Reorganizing School Health - Overview

Managed care's impact on our health care system has been monumental -- altering the delivery and evaluation of health care services. Leading to a paradigm shift focusing on outcomes and accountability, managed care is stimulating similar changes in schools as well. Coinciding with this shift is an increasing interest in both the medical and political communities about how we can best meet children's health care needs. Many see providing medical homes as the answer to ensuring access to care. This trend, reflected in the recent passage of the State Child Health Insurance Program (CHIP), comes about at a time when children are losing private insurance coverage at alarming rates and suffering from elevated rates of asthma, obesity and other preventable conditions. Due to their daily access to children, schools serve as a logical point to begin discussions about how these changes in health care will impact children. Two other coinciding trends -- the proliferation of Medicaid managed care and the recent increase in school-based health centers -- are reflective of the move towards providing medical homes and suggest that this an ideal time to consider the possibility of reconceptualizing school health services within this changing environment.

Study purpose. In light of these trends, Rosenberg & Associates conducted a study of school health services funded by the Robert Wood Johnson Foundation to examine how school districts across the country are exploring innovative ways to better serve their students' physical and mental health needs. Throughout this process, we have defined school health as consisting of three basic functions -- assessment, linkage and tracking. We see these services as going beyond mandated school health services but not necessarily encompassing the provision of primary care that would occur in a school-based health center. Using this definition of school health, a district's responsibility is not necessarily to provide services to students but to develop relationships with local health care providers to ensure that students can get these services in the community. An essential part of this process is an effective tracking protocol which monitors whether or not services are actually received, bringing a level of accountability to the program. Thus, we examined the organization of school health services at eight different districts, specifically concerning ourselves with issues of staffing and supervision, referral and tracking, data collection and Continuous Quality Improvement (CQI) processes and the influence of politics.

Study findings. Interviews with key informants around the country demonstrated the degree to which many school districts are struggling to integrate their programs into the local health care system. Many of the districts we visited are encountering similar barriers, as well as benefits, along the way to creating more tightly linked programs. The most fundamental distinction we noticed in districts best able to provide an effective school health program was their level of integration into the local medical establishment. Two school districts, Pasadena and San Antonio, were able to reach this level of integration through taking on a significant portion of the community's primary care function, in effect becoming a safety net provider. Most districts strengthened their integration with the community-based health system through employment mechanisms -- staffing their programs with personnel employed by a provider in the local medical community. Both Broward County and Palm Beach County school districts took this route. They staffed their school health programs with nurses employed by community hospitals and their respective, tax-supported hospital and health care districts. Doing so removed the isolation of school nurses traditional in school health and institutionalized the ability to refer students for necessary care. Although few districts have created effective tracking protocols, those who are integrated into the local health care community have the organizational framework to do so.

Common challenges. While trying to lay this groundwork, districts are confronted by many of the same obstacles. As increasing numbers of partners are brought into school health programs, issues arise around legal and medical liability, treatment authorization, and ownership and maintenance of health records. The Guilford County School Health Alliance, a collaborative of health and education agencies committed to creating a comprehensive school health program, faced numerous technical and legal issues as they tried to resolve employment and liability concerns. Political opposition from the school nurses' union in Boston, as well as a high level of bureaucratization within the school system, has kept the district from reaching similar levels of collaboration. Coinciding with these legal, technical and political problems are uncertainties about data collection and analysis processes which can allow for program refinement as well as demonstrate the value of school health services. Although still working through the details, Austin's privatization of school health services has resulted in the creation of CQI processes which have been instrumental in reflecting the program's value and winning community support.

Opportunities for the future. Despite these barriers, collaboration around school health issues has brought with it many secondary benefits above and beyond more effective school health programs. Seattle, although still struggling to create an integrated school health program, has enjoyed a renewed political emphasis on children's issues due to recent reorganizations of school health services. Other districts that have attempted to reorganize their school health programs through a collaborative process have generated community goods ranging from the development of clinical protocols across providers to increased communication within the medical establishment.

The selected study school districts, chosen for their innovations in school health, are capitalizing on new opportunities and establishing themselves as essential players in their local medical communities. Their experiences underscore the complexities involved in recognizing and responding to environmental changes and developing model school health programs which reflect the health care industry's focus on outcomes-based accountability. The lessons learned in these communities offer a wealth of information to other districts as they move towards creating tightly linked school health programs which can positively impact the health status of their school-aged populations. The ingenuity demonstrated by these districts suggests the potential for similar efforts in other communities that are dedicated to reconceptualizing their school health programs to ensure that they meet children's needs.