.
NYCDOE (2013). Educator Guide: The New York City Progress Report Transfer High School 2012-2013. New York,
NY: Author. Retrieved from http://schools.nyc.gov/NR/rdonlyres/3679B833-98F9-4156-97DA1F957732B539/0/EducatorGuide_HST_2013_11_25.pdf (“A student designated as over-age/under-credited is
considered to be two or more years behind expected credit accumulation.” It defines as over-age any student
who, by December 31st, is 17 years old with fewer than 22 credits (not yet in the 11 th grade), or 18 years old with
fewer than 33 credits (not yet in the 12th grade)); NYCDOE Office of Multiple Pathways to Graduation (2006,
October 23). Multiple Pathways Research and Development: Summary Findings and Strategic Solutions for Overage,
Under-Credited Youth. New York, NY: Author. Retrieved from http://schools.nyc.gov/NR/rdonlyres/B5EC6D1CF88A-4610-8F0F-A14D63420115/0/FindingsofOMPG.pdf (“An overage, under-credited student is at least 2 years
off-track relative to expected age and credit accumulation towards earning a diploma.”).
17
NYCDOE (2013, November 18). Educator Guide: The New York City Progress Report Elementary/Middle/K-8 201213. New York, NY: Author. Retrieved from http://schools.nyc.gov/NR/rdonlyres/7B6EEB8B-D0E8-432B-9BF63E374958EA70/0/EducatorGuide_EMS_20131118.pdf (Middle schools’ progress report includes “percent students
2 or more years overage upon entry into 6th grade”). Chancellor’s Regulation A-501 has specific promotion
provisions for students who are “2 or more years overage by December 31st of the current school year,” but also
does not provide additional guidance on how this is to be calculated. Under Chancellor Fariña (2014, June 2).
Regulation of the Chancellor A-501.IV.D.2 & A-501.V.D.2.
18
ROAG defines as over-age for their grade level “those students whose age is greater (emphasis added) than the
calculated ‘on-grade age.’ A student’s age is calculated by subtracting their birth year from the start of the current
school year. That is, for school year 2013-14, birth year is subtracted from 2013. The ‘on-age grade (sic)’ is then
16
8 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
112
“ Why am I going to go back to that school? I already did all this. ”
Third-time seventh grade student
Counting only those students who are three or more years over-age significantly underrepresents the
over-age crisis in New York City middle schools and is out of sync with the way over-age is defined
by high schools. For example, for an eighth grader to appear on the ROAG for the 2013-14 school
year, she must have turned sixteen by December 31, 2013.20 If this same student wanted to apply to
one of the NYCDOE’s high schools for ninth graders who are at least two years over-age, however,
she would find herself too old to apply.21 These discrepancies in the way the NYCDOE defines
over-age do not just complicate individual student planning; they also make it very difficult to
identify trends among over-age students and to craft policy changes to better serve them. Given the
lack of publicly available data on over-age middle school students, unless otherwise indicated, the
demographic analysis below relies upon data obtained from the New York City Independent Budget
Office and refers to students who are at least one year over-age.
In order to address the over-age middle school phenomenon, it is critical that we understand who
these young people are and where they attend school. Students from certain disadvantaged groups
tend to be overrepresented in the population of over-age middle school students in New York City.
For example, in 2011-12, the most recent school year for which data is available, while 70% of all
New York City middle school students identified as Black or Hispanic, nearly 83% of middle school
students who are at least one year over-age identified as Black or Hispanic (see Figure 1).22
Furthermore, the percent of over-age middle school students with special education needs was twice
that of all middle school students in New York City (35% versus 17.5%, respectively).23 By contrast,
low-income students (as determined by eligibility for Free and Reduced Meals) and English
Language Learners did not appear to be overrepresented in the population of over-age middle
school students in New York City.
calculated by ADDING 7 TO THE GRADE LEVEL (emphasis in original).” The report lists the “on grade age” for
6th grade as 13, for 7th grade as 14, and for 8th grade as 15.
19
ROAG, 2013-14. In 2011-12, this figure was 4.7% and in 2012-13, it was 4.3%.
20
Only eighth-grade students born in 1997 or earlier are listed on this report.
21
High School for Excellence and Innovation and Brooklyn Frontiers High School serve students who they define
as 2 years over-age. At both schools, incoming students must be 15 or 16 years old (born in 1998 for Fall 2014),
entering high school for the first time, and have been held back at least twice in previous grades. NYCDOE (2014).
2014-2015 Directory of NYC Public High Schools, New York, NY: Author. Retrieved from
http://schools.nyc.gov/ChoicesEnrollment/High/Directory/school/?sid=5025 &
http://schools.nyc.gov/ChoicesEnrollment/High/Directory/school/?sid=4976.
22
AFC calculation (2014) using IBO data, 2011-12. All of the statistics in this paragraph reflect students who are 1
year or more over-age according to the IBO. This overrepresentation becomes even more pronounced among
more significantly over-age students; 89% of two-year over-age students and 91% of three-year over-age students
identify as Black or Hispanic.
23
These figures represent students who have been identified with disabilities and provided with an Individualized
Education Program (IEP). It remains unclear whether these students were provided with IEPs before or after
becoming over-age.
September 2014 | 9
113
FIGURE 1:
Demographic Indicator for Students in Grades 6-8 in NYC Public
Schools, by Over-Age Status (2011-2012)
100%
90%
All New York City
Middle School
Students
80%
70%
60%
50%
Overage New
York City Middle
School Students
40%
30%
20%
10%
0%
Male
Female
Black/Hispanic Low-Income
IEP
ELL
Source: New York City Independent Budget Office (2014)
FIGURE 3:
Attendance Rates for Students in Grades 6-8, by
Over-Age Status (2011-2012)
Attendance Rates for Black and Hispanic Students in
Grades 6-8, by Over-Age Status (2011-2012)
Attendance Rate
FIGURE 2:
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Grade 6
On-age
Grade 7
Grade 8
Over-age
Source: New York City Independent Budget Office (2014)
Grade 6
On-age
3 years over-age
Grade 7
1 year over-age
4 years over-age
Grade 8
2 years over-age
Source: New York City Independent Budget Office (2014)
10 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
114
Over-age middle school students have notably lower attendance rates
than their on-age peers (see Figure 2). Additionally, this gap widens with
each grade level. That is, while the difference in attendance rates
between on-age and over-age sixth graders is only 4%, this difference
increases to 6% and 8% for seventh and eighth graders, respectively.24
This trend is also apparent within each grade level: attendance rates
decline drastically the more over-age a student becomes (see Figure 3).25
While twelve- and thirteen-year-old sixth graders have similar (and in
fact, slightly better) attendance rates to on-track peers, attendance begins
to plummet when fourteen- and fifteen-year-old students reach the
seventh and eighth grades, or when students are still stuck in the sixth
grade at age fourteen. This data is borne out by many of AFC’s overage clients who describe becoming increasingly disengaged after their
first or second year of middle school. As one school administrator put
it: “Why would you endure this anymore? These are not kids who blend
in quietly — they are physically more developed.”26 He went on to
explain that almost all, if not all, of his school’s two-year over-age
students had experienced bullying as a result of being over-age.27
Whether bullying, embarrassment, or just utter frustration drives these
significantly over-age students away, it is clear that their attendance
decreases as they become more out-of-sync with their peers in terms of
age and grade.
JENNIFER’S STORY
Jennifer is a 16-year-old
seventh grader. Because of
her family’s chronic
homelessness, Jennifer had
attended six schools in four
states before enrolling at a
middle school in the Bronx.
She has been retained twice in
the past because her family
had been forced to move too
early in the summer for
Jennifer to complete summer
school or her mother to
appeal the retention. Only
during Jennifer’s second time
in seventh grade in the Bronx
was she evaluated for special
education and provided
additional academic supports.
In order to fully understand this issue, it is also important to examine
the middle schools where over-age sixth-, seventh- and eighth-grade
students are concentrated. As previously discussed, the only schoollevel data on over-age middle school students available to AFC at the
time of publication was the NYCDOE’s Overage for Grade Report,
(ROAG), which defines over-age students as those who are at least three
24
AFC calculation (2014) using IBO data, 2011-12.
AFC calculation (2014) using IBO data, 2011-12. Figure 3 illustrates this trend among middle school students
who identify as Black or Hispanic. Analysis was conducted only for this population of students because they
represent the vast majority (83%) of over-age middle school students in New York City.
26
Neil Pergament, Assistant Principal of Brooklyn Frontiers, a high school for first-time 9th graders who are 2 years
over-age, phone interview, August 8, 2014.
27
Ibid.
25
September 2014 | 11
115
“ If you are a 15-year-old kid and you have
been held back twice — it is so traumatic
one time — if that happens twice, what
kind of conclusions do you draw about
yourself and your intelligence? And what
conclusions do you draw about the
education system as a whole? Most of our
[two-year over-age] kids come in with such
negative views about themselves and their
abilities and the school system…”
Administrator at a high school
for over-age students
FIGURE 4:
Distribution of Over-Age Students in Middle
School, by Borough (2013-2014)
Staten
Island
4%
Manhattan
9%
Queens
20%
Bronx
40%
Brooklyn
27%
Source: ROAG Data (2014)
years behind.28 Because school-level data for oneor two-year over-age students was not available at
the time of publication, the analysis in the sections
below refers only to students who were three or
more years over-age in 2013-14. Furthermore,
because the ROAG report lists data only for
traditional public schools, charter schools are not
included in the following discussion.29
A review of the New York City middle schools
with the highest concentration of three-year overage students paints a clearer picture of the
environments in which students become
significantly over-age. A full 67% of over-age
middle school students, compared to 53% of all
NYCDOE middle school students, attend schools
in the Bronx and Brooklyn (see Figure 4).30 Further
analysis reveals that these significantly over-age
middle school students are disproportionately
concentrated in schools in Hunts Point,
Morrisania, and large sections of south and east
Bronx; in northeast Brooklyn, especially Bed-Stuy,
and East New York; and in Washington Heights in
Manhattan (see Appendix A and Figure 5).31
Although 20% of over-age middle school students
attend school in Queens, no single district in that
borough has an over-age middle school population
greater than 5%.32 That is, over-age middle school
students in Queens tend to be concentrated in one
or two schools per district, rather than in a specific
district or neighborhood.33
28
See Footnote 18.
ROAG, 2013-14. The NYCDOE redacted some data citing the Family Educational Rights and Privacy Act
(FERPA). In these cases, the missing data was imputed using the percentage of students who were at least 2 years
over-age when entering 6th grade, as defined by NYC Progress Reports. The analysis below excludes K-8 schools
because grade 6-8 data could not be isolated for these schools.
30
Ibid; NYCDOE (2014). Monthly Aggregate Registers by Boro. Retrieved from
https://reports.nycenet.edu/Cognos84sdk/cgi-bin/cognosisapi.dll.
31
ROAG, 2013-14. All middle schools in Manhattan with three-year over-age populations greater than 5% are
located in the neighborhoods of Harlem and Washington Heights, except Henry Street School for International
Studies (Lower East Side) and M.S. 256 Academic & Athletic Excellence (Upper West Side).
32
Ibid.
33
Ibid.
29
12 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
116
FIGURE 5:
Percent of Three-Year Over-Age Students in Middle School, by District
(2013-2014)
10
11
■ > 6%
■ 5.0% — 5.9%
■ 4.0% — 4.9%
■ 2.5% — 3.9%
■ < 2.5%
6
9
12
7
5
8
4
3
30
25
2
26
1
24
14
13
23 19
17
15
28
32
16
29
27
18
20
31
22
21
Source: ROAG Data (2014)
Figure 6 illustrates the correlation between economic need and percent of over-age middle school
students by school. The NYCDOE uses an Economic Need Index to reflect the socioeconomic
characteristics of a school’s student population.34 Clearly, a positive association exists: the greater
the Economic Need Index of an individual school, the higher the percentage of over-age middle
school students at that school. Schools with a higher Economic Need Index also tend to be
concentrated in the Bronx, Brooklyn, Washington Heights, the same neighborhoods where schools
with the highest concentrations of significantly over-age middle school students are located.
34
NYCDOE, 2013. Educator Guide: The New York City Progress Report Elementary/Middle/K-8 2012-13. The formula
for the Economic Need Index, which ranges from 0 to 2, takes into account the percentage of students who have
been identified as residing in temporary housing in the past 4 years, the percentage of students identified by the
Human Resources Administration as receiving public assistance, and the percentage of students eligible for free
lunch.
September 2014 | 13
117
FIGURE 6:
Percent of Three-Year Over-Age Students vs. Economic Need, By Middle
School and Borough (2013-2014)
Total Percent of MS Students Over-age
(3+ years)
25%
Manhattan
Bronx
Brooklyn
Queens
Staten Island
20%
15%
10%
5%
0%
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Economic Need
Source: ROAG Data (2014); New York City Middle School Progress Reports (2012-2013)
FIGURE 7:
Percent Incoming Over-Age vs. Percent Over-Age, By Middle School and
Borough (2013-2014)
Total Percent of Students Overage
(3+ years)
25%
Manhattan
Bronx
Brooklyn
Queens
Staten Island
20%
15%
10%
5%
0%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
13%
14%
15%
Percent of Incoming Overage Students (2+ years)
Source: ROAG Data (2014); New York City Middle School Progress Reports (2012-2013)
14 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
118
“ I want to be in school — I would go if I was with people my own age. ”
Seventeen-year-old eighth grader
According to the NYCDOE, approximately 4.1% of middle school students are three or more years
over-age.35 While some students are a year over-age as a result of late enrollment or transferring
from a school district with different age-grade requirements,36 nearly 3% of New York City
incoming sixth-graders were retained at least twice between kindergarten and fifth grade.37 This
data, taken together, suggests that most three-year over-age middle school students in New York
City were at least two years over-age when they enrolled in sixth grade. Not surprisingly then, the
percentage of incoming over-age sixth graders at a given school is positively correlated with the total
percentage of over-age middle school students at that school (see Figure 7). Additionally, nearly 60%
of New York City students entering middle school over-age are concentrated in just 25% of the
city’s middle schools.38
In New York City, communities with the highest concentrations of significantly over-age middle
school students also enroll a disproportionate number of students who experience instability in their
lives. Although statistics on the rates of homelessness among over-age middle school students were
not made available in time for publication, NYCDOE officials have estimated in the past that
roughly 25% of already-over-age retained students had recently been homeless.39 A number of
AFC’s over-age clients have been retained, in part, due to unstable housing situations which have
prevented them from completing summer school or submitting timely promotion appeals.
Additionally, as illustrated in Figure 6, middle schools with a greater Economic Need Index tend to
have a higher concentration of three-year over-age students. While a clear causal connection cannot
be made for certain, one of the indicators used to calculate a school’s Economic Need Index is the
percentage of students who have been identified as living in temporary housing during the past four
years.
Another disruptive factor common among over-age middle school students is involvement in the
juvenile or criminal justice systems. While 4.1% of middle school students citywide are three or
35
ROAG, 2013-14.
In contrast to New York City’s policy of admitting to kindergarten any student who turns 5 by December 31 st,
many school districts across the country require entering students to have turned 5 years old by as early as August
or September of their kindergarten year. National Center for Education Statistics (2012). Table 5.3 Types of state
and district requirements for kindergarten entrance and attendance, by state: 2012. Washington, D.C.: U.S. Department
of Education, State Education Reforms. Retrieved from http://nces.ed.gov/programs/statereform/tab5_3.asp.
37
AFC calculation (2014) using NYCDOE Progress Reports and ROAG, 2012-13.
38
Ibid.
39
Decker, G. “In Promotion Ban Rollback, Some Students Get Another Chance.” Chalkbeat New York, June 1, 2012.
http://ny.chalkbeat.org/2012/06/01/in-rollback-of-promotion-ban-some-students-will-get-anotherchance/#.U5IOsDmcxAQ.
36
September 2014 | 15
119
RUBY’S STORY
Ruby started struggling with her work
in sixth grade and was retained three
times in eighth grade. After all of her
friends moved on to high school, Ruby
grew increasingly depressed. Some
days, she was too anxious to leave her
apartment; other days she spent crying
in the school office. The school offered
Ruby independent study materials, but
never suggested referring Ruby for
special education evaluations. When
Ruby turned seventeen and still had
not been promoted to ninth grade, her
family felt they had no choice but to
sign Ruby out of school and admit her
to a mental health treatment program.
When she was released, Ruby tried
enrolling in a high school equivalency
program, but could not find one that
could address her significant mental
health needs. With the help of an
advocate, Ruby was promoted to the
ninth grade and evaluated for special
education services. She is now
receiving home instruction while she
awaits placement in a therapeutic
school. Had Ruby been offered special
education services during her first or
second year in the eighth grade, she
may have graduated from high school
already, rather than just starting high
school at eighteen years old.
more years over-age, 58% of seventh and eighth graders at
Passages Academy, the program that educates students in the
juvenile justice system, were three or more years over-age in
2013-14.40 Of the seventy over-age middle school students
AFC served during the 2013-14 school year, seventeen
reported being court-involved. These over-age, court-involved
students often reach out to AFC because they have been
working with a therapist or case worker to make positive
changes in their lives, but are unable to find an age-appropriate
school that can meet their needs.41 When the only option is
returning to a previous middle school where they have already
experienced failure, and which may have contributed to their
court involvement, many of these students are frequently
absent or remain out of school entirely.
Middle school can be tough for any student. Adolescents are
firmly entrenched in the process of identity formation.42
Establishing a sense of competence and social status in relation
to others is an important part of this process. Middle school
students also have a deep need to fit in and belong to a group.
At the same time, the emergence of abstract reasoning skills
makes adolescents particularly vulnerable to social anxiety as
they simultaneously become more self-aware and more
concerned about what adults and peers think of them.43
In addition, middle schools are often less supportive, larger,
more specialized and more competitive than elementary
40
2013-14 ROAG report data for Passages Academy. The DOE did not release data for the percent of 6th grade
students who are over-age at Passages Academy. Students detained as a result of a pending delinquency or (for
those under age 16) criminal case attend Passages Academy while they are held at secure and non-secure
detention sites throughout the city. Students placed in ACS custody following a family court delinquency
disposition also attend Passages Academy
41
Some limited program options for over-age middle school students do exist within District 79’s Restart
Academy. See Section IV and Table 1 for a discussion of these programs.
42
McNeely, C. & Blanchard (2009). The Teen Years Explained: A Guide to Healthy Adolescent Development. Baltimore,
MD: Center for Adolescent Health at Johns Hopkins Bloomberg School of Public Health. Retrieved from:
http://www.jhsph.edu/research/centers-and-institutes/center-for-adolescenthealth/_includes/Interactive%20Guide.pdf.
43
Rosso, I.M., A.D. Young, L.A. Femia & D.A. Yurgelun-Todd (2004, June). “Cognitive and Emotional Components
of Frontal Lobe Functioning in Adulthood and Adolescence.” Annals of the New York Academy of Sciences 1021: 355362.
16 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
120
“ When you have been left back, teachers doubt you in a bad way.
[They] tell the younger kids, ‘Oh, don’t hang out with him, he’s bad.’ ”
Thirteen-year-old sixth grader
school. Middle school students also are expected to be more autonomous and responsible for their
own work, which can be difficult for any student, especially those who are not adequately prepared
or supported. Regardless of when they become over-age, being older than their peers becomes
increasingly important and apparent as students enter adolescence.44 At this age, other students are
aware when a student is older than the rest of the class or is in the same grade for a second year.
For over-age middle school students, the reality of being older than their classmates often leads to
extreme frustration, low self-esteem, and disengagement from school.45 AFC clients retained in the
middle grades describe feeling left behind when their peers progress to high school without them.
Over-age adolescents may disengage from middle school because they feel like failures, are
embarrassed to be in class with younger peers, are teased by classmates, are frustrated that they are
not earning high school credits, and do not see a clear path to high school or graduation.46 In
addition to feeling isolated among much younger students, students may feel stigmatized by teachers
for their age. “When you have been left back, teachers doubt you in a bad way,” said one thirteenyear-old sixth grader. “[They] tell the younger kids, ‘Oh, don’t hang out with him, he’s bad.’”47
Middle schools may make matters worse by retaining these struggling students repeatedly, placing
them at an even greater disadvantage,48 while expecting them to repeat the same curriculum that
failed to address their needs the previous year.49
As previously discussed, when students feel out of place among younger peers, many cut classes and
eventually stop attending school entirely. As one seventeen-year-old eighth grader expressed, “I
want to be in school – I would go if I was with people my own age.”50 This is a statement AFC
hears again and again from our over-age middle school clients. Though they want to graduate from
high school, many simply cannot bear to sit in classes with much younger students where they are
teased by classmates and singled out by adults.
When students do not attend school, it is not uncommon for the New York City Administration for
Children’s Services (ACS) to conduct an educational neglect investigation, to determine whether a
44
Roderick, M. (1994, Winter). “Grade Retention and School Dropout: Investigating the Association.” American
Educational Research Journal 31(4): 726-759.
45
McGinley, N. J. (2006). Core Strategy V Update: Safe and Orderly Schools. Charleston, SC: Charleston County
School District; Jimerson, S.R. & P. Ferguson (2007). “A longitudinal study of grade retention: Academic and
behavioral outcomes of retained students through adolescence.” School Psychology Quarterly 22(3): 314-339.
46
Roderick, 1994 at 742; Weathersbee, T. (2007, April 30). “Overage Students Need More Help.” Florida TimesUnion. Retrieved from http://www.jacksonville.com/tu-online/stories/043007/new_166180827.shtml; NYCDOE
(2013, June 7). Final Changes to Elementary/Middle/K-8 Progress Reports for 2012-13. New York, NY: Author.
Retrieved from http://schools.nyc.gov/NR/rdonlyres/3B78B0E6-6270-4FB0-B4E29700308255BA/0/201213FinalChangesEMS.pdf (“Principals indicated, and research confirms, that students that are
overage in middle school have lower outcomes than similar students.”).
47
AFC interview with group of over-age middle school students in Brooklyn, NY, June 9, 2014.
48
Bachman, 1971.
49
Weathersbee, 2007.
50
AFC client interview, Brooklyn, NY, March 6, 2014.
September 2014 | 17
121
BEN’S STORY
Ben is a court-involved
student who has repeated the
eighth grade three times. Last
year, Ben completed eighthgrade coursework at a
Residential Treatment Center.
His caseworker, however,
could not find any record of
his eighth-grade promotional
exam scores when he
returned to the city last
summer. Ben took and
passed one of the eighthgrade tests during summer
school, but had a court date
on the day of the second test
and was unable to sit for the
exam. Ben was denied a
ninth-grade placement in the
fall because he did not take
the second test. In March of
this year, Ben was denied a
mid-year promotion by his
district Superintendent. He
remains out of school.
parent or guardian’s behavior is preventing the student from attending
school. A senior ACS official reports that 60% to 70% of unfounded
ACS educational neglect cases involve students ages thirteen to
seventeen.51 She believes that a large percentage of these students are
not attending school regularly due to inadequate academic supports
for struggling students, bureaucratic barriers to effectuating school
transfers, and a lack of age-appropriate programs within high-need
communities.
Not surprisingly, students with poor attendance in middle school are
much less likely to graduate from high school than other students. In
one study, middle school students who missed more than twenty days
of school achieved graduation rates 40% lower than their peers.52
Over-age middle school students must be in school regularly and
participating in classes in order to have even a chance of completing
their education. When these students’ attendance has declined
significantly, they need access to programs that will help them
reengage in school by allowing them to be with peers their own age
while acquiring the skills necessary to move on to high school.
51
AFC interview, April 7, 2014.
Baltimore Education Research Consortium (2011). Destination Graduation: Sixth Grade Early Warning Indicators for
Baltimore City Schools: Their Prevalence and Impact. Baltimore, MD: Author. Retrieved from http://baltimoreberc.org/pdfs/SixthGradeEWIFullReport.pdf.
52
18 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
122
Promotion Policies in New York City:
A Brief History
Retention – being “left back,” “held over” or made to “repeat” a grade – has been identified as the
single most powerful predictor of a student’s likelihood of dropping out of school.53 According to
the National Center of Educational Statistics, 21% of students who have been retained drop out of
high school.54 Even after controlling for grades and attendance, students who are retained are
significantly more likely to become dropouts than those who are promoted.55 Although studies vary
as to specifics, over-age and retained students are between two and eleven times more likely to drop
out than their on-track peers.56 Retained students have lower self-esteem, more negative attitudes
toward school than comparable students who were promoted,57 and are significantly less likely to
pursue post-secondary education.58 Despite this data, the New York City public schools have at
times embraced retention as a primary strategy for boosting student achievement. The following
sections will discuss changes in the NYCDOE policy regarding retention over time and
corresponding efforts to address the needs of students who are retained and become over-age.
In 1981, through a program called Promotional Gates, New York City began retaining fourth- and
seventh-grade students who failed to pass citywide standardized tests, without regard for students’
classroom performance. Tens of thousands of students were retained under the program, including
25,000 in the first year alone.59 By 1988, more than 40% of students were entering high school overage.60 After ten years, the Board of Education quietly abandoned the program. In doing so, the
Board acknowledged findings from a longitudinal study that demonstrated the program’s
detrimental impact.61 Students held over in Promotional Gates classes were more likely to drop out
53
Rumberger , R. (1995). “Dropping out of Middle School: A Multilevel Analysis of Students and Schools.” American
Educational Research Journal 170:1-35 (Grade retention is “the single most powerful predictor” of dropping out of
middle school.); Janosz, 1997 (After examining school, family, behavioral, social and personality variable as
predictors of dropping out, “grade retention was the most powerful predictor of all variables”).
54
National Center for Education Statistics, 1992. See also FairTest, 2007; Louisiana Department of Education,
2011.
55
Roderick, 1994 at 739 (controlling through the end of 6th grade).
56
Rumberger & Larson, 1998; National Center for Education Statistics, 1992; Barro & Kolstad, 1987; Jimerson,
2001; NYCDOE Office of Multiple Pathways, 2006. See Footnote 11.
57
Holmes & Matthews, 1984.
58
Brooks-Gunn, Guo, & Furstenberg, 1993.
59
House, E.R. (1998). The Predictable Failure of Chicago’s Student Retention Program. Retrieved from
http://www.designsforchange.org/pdfs/house.pdf.
60
Roderick, 1994 (citing PINS Advisory Committee (1998). Promotional policies and children in New York City schools.
New York: New York City’s Chancellor’s Office and Board of Education).
61
House, 1998.
September 2014 | 19
123
“ There is no evidence, therefore, that holdovers make academic progress, although
there is evidence that holdovers demonstrate greater social and emotional difficulties. ”
NYC Board of Education Resolution (1991)
of high school than other students, and fourth-grade holdovers under the program were no more
likely, three years later, to have met seventh-grade promotional standards than other low-achieving
students who had been promoted. Furthermore, students who had been retained were still failing to
meet cut-off scores after a year of retention.62 The Board concluded that there was no evidence to
support the idea that holdovers make academic progress, but that there was evidence demonstrating
that these students face greater social and emotional difficulties as they attempt to move forward.63
Despite the well-documented failure of Promotional Gates, the Bloomberg-Klein administration in
2004 resurrected the strict retention policies of earlier years, amending Chancellor’s Regulation A501 to require third-grade students to score at least a two64 on the citywide English Language Arts
(“ELA”) and math tests in order to be promoted to the next grade.65 By 2009, this requirement had
expanded to include students in all tested grades: three through eight.66 In addition, principals were
empowered to retain students, regardless of their scores on the citywide assessments, if the principal
determined, based on student work, teacher observation, and grades, that the student was not ready
62
House, 1998.
Advocates for Children of New York (2000). Analysis of the Board of Education’s Change of Policy Regarding the
Retention of Students. New York: NY: Author (citing New York City Board of Education (1991, Sept. 11).
Resolution: Authorization to Amend Promotional Standards for Students in Kindergarten through Grade 9 Including the
Promoting Success Program in Grades 3 and High School Eligibility Requirements.” New York, NY: Author.); FairTest
(2007). “First, Do No Harm: A response to the proposed New York City third grade retention policy.” Fair Test ENewsletter, Cambridge, MA: Author. Retrieved from http://www.fairtest.org/first-do-no-harm-response-proposednew-york-city-t.
64
Students could earn scores between 1 and 4 on these tests. Though the definitions at each performance level
have changed slightly over time, a 3 has consistently meant meeting standards, while a 2 is sufficient to pass. New
York State Education Department (2006). Definition of Performance Levels. Albany, NY: Author. Retrieved from
http://www.p12.nysed.gov/irs/ela-math/2006/math-06/Scale-Score-to-Performance-LevelMath.html; New York State
Education Department (2009). Definitions of Performance Levels for the 2009 Grades 3-8 English Language Arts Tests.
Albany, NY: Author. Retrieved from http://www.p12.nysed.gov/irs/elamath/2009/Press/2009ELADefinitionsofPerformanceLevels.doc.
65
Under Chancellor Klein (2004, April 5). Regulation of the Chancellor A-501. New York, NY: Author (Students
with disabilities whose IEPs specified modified promotion criteria and some English Language Learners were
exempt from these requirements).
66
Under Chancellor Klein (2006, Feb. 1). Regulation of the Chancellor A-501. New York, NY: Author (expanding
testing requirement to 7th grade); Under Chancellor Klein (2009, June 29). Regulation of the Chancellor A-501.
New York, NY: Author. Retrieved from http://docs.nycenet.edu/docushare/dsweb/Get/Version-2711/A501%20Final.pdf (expanding testing requirement to 8th grade); Under Chancellor Klein. (2009, November 13).
Regulation of the Chancellor A-501. New York, NY: Author. Retrieved from
http://docs.nycenet.edu/docushare/dsweb/Get/Document-24/A-501.pdf. (expanding testing requirements to 6th
grade). Throughout this period, eighth graders also had to pass their core academic subjects of ELA, math, science
and social studies in order to move on to high school. However, eighth-grade students who had already been
retained in middle school could be promoted in August if they demonstrated effort toward meeting promotion
standards.
63
20 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
124
to be promoted.67 In other words, principals were given the authority to retain students on the basis
of factors other than standardized test scores, but were not authorized to promote them on these
same bases.68
During the same time period, the NYCDOE experimented with a program called Eight-Plus, which
was designed to provide retained eighth-grade students with a “structured setting in which intensive
intervention will lead to the attainment of graduation requirements,” as per Chancellor’s Regulation
A-501.VI.S.69 According to a memorandum issued by then-Deputy Chancellor Carmen Fariña in
2005, the program gave administrators the flexibility to promote students mid-year based on a
combination of student work, teacher observation, grades, and attendance, otherwise known as a
promotion portfolio.70 Eight-Plus was intended to be offered in high schools, so that over-age
middle school students could take some high school classes and interact with similar-age peers. The
memorandum required regional superintendents to create a Regional Eight-Plus Plan for the 200506 school year, including advisories, guidance, and youth services to address the needs of the whole
child, while also providing smaller class sizes and a rigorous curriculum for students.71
During interviews conducted by Advocates for Children in 2008, principals reported that the
NYCDOE ultimately failed to provide the resources or flexibility necessary for the Eight-Plus
program to be successful.72 For example, principals explained that the curriculum was not modified
sufficiently to address the difficulties experienced by students. As a result, students were reviewing
the same material they had been unable to master the previous year without additional supports.
Principals also reported that additional counselors, who were critical to the success of this program,
were not provided. 73 Finally, though they were intended to be located on high school campuses,
67
Under Chancellor Klein (2009, November 13). Regulation of the Chancellor A-501.
Students could be retained on the basis of the principal’s determination alone. In June and August, principals
could recommend that students be promoted based on a promotion portfolio; however, the final promotion
determination would be made by the Community Superintendent. Under Chancellor Klein (2009, November 13).
Regulation of the Chancellor A-501.
69
Fariña, C. (2005, July 7). Planning the Eight-Plus Program from 2005-2006. Memorandum. New York, NY: Office of
the Chancellor, NYCDOE. Retrieved from
http://schools.nyc.gov/offices/d_chanc_oper/budget/dbor/allocationmemo/fy05-06/datafiles/sam51.pdf.
70
Ibid.
71
Ibid.
72
Advocates for Children of New York (2008). Stuck in the Middle: The Problem of Overage Middle School Students in
New York City. New York, NY: Author. Retrieved from
http://www.advocatesforchildren.org/Stuck%20in%20the%20Middle%28final%29.pdf?pt=1.
73
Ibid. See also Fariña, C. (2005, July 7). Planning the Eight-Plus Program from 2005-2006. Memorandum. New York,
NY: Office of the Chancellor, NYCDOE. Retrieved from
http://schools.nyc.gov/offices/d_chanc_oper/budget/dbor/allocationmemo/fy05-06/datafiles/sam51.pdf (“Guidance
counselors should be an integral part of your region’s Eight-Plus Program support team. Counseling services are
essential to helping the students address the social, emotional, and academic issues that may be hindering their
progress.”).
68
September 2014 | 21
125
Eight-Plus programs were sometimes placed wherever the local district could find space; some
programs were held in non-school buildings or in District 75 schools where Eight-Plus students did
not have access to other general education students.74 Although imperfect, principals applauded the
program for allowing students to learn among age-appropriate peers.75 In addition, they felt the
Eight-Plus program’s mid-year promotion opportunity served as a useful incentive for engaging
over-age students.76 The NYCDOE eventually eliminated mid-year promotion as an option for
Eight-Plus students, removing this important incentive. By 2007-08, Eight-Plus was officially shut
down.77
Even after 2008, some middle schools continued to operate under-the-radar programs similar to
Eight-Plus to reengage and remediate retained eighth graders, some of whom were promoted to
high school mid-year. However, during the 2012-13 school year, the NYCDOE disabled the
function allowing school-based administrators to change a student’s grade level in ATS, the
automated data system that records, among other things, admissions, transfers, and grade
promotion.78 This change ended “unsanctioned” mid-year promotions, with the exception of very
limited circumstances requiring the support of central-based administrators, essentially eliminating
the last vestiges of the Eight-Plus program.
By the 2010-11 school year, 10,655 middle school students, 5% of those registered, were three or
more years over-age.79 Of the roughly 9,200 students retained that year citywide, the DOE reported
that approximately 13% were already over-age for their grade and had been held back multiple
times.80 The following school year, the NYCDOE modified its promotion requirements for
students in grades three through eight who were two or more years over-age.81 The NYCDOE
anticipated that the new regulation, adopted in July 2012, would allow approximately 450 additional
over-age students to be promoted that August on the basis of a portfolio assessment indicating that
74
AFC interview with DOE administrator, August 13, 2014.
Advocates for Children of New York, 2008.
76
Ibid.
77
Ibid.
78
AFC interview with DOE administrator, November 25, 2013.
79
ROAG, 2010-11.
80
Decker, G. (2012, June 1). “In Promotion Ban Rollback, Some Students Get Another Chance” Chalkbeat New
York. Retrieved from
http://ny.chalkbeat.org/2012/06/01/in-rollback-of-promotion-ban-some-students-will-get-anotherchance/#.U5IOsDmcxAQ.
81
Under Chancellor Walcott (2012, July 18). Regulation of the Chancellor A-501. New York, NY: Author. On file
with the author (see Sections VI.E.3 & VII.E.2). Previously, only over-age 8th graders who had already been
retained in middle school could be promoted on appeal in August if they demonstrated effort toward meeting
promotion standards. This amendment modified the August standard slightly and expanded the option to grades 3
through 7. See Under Chancellor Walcott (2009, June 29). Regulation of the Chancellor A-501.VI.AA.3.
75
22 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
126
the student had shown gains on multiple measures of
performance.82 Perhaps as a result of this policy, nearly 1,000
fewer middle school students were three or more years over-age
in 2012-13.83
In February 2014, a New York State Board of Regents
subcommittee, including State Education Commissioner John
King, recommended that districts rely on multiple measures of
student performance rather than high stakes tests when making
promotions decisions.84 Soon after, NYCDOE Chancellor Fariña
announced a dramatic departure from the city’s reliance on
standardized tests for promotion. The new Chancellor’s
Regulation A-501, issued in June 2014, directs schools to rely on
multiple measures when making promotion decisions for all
students in grades three through eight.85 Furthermore, the
regulation states that “state test scores may not be the primary or
major factor in promotion decisions,” and citywide testing will no
longer be conducted in August.86 Instead, students who do not
initially meet promotion standards may be promoted in June or in
August on the basis of a promotion portfolio.87 Principals are
also no longer permitted to retain students who meet the initial
promotional criteria.88 This change in promotion policy is in
sharp contrast to the policy under the previous administration,
which relied heavily on test scores and allowed principals to retain
students independently of test scores.89 However, the regulation
maintains the specific language regarding over-age students from
2012, which allows (but does not require) principals to promote
over-age students who demonstrate gains on the basis of multiple
measures.90
JACOB’S STORY
Jacob is seventeen years old.
During his first and second years
in eighth grade, he struggled with
attendance and was frequently out
of school. Last year, when he was
in eighth grade for the third time,
Jacob was arrested and ordered to
participate in a diversion program
at the Brownsville Community
Justice Center. There, he
connected with a case manager,
regularly attended the after-school
program, and resolved to make
better decisions regarding school.
Because Jacob was so much older
than the other eighth graders, he
did not feel comfortable returning
to a regular middle school. Like
many court-involved students,
Jacob was looking for a fresh start.
He still wanted a high school
diploma and knew that he had
time to graduate if he kept on
track. Jacob and his case
manager searched for alternative
programs and applied to the only
alternative middle school program
he was eligible for in Brooklyn.
Unfortunately, Jacob was not
accepted into that program and
spent almost the entire year out of
school. He remains out of school.
82
Decker, 2012 (The change also came with funding for an additional $1500 per student for intervention services).
ROAG (In 2011-12, 10,045 students, 4.7% of those registered in grades 6-8, were 3 years over-age. In 2012-13,
this number dropped to 9,041, 4.3% of those registered).
84
Decker, 2014.
85
Under Chancellor Fariña (2014, June 2). Regulation of the Chancellor A-501.
86
Ibid at IV.A.1.A.
87
Ibid at IV.A.2 and IV.D.
88
Ibid at “Summary of Changes,” Bullet 3.
89
See Section III, Bloomberg-Era Policies.
90
Under Chancellor Fariña (2014, June 2). Regulation of the Chancellor A-501 (see Sections IV.D.2 and V.D.2).
83
September 2014 | 23
127
While many educators have hailed these changes as a step in the right direction,91 further
modifications to the promotion policy are necessary to fully address the needs of over-age middle
school students. Many school administrators who have worked with over-age students in the past
expressed the need for greater flexibility to promote over-age middle school students at additional
points during the school year.92 The current A-501 regulation directs:
“[s]tudents who do not achieve the requirements for graduation from grade 8 will be provided
with additional time and support needed [emphasis added] to complete 8th grade
graduation requirements. It will be the responsibility of each school to provide those students
retained in grade 8 with a structured setting in which intensive intervention will lead to meeting
the promotion requirements.”93
While this language could be interpreted to allow promotion from eighth to ninth grade mid-year,
after students have received intensive intervention services, NYCDOE staff report that this practice
is not currently permitted by the district’s computer system.94 Moreover, the regulation does not
contain any such language for students who are retained in sixth or seventh grade. As such,
additional amendments to the regulation would be required to mandate further supports for all overage students and permit mid-year promotion for these students.
91
Metz, C. (2014, April 7). “Promotion Policy Change Gets Thumbs Up.” New York Teacher. New York, NY:
United Federation of Teachers. Retrieved from http://www.uft.org/news-stories/promotion-policy-changes-getthumbs; NYCDOE (2014, April 9) Chancellor Fariña Announces New Promotion Policy for Students in Grades 3-8. New
York, NY: Author. Retrieved from http://schools.nyc.gov/Offices/mediarelations/NewsandSpeeches/20132014/Chancellor+Fari%C3%B1a+Announces+New+Promotion+Policy+for+Students+in+Grades+3-8.htm
92
Advocates for Children of New York, 2008.
93
Under Chancellor Fariña (2014, June 2). Regulation of the Chancellor A-501.V.E.
94
Personal communication with DOE staff, November 25 and December 5, 2013. In interviews, NYCDOE staff
report that the function in ATS that previously permitted principals to change a student’s grade level has been
disabled. Mid-year promotions must now be processed through central-based staff.
24 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
128
Current Program Options for Over-Age
Middle School Students
Currently, New York City has several options available to over-age students who make it to high
school. For example, over-age high school students can apply to one of the NYCDOE’s fifty
transfer schools, twenty-three Young Adult Borough Centers (YABCs),95 or two high schools for
over-age first-time ninth graders96 Additionally, they can enroll in high school equivalency
programs97 or one of the charter high schools geared toward over-age youth, such as ROADS,98
Urban Dove,99 Wildcat Academy,100 and New Dawn Charter High School.101 In contrast, when
over-age students are stuck in middle school, there are very few alternatives available to them.
Despite the fact that there are over 50,000 over-age middle school students in NYCDOE schools,102
there are fewer than 450 seats for them in age-appropriate programs in New York City.
Furthermore, approximately one third of these seats are provided by ROADS Charter High School,
which operates independently of the NYCDOE (see Table 1).103
Among the programs available to over-age middle school students, admission criteria and program
characteristics vary significantly. All programs give students the opportunity to attend school with
peers near their own age; some offer smaller classes, additional enrichment programs, and regular
access to counselors to support students’ social-emotional needs. As Table 1 indicates, many of
these programs have geographic or age limitations or other criteria that preclude many over-age
95
Transfer schools are small, full-time high schools designed to re-engage students who are behind in high school
or have dropped out. Students between the ages of 15 and 21 who have been enrolled in another high school for
at least 1 year are eligible. Students earn a high school diploma and are subject to the same graduation
requirements as students at regular high schools. YABCs are alternative education programs for 17.5- to 21-yearolds with at least 17 credits, where students are given the opportunity to earn a high school diploma in the
evening, explore college and career options, and gain work experience. NYCDOE (2014). Additional Ways to
Graduate Directory: High School Diploma and Equivalency Programs 2014-2015. New York, NY: Author. Retrieved
from http://schools.nyc.gov/NR/rdonlyres/21205E01-0646-409F-970B-1BCBE3A77972/0/AWTG14_15
forposting.pdf. Transfer schools have shown to be effective in raising graduation rate among over-age and undercredited high school students within the NYCDOE. See NYCDOE Office of Multiple Pathways, 2006 (only 19% of
over-age and under-credited high school students ultimately receive a high school diploma or GED if they stay in
articulated high schools. By contrast, 56% of over-age, under-credited students who attend transfer schools go on
to graduate).
96
See Footnote 21 for information regarding High School for Excellence & Innovation and Brooklyn Frontiers, high
schools for over-age first-time ninth graders.
97
NYCDOE. Additional Ways to Graduate Directory: High School Diploma and Equivalency Programs 2014-2015.
98
See Table 1; ROADS is a charter high school for over-age 8th and 9th grade students. www.roadsschools.org
99
Urban Dove is a three-year charter high school for struggling 9th and 10th grade students.
www.urbandove.org/team-charter-school.html
100
Charter high school for 16- to 21-year old students who have become disenfranchised with, and have dropped
out of, traditional high schools. www.jvlwildcat.org
101
Charter high school for under-credited students ages 15 – 21. www.ndchsbrooklyn.org
102
AFC calculation (2014) using IBO data, 2011-12. Data includes students who are 1 year or more over-age.
103
Dr. Gisele C. Shorter, Managing Director, External Relations and Communications, ROADS School, personal
communication, September 9, 2014. ROADS is authorized by State University of New York.
September 2014 | 25
129
students from participating. Most programs serve only over-age eighth graders; only New
Directions Secondary School, Outreach Academy and Center for Community Alternatives’ ReStart
Program accept sixth- and seventh-grade students. While these programs are viable options for a
small handful of the city’s over-age middle school students, they simply do not have the capacity to
serve all of the students who need them. Any plan designed to address the needs of over-age
students must involve an expansion of specialized programs, in addition to increased supports
within regular middle and high schools.
TABLE 1: NYC Programs Serving Over-Age Middle School Students
Ages 12+
162 in 2014-15
Grades 6-8
New Directions Secondary School is a NYCDOE community school in the south Bronx that serves students who are
one year or more over-age for their grade. The school opened its doors in 2013 and currently serves sixth- through
eighth-grade students, but plans to expand to grade twelve so that students can stay at the school until they graduate
from high school. The school utilizes harm-reduction strategies and operates in partnership with a community-based
organization that provides six advisors and three volunteers to support students’ social-emotional development. New
Directions gives priority to students in Districts 7, 9 and 10 and opens up any remaining spots to other Bronx
students. The school conducts rolling admissions to accept new students as seats open up throughout the year.
Interested families are encouraged to reach out to the school directly.
New Directions Secondary School104
ROADS Charter School105
Grades 8-12
147 in 2014-15
ROADS Charter School serves over-age students at two sites, in the Bronx and Brooklyn. Students must have
completed the seventh grade and be fifteen or sixteen years old to apply. Students can remain at ROADS until they
graduate from high school. Priority is given to students who are court-involved, in temporary housing, or involved with
the child welfare system. Interested students apply directly to the school. The school maintains a waitlist and admits
students on a rolling basis. When ROADS opened in fall of 2012, it received over 1,400 applications for 300 open
seats. During the application period for the 2013-14 school year, ROADS received over 800 applications for the 100
open seats.
104
James Waslawski, Principal, New Directions Secondary School, personal communication, February 25, 2014 and
September 4, 2014.
105
Dr. Gisele C. Shorter, Managing Director, External Relations and Communications, ROADS School, personal
communication, various dates. ROADS admitted 532 students during the 2012-13 and 2013-14 school years.
Over the past three years, 52% of students admitted to ROADS were middle schoolers at the time of admission.
26 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
130
Ages 12-16
30
Grades 6-8
This program in Richmond Hill Queens serves middle school students who have substance abuse treatment needs
and/or a family member with a history of substance abuse. The setting is small and provides academic instruction as
well as individual and group counseling. The program uses a number of evidence-based practices including Seven
Challenges, designed to help young people make wise decisions about alcohol and other drugs. Outreach Academy is
part of the NYCDOE ReStart Academy, which operates within a host of behavioral health, mental health and drug
treatment organizations throughout the city.
Outreach Academy
MS Plus: Back on Track at W.E.B. DuBois High
School106
Ages 14-17
Grade 8
20-25 in 2013-14
Also part of the NYCDOE’s ReStart Academy, the Back on Track program shares a building with W.E.B. DuBois High
School. This program is for eighth-grade students who have met roadblocks to academic success in their previous
school. The school is the product of collaboration between the NYCDOE and the Brooklyn District Attorney’s office
and provides academic instruction as well as supports designed to help students reengage in school. Students must
live in Brooklyn to be eligible.
MS Plus107 at Mott Haven Community High School;
MS Plus at Flushing High School; and
MS Plus at Long Island City High School
Ages 14-17
Grade 8
20-24 at each
anticipated in
2014-15
These NYCDOE ReStart Academy programs, new in 2014-15, will give over-age eighth-grade students the
opportunity to work toward mastery of eighth grade standards alongside other students who are over-age for their
grade. Sited on high school campuses, these programs will also give students an opportunity to participate in
electives or physical education classes with ninth grade students. The DOE reports that students who meet eighthgrade promotion standards by the end of the first semester may be promoted to ninth grade mid-year.108
Ages 14-16
10 anticipated in
Grades 6-8
2014-15
anticipated
This NYCDOE ReStart Academy program is also new in 2014-15. Students must be court-involved and will have
access to Center for Community Alternatives (CCA) services including art and music, anger management, leadership
development, tutoring and recreational services.
ReStart Academy at Center for Community
Alternatives 109
106
Stacey Michael, Director, Back on Track, personal communication, February 26, 2014 & August 7, 2014.
Christina McLeod, Assistant Principal, ReStart Academy, email communication, August 29, 2014.
108
Timothy Lisante, Superintendent, Alternative Schools & Programs, personal communication, August 13, 2014.
109
NYCDOE District 79 (2014, August). ReStart Academy Opportunities for Over-Age and Under-Credited Students.
New York, NY: Author. On file with the author; Hans Menos, Director of Youth Services, Center for Community
Alternatives, phone interview, August 7, 2014.
107
September 2014 | 27
131
Recommendations
This paper provides only a preliminary analysis of the over-age phenomenon in New York City
middle schools. We have identified a number of characteristics of over-age students and the schools
they attend; however, much more investigation must be done into the scope of this problem and the
reasons young people become over-age. The NYCDOE is in the best position to gather data,
identify experts in this area, develop expertise about how to meet these students’ needs, and provide
training and resources to the schools who serve them. We urge the NYCDOE to develop and
articulate a plan to identify over-age middle school students and provide them with the necessary
supports to advance to high school. In particular, we recommend that the Department take the
following steps:
One of the challenges in identifying over-age students and developing solutions to the problem is
the lack of a single, coherent definition of what it means to be an over-age middle school student.
Even when over-age students are defined as those two or more years over-age, the NYCDOE does
not have a uniform way of calculating which students meet this definition. We urge the NYCDOE
to create a single, clear definition about what it means to be on-age and to collect and report data on
students who are above this age at each grade level.
Define as “on-age” only those students who turn 11, 12 or 13 by December 31st of their
6th, 7th or 8th grade year, respectively.
We recommend that the NYCDOE define as on-age only those students who entered kindergarten
in the calendar year in which they turned five and have never been retained. According to the
NYCDOE’s most frequently cited definition, over-age students are those who are two or more years
off-track.110 However, the data we received from the NYCDOE in response to a FOIL request
counted students who were two years older than their on-track peers as on-age, listing as over-age only
students who were at least three years off-track.111 To count a fifteen-year-old eighth grader as “on-age”
not only significantly underrepresents the over-age population, but is also out of sync with the
common understanding of what it means to be over-age and the way transfer schools and high
schools that specialize in over-age students define over-age. Having conflicting definitions, and thus
110
111
See Section II, The Definition of “Over-Age” and Footnotes 16 & 17.
See Section II, The Definition of “Over-Age” and Footnote 18.
28 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
132
incomplete data, regarding over-age middle school students also makes it difficult to track outcomes
for these students and to plan for their transition to high school. A standard, common-sense
definition of what it means to be an “on-age student” will allow for continuity across programs, the
collection and dissemination of more accurate data, and better understanding of the scope of issues
affecting over-age students.
Identify and publicly report data on students who are one, two, and three or more years
over-age.
Once we have a standard definition of what it means to be on-age, the NYCDOE should identify all
students who are above this age and should make this data publicly available.112 This more accurate
and usable data should be disaggregated by number of years over-age (i.e. one year, two years, three
years or more) in order to determine if and how the number of years that a student is over-age
affects their educational trajectory. Data should be further disaggregated by school district, race,
gender, IEP status, ELL status, eligibility for free or reduced meals, and students who have been
identified as living in temporary housing under The McKinney-Vento Homeless Assistance Act.113
Thorough disaggregation of this data would help to identify needs and trends among over-age
students and allow for a detailed analysis into the underlying reasons why students become over-age
in New York City middle schools.
Identify and publicly report the number of middle school students designated as longterm absentees.
Given the strong correlation between over-age students and low attendance rates,114 the NYCDOE
should also identify students at risk of becoming over-age by reporting the number of middle school
students who have been absent for more than twenty consecutive days. The needs of these students
should be closely examined when designing any new programming for over-age students.
AFC applauds the NYCDOE’s recent changes to its promotion policy to move away from a reliance
on high-stakes tests. However, further revision is necessary to meet the needs of over-age students.
112
The NYCDOE has, for years, made available data about over-age high school students. See, e.g.
http://schools.nyc.gov/NR/rdonlyres/B5EC6D1C-F88A-4610-8F0F-A14D63420115/0/FindingsofOMPG.pdf.
113
42 U.S.C. § 11431.
114
See Section II, Bloomberg-Era Policies
September 2014 | 29
133
Re-examine Chancellor’s Regulation A-501, as well as the Promotion Portfolio Teacher’s
Manuals,115 at all grade levels to ensure that students are retained in the early grades
only as a last resort.
Most of the current over-age middle school population was retained in the early grades.116 Many
studies indicate that while retained students may show short-term gains, their long-term outcomes
are worse than similarly-situated students who are promoted.117 As such, elementary school teachers
and principals should be trained on the long-term consequences of retention, and promotion
decisions should be reviewed to ensure that retention is used as a last resort only when all other
interventions have been exhausted.118
Revise Chancellor’s Regulation A-501 to provide over-age students the opportunity to
catch up with their on-track peers.
Chancellor’s Regulation A-501 should be revised to allow for the mid-year promotion of retained
students, provided that they have met promotion standards. As described in Section III, the current
regulation could be interpreted to allow mid-year promotion for eighth-grade students. However,
revision of the regulation is necessary to expand this option to students in all grades, and procedures
and protocols for entering student data in ATS needs to be modified accordingly. Additionally,
given the number of middle school students who are significantly over-age, the policy should permit
schools to promote these students two grade levels in June or August, provided they have met
promotion standards. These types of policies could serve as valuable incentives to get over-age
students reinvested in their education and back with age-appropriate peers in high school.
Families must be properly advised regarding promotion rights and appeals to ensure that they
understand the retention process and know how to advocate for their children. The following
changes would make the process more accessible to families:
Create a simple form for parents to fill out when requesting a promotion appeal.
Parents have the right to appeal promotion decisions in writing to the principal in late August.
However, neither the regulations nor the NYCDOE website provides the parent with an appeal
form, specific submission and decision dates, or instructions about what to include in an appeal.
115
AFC requested copies of the current Promotion Portfolio Teacher’s Manuals through a FOIL request on June
24, 2014. However, at the time of publication, these materials had not been released by the NYCDOE.
116
See Section II, Status at Point of Entry to Middle School.
117
See Section III.
118
For additional guidance, see National Association of School Psychologists (2011). Grade Retention and Social
Promotion (White Paper). Bethesda, MD: Author. Retrieved from
http://www.nasponline.org/about_nasp/positionpapers/whitepaper_graderetentionandsocialpromotion.pdf.
30 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
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Providing parents with a form on which to submit their appeals would make the process much
clearer and more accessible.
Give parents a central-based contact person whom they can call to seek assistance with
late appeals and promotion appeals for over-age students.
Many parents of over-age middle school students have expressed frustration with the promotion
appeals process. In some instances, these parents have missed the August appeal deadline and have
been informed by their local school that their only option is to wait for the following June to seek a
promotion for their child. For assistance with these difficult situations, families should be provided
with the contact information for central-based staff familiar with over-age promotion appeals and
with late promotions appeals.
The needs of schools serving over-age students vary significantly. Some schools, particularly those
in high-need areas of the Bronx and Brooklyn, have large concentrations of over-age students, while
other schools have only a handful of these young people. In order to serve all over-age middle
school students, the NYCDOE cannot simply rely on individual schools to share information and
create solutions to this citywide problem.
Identify central-based staff to support schools serving over-age students.
At AFC, we often hear from school-based staff at a loss for how best to meet the needs of a specific
over-age student. The NYCDOE should establish a team of central-based experts who can support
school-based staff to develop strategies for over-age students. While there is at least one person
focused on middle school within the NYCDOE’s newly established Office of Guidance and School
Counseling, one person is not enough to meet this need. This team must be knowledgeable about
the work being done throughout the city to serve over-age youth and must be able to advise and
support schools in finding solutions to the needs of individual over-age students. This team should
also establish a structured forum for schools to share best practices for working with this
population. Finally, this team should ensure that staff working at the Referral Centers and Office of
Student Enrollment is trained to identify over-age middle school students and effectively connect
these students with appropriate programs.
List Re-Start programs and other NYCDOE alternative middle school programs in the
Additional Ways to Graduate Directory.
September 2014 | 31
135
Over-age middle school student and their families often start looking for alternative options by
searching the NYCDOE website or thumbing through an Additional Ways to Graduate Directory.119
Currently, that directory lists only transfer schools, YABC programs and high school equivalency
programs. ReStart Academy programs and any other NYCDOE alternative programs should be
listed in this guide where families, guidance counselors and students can easily access them.
In August, 2014, District 79 Superintendent Tim Lisante announced an expansion of the Re-Start
Academy program to four additional sites in the Bronx, Brooklyn and Queens. While this expansion
provides a welcome increase to the number of seats in specialized programs, bringing the total to
nearly 450, these programs do not come close to meeting the demand of the over 8,000 three-year
over-age middle school students or the many more two-year over-age students who need an ageappropriate school option.120
Explore a variety of models.
More age-appropriate school options are essential for the success of our current over-age middle
school students. The ReStart Academy model is just one model that should be examined for
possible expansion. Currently, there are multiple program options for over-age high school
students; these programs should be examined for possible adaption for over-age middle school
students as well. The DOE also should investigate other successful intervention models from New
York and elsewhere, such as block scheduling,121 extended school days,122 and Passages Academy’s
35-Day cycle model.123 NYCDOE staff we interviewed overwhelmingly recommended that overage middle school students be given the opportunity to participate in a high school setting. As such,
the NYCDOE should consider creating more programs that include grades six through twelve, such
as the one being built at New Directions Secondary School.
Give schools support and flexibility when developing alternative approaches to meeting
the needs of over-age students.
119
NYCDOE (2013). Additional Ways to Graduate Directory: High School Diploma and GED Programs 2013-2014. New
York, NY. Retrieved from http://schools.nyc.gov/NR/rdonlyres/706FD7CE-D120-4819-99EAF5023E25178A/149283/AWTG13_14.pdf. Currently, Re-Start programs are listed in a separate document:
NYCDOE Restart Academy (2013-14). School Year 2013-2014 Site List. New York, NY: Author. Retrieved from
http://schools.nyc.gov/NR/rdonlyres/07E3D656-F2C9-425F-8E98-87DE66633CEE/0/ReStartAcademy.pdf.
120
See Sections II, The Definition of “Over-Age” and Section IV.
121
Block scheduling allows for greater flexibility with regard to scheduling. Students who are struggling in particular
areas can get extra help and more time to receive the support they need in those areas.
122
Extended school days are longer than the average 8 hour school day, allowing for additional time for teacher
help and to make up missing class credits needed for grade promotion.
123
At Passages Academy, high school students can earn up to 3.5 credits every 21 to 25 school days. Phone
Interview with Passages Academy social worker, June 25, 2014.
32 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
136
Given the scope and complexity of this issue, middle and high schools need to be given the
necessary support and flexibility to develop alternative approaches to serving over-age students. As
mentioned in Section III, some middle schools have run innovative but under-the-radar programs to
serve their over-age population, including afterschool and Saturday remediation programs, options
that should be available to any over-age student. All of these programs should be identified and
given the resources to expand if they can demonstrate gains in achievement and engagement among
over-age students.
Concentrate expansion of options in the communities where most over-age students live.
When creating programs for over-age middle school students, it is imperative that the NYCDOE
keep in mind those communities that could benefit most from these programs: areas of New York
City with the highest concentration of over-age middle school students.
Ensure that all alternative programs can accommodate the needs of students with
disabilities.
Given that over-age students are twice as likely to need special education services as their on-age
peers,124 any programs designed to meet the needs of over-age students must include access to a full
range of special education supports and services. The NYCDOE must ensure that all of its
programs for over-age middle school students have special educators on staff and are capable of
implementing students’ Individualized Education Programs. Housing alternative programs for overage students within large campuses where there are other high schools on site could help ensure that
students have access to special education teachers and providers even within small, specialized
programs.
Expand alternative programs that serve over-age sixth- and seventh-grade students.
There were approximately 2,900 three-year over-age seventh-grade students registered with the
NYCDOE during the 2013-14 school year.125 We know from the data that over-age seventh graders,
like their eighth-grade counterparts, struggle with attendance and are often significantly disengaged
from their middle school.126 At the moment, there are only three programs in New York City that
can accept over-age seventh-grade students.127 These schools, New Directions Secondary School
Outreach Academy, and ReStart Academy at Center for Community Alternatives, have
approximately 200 seats between them and cannot come close to meeting the demand of the city’s
over-age seventh-grade population. District 79 Superintendent Timothy Lisante reports that his
district’s ReStart Academy program simply does not have the capacity to meet the needs of the overage seventh-grade population.128 More alternatives must be created in order to meet this need.
124
See Section II, Demographics of Over-Age Middle School Students
AFC Calculation (2014) using ROAG data 2013-14.
126
See Section II & Figures 2, 3 & 8.
127
See Figure 10.
128
Interview, August 13, 2014.
125
September 2014 | 33
137
Data also indicates that sixth graders who are more than three years over-age are at serious risk of
disengagement. This population also must be a high priority when creating programming for overage students. The NYCDOE should examine the grades-six-to-twelve model in place at New
Directions Secondary to determine whether it can be expanded to other high-need neighborhoods in
the Bronx, Brooklyn, and northern Manhattan. The NYCDOE Office of Multiple Pathways should
consider expanding its current alternative programs to serve over-age middle school students and
include sixth and seventh graders in any new programs.
Pathways should be created that allow over-age middle school students to earn high school credits
by partnering with high schools in high-need areas. New York State regulations permit eighth-grade
students to take courses for high school credit if the student has demonstrated readiness and passed
a Regents exam, Career and Technical Education (CTE) exam, or locally-developed assessment that
establishes student performance at a high school level.129 Under these regulations, over-age students
who are still working toward eighth-grade mastery in math, for example, could be permitted to take
high school English courses. Allowing over-age eighth graders to earn high school credits could be
extremely motivating for the students and would increase the likelihood that they graduate from
high school before aging out at twenty-one. Additionally, co-locating alternative programs for overage middle school students with high schools would allow students to interact with age-appropriate
peers and to participate in high school extra-curricular and enrichment activities.
When over-age students are promoted to high school, they often are unable to gain acceptance to
any of the transfer high schools designed for over-age students. Currently, transfer schools have
complete autonomy over their admissions. The DOE should provide incentives to high schools and
transfer schools accepting over-age, first-time freshmen or over-age seventh- and eighth-grade
students. For example, the current High School Progress Report could be modified for any transfer
school that sets a “zero reject policy” as one of its goals and objectives. For these schools, the
weight given to goals and objectives could be increased relative to test scores. The High School
Progress report also could be adjusted to give greater weight to five- and six-year graduation rates,
and high schools could be empowered to create five and six-year graduation programs that can
accept over-age seventh- and eighth-grade students, to allow for age-appropriate peer interactions
and to reengage students in their education.
129
New York State Education Department (2008, December). 100.4 Program Requirements for Grades Five through
Eight. Albany, NY: Author. Retrieved from http://emsc32.nysed.gov/part100/pages/1004.html (See Part
100.4(d)(3)).
34 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
138
Conclusion
As the NYCDOE focuses much-needed attention on middle schools, it must not forget the
thousands of students who are over-age for their grade. With improved programs and policies,
these students, who are among the most vulnerable in the city, will have a real chance to get back on
a path toward high school graduation. Addressing this issue is critical to ensuring that middle school
does not become any student’s last stop before dropping out.
September 2014 | 35
139
Appendix A
10%
9.25%
9%
1
2
3
4
5
7.39%
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
District Number
■ Manhattan ■ Bronx
Source:
1.85%
1.98%
4.06%
3.23%
0.58%
2.00%
1.51%
1.42%
3.78%
3.91%
5.42%
5.62%
5.70%
4.98%
4.61%
6.67%
6.76%
7
5.41%
6
1.34%
0%
1.28%
1.26%
1%
2.19%
2%
3.18%
3%
3.47%
4%
5.81%
4.78%
5%
5.76%
6%
5.77%
6.91%
7%
1.68%
8%
■ Brooklyn ■ Queens
■ Staten Island
ROAG data 2013-14. The NYCDOE redacted some data citing the Family Educational Rights and
Privacy Act (FERPA). In these cases, missing data was imputed using the percentage of students
who were at least two years over-age when entering sixth grade, as defined by NYC Progress
Reports. The analysis excludes K-8 schools because grade 6-8 data could not be isolated for these
schools.
36 | Sixteen Going on Seventh Grade: Over-Age Students in New York City Middle Schools
140
Additional Resources
Education and Housing
From:The Institute for Education and Social Policy
Housing, Neighborhoods & Communities, The Inst. for Educ. & Soc.
Pol'y , http://steinhardt.nyu.edu/iesp/
housing_neighborhoods_communities.
Horn, K. M., Ellen, I. G., and Schwartz, A. E. (2014). "Do Housing Choice
Voucher Holders Live Near Good Schools?" Journal of Housing
Economics, 24, 109-121. DOI: 10.1016/j.jhe.2013.11.005
Schwartz, A. E., McCabe, B. J., Ellen, I. G., & Chellman, C. (2009). "Do
Public Schools Disadvantage Students Living in Public Housing?" Working
Paper #09-08.
Schwartz, A. E., Stiefel, L. & Carlton, A. C. (2009). "From Front Yards to
Schoolyards: Linking Housing Policy and School Reform." Working Paper
#09-07.
141
Health + Education = Opportunity:
An Equation that Works
N O V E M B E R
2 0 1 4
142
CDF Mission
CDF Mission Statement
The Children’s Defense Fund Leave No Child Behind mission is to ensure every child a Healthy Start, a
Head Start, a Fair Start, a Safe Start and a Moral Start in life and successful passage to adulthood with
the help of caring families and communities.
®
CDF provides a strong, effective and independent voice for all the children of America who cannot vote,
lobby or speak for themselves. We pay particular attention to the needs of poor and minority children and
those with disabilities. CDF educates the nation about the needs of children and encourages preventive
investments before they get sick, drop out of school, get into trouble or suffer family breakdown.
CDF began in 1973 and is a private, nonprofit organization supported by foundation and corporate grants
and individual donations.
Acknowlegements
The principal author of this report was Andrew Leonard of the Children’s Defense Fund – New York (CDF-NY).
Melanie Hartzog and Lorraine Gonzalez-Camastra, also of CDF-NY, contributed significant guidance and
support. Erica Eliason and Julia Keyser, CDF-NY Health Policy Interns, provided additional research and
review for the report.
Financial support for this project was provided by the Altman Foundation. The mission of the Altman
Foundation is to support programs and institutions that enrich the quality of life in New York City, with a
particular focus on initiatives that help individuals, families, and communities benefit from the services and
opportunities that will enable them to achieve their full potential.1 The views presented here are those of
the author and do not necessarily reflect those of the Altman Foundation or its directors, officers, or staff.
The insight, experience and input of a working group of children’s health and education stakeholders helped
to inform and shape this report and the subsequent recommendations. The recommendations do not
necessarily reflect the views of individual task force members nor have they endorsed the recommendations
and conclusions of this report. The following individuals contributed to the report by participating in work-group
sessions, meeting with CDF-NY individually both in-person and by phone, or providing written feedback on
drafts of the report:
Marcelo De Stefano
Roger Platt, M.D.
Lorraine Tiezi
Sharita Alam
Aaron Anderson
Beverly Colon
Adria Cruz
Aaron Felder
Anthony Feliciano
Michline Farag
David Appel, M.D.
Margee Rogers
Elizabeth Powers
1
Office of School Health; NYC Department of Education
Office of School Health; NYC Department of Education
Office of School Health; NYC Department. of Education
Formerly NYC Office of Management and Budget
NYC Office of Management and Budget
The Children’s Aid Society
The Children’s Aid Society
Lutheran Family Health Centers
Commission on the Public’s Health System
Administration for Children’s Services
Montefiore Medical Center
Montefiore Medical Center
Children’s Defense Fund – New York
http://www.altmanfoundation.org/index
© 2014 Children’s Defense Fund. All rights reserved.
Cover photo: Getty Images • Inside photos: Biljana Milenkovic, Alison Wright Photography and Getty Images
ii
Children’s Defense Fund – New York
143
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
School Health Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Office of School Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
School-Based Health Centers . . . . . . . . . . . . . . . . . . . . . . . . . 10
Intersection of the Two Systems . . . . . . . . . . . . . . . . . . . . . . . 11
The Role of Health Care Services in Schools . . . . . . . . . . . . . . . . . . . 11
Addressing Critical Child Health Indicators in Schools . . . . . . . . . . . . . 13
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Teen Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Ta b l e o f C o n t e n t s
Table of Contents
Moving Forward: Recommendations for an Improved
School Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Scope of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Increasing Capacity and Securing Financing . . . . . . . . . . . . . . . 19
Integrating School-Based Health Centers and
School Nursing Services . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Health + Education = Opportunity: An Equation that Works
144
iii
iv
Children’s Defense Fund – New York
145
ew York City educates 1.1 million students across approximately 1,800 schools in the five boroughs.2
These students experience a vast array of health care needs. While the primary mission of schools is to
educate children so they can go on and lead successful lives, that goal cannot be reached if their
health needs are unmet. Currently in New York City, all children receive, or have access to, some basic services
in schools from nurses and other health care professionals through the Office of School Health. Still other
students receive a greater range of primary and preventive services — varying by site — from school-based
health centers.
N
As the capacity for health care delivery in schools increases, significant opportunities exist to better connect
schools to the larger health care infrastructure that works to secure children’s health and wellness. Schools
must be considered as essential to children’s health as community providers, specialists and hospitals. They
offer unique advantages in their ability to improve health outcomes for children.
Executive Summary
Executive Summary
As a key link in the spectrum of children’s health care services, school health providers and systems must develop
a uniform scope of services available to all New York City school children. The Children’s Defense Fund – New
York (CDF-NY) believes that schools must play a two-fold role as a link in the greater health care system for
children. Ultimately, CDF-NY has concluded that to fully achieve a satisfactory school-based health care delivery
system, schools must be able to:
1. Manage those health conditions that must be addressed to facilitate the optimal personal learning
environment for students and;
2. Manage those health conditions that are detrimental to creating a foundation for lifelong wellness,
particularly those conditions not well managed by traditional community providers.
By directing efforts and resources toward these two responsibilities, schools can fulfill a necessary and unique
role for children. This model accounts for the inherent advantages of the school setting and promotes positive
growth on a number of long-term indicators of wellness.
2
http://schools.nyc.gov/AboutUs/default.htm
Health + Education = Opportunity: An Equation that Works
146
1
Methodology
This report reflects the input of a group of committed children’s health and education stakeholders. In November
2013, with support from the Altman Foundation, CDF-NY convened the School Health NYC task force.
The task force included representatives from the Office of School Health, labor unions representing school
nurses, school-based health centers, and New York City administrators. CDF-NY asked the task force members
to consider an optimal scope of services that stresses enhanced care coordination for New York City school
children. Following the meetings of the task force, CDF-NY conducted extensive research into New York City’s
school health system and successful models across the nation, and completed more individualized follow-up with
task force members.
School Health Delivery Systems
Two largely separate service delivery systems provide school-based health care to New York City students:
the Office of School Health (OSH) and independently operated school-based health centers (SBHCs).
Office of School Health
The Office of School Health is an administrative division drawn from the New York City Department of Education
(DOE) and the Department of Health and Mental Hygiene (DOHMH). OSH plays the dual role of overseeing all
school health services and making relevant policy decisions, while also delivering health care services to most
New York City schools. The largest portion of OSH services are provided by school nurses. Ninety percent of
schools, excluding those with a SBHC, have a nurse on site.3 School nurses treat the daily first aid needs of the
student body, assist in the management of chronic illnesses, and provide a number of other services. While
school nurses provide the majority of health care services in schools, OSH offers a vast array of services far beyond
daily first aid management and skilled nursing services. OSH attempts to provide universal screenings for vision,
obesity, asthma and more. Additionally, OSH makes available school physicians to perform physicals for students
seeking working papers, or camp and sports physicals. OSH also coordinates the provision of behavioral health
services through Article 31 clinics operated in a manner similar to the SBHCs. Moreover, OSH plays a strong
public health role, developing and implementing a number of campaigns aimed at increasing children’s knowledge
of conditions such as asthma and obesity, ensuring compliance with vaccination requirements, and reducing
the spread of infectious diseases.
School-Based Health Centers
One hundred thirty-eight school-based health centers, serving students in 330 schools, deliver high-quality,
comprehensive services to many New York City children.4 Over 99,000 New York City school children receive
services from a school-based health center each year.5 These clinics are fully certified as New York Article 28
clinics. The total program budget for New York City school-based health centers is approximately $39 million
per year.6 School-based health centers provide a range of primary care and ancillary care services. Namely,
these include: first aid; diagnosis and treatment for pediatric and adolescent health needs; assessments and
examinations for sports physicals and working papers; chronic disease monitoring and treatment; laboratory
testing; reproductive health services; STI/HIV testing, treatment, and counseling; vaccinations; and mental
health services. Centers also have the option to provide dental services.
2
3
http://schools.nyc.gov/Offices/Health/default.htm
4
http://schools.nyc.gov/Offices/Health/default.htm
5
http://www.health.ny.gov/statistics/school/skfacts.htm
6
http://www.health.ny.gov/statistics/school/skfacts.htm
Children’s Defense Fund – New York
147
Intersection of the Two Systems
The two service delivery systems currently do not operate under a collaborative model. Largely, the systems exist
apart from each other. Except in rare situations, OSH does not place a school nurse in a school that already has
a SBHC.7 Of course, if a SBHC only operates part-time in a school, OSH will place a nurse or other appropriate
OSH provider in the school when the SBHC is not present. The task force agreed that the current division of
services does not reflect the optimal model of care delivery. Members also noted challenges relating to space
and financing. These issues currently prevent a more collaborative sharing of resources and a more coordinated
system of care delivery. Overall, the current level of services provided is not enough for schools to be an integral,
essential link in the greater health care infrastructure for all children. The current system, however, offers a sound
model that ought to be preserved and expanded with the recommendations of this report so that schools can
become critical health care access points for all children.
The Role of Health Care Services in Schools
Undoubtedly, schools cannot be the sole source of care for a child. Children need access to more intensive
care settings, a broader range of specialty physicians and necessary emergency services. Schools, however, are
increasingly important entry points for children to access health care services and address health inequities. As
a fully integrated part of the health care delivery system, schools can play a strong public and primary health
care role for children, improving both individual student and school-wide population health.
When detailing the specific role that schools should play in the continuum of children’s health, it is important
to consider the unique characteristics and advantages of schools. First, school health services must foster the
optimal opportunity for children and youth to learn. Children with unmet health needs are far less likely to succeed
in school.8, 9 A school that can better manage the day-to-day health care needs of its students will enable the
best educational outcomes. Health care services should be delivered with a goal of returning students to class
with minimal disruption.
School health services, particularly in New York City Schools, must also serve as a public health safety net.
Schools enjoy distinct advantages over community providers in terms of providing care to an often difficultto- reach population. Schools are a gathering place for nearly all New York City children. With so much of the
young population easily accounted for, school health providers can generate serious health improvements by
addressing a comprehensive and attentive audience. Additionally, schools provide a space in which providers
can offer care in a more comfortable and confidential environment. Many of the services older students need
most deeply are sensitive in nature. In the school setting, adolescents can discreetly access these needed services
and improve their health care status.
Addressing Critical Child Health Indicators in Schools
While children face a wide range of health conditions, a few highly prevalent conditions affect children in such
a way that they can adversely influence learning and future health. CDF-NY has identified four critical areas of
need: asthma, behavioral health, obesity, and teen pregnancy. It is important for New York City to provide the resources
for all schools to skillfully manage these conditions for all school children. Properly allocating health resources
in a manner that satisfactorily addresses these prevalent health concerns will help secure the greatest academic
and future health outcomes for children.
7
http://schools.nyc.gov/Offices/Health/default.htm
8
Case, A., Lubotsky, D., & Paxson, C. (2002). Economic status and health in childhood: The origins of the gradient. The American
Economic Review, 92, 1308–1334
9
Ding, W., Lehrer, S. F., Rosenquist, J. N., & Audrain-McGovern, J. (2009). The impact of poor health on academic performance:
New evidence using genetic markers. Journal of Health Economics, 28(3), 578-597.
Health + Education = Opportunity: An Equation that Works
148
3
Recommendations
The school health system in New York City plays a crucial safety net role in addressing the academic and health care
needs of New York’s children. With adequate support and a strategic analysis of need, school health stakeholders
can foster positive growth for the role of schools in the larger children’s health infrastructure. The recommendations
presented in this report provide an early road map for the preservation and expansion of school health resources.
An enhanced, coordinated and well-funded school health system will better guarantee that New York City’s
school-aged children achieve their full academic potential, while establishing a foundation for life-long health
and wellness. The following recommendations will support a more efficient and sustainably expanded model
for schools.
Data Collection
Accurate and population-wide data are the foundation of an efficient and comprehensive school health system.
The current school health system does not have an agreed upon method for sharing data across different OSH and
SBHC provider systems. Developing a universal method for tracking school level data points, with appropriate
protections for a student’s protected health information, will be crucial to determining the best allocation of resources.
• Improve the collection and sharing of data between Office of School Health providers and
school-based health center providers.
• Connect school health records with relevant providers in the greater children’s health infrastructure.
• Track school-level data focusing on key health indicators that demonstrate high demand for health
care services.
• Use enhanced data to determine the placement of more intensive school health services, specifically
SBHCs.
4
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Scope of Services
With the new data systems in place, school health stakeholders can move forward in developing a universal
scope of services. In order to have an equitable health care system in schools, all children must have access to
a standard baseline level of services, which stresses universal assessment and preventive screenings for at least
asthma, behavioral health issues, sexual health issues and obesity. Additional services can be provided above
the baseline level based on need identified by school input and data.
• Develop a uniform scope of services, focusing on preventive services for all and intensive services
for those identified as having increased needs.
Increasing Capacity and Securing Financing
Preservation and expansion of the school-based health model
are deeply needed. The best school health system cannot be
achieved by simply maintaining the current level of services.
Before expanding, school health delivery models must secure
the necessary operational capacity and financial viability.
• Require school administrators to consider the health
care needs of a community when constructing a new
school or performing a major capital renovation on an
existing school.
• Partner with community organizations to deliver
health care services off-site.
• Secure enhanced Medicaid funding for Office of
School Health services.
• Preserve the financial viability of SBHCs at the
state level, particularly with regard to Medicaidmanaged care.
An enhanced, coordinated
and well-funded school
health system will better
guarantee that New York
City’s school-aged
children achieve their
full academic potential,
while establishing a
foundation for life-long
health and wellness.
• Work with private and Child Health Plus (CHPlus)
plans and the State Department of Health
to develop a satisfactory model for SBHC providers to bill for reimbursement.
• Explore the possibility of SBHCs joining or forming a Performing Provider System (PPS) under
the state’s Delivery System Reform Incentive Payment (DSRIP) initiative.
Integrating School-Based Health Centers and School Nursing Services
An optimal school health delivery system is one that finds school-based health centers and school nurses
working together. A complementary model that utilizes the talents of both SBHC and OSH staff will enable
schools to offer a universal baseline of services, while also addressing more intensive needs.
• Develop a complementary model that incorporates school nurses into school-based health centers.
Already, New York City delivers care in schools under a robust and diverse provider system. The recommendations
in this report hope to capture the strengths of the existing school health system and sustain that model in a
changing health care landscape. The intersection of health and education may happen first for children in
their school, but these two forces will continue to cross paths long into adulthood. Children’s advocates should
safeguard this initial crossroads and work to ensure that it becomes a launching pad for life-long wellness.
Health + Education = Opportunity: An Equation that Works
150
5
151
ew York City educates 1.1 million students across approximately 1,800 schools in the five boroughs.10
These students experience a vast array of health care needs. While schools are not positioned to provide
all of the health care services a child may require, health care delivery in schools holds a great deal of
promise for improving the health of New York’s young people. For years, schools have been home to at least
some, minimal level of health care services. Over time, schools have grown increasingly capable of treating
student’s health care needs above and beyond daily first aid needs. Currently in New York City, all children
receive, or have access to, some basic services in schools from nurses and other health care professionals
through the Office of School Health. Still other students receive a range of more comprehensive services,
varying by site, from school-based health centers.
N
As the city moves towards a greater appreciation of the “community school” model, children’s health stakeholders
are well positioned to reconsider and promote the role of health care in schools. The community school model
is one that wraps health and social supports around the traditional educational offerings of schools. Community
schools seek to foster a positive, encouraging space in which children can grow and develop into healthy,
productive adults. As the capacity for health care delivery in schools increases, significant opportunities exist
to better connect schools to the larger health care infrastructure that works to secure children’s health and
wellness.
Indeed, schools must be considered an integral player in the larger children’s health infrastructure. No longer can
school health systems afford to exist as an extraneous care delivery mechanism. Schools must be considered as
essential to children’s health as community pediatricians, specialists and hospitals. They offer unique advantages
in their ability to improve health outcomes for children. Providing health care services in a learning environment
enables students to receive care in a confidential setting open to nearly all New York City children and fosters a
10
Health + Education = Opportunity
Introduction
http://schools.nyc.gov/AboutUs/default.htm
Health + Education = Opportunity: An Equation that Works
152
7
fertile atmosphere for academic growth. Bringing school-based health interventions into the larger health care
landscape will better enable all providers to ensure the health and wellness of children. Additionally, a greater
connectivity to more mainstream delivery systems will better ensure the long-term stability of school health
providers.
Schools can play a comprehensive and unique role in the continuum of health care services needed by children
as a complementary – not duplicative – primary and preventive care access point. As a key link in the spectrum
of children’s health care services, school health providers and systems must develop a uniform scope of services
available to all New York City school children. While all students deserve barrier-free access to a full range of
health care services, the reality of having a full-service school-based health center in every New York City public
school is not practical given current fiscal and logistical constraints. The placement of more intensive services
currently depends on a number of factors including intensity of need, school principal and health care provider
buy-in, space availability and financial viability. Often times, those non-health factors prohibit the most strategic
placement of more intensive school health services. Consequently, the resulting school health system does not
reflect a universal scope of services. Some students have access only to first aid services and sparse health
education. Others can access the full benefits of a school-based health center.
The role of school health, and the resulting scope of services, must be settled and agreed upon before it can be
welcomed as an essential actor in the broader health care system. The Children’s Defense Fund – New York
(CDF-NY) believes that schools must play a two-fold role as a link in the greater health care system for children.
Ultimately, CDF-NY has concluded that to fully achieve a satisfactory school-based health delivery system,
schools must be able to:
1. Manage those health conditions that must be addressed to facilitate the optimal personal learning
environment for students and;
2. Manage those health conditions that are detrimental to creating a foundation for lifelong wellness,
particularly those conditions not well managed by traditional community providers.
By directing efforts and resources toward these two responsibilities, schools can play a necessary and unique
role for children. This model accounts for the inherent advantages of the school setting and promotes positive
growth on a number of long-term indicators of wellness.
The remainder of this report discusses the current school health system and its natural advantages, and details
a list of four critical children’s health needs that require attention to achieve the two above stated goals.
The report concludes with a number of steps that service providers can take to facilitate the implementation
of this scope of services and prepare schools to more fully engage in the broader children’s health landscape.
Methodology
This report reflects the input of a group of committed children’s health and education stakeholders. In November
2013, with support from the Altman Foundation, CDF-NY convened the School Health NYC task force. The
task force included representatives from the Office of School Health, labor unions representing school nurses,
SBHCs, and New York City administrators. CDF-NY asked the task force members to consider an optimal scope
of services that would stress enhanced care coordination for New York City school children. After the initial
group meeting, CDF-NY identified three important areas needing further exploration; School Health Financing,
Care Coordination, and Care for Children with Special Health Care Needs. Stakeholders divided into three
subgroups based on the identified areas of need. Each of these subgroups met an additional two times via
conference call to further discern the appropriate action needed to address these unique challenges. Following
these meetings, CDF-NY conducted extensive research into New York City’s school health system, successful
models across the nation, and completed more individualized follow-up with task force members.
8
Children’s Defense Fund – New York
153
School Health Delivery Systems
Two largely separate service delivery systems provide school-based health care to New York City students;
the Office of School Health (OSH) and independently operated school-based health centers (SBHCs).
Office of School Health 11
OSH is an administrative division drawn from the New York City Department of Education (DOE) and the
Department of Health and Mental Hygiene (DOHMH). OSH plays the dual role of overseeing all school health
services and making relevant policy decisions, while also delivering health care services to most New York City
schools. The largest portion of OSH services are provided by school nurses.i City, state and federal laws mandate
the majority of OSH services. Local law 57 mandates that elementary schools have a school nurse and that
middle schools have either a school nurse or a public health advisor.12 High schools do not have a mandate to
deliver school nursing services. Ninety percent of schools, excluding those with a SBHC, have a nurse on site.13
School nurses treat the daily first aid needs of the school, assist in the management of chronic illnesses,
and provide a number of other services. Section 504 of the Rehabilitation Act and the Americans with
Disabilities Act (ADA) outlines the need for schools to provide a nurse to administer medication to children
with identified needs.14,15 Additionally, the Individuals with Disabilities Education Act (IDEA) prescribes the
creation of Individualized Education Plans (IEPs) for students with special needs. IEPs often require a student
to receive skilled nursing services. These skilled nursing services are provided by an OSH nurse. School nurses
often deliver high-quality chronic disease management for children under these regulations. For a child with
diabetes, a school nurse may be responsible for routinely administering medication, monitoring blood glucose
levels, and taking appropriate remedial actions in the event of a diabetes related emergency.16
While school nurses provide the majority of health care services in schools, OSH offers a vast array of services
far beyond daily first aid management and skilled nursing services. OSH attempts to provide universal screenings
for vision, obesity, asthma and more. Furthermore, OSH makes available school physicians to perform physicals
for students seeking working papers, or camp and sports physicals. OSH also coordinates the provision of behavioral
health services through Article 31 clinics operated in a manner similar to the SBHCs.
Moreover, OSH plays a strong public health role, developing and implementing a number of campaigns aimed at
increasing children’s knowledge of conditions such as asthma and obesity, ensuring compliance with vaccination
requirements, and reducing the spread of infectious diseases.17 OSH has a strong track record of promoting
improved population health with its public health experience and resources.
Funding for OSH programs comes largely from New York City budget allocations. The New York City DOHMH
and DOE each set aside funding for the provision of school-based health interventions. A very small portion of
funding comes from the Medicaid School Supportive Health Services Program.
i
New York City school nurses work under either DOHMH or DOE. DOHMH employs 61.5% of general education nurses. District Council
37 represents DOHMH nurses. DOE employs the remaining 38.5% of general education nurses. The United Federation of Teachers (UFT)
represents DOE nurses. DOE nurses also provide services in New York City’s District 75 schools which serve children with severe learning
challenges. They too are represented by the UFT.
11
http://schools.nyc.gov/Offices/Health/default.htm
12
http://legistar.council.nyc.gov/LegislationDetail.aspx?ID=662393&GUID=04D6ABD5-E7CA-4382-BF5F-0801AA403618&Options=&Search=
13
http://schools.nyc.gov/Offices/Health/default.htm
14
http://www.hhs.gov/ocr/civilrights/resources/factsheets/504ada.pdf
15
http://www.hhs.gov/ocr/civilrights/resources/factsheets/504.pdf
16
http://schools.nyc.gov/NR/rdonlyres/952DB10B-23B4-4BA5-A09C-4327CBA5B3E9/0/5RevisedDMAF.pdf
17
http://schools.nyc.gov/Offices/Health/default.htm
Health + Education = Opportunity: An Equation that Works
154
9
School-Based Health Centers 18
One hundred thirty-eight SBHCs, serving students in 330 schools, deliver high-quality, comprehensive services
to many New York City children.19 Over 99,000 New York City school children receive services from a school-based
health center each year.20 These clinics are fully certified as New York Article 28 clinics. School-based health
centers provide a range of primary care and ancillary care services. Namely, these include: first aid; diagnosis and
treatment for pediatric and adolescent health needs; assessments and examinations for sports physicals and
working papers; chronic disease monitoring and treatment; laboratory testing; reproductive health services;
STI/HIV testing, treatment, and counseling; vaccinations; mental health services; and, optionally, dental care.21
Improving the health
of a child in poverty
enhances his or her
chance of educational
achievement and
advancement out
of poverty.
Centers are staffed by a multi-disciplinary team of licensed health
care professionals and support staff. By and large, they are staffed
by Nurse Practitioners (NPs) or Physician Assistants (PAs). One
NP or PA is designated to serve between 700 and 1,500 students.
A supervising physician from the center’s sponsoring agency is
required to be accessible to the NP or PA at all times during operating
hours. Mental health needs may be addressed at the school site or
by referral. If services are provided on-site, one full-time licensed
mental health provider should be available for every 700-1,500
students enrolled in the program. Lastly, all Centers have a medical
or health assistant on site who schedules appointments, conducts
data entry, and assists the NP and PA in patient care.
Centers that offer expanded services may have additional staff on-site, which may include a health educator, a
community outreach worker, registered nurses, a nutritionist, or a dental professional. The multi-disciplinary
teams deployed by SBHCs create a “one-stop shop” care model to promote care coordination and ensure that
providers address all aspects of a child’s wellness. The nature of this model allows providers to focus on
achieving high-quality outcomes for their patients.
The total program budget for New York City SBHCs is approximately $39 million per year.22 SBHC revenue
comes from a variety of sources. Approximately half of SBHC operating revenue comes from the Medicaid
program.23 Additional funding comes from state and federal grants.
History and data have shown that access to SBHC care is a fundamentally effective model to promote improved
health outcomes. SBHCs skillfully provide disease prevention and early detection and treatment that fosters
both immediate and long-term wellness.24 Moreover, SBHCs lead to educational advancement and economic
development for youth who are poor and underserved. Studies have shown improved school attendance, grades
and graduation rates as a result of SBHC intervention.25 Improving the health of a child in poverty enhances his
or her chance of educational achievement and advancement out of poverty.26
18
10
Information in this section is borrowed largely from CDF-NY’s previously released report on school-based health centers. The report
can be accessed here: http://www.cdfny.org/research-library/latest-reports/school-based-health-centers.pdf.
19
http://schools.nyc.gov/Offices/Health/default.htm
20
http://www.health.ny.gov/statistics/school/skfacts.htm
21
The New York State Department of Health considers dental services to be “optional.” Many school-based health centers are unable to
provide dental services because of the high cost and inability to supplement Medicaid dental revenue with grant funding.
22
http://www.health.ny.gov/statistics/school/skfacts.htm
23
http://www.cdfny.org/research-library/latest-reports/school-based-health-centers.pdf.
24
Webber et. al. (2005). Impact of Asthma Intervention in Two Elementary School Based Health Centers in the Bronx.
Pediatric Pulmonology: 40 (6), 497-493.
25
http://www.eric.ed.gov/PDFS/ED539815.pdf.
26
Webber MP, Carpinellos KE, Oruwariye T, Lo Y, Burton WB, Appel DK. (2003). Burden of Asthma in inner-city Elementary
School children: Do School-Based Health Centers Make A Difference?” Arch. Pediatric & Adolescent Medicine, 157, 125-129.
Children’s Defense Fund – New York
155
Intersection of the Two Systems
The two service delivery systems currently do not operate with a collaborative model. Largely, they exist apart
from each other. Except in rare situations, OSH does not place a school nurse in a school that already has a
SBHC.27 Of course, if a SBHC only operates part-time in a school, OSH will often place a nurse or other
appropriate OSH provider in the school when the SBHC is not present. The task force agreed that the current
division of services does not reflect the optimal model of care delivery. Members also noted challenges relating
to space and financing. These issues currently prevent a more collaborative sharing of resources and a more
coordinated system of care delivery. Overall, the current level of services provided is not enough for schools to be
an integral, essential link in the greater health care infrastructure for all children. The current system, however,
offers a sound model that ought to be preserved and expanded with the recommendations of this report so that
schools can become critical health care access points for all children.
The Role of Health Care Services in Schools
Undoubtedly, schools cannot be the sole source of care for a child. Children need access to more intensive care
settings, a broader range of specialty physicians and necessary emergency and inpatient services. Schools,
however, are increasingly important entry points for children to access health care services and address health
inequities. The traditional role of the school nurse has grown in scope with nurses now capable of providing
more complex health management activities within schools, with support from additional OSH providers, such
as school physicians and public health advisors. SBHCs have brought full-scale medical clinics into the school
building. These school-based interventions have a unique ability to provide primary and preventive care in a
27
http://schools.nyc.gov/Offices/Health/default.htm
Health + Education = Opportunity: An Equation that Works
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11
way that brings significant savings to the health care system. With that in mind, school health must be considered
as a deeply important link in the larger public health infrastructure for children. No longer should children’s health
stakeholders consider school health as a separate care delivery system. School-based health interventions must
be an integral part of the continuum of care provided to children, ensuring solid connections to community
hospitals, clinics and providers while providing a unique scope of services. As a fully integrated part of the health
care delivery system, schools can play a strong public and primary health care role for children; improving both
individual student and community health.
When detailing the specific role that schools should play in the continuum of children’s health care, it is important
to consider the unique characteristics and advantages of schools. First, school health services must foster the
optimal opportunity for children and youth to learn. Schools primarily serve as educational institutions. As such,
the aim of all school-based services should be to return to children to the classroom and promote the intellectual
growth of children. Children with unmet health needs are far less likely to succeed in school.28, 29 The presence
of unmanaged health conditions in children was shown to be highly correlated with negative performance on
math and reading standardized tests.30 Without proper school-based health support, children lose significant
academic seat time. With minimal health care services in a school, an asthma attack that could be properly
managed in a clinic or prevented with health education and self-management instruction becomes an emergency
room visit that takes the student away from school for at least the rest of that day. Such inefficient care demands
greater financial and parental resources. A school that can better manage the day-to-day health care needs of
its students will enable the best educational outcomes. Health care services should be delivered with the goal
of returning students to class with minimal disruption. The National Association of School Nurses reports the
presence of a school nurse saves teachers an average of 20 classroom minutes each day.31 This health
management must occur for the full spectrum of health care needs, both large and small. Health staff must
manage the minor, first-aid and urgent care needs of students, while also taking on larger health issues – managing
chronic conditions such as asthma and diabetes; accommodating children with special health needs; managing
behavioral health concerns; monitoring children’s weight, diet and exercise; and preventing teen pregnancy.
Second, school health services, particularly in New York City Schools, must serve as a public health safety net.
Beyond ensuring that students have the tools needed to succeed academically, schools are uniquely positioned
to provide health services that students may not sufficiently receive through traditional community providers.
Schools enjoy distinct advantages over community providers in terms of providing care to an often difficult-to-reach
population. Schools are a gathering place for nearly all New York City children. Over 98 percent of children in
the United States between the ages of 7 and 13 are enrolled in school.32 With so much of the young population
easily accounted for, school health providers can generate serious health improvements by addressing a
comprehensive and attentive audience.33 Schools therefore are equipped to serve as the medium for universal
health assessments. Schools promote better overall population health by requiring students to receive needed
immunizations, universal vision screenings, as well as other necessary health screenings. The early detection
and treatment of pressing health care needs helps to secure improved long-term wellness.
12
28
Case, A., Lubotsky, D., & Paxson, C. (2002). Economic status and health in childhood: The origins of the gradient. The American
Economic Review, 92, 1308–1334
29
Ding, W., Lehrer, S. F., Rosenquist, J. N., & Audrain-McGovern, J. (2009). The impact of poor health on academic performance:
New evidence using genetic markers. Journal of Health Economics, 28(3), 578-597.
30
Eide, E. R., Showalter, M. H., & Goldhaber, D. D. (2010). The relation between children’s health and academic achievement.
Children and Youth Services Review, 32(2), 231-238.
31
Five Ways a School Nurse Benefits a School; http://www.nasn.org/Portals/0/about/FiveWays.pdf
32
https://nces.ed.gov/programs/digest/d12/tables/dt12_007.asp
33
Public schools are the major recipient of OSH services. School health services, however, are also available in some private and
charter schools.
Children’s Defense Fund – New York
157
Additionally, schools provide a space in which providers can offer care in a more comfortable and confidential
environment. Many of the services older students need most deeply are sensitive in nature. Often, community
providers are unable to adequately offer the services that address the unique needs of children and adolescents.
Students often fail to seek behavioral and reproductive health services because of the stigma found among
peers and within their communities. In the school setting, adolescents can discreetly access these needed
services and improve their health status.
Addressing Critical Child Health Indicators in Schools
While children face a wide range of health conditions, a few highly prevalent conditions affect children in such a way
that they can adversely influence learning and future health. CDF-NY has identified four critical areas of need:
asthma, behavioral health, obesity, and teen pregnancy. It is important for New York City to provide the resources
for all schools to skillfully manage these conditions for all school
children. Properly allocating health resources in a manner that
Students often fail to
satisfactorily addresses these prevalent health concerns will help
seek behavioral and
secure the greatest academic and future health outcomes for children.
Asthma
Asthma affects more than 10 percent of New York City elementary
school students.34 The high prevalence of asthma among New York
City children has negative effects beyond a student’s health status.
Uncontrolled asthma can lead to increased school absences and
worsened academic performance resulting from frequent trips to
the emergency room during severe asthma attacks.35 One study
found that, on average, children with asthma were absent from
schools five days more than children who do not suffer from
asthma.36 Nationally, children miss 14 million days of school
because of asthma.37 With such reduced seat time, children have
greater difficulty learning. Asthma additionally affects children
from low-income neighborhoods at a higher rate than those in
medium and upper-income neighborhoods. Lower-income
neighborhoods in the Bronx and central Brooklyn have some of
the highest rates of asthma in the country.38
reproductive health
services because of
the stigma found
among peers and
within their
communities. In
the school setting,
adolescents can
discreetly access
these needed services
and improve their
health status.
Research has shown that the presence of school health services aimed at better managing asthma yields both
positive health and educational gains. Though highly prevalent, asthma is one condition that can be treated
easily with proper care management. Accordingly, children can reach their maximum academic potential if
school health providers meet a child’s asthma needs. One study conducted in Detroit elementary schools found
that children who received a school-based asthma intervention experience fewer daytime and nighttime symptoms,
were absent less often, and even achieved higher grades in science.39
34
http://schools.nyc.gov/Offices/Health/default.htm
35
Fowler, M. G., Davenport, M. G., & Garg, R. (1992). School functioning of US children with asthma. Pediatrics, 90(6), 939-944.
36
Fowler, M. G., Davenport, M. G., & Garg, R. (1992). School functioning of US children with asthma. Pediatrics, 90(6), 939-944.
37
http://www.nhlbi.nih.gov/files/docs/resources/lung/asth_sch.pdf
38
http://www.osc.state.ny.us/reports/economic/asthma_2014.pdf
39
http://journal.publications.chestnet.org/data/Journals/CHEST/22008/1674.pdf
12
Health + Education = Opportunity: An Equation that Works
158
13
New York City’s school health system’s treatment of asthma could be used as a model for the scope of services
discussed in this report. Currently, OSH provides a significant level of services aimed at reducing asthma morbidity.
OSH has developed and implemented programs that identify students with this particular need, and equip
these children with the tools to adequately address their asthma as a means of ensuring future health and
academic achievement.
Behavioral Health
One of the most understated health disparities facing children is the lack of treatment for behavioral health
conditions. Among adolescents aged 13-18, more than 20 percent experience a form of mental illness that is
severe enough to impact daily functioning. In a standard class room of approximately 20 students, one would
expect to find four to five adolescents suffering from a serious mental health condition.40 These issues include
such conditions as depression, anxiety, attention disorders and suicidal ideation. Such conditions are certainly
not restricted to adolescents. One report found that among New York City school-aged children, 270,000 were
experiencing some form of significant mental illness.41 An additional 50,000 children under the age of 5 also
experienced some behavioral health issue.42 Despite the high prevalence of behavioral health conditions, research
has shown that treatment uptake rates remain woefully low. One study estimated that half of 8-15 year olds living
with a behavioral health disorder received no treatment in the past year.43 Black children were 70 percent more
likely than White children not to receive needed mental health services.44
Children suffering from behavioral health conditions are likely to miss school more frequently than their peers,
and perceive themselves to be less capable of achieving academic success. 45, 46 One study showed that many
students with a behavioral disorder scored below average on standardized reading, writing and math tests.47
The rate of suspension and expulsion for children with behavioral health needs is three times that of their
peers.48 Unmet behavioral health needs have negative consequences for children beyond the schoolroom.
The percentage of youth in the juvenile justice system experiencing a behavioral health disorder exceeds 70
percent, a disproportionately large share when compared with the general population.49
With so many New York City children experiencing the detrimental impacts of unmanaged behavioral health
diagnoses, it remains critical for schools to be able to manage such conditions. Management of these conditions
has positive returns in the short-term through improved academic success, and in the long-term through a host
of enhanced social outcomes. Half of all lifetime cases of mental health and substance abuse disorders start by
14
40
Blum, R. W., Beuhring, T., & Rinehart, P. M. (2000). Protecting Teens: Beyond Race, Income and Family Structure.
41
Citizens Committee for Children. (2013). A Prescription for Expanding School-Based Mental Health Services In New York City
Public Elementary Schools (1sted.). New York, NY.
42
Citizens Committee for Children. (2013). A Prescription for Expanding School-Based Mental Health Services In New York City
Public Elementary Schools (1sted.). New York, NY.
43
Merikangas, K., He, J., Brody, D., Fisher, P., Bourdon, K., & Koretz, D. (2010). Prevalence and treatment of mental disorders
among US children in the 2001-2004 NHANES. Pediatrics, 125(1), 75-81. doi: 10.1542/peds.2008-2595
44
Children’s Defense Fund. (2014). The State of America’s Children. Washington, DC.
45
Gall, G., Pagano, M. E., Desmond, M. S., Perrin, J. M., & Murphy, J. M. (2000). Utility of Psychosocial Screening at a School based
Health Center. Journal of School Health, 70(7), 292-298.
46
Masi, G., Tomaiuolo, F., Sbrana, B., Poli, P., Baracchini, G., Pruneti, C. A., ... & Marcheschi, M. (2001). Depressive symptoms and
academic self-image in adolescence. Psychopathology, 34(2), 57-61.
47
http://csmh.umaryland.edu/Resources/Reports/CSMH%20SMH%20Impact%20Summary%20July%202013.pdf
48
Blackorby, J.; Cameto, R. 2004. Changes in School Engagement and Academic Performance of Students with Disabilities.
In Wave 1 Wave 2 Overview (SEELS). Menlo Park, CA: SRI International.
49
http://www.ncmhjj.com/resources/faq/
Children’s Defense Fund – New York
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age 14.50 Treatment of behavioral health issues as they emerge during these crucial development years creates
a foundation for recovery, upon which students can achieve improved overall health and social-economic success.
Students who received behavioral health interventions through a school-based program experienced drastic
growth in GPA51; were absent less often52; and were twice as likely as those who did not seek services to remain
in school.53
The adequate treatment of behavioral health conditions requires a robust infrastructure of qualified personnel,
specialized resources and confidential space. While schools have access to students in a comfortable space,
more discussion is needed around developing an adequate scope of services for behavioral health interventions
in schools.
Obesity
Nearly half of New York City school children are living at an unhealthy weight.54 One study of New York City
elementary school students found that 43 percent of students were overweight, of whom more than half were obese
(24 percent overall).55 Prevalence of childhood obesity appears to correlate strongly with a child’s neighborhood.
Lower-income neighborhoods in the Bronx and Central Brooklyn reported the highest rates of childhood
obesity.56 Research has clearly established that obesity makes children more likely to develop diabetes, cancer,
and heart disease later in life. One major study discovered that well over half of obese children showed serious
warning signs for heart disease, and one-quarter displayed warning signs for diabetes.57, 58 More recently, research
is beginning to emerge that also links obesity to poorer educational performance. One study found that obese
children performed worse in mathematics compared to their non-obese peers.59 The researchers suggest that
obesity fosters feelings of social isolation and loneliness, which negatively affect school performance.
Schools manage a large portion of a child’s diet and exercise. Accordingly, they are well suited to improve the
physical health of students by ensuring access to quality food and allowing adequate time for proper physical
activity. Under the existing service model, New York City schools both universally assess the Body Mass Index
of students and educate children on the need and means for getting fit. Schools must heighten and expand
current efforts.
School-based health interventions leveled at getting children to a healthy weight have been shown to yield positive
outcomes for students. A study conducted in Massachusetts schools found that an obesity intervention had
significant downward effects on the prevalence of obesity among students, particularly female students.60
50
Citizens Committee for Children. (2013). A Prescription for Expanding School-Based Mental Health Services In New York City
Public Elementary Schools (1sted.). New York, NY.
51
Walker, S. C., Kerns, S. E., Lyon, A. R., Bruns, E. J., & Cosgrove, T. J. (2010). Impact of school-based health center use on
academic outcomes. Journal of Adolescent Health, 46(3), 251-257.
52
Gall, G., Pagano, M. E., Desmond, M. S., Perrin, J. M., & Murphy, J. M. (2000). Utility of Psychosocial Screening at a
School based Health Center.Journal of School Health, 70(7), 292-298.
53
Brown, M. B., & Bolen, L. M. (2008). The school based health center as a resource for prevention and health promotion.
Psychology in the Schools, 45(1), 28-38.
54
http://schools.nyc.gov/Offices/Health/default.htm
55
Thorpe, L. E., List, D. G., Marx, T., May, L., Helgerson, S. D., & Frieden, T. R. (2004). Childhood obesity in New York City
elementary school students. American Journal of Public Health, 94(9), 1496
56
http://www.nyc.gov/html/doh/downloads/pdf/epi/nyc_comhealth_atlas10.pdf
57
http://www.cdc.gov/healthyyouth/keystrategies/pdf/make-a-difference.pdf
58
http://www.nhlbi.nih.gov/health/health-topics/topics/obe/risks.html
59
Gable, S., Krull, J. L., & Chang, Y. (2012). Boys’ and girls’ weight status and math performance from kindergarten entry through
fifth grade: a mediated analysis. Child development, 83(5), 1822-1839.
60
Gortmaker, S. L., Peterson, K., Wiecha, J., Sobol, A. M., Dixit, S., Fox, M. K., & Laird, N. (1999). Reducing obesity via a schoolbased interdisciplinary intervention among youth: Planet Health. Archives of pediatrics & adolescent medicine, 153(4), 409-418.
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More specifically, researchers showed that the wellness program reduced the number of hours students
watched television and increased their consumption of healthy fruits and vegetables.61
Teen Pregnancy
The reality of pregnancy is one that confronts nearly
17,000 New York City adolescent females each
year.62 The rate of teen pregnancy in New York City
per 1,000 females ages 15-19 is 99.4. That number
jumps to 137.2 in the Bronx. While the rate of teen
pregnancy in New York City has fallen 30 percent
since 2001, it remains well above the national
average of 79.8, and far higher than the rate in many
nearby cities (Boston: 19.4).63 Like asthma and
obesity, teen pregnancies are not evenly distributed
across all neighborhoods. Lower-income neighborhoods
in the Bronx, Harlem and Central Brooklyn report the
highest rates of teen pregnancy.64
Teen pregnancy affects a student’s opportunity to
learn. Faced with the demanding task of caring for
a child of their own, New York City adolescents who
become parents must devote the majority of their
energies toward their child. Just one in three teenage
mothers obtains a high school diploma on time. Even
fewer receive a college degree — less than 1.5 percent
of teenage mothers earn an undergraduate degree by
the time they reach 30 years of age.65
Community providers often do not adequately address
the sexual health needs of adolescents in New York
City. A perceived lack of confidentiality and an
unwillingness of some providers to address these issues contribute to students’ inability to access these services.
New York City schools have been actively delivering sexual health services in neighborhoods with high rates of
teen pregnancy. Through interventions like the Nurse Family Partnership and the Connecting Adolescents to
Comprehensive Healthcare (CATCH) program in schools, New York City DOHMH providers have sharply reduced
the teen pregnancy rate in New York City. Among adolescents who received services under the Nurse Family
Partnership program, new mothers were more likely to have fewer, more spaced out pregnancies and were more
likely to graduate from high school or receive their General Educational Development diploma.66
61
Gortmaker, S. L., Peterson, K., Wiecha, J., Sobol, A. M., Dixit, S., Fox, M. K., & Laird, N. (1999). Reducing obesity via a schoolbased interdisciplinary intervention among youth: Planet Health. Archives of pediatrics & adolescent medicine, 153(4), 409-418.
62
Teen Sexual and Reproductive Health in New York City, Citizens’ Committee for Children of NY Policy Briefing, October 23rd,
2013, Deborah Kaplan, DrPH, MPH, R-PA, Assistant Commissioner, Bureau of Maternal, Infant and Reproductive Health, NYC
Department of Health and Mental Hygiene
63
http://www.massteenpregnancy.org/research/teen-pregnancy-and-birth-rates
64
NYC Vital Statistics of 2012: Pregnancy Outcomes 2012. http://www.nyc.gov/html/doh/downloads/pdf/vs/vs-pregnancy-outcomes2012.pdf.
16
65
https://www.dosomething.org/tipsandtools/background-teenage-pregnancy
66
http://www.cccnewyork.org/wp-content/uploads/2013/11/DOHMHPresentation.pdf
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Based on the assessment of the existing school health landscape and the insight and guidance of the School
Health NYC task force, CDF-NY has developed a set of recommendations to further expand and enhance the
school-based health care system in New York City. The recommendations fall into four broad categories: data
collection; scope of services; securing financing and increasing capacity; and integrating SBHCs and school
nursing services.
Data Collection
Accurate and population-wide data are the foundation for an efficient and comprehensive school health system.
The current school health system does not have an agreed upon method for sharing data across different OSH
and SBHC provider systems. Developing a universal method for tracking school level data points will be crucial
to determining the best allocation of resources.
The recommendations in this report regarding data sharing must be intensely mindful of privacy concerns.
Children’s health stakeholders must maintain appropriate security and confidentiality when sharing any child’s
“protected health information” (PHI). Two sets of federal law protect the health records of students receiving
care in a school; Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and
Accountability Act (HIPAA).67 In particular, these laws restrict the sharing of behavioral and reproductive health
information.
Improve the collection and sharing of data between OSH providers and SBHC providers. Currently,
OSH providers and SBHC providers do not share medical records. OSH providers use the Automated School
Health Record (ASHR) system to collect patient data. The ASHR system is a health record accessible by school
nurses in all New York City elementary, intermediate and high schools.68 It tracks information based on a student’s
“Child & Adolescent Health Examination” form, any IEP information, and any visits to the school nurse. SBHC
providers employ one of many private electronic health record systems. The creation of a new, universally adopted
electronic medical system would be cost prohibitive and would require a burdensome upfront investment of
financial and staff resources. OSH and SBHCs need to offer some access to one another’s medical records,
while protecting a patient’s PHI. At the simplest level, OSH and SBHC providers could create a standard,
shared process for student case management to track health outcomes for students who have received services
from both OSH and a SBHC. The cross-availability of medical records would facilitate better communications,
would reduce duplicate services, and would ensure more coordinated care.
Recommendations
Moving Forward: Recommendations for an Improved
School Health System
Connect school health records with relevant providers in the greater children’s health infrastructure.
In Delaware, school nurses have had success improving the delivery of care to students by connecting school
health records with those of a large community health care system, which includes hospitals and clinics.69
The data linkage has made care more efficient by ensuring that school nurses have the most up-to-date information
on students, helping nurses avoid duplicative or unnecessary tests and follow-up that might take students away
from the classroom. Such a data linkage would be logistically challenging to implement. Providers would need
to be careful to preserve the confidentiality of student’s PHI. Additionally, students in New York City schools
receive care from a multitude of community providers. Connecting school nurses to community provider data
67
Department of Education and Department of Health and Human Services. (2008). Joint Guidance on the Application of the Family
Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To
Student Health Records. Washington, DC.
68
http://schools.nyc.gov/Offices/Health/default.htm
69
http://www.pbs.org/newshour/rundown/access-students-online-health-information-boon-school-nurses/
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would be challenging, but may be successful with an initial pilot program. For example, schools in Brooklyn may
be better served by connecting to the health information systems of a large health system that serves a large number
of children throughout the borough.
New York City schools could connect with certain statewide
data integration efforts. New York State is creating regional
health information organizations (RHIOs) in different areas
of the state to better facilitate the sharing of information
from multiple providers, including primary care physicians,
specialists, hospitals and other community providers. School
health providers, both OSH and SBHCs, should seek to be a
critical contributor and receiver of health information made
accessible by RHIOs.
Such connectivity with local partners will be more complex
in intermediate schools and high schools. Because New York
City allows students to apply to schools outside of their home
district, a school’s student population may not reflect the
population of the community.70 In these cases, many students’
local community providers may be more diversely distributed
across the five boroughs. Evidence suggests, however, that
students tend to favor nearby schools as their first choice.71
Over 80 percent of high school applicants selected a school
in their home borough, at an average of just 2.5 miles
from their home zip code, as their first choice. This finding
suggests that connectivity with local health providers may
still yield worthwhile benefits.
While as described above, optimal, secure and comprehensive data integration will require significant investment
and patience, such investments will have long-term positive returns both financially and for child health.
Track school level data focusing on key health indicators that demonstrate high demand for health
care services. As previously noted, the major public health concerns facing New York City’s school aged
children include high rates of asthma, untreated mental health needs, high rates of obesity, and teen pregnancy.
To best understand the fullness of these health indicators on children’s health and welfare, administrators
and children’s health stakeholders must be aware of the prevalence of these conditions at the school level.
Schools would gain from the development of a simple children’s health vulnerability index, which would identify
those schools and communities most vulnerable to negative educational outcomes and poor adult health.
This vulnerability index would benefit from being simple and universally adopted. It would be helpful to
supplement health data with additional factors about the school; particularly, the poverty rate within the
school, the school’s graduation rate, the number of suspensions, the number of students with IEPs, and the
school absenteeism rate. These factors have been shown to reliably indicate social service need.72 With all
schools adopting the children’s health vulnerability index, Office of School Health staff would have a standardized
tool for assessing which schools face the greatest health challenges.
18
70
http://schools.nyc.gov/ChoicesEnrollment/Transfers/PublicSchoolChoice/default.htm
71
Corcoran, S. P., & Levin, H. M. (2011). School choice and competition in the New York City schools. Education reform in New York
City: Ambitious change in the nation’s most complex school system, 199-224.
72
Balfanz, R., & Byrnes, V. (2012). Chronic Absenteeism: Summarizing What We Know From Nationally Available Data. Baltimore:
Johns Hopkins University Center for Social Organization of Schools.
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Use enhanced data to determine the placement of more intensive school health services, specifically SBHCs.
Data collected from children’s health vulnerability index can be combined with existing school health data to
create a more comprehensive assessment of school health need. Schools typically receive more intensive
health care services based on the number of students in each school, the presence of students with special health
care needs, a principal’s desire to have enhanced health services, and the availability of a willing provider and
adequate space within a school. With limited resources for school health delivery, it remains important for the
OSH to identify schools with the highest health care needs. Of course, implementation of more intensive school
health services will still yield to principal and provider discretion and space availability, but the availability of
more transparent and accessible data will stress the need to address health care concerns within the most
vulnerable schools.
Scope of Services
With the new data systems in place, school health stakeholders can move forward in developing a universal
scope of services. In order to have an equitable health care system in schools, all children must have access
to a standard baseline level of services. This baseline of services should manage those conditions that dampen
children’s ability to learn and increase their likelihood of being unhealthy adults. Additional services can be
provided above the baseline level based on need identified by school input and data.
Develop a uniform scope of services, focusing on preventive services for all and intensive services for
those identified as having increased needs. A school health scope of services should reflect the ability to
manage those conditions that impact a child’s ability to learn and grow into healthy adults; specifically, asthma,
behavioral health, obesity and teen pregnancy. While an ideal school health system with unlimited resources would
provide comprehensive, intensive health care services in all schools, New York City schools face limitations of
funding and space. Scarce, intensive health care resources need to be allocated in a strategic manner. The
baseline of services should stress universal assessment and preventive screenings. All schools should have the
capacity to screen students for — at minimum — asthma, behavioral health issues, sexual health concerns and
obesity. Universal screening would then lead into lower level treatment options, such as asthma self-management
education, appropriate behavioral health referrals, sexual health education and appropriate access to contraceptives,
and nutritional counseling and physical education. Students who display a greater need for services would be
directed to more comprehensive services. In conjunction with earlier recommendations around data sharing, schools
identified as having a higher need would be prioritized for receiving a greater share of school health resources.
In many ways, this scope of services is at least initially reflected in the current OSH delivery model. OSH promotes
universal screenings for prevalent health care issues, monitoring students’ body mass index, assessing vision
problems and more. On top of these screenings, OSH has launched a number of initiatives that seek to provide
more intensive services for prevalent conditions. For example, the Healthy Options and Physical Activity Program
(HOP) helps students reach a heathier weight following initial assessment.73 CDF-NY, however, recommends
further collaboration between OSH and SBHC services as a means for fully implementing the universal scope
of services. This collaborative model is further described in a later recommendation.
Increasing Capacity and Securing Financing
Preservation and expansion of the school-based health model are deeply needed. The best school health system
cannot be achieved by simply maintaining the current level of services. Before expanding, school health delivery
models must secure the necessary operational capacity and financial viability.
73
http://schools.nyc.gov/Offices/Health/default.htm
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Require school administrators to consider the health care needs of a community when constructing a
new school or performing a major capital renovation on an existing school. In New York City, administrators
face great difficulty finding adequate space to accommodate the educational and social supports children
need. With so many schools constructed before the advent of SBHCs, many schools simply do not have the
space to accommodate a fully functioning health clinic. As administrators and the School Construction Authority
seek to develop new schools and perform capital renovations, the health care needs of children should influence
the design of schools.74 With the development of the community schools model, future schools will not only be
educational institutions, but also centers of social support and empowerment. The inclusion of health care needs
and the appropriate space to develop healthy children from the initial stages of the planning process will be
critical to the achievement of the goals outlined in the community schools model.
Partner with community organizations to deliver health care services off-site. Understandably, not every
school will be able to accommodate a full-fledged school-based health center. For these schools, it will be important
for administrators and OSH staff to secure memorandums of understanding (MOUs) with community organizations
to provide health care services beyond what OSH can routinely administer. The appropriate MOUs will ensure
that the schools meet the previously described scope of services. Community health centers, hospitals and
behavioral health providers will be crucially important partners when establishing needed care connections.
For example, schools in Brooklyn partnered with the non-profit organization OneSight to deliver vision services
to students.75 Under an agreement with two Brooklyn schools, OneSight parks its “Vision Van,” a mobile vision
clinic, in front of the school where it can conveniently provide services to students. Students can receive an eye
exam and obtain needed eyewear with minimal disruption to their time in the classroom. MOUs with organizations
that can provide near by clinic space or mobile units for the delivery of certain, needed services can help
mitigate school space issues. This strategy helps schools manage those more intensive health care issues
that traditionally require a full clinic to treat.
Secure enhanced Medicaid funding for Office of School Health services. Currently, OSH services draw
very few Medicaid reimbursement dollars. As previously noted, allocations from school districts and the
DOHMH budget fund those school health services not provided by SBHCs. Burdensome regulations regarding
Medicaid billing and an inability to properly document services at the service delivery location have prevented
school health providers from eliciting critical Medicaid funds. A recent report from the New York City Comptroller’s
Office noted that New York City failed to secure $356 million in Medicaid revenue under the School Supportive
Health Services Program (SSHSP) between fiscal years 2012 and 2014.76 As of 2010, New York State received
approval from the Centers for Medicare and Medicaid Services to distribute Medicaid dollars in schools for the
following services delivered to students with IEPs:77
20
• Medical Evaluations
• Occupational Therapy
• Medical Specialist Evaluations
• Speech Therapy
• Psychological Evaluations
• Psychological Counseling
• Audiological Evaluations
• Skilled Nursing
• Physical Therapy
• Special Transportation
74
School Construction Authority; http://www.nycsca.org/Business/WorkingWithTheSCA/Design/Pages/DesignRequirements.aspx
75
http://www.ny1.com/content/news/education/207525/nonprofit-has-clear-vision-for-city-s-underserved-students
76
Office of the New York City Comptroller. (2014). Money Left on the Table: A Review of Federal Medicaid Reimbursement
to the New York City Department of Education (1sted.). New York, NY: Scott Stringer.
77
Office of the New York City Comptroller. (2014). Money Left on the Table: A Review of Federal Medicaid Reimbursement
to the New York City Department of Education (1sted.). New York, NY: Scott Stringer.
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Medicaid funding could help reallocate existing funding toward expanded services and more universal assessments
aimed at identifying major public health needs. It should be noted that, currently, DOE, not DOHMH, is responsible
for securing SSHSP Medicaid reimbursement. While further sustaining the financing of school health through
the integration of DOE and DOHMH funds would be optimal, it presents a complex challenge.
School health stakeholders must carefully examine the practice areas for which schools can submit Medicaid
reimbursement claims. City funds should not be used for services that could possibly be paid for with federal
dollars. However, considering the intense federal scrutiny over these services, administrators and providers must
be careful to seek reimbursement only for appropriate services that can be correctly documented. The process
of developing the appropriate protocols and data-sharing needed for school health Medicaid reimbursement will
require significant input from providers and administrators at all levels of government.
Preserve the financial viability of SBHCs at the state level, particularly with regard to Medicaid
managed care. The New York State Department of Health has scheduled school-based health center providers
to transition into a Medicaid managed care reimbursement model by July 1, 2015. CDF-NY previously developed
a report and set of recommendations on this issue. Typical managed care protocols require providers to perform
more care coordination activities — often in the form of seeking prior authorization for services, obtaining referrals
and establishing contracts with each managed care organization. In order to preserve financial viability of SBHC
providers who already face a difficult financial landscape, the transition to managed care will need to ensure
that providers can secure guaranteed reimbursement for services delivered to students. While it is acceptable
to require SBHC providers to secure prior authorization and submit to care coordination requirements for primary
and preventive services; chronic disease management, urgent, behavioral, and reproductive care will need to
remain accessible without first securing authorization from managed care organizations. Additionally, the state
must ensure that managed care organization reimburse SBHCs at sustainable rates. CDF-NY’s report showed that
a transition to typical managed care rates would draw approximately $14 million from SBHCs in the downstate
region. Clearly, average managed care rates would lead to the closure of some SBHC sites in New York City and
would make expansion of the program nearly impossible. Lastly, in order to be prepared by the July 1, 2015
deadline, SBHCs will need to be able to contract with managed care organizations and credential providers
in an expedited fashion. The ability to adequately bill providers will be essential to securing any Medicaid
revenue. For a further analysis of this issue, you can access CDF-NY’s report here:
http://www.cdfny.org/research-library/latest-reports/school-based-health-centers.pdf.
Work with private and Child Health Plus (CHPlus) plans and the Department of Health to develop a
satisfactory model for SBHC providers to bill for reimbursement. As SBHCs transition into Medicaid
managed care, they will need to develop the capacity to bill multiple managed care organizations. With only
minimal extra resources, this capacity can easily translate into the ability to more easily bill private insurance
companies and Child Health Plus plans. More complete billing will enable SBHCs to secure a greater amount
of revenue and decrease the amount of uncompensated care delivered. Many private and CHPlus plans do not
reimburse primary care services not provided by a child’s primary care physician. SBHCs, however, typically
provide complementary, rather than duplicative, services. State administrators, plan managers and SBHC
providers must create a rate structure that reimburses SBHCs for the complementary services provided by a
non-PCP SBHC provider that improve a child’s health outcomes.
Additionally, providers and plans must be sure to address issues around confidential services and the consequent
explanation of benefits. Currently, SBHCs often provide care for confidential services, such as STI counseling,
without reimbursement because the submission of a claim would send an explanation of benefits to a child’s
parents, thus violating that child’s confidentiality. Managed care plans, CHPlus plans and private plans will
need to develop a mechanism for identifying confidential visits and ensuring that they suppress the explanation
of benefits.
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Explore the possibility of SBHCs joining or forming a Performing Provider System (PPS) under the
state’s Delivery System Reform Incentive Payment (DSRIP) initiative. The state has introduced a bold
vision for reforming the payment structure within Medicaid. The DSRIP program would work to slowly shift
Medicaid funding toward an outcome based reimbursement model. Performing Provider Systems will be networks
of Medicaid providers and community-based organizations that coordinate a comprehensive list of services aimed
at better coordinating care, avoiding unnecessary hospitalizations and improving patient health outcome measures.
These projects will begin receiving payments in 2015. The state has identified a desire to make this delivery
system reform a cornerstone of the newly emerging health care landscape in New York.
SBHCs would benefit from inclusion in a PPS. The services delivered by SBHCs already work to integrate a
diverse team of providers in a way that fosters integrated, outcome based care. Inclusion in a PPS would enable
a SBHC to receive payment for their strong capacity to promote improved health outcomes, while best positioning
themselves to be active players in the future of New York’s Medicaid delivery system. For example, SBHCs have
worked to reduce hospitalizations associated with asthma attacks. Often these hospitalizations can be avoided
with proper self-management education and appropriate medical attention in the SBHC setting. Such a capacity
to reduce unnecessary emergency room visits and hospitalizations would make SBHCs a valued partner in a
PPS. Additionally, securing prominent roles within PPS networks would help establish schools as a key component
of the health care infrastructure needed to foster the wellness of children.
Integrating School-Based Health Centers and School Nursing Services
An optimal school health delivery system is one that finds school-based health centers and school nurses working
together. A complementary model that utilizes the talents of both SBHC and OSH staff will enable schools to
offer a universal baseline of services, while also addressing more intensive needs.
Develop a complementary model that incorporates school nurses into school-based health centers.
The OHS does not place a school nurse in schools that have a SBHC. This existing policy creates a bifurcated
school health care system in which school nurses and other OSH staff coordinate very little with SBHCs. CDF-NY
believes that the systems need not be mutually exclusive. School health stakeholders should develop a model
that combines school nurses with services offered by SBHCs.78
School nurses and SBHC providers have found success working under
a collaborative model in other parts of the country. Public schools in
Maryland have particularly enjoyed the benefits of the collaborative
model. During the school year beginning in 2007, 72 schools
employed the services of both a registered school nurse and a SBHC.
Under the Maryland model, the school nurse often served as the
child’s access point for care. The school nurse would assess the
situation and evaluate whether the children could be treated under
the nurse’s care or would need to be referred for a higher level of care
provided through the SBHC.
78
22
http://www.marylandpublicschools.org/msde/divisions/studentschoolsvcs/student_services_alt/school_based_health_centers/index.html
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Already, OSH providers and SBHCs provide distinct and complementary services. Under a more collaborative
process, OSH providers, primarily school nurses, would manage the day to day flow of health needs within the
school; while SBHCs would deliver more comprehensive, in-depth health services.79 School nurses would be
able to perform standard screenings and assessments, manage students’ first aid needs, monitor chronic illnesses
and administer medications, and implement students’ IEPs. SBHCs would continue providing primary, behavioral
and oral health services, offering physicals, prescribing medication, performing lab tests, and connecting students
with public and private health insurance options. The two provider systems, under this model, could coordinate
the care of students, and collaborate on services such as developing and offering health education programs.
Under this model, OSH providers and SBHCs could best ensure the healthy growth and development of children,
while also ensuring they have the best opportunity to succeed without creating inefficiencies.
Conclusion
As New York City moves toward a future of community schools, children’s health stakeholders must discern the
appropriate role of health care services within schools. This report suggests that schools should play a fundamental
role in the fostering of healthy children. The children’s health care delivery system must evolve to better incorporate
schools as an integral actor in the promotion of wellness. While schools cannot supplant traditional care delivery
models, it would be foolish to diminish the inherent advantages of school-based health care delivery to the simple
management of daily first aid needs. Schools capture an often hard-to-reach population and offer a safe,
confidential space in which providers and students can engage in honest and meaningful conversations that
promote children’s wellness. In a time where the health care landscape is renewing its focus on outcomes based
medicine, schools provide an exceptional opportunity to capture the positive health outcomes that ensure both
an optimal learning environment and a healthy adulthood.
Already, New York City delivers care in schools under a robust and diverse provider system. The recommendations
in this report hope to capture the strengths of the existing school health system and further strengthen and
sustain that model in a changing health care landscape. CDF-NY’s recommendations regarding data collection;
scope of services; securing financing and increasing capacity; and integrating SBHC and school nursing services
will help school health delivery systems meet the long-term needs of New York City school children. The intersection
of health and education may happen first for a child in their school, but these two forces will continue to cross
paths as graduation approaches and long into adulthood. Children’s advocates ought to safeguard this initial
crossroads and work to ensure that it becomes a launching pad for lifelong wellness.
79
National Assembly on School-Based Health Care and National Association of School Nurses;
http://ds5cvxtqu2rt0.cloudfront.net/media/pdf/FactSheet_June14_1.pdf
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15 Maiden Lane, Suite 1200, New York, NY 10038
p (212) 697-2323
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www.cdfny.org
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