Prior to 1993, and at the time of the last SACS visit, the Health Service was staffed 24 hours per day, including weekends, with registered nurses. A pediatrician served as the Director of Health Services and was available 2 hours per day. A contracted nurse practitioner provided limited gynecological services. In 1993, the Health Center model was revised by the college administration and an OB/GYN nurse practitioner was hired as the Director of Health Services. The 24 hour nurse position were eliminated and a head nurse who staffed the Health Center 8:30 AM to 5 PM Monday through Friday. A part-time Family Practice Physician provided 4 hours of on-site coverage per week (one hour per day for 4 days). In the November of 1995, the OB/GYN nurse practitioner resigned. The Health Service was once again re-evaluated by the college administration and the model of "primary care" was adopted. An adult nurse practitioner with an academic background was employed as the Director of the Health Service on February 1, 1996. The part-time physician hours were reduced to only 2 hours per week of on-site appointments with full 24-hour consultation to the nurse practitioner. In addition, the adult nurse practitioner provided all after-hours-call in collaboration with the Resident Coordinators and Campus Safety.

In the fall of 1996, the two separate divisions of health and counseling were merged by the college administration. The Director of Heath Services was appointed as the Director of Health and Counseling and given the mission to develop a clinical counseling center. This change was a direct result of the resignation of the full-time counselor in the spring of 1996. Prior to 1996, licensed counselors had staffed the counseling center since 1986. (See CCL Binder.)

The Mary F. Harley Health Center, which encompasses both health and counseling services, has evolved into a holistic model of primary care. The holistic model is established from the concept of the whole person (Mattson, 1982). The holistic model defines health as the state of being in which a person’s body, mind, and spirit are in balance, functioning with utmost capacity or at a high level of wellness, and in tune with the natural, social and spiritual environments. However, it is not to suggest an alignment with a particular faith, but rather the acknowledgment that the three components mind, body and spirit need to work in harmony with the environment. This framework is most appropriate for a woman’s college because of both the low and high health risks of this age and gender group. This framework provides an opportunity to educate women about their own bodies and health risks, which supports the academic mission of both the student and the institution.

In comparison, this model differs significantly from most student health centers of other small colleges. Many student health centers do not provide total primary care or follow chronic cases because they are staffed by RNs only and are often located in a college town setting with a hospital. This is ineffective in a rural location, such as Sweet Briar, because ill students would find that they had to rely on seeing a physician only during certain times or use the emergency room as their source for immediate or primary care. As a result there may be multiple trips to the health center or emergency room with time missed from academics. In addition, students would have to seek outside referrals for many conditions that could not be diagnosed by RNs. In contrast, the concept of cost-effective primary care provides a health care provider, such as a nurse practitioner, who is knowledgeable and licensed to diagnosis, treat and manage acute and chronic illnesses and injuries.

The primary care framework is most suitable for college health (ACHA Guidelines, 1993). At Sweet Briar College, this model incorporates the team concept of a RN/LPN, NP, MD and counselor who work collaboratively. Included in this team are two highly specialized areas of medicine: psychiatry and orthopedics. A psychiatrist is available 24 hours a day for consultation and sees referred students in his office. Rotating orthopedic surgeons provide on-site clinic times to students, typically athletes, every other week and at other times in their offices. When necessary, the NP or MD either can refer students to other specialist. Collaboration also exists between the student’s "primary care physician" at home and the health care provider in the health center in order to ensure continuity of care. The counseling staff contracted from Centra Health, completes the team concept of primary care by allowing convenient and accessible evaluation and treatment of psychosocial issues while collaborating with the NP and MD. Short term psychotherapy is the model for the counseling center.

Another important component of primary care is patient education. Patient education is achieved primarily in two ways. First, by promoting self-care. Self-care is a strong principle in effective holistic care. It is not to be confused with self-help groups, which are problem-oriented or disease-oriented. Rather, self-care relies on the individual taking responsibility for their health (Levin, 1976). Self-care strategies are incorporated in individual appointments and programs and available in pamphlets and literature located at the health center. Secondly, peer education has been shown as a very effective way to promote health (Bento, 1995). In the fall of 1997, the Director of Health Services initiated the peer health educator and advocate program, known as the Sweet PEAs. Students were selected from an application pool and trained in the areas of alcohol and drugs, nutrition, sexuality, relationships and stress management. The purpose of the Sweet PEA program is "To heighten the awareness and understanding of women’s issues pertinent to student health and well-being in order to establish a campus wide climate of healthy lifestyles." The goals of the program are to:

1. Provide information and guidance to enhance the development of the student’s optimal social, spiritual, mental, physical and emotional well being.
2. Increase health-promoting behaviors to guard against disease and to seek appropriate care when indicated to minimize the effects of disease and maintain optimal wellness.

The Director of Health and Counseling Services is the Sweet PEA advisor and coordinates all training, programming and funding for the program. Since its inception, the group has grown from six charter members to a present student staff of fourteen members in four years. The Sweet PEAs have developed and implemented their own publication, known as Stall Stories, conducted and organized dorm and campus-wide educational events on alcohol, nutrition, HIV, stress management and healthy relationships and participated in local, state and national conferences.

The process of assessing the changes that have occurred since the last SACS visit have consisted of reviewing the utilization of services, the initiation of patient satisfaction surveys in 1997 through 2000, and the analysis of other data reflective of services provided by health and counseling. For example, the hours of service received a low satisfaction on surveys, which resulted in the expanding of morning hours to include the student’s lunch hour. Overall, the utilization of health and counseling services has risen by 43% since 1993, primarily due to the assessment based changes. Students have indicated on patient satisfaction surveys and other surveys a high rating in confidentiality, quality of service and usefulness of educational programs. (See CCL Binder.)