Redesigning school health to address health and educational disparities in Baltimore City

What if by reimagining school health, we could harness the power of schools to reduce health and educational disparities at the same time?

Photo of Sara Johnson
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Founding Story: Share a story about a key experience or spark that helps the network understand why this project got started or a story about how you became inspired about the potential for this project to succeed.

In the Spring of 2015, Freddie Gray’s death in police custody prompted an uprising in Southwest Baltimore that directly impacted the neighborhoods where students at KIPP Baltimore school, the site of this project, and their families live. When school opened after the uprising, teachers remarked that many students seemed relatively unfazed by the chaos that had erupted around them. The challenges that children in Baltimore had faced for generations were laid bare in the national media, but it was business as usual, even for the youngest children. Our team has worked at Johns Hopkins' Harriet Lane Clinic for years providing culturally-competent, community-linked child and family services to highly-vulnerable families in Baltimore. Nonetheless, the uprising underscored that to address the root causes of intergenerational transmission of disadvantage and poor health, we need to leave the clinic and go where kids and families spend their time: schools. Equally importantly, we need partner with schools, not simply co-locate clinical services in schools, to provide what it takes to be healthy and ready to learn. Beyond meeting every student's basic healthcare needs, we need to link students with mental health services and scaffold the skills that facilitate both health and academic achievement across the life span. This happens in classrooms, playgrounds and hallways, as well as in clinical settings.

Which categories describe you? (the answer will not be public)

  • White (for example: German, Irish, English, Italian, Polish, French, Caucasian)


Location: Where is your organization headquartered? [State]

  • Maryland

Location: Where is your organization headquartered? [City]

Baltimore City

Location: Where is your project primarily creating impact? [State]

  • Maryland

Location: Where is your project primarily creating impact? [City]

Baltimore City

Problem: What problem is this project trying to address?

Children growing up in poverty are, overall, less healthy than their more advantaged peers. This is due to their greater exposure to a variety of health risks (e.g., limited primary care, poor nutrition, lack of physical activity, trauma, family instability). Poor physical and mental health in childhood negatively impacts attention, learning, persistence, and school engagement, as well as future educational achievement and attainment. Given the interdependent relationship between health and educational outcomes, promoting a healthy foundation for poor children is key to closing the achievement gap. To date, however, health and educational interventions have been implemented separately, limiting their overall impact on child health outcomes.

Children growing up in poverty are, overall, less healthy than their more advantaged peers. This is due to their greater exposure to a variety of health risks (e.g., limited primary care, poor nutrition, lack of physical activity, trauma, family instability). Poor physical and mental health in childhood negatively impacts attention, learning, and school engagement, as well as future educational achievement and attainment. Given the interdependent relationship between health and educational outcomes, promoting a healthy foundation for socioeconomically disadvantaged children is key to closing the achievement gap. To date, however, health and educational interventions have been implemented separately, limiting their overall impact.

Schools provide a natural setting in which to address children’s health and psychosocial needs. Though many school-based health clinics exist, their services are typically limited in scope, restricted to a subset of students, and not integrated with educational activities. Given the acute and complex needs of children in poverty, a new approach to school health is needed. This approach must: 1) provide comprehensive pediatric care tailored to the needs of children in poverty; 2) promote the foundations of wellbeing for all students (healthy behaviors, socio-emotional skills development, stress management) as part of the school day; and 3) promote a positive school climate. By working in partnership, health and educational stakeholders can address the shared determinants of health and educational disparities that limit opportunities for students to achieve their full potential.

In August 2015, with a gift from philanthropy, Johns Hopkins University, under contract with the Baltimore City Health Department, partnered with KIPP Baltimore school to launch the Rales Health Center (RHC). KIPP Baltimore is a Baltimore City Public charter school whose student body (n=1,500 students) is 99% African American and 88% free-lunch eligible. RHC is staffed by a pediatrician, nurse practitioner, two school nurses, a medical assistant, a school wellness coordinator, and a family advocate. A mental health team is also on site. RHC provides school health services (i.e., school nursing) to all students in the school, as well as pediatric care including acute care, chronic disease management, and preventive health services for health center enrollees. Schoolwide efforts include screening, and health campaigns for all students. In addition, RHC staff explicitly work in partnership with school leadership and staff to identify and address student psychosocial needs that impact education, e.g., promoting attendance, attending individualized education plan meetings and parent-teacher conferences, and screening students with disciplinary problems for unmet psychosocial, mental health or other medical needs.

In the fully integrated RHC model, clinicians are focused on wellness and prevention, rather than simply health care and treatment of disease. Further, RHC engages with students and families where they already spend time and makes addressing wellness a natural part of the fabric of families’ lives. The expectation that wellness is both attainable and accessible, is critical to building student, family, and community well being.

Is your model focused on any of the following traditionally underserved communities?

  • Communities of color
  • Low-income communities

Does your model work within any of the following sectors?

  • Education
  • Mental Health
  • Other

If you chose "other," please share the sector you work within here:

Health care

Year Founded


Project Stage

  • Growth (the pilot has already launched and is starting to expand)

Example: Walk the network through a specific example of what happens when a person or group engages with your solution.

Last year, "Janae", a student with asthma was absent 23 days. She was sent home from school repeatedly by the school nurse, and her mother struggled to pick her up while keeping her job. This year, when the Rales Health Center (RHC) opened, they determined that she had not been taking her asthma medication because it was challenging to get to the pharmacy. The RHC team now has her asthma medication delivered to school and she takes it with a nurse every day. Her symptoms are under control so she is participating in an after-school kickball program and a healthy cooking class. She is learning mindfulness based stress reduction and socio-emotional skills in her classroom. She has missed only 2 days of school.

Impact: What was the impact of your work last year? Please also describe the projected future impact for the coming years.

This year, Rales Health Center (RHC) at KIPP Baltimore had more than 16,800 visits to the school nurse, and more than 1000 visits to the pediatrician or nurse practitioner. RHC avoided more than 60 emergency department visits through services including prescription delivery to school, treatment by a doctor in school, and more than 4200 visits for daily medication administration and chronic disease management (e.g, asthma, diabetes, ADHD). More than 100 students were found to have vision problems and received glasses to facilitate school success and engagement. A variety of wellness programs including student mindfulness, conflict resolution and life skills, reproductive health education, oral health screening, before and after school physical activity programs, as well as parent and teacher-focused wellness programs (yoga, cooking, fitness contests) helped us to reach every student.

Organization Type

  • nonprofit/NGO/citizen sector

Annual Budget

  • $500k - $1m

Financial Sustainability Plan: What is your solution’s plan to ensure financial sustainability?

This project is currently supported by philanthropy. Health care reform provides a window of opportunity for program sustainability. The Affordable Care Act provides support for establishing new primary care access points. Further, providers and insurers are compensated (or penalized) based on their ability to meet population health and quality of care benchmarks, suggesting that insurers are a key potential future source of funding.

Unique Value Proposition: How else is this problem being addressed? Are there other organizations working in the same field, and how does your project differ from these other approaches?

This program is arguably the most comprehensive school health model in the country. While many excellent school based health centers exist, and there are outstanding models for wellness programs in the community (some of whom we partner with in this endeavor), the unique value proposition for this project is integrating both direct provision of health care and preventive services, along with weaving health into children's everyday lives at school. This is designed to promote the health and achievement of the whole school, including staff, not just the students who seek health care.

Reflect on the Field and its Future: Stepping outside of your project, what do you see as the most important or promising shifts that can advance children’s wellbeing?

Alignment of healthcare, public health, and educational sectors requires common priorities, cost-sharing, and a systematic approach to data sharing. To date, data sharing has been limited by historical separation between health and educational stakeholders and by privacy laws. Linked health and educational data systems and a consistent approach to addressing privacy laws (HIPAA/FERPA) to support communication are needed to fully realize the power of schools in promoting student health and well being.

Source: How did you hear about the Children’s Wellbeing Challenge? (the answer will not be public)

  • Word of mouth

Program Design Clarity

The main beneficiary community is students, parents, staff and community members at KIPP Baltimore, a public charter school in over Baltimore City. We provide health services, and we partner with the school to support wellness programs that are designed to reach the whole community (e.g., a FunRun, cooking classes, stress reduction classes). These activities take place daily throughout the school year. A parent advisory committee guides programming, identifies priorities, and provides feedback. A school wellness committee includes, including staff, parents, students and wellness experts.

Community Leadership

We engaged in a community needs assessment before launching the Rales Health Center, soliciting the input of families, school staff, and community members. We have an active parent advisory group, led by a team member with expertise in community organizing. The parent advisory group explicitly focuses on building parents’ voice in programming and leadership skills for change making and as a vehicle for promoting equity and inclusion.

Age of Children Impacted

  • 3 - 5
  • 6 - 12
  • 12+

Spread Strategies

The goal of this project is to provide proof of concept for scaling of the model to other urban settings and school districts. Johns Hopkins University researchers will carefully evaluate the impact and cost-effectiveness of this program for the healthcare and educational systems and for society. This kind of evaluation data, which is critical to justifying further integration between healthcare and educational sectors, is currently lacking.

Reflect on how your work helps children to thrive. How are you cultivating children’s sense of self, belonging, and purpose through your model?

This program is focused on helping children get the tools they need to thrive- good health, strong socioemotional skills, supportive and nurturing learning environments, and tools to help them deal with the adversity and challenge that they face. Activities such as mindfulness based stress reduction, socio-emotional skills development, and promotion of positive school climate help to create conditions of safety, belonging, and well-being.

Leadership Story

Co-Directors of the Rales Center, Drs. Tina Cheng and Sara Johnson have been working to reduce health and educational disparities in Baltimore City for many years. Our clinic, the Johns Hopkins Harriet Lane Clinic is a national model for addressing the social determinants of health. Nonetheless, many of our patients were not making it to the clinic, so we needed to go where kids and families spend time: school. Child health and educational outcomes are interdependent, and we came to realize we should address the shared determinants of health and educational disparities in an integrated way.

Leader's LinkedIn Profile (URL)

Evaluation results

3 evaluations so far

1. Relevance: Does this project seem to help children (ages 0 to 12 years) develop a strong sense of self, belonging, and purpose?

5 - Yes, this is great! The project lays out a strong, compelling case for how its model nurtures children’s wellbeing. - 66.7%

4 - It seems like a good fit, and the model talks explicitly about children’s wellbeing. - 33.3%

3 - I think so. The project seems related to children’s wellbeing, but the logic is vague. - 0%

2 - Not sure. The project doesn’t have much to do with wellbeing, or it doesn’t give enough information. - 0%

1 - Nope, this project definitely doesn’t fit the challenge brief (e.g., It doesn’t help kids younger than 12, isn’t in the U.S., etc.) - 0%

2. Innovation: Does this project tackle children’s wellbeing from a new angle?

5 - I loved this! The project describes a novel model that addresses important cultural or systemic barriers. - 66.7%

4 - This is pretty cool. The project is addressing an important problem in a new or compelling way. - 0%

3 - I feel like there’s something there, but I want more details about what makes it distinctive. - 0%

2 - It’s a good project, but I’ve seen others like it before. - 33.3%

1 - It was confusing or hard to tell what it made it different. - 0%

3. Social Impact: What is this project’s potential for creating positive social impact?

5 - Lots of potential. This project is achieving impressive results, and it’s growing quickly. It could absolutely inspire changes in the ways we approach caring for kids nationally, across sectors (e.g. childcare, healthcare, education). - 66.7%

4 - Pretty good potential. This project demonstrates significant positive impact so far, and it could scale regionally or nationally one day and fundamentally change how a system operates (e.g. childcare, healthcare, education). - 33.3%

3 - Budding potential. This project is creating local impact, but it would take a few adjustments before it could scale. - 0%

2 - Some potential. This project demonstrates some initial positive impact, but it would require major changes before it could scale. - 0%

1 - Limited potential. This project has great intentions, but it looks like it does not include key drivers of a shift towards children’s wellbeing. - 0%

4. Overall, how do you feel about this idea?

5 - This idea rocked my world. It’s awesome! - 33.3%

4 - This idea seems really exciting. With a little more polishing, it’d be among my favorites. - 33.3%

3 - I think the idea is great, but it needs some work before it moves onto the next round. - 0%

2 - I liked it fine but preferred others. - 33.3%

1 - It didn’t make my heart beat faster. Needs significant revisions. - 0%

5. Offer some feedback. Where should this participant spend some time revising?

DEFINING THE PROBLEM. Make sure to articulate the root causes or main barriers of the social issue your project addresses. (Founding Story, Problem, Solution). - 0%

CLARITY OF MODEL. Make sure to mention (a.) the beneficiary, b) the main activities, and c) how those activities drive social impact. Keep it streamlined! - 0%

MARKETPLACE. Make sure to research other players in this space and articulate how this project is different. I didn’t get a complete sense of how this project compares to others. - 100%

IMPACT POTENTIAL. Make sure to use specific numbers to describe what your project has achieved so far! And consider how you might scale the model or its insights, through partnerships, trainings, or franchising. - 100%

WRITING STYLE. Try to stay concise and make it vivid. Avoid jargon. - 0%

Nothing stands out! I thought it was great. - 100%


Join the conversation:

Photo of Samantha Wilson

Hi Sara,
Thanks for sharing the story. Being a leader of the research group (Basic Education in Richmond and Basic Education Tips), I know myself that exceptional leaders are invariably down to earth and humble people. They do not fish for compliments or endeavor to be in the spotlight. Quite the contrary. It is for others to highlight their achievements and glorify them. As part of their position and due to their knowledge and skills, they are expected to be the spokesperson for the organization. Eventually, leaders are only concerned about results and the best possible manner to achieve them.

Photo of Alicia Spitznagel

Excellent job Sara! I am rooting for you and the entire Rales Center team!!

Photo of Brittany Lothe

hi Sara - I enjoyed learning more about your work likely a direct result of Awesome partners in your network. Congrats on your early successes!