CERTIFICATION STANDARDS FOR SCHOOL-BASED HEALTH CENTERS:

FACILITATING RELATIONSHIPS BETWEEN SCHOOL-BASED HEALTH CENTERS AND MANAGED CARE ORGANIZATIONS IN COLORADO

I. Purpose of the Certification Standards

The primary purpose of these standards is to facilitate the inclusion of School-Based Health Centers in health plan provider networks. Because School-Based Health Centers have been developed through local planning efforts according to assessments of community need, each program is unique. While diversity contributes to the value of these programs to their communities, their acceptability, and their efficiency, it makes contracting with managed care organizations difficult, especially in situations where primary care is capitated.

Under capitation, it is expected that one provider or provider group will provide a full range of primary care services year-round with twenty-four-hour-a-day accessibility. In some communities, the School-Based Health Center (SBHC) functions as a “full-service” primary care provider and thus fits the managed care model. But in other communities, the SBHC is designed to be a convenient extension of another provider, bringing the most needed services to where the children are — in school. In still other communities, the SBHC has been designed to fill gaps, that is, to provide services not available through other providers in the area, or not accessible to certain segments of the population, usually children who are uninsured or covered by a government program such as Medicaid.

Through thoroughly describing three basic models for providing school-based health services, we have attempted to contribute to the acceptance of SBHCs as a legitimate, highly accessible, high quality and efficient system for delivering preventive and primary health services to school-age children, a system that will add value to the products offered by managed care organizations. It is also hoped that the standards will serve as a planning tool for communities that wish to develop a SBHC, and that they will foster a degree of consistency among SBHCs in Colorado without stifling the innovation that has been one of the movement’s strengths.

Because SBHC programs often have multiple sites and employ different models according to the needs of individual schools within a school district, each SBHC site will be surveyed and will receive a Level I, II, or III designation. For the purposes of contracting with managed care organizations, each program will also receive an overall designation. It should be noted that Level I and Level II SBHCs offer the same scope of services. The differences between these designations involve the way the services are organized and delivered.

II. Definitions

A. School-Based Health Center (SBHC) – offers preventive, primary, mental and/or dental health care on a regular basis to school-aged children within or adjacent to an elementary, middle or high school.

B. School-Based Health Center (SBHC) Program – the organization which sponsors and/or hires staff to administer one or more School-Based Health Center.

C. School-Based Health Center (SBHC) Site – the physical location where a School-Based Health Center is located.

D. Primary Care Provider – A family, pediatric or general practice health care provider who is licensed or certified to practice in Colorado, who is practicing consistent with the Medical Practice Act or Nurse Practice Act, and who is responsible for providing and directing the health care of individuals who are assigned to the Primary Care Provider under certain health benefit plans.

E. Adolescent – A person between the ages of twelve and twenty-one years.

 

III. Standards for Level I School-Based Health Center Designation

A. Introduction:
The Level I designation is intended for SBHC Sites that are capable of serving as a child’s sole Primary Care Provider. Therefore, a Level I SBHC Site must deliver comprehensive preventive and primary medical care that is accessible year-round with twenty-four-hour-a-day coverage.

B. Scope of Services

1. A Level I SBHC must offer all of the following services:

  1. age-appropriate well-child exams consisting of a comprehensive health history, complete physical assessment, screening procedures, and anticipatory guidance.Appropriate tools for guiding well-child exams are: the federal Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program requirements, Guidelines for Adolescent Preventive Services (GAPS) prepared by the American Medical Association, and Bright Futures available through the Maternal and Child Health Division of the U.S. Department of Health and Human Services.
  2. immunizations including:
    • Diphtheria, Tetanus and Pertussis (DTaP or DTP)
    • Tetanus and Diphtheria toxoids (Td)
    • Polio (IPV or OPV)
    • Hemophilus influenzae type b (Hib) (for children under five only)
    • Measles, Mumps and Rubella (MMR)
    • Hepatitis B
    • Varicella (chicken pox)
    • Influenza virus
  3. diagnosis and treatment of acute illness and injury.
  4. management and monitoring of chronic conditions.
  5. basic laboratory services on site including:
    • 36415 Routine venipuncture or finger, heel, ear stick for collection of specimens
    • 81000 Urinalysis, by dipstick or tablet reagent; with microscopy
    • 82270 Blood, occult; feces screening, 1-3 simultaneous determinations
    • 85013 Spun Microhematocrit
    • 85018 Hemoglobin
    • 87205 Smear, primary source, with interpretation; routine stain for bacteria, fungi, or cell types (Saline Wet Mount)
    • 87220 Tissue examination for fungi (KOH slide)
      If SBHC Site serves adolescents:
    • 81025 Urine pregnancy test, by color comparison methods
  6. additional laboratory tests through a written contract with at least one commercial laboratory for the processing and interpretation of specimens collected on site.
  7. capability to prescribe or dispense commonly used medications, in accordance with medical and pharmacy practice acts
  8. patient health education and anticipatory guidance for students and parents.
  9. age-appropriate information on human sexuality, diagnosis and treatment of sexually transmitted diseases, and provision of or referral for HIV testing and counseling.
  10. informing, prescribing, dispensing or referring for birth control.A Level I SBHC may also offer the following services:
    1. basic mental health services including mental health assessment; individual, group and family counseling; and consultation with school administrators, parents, teachers and students. If offered, basic mental health services must be provided by a psychiatrist, licensed clinical psychologist, licensed social worker, psychiatric nurse, or master-degreed mental health therapist.¹
    2. substance abuse services including problem assessment and prevention, intervention and treatment. If offered, substance abuse services must be provided by a specialist certified as a Counselor II or III.
    3. violence prevention and intervention education and counseling.
    4. preventive and primary dental care.

C. Availability of Services

1. The SBHC Site must be operational (with a provider present) a minimum of four hours each day, Monday through Friday of each week, except for a maximum of twenty scheduled closure days each year.

2. The SBHC Site must provide both scheduled appointments and urgent appointments within the same or following business day.

3. The SBHC Site must have in place a 24-hour on-call system of back-up so that patients can easily obtain urgent care and advice when the SBHC Site is closed. When the SBHC Site is closed, the SBHC’s usual published telephone number must either 1) be answered by a commercial service that is capable of contacting the provider on-call within ten minutes, or 2) be answered by a recorded message which gives clear instructions for accessing the back-up system. In addition, instructions for after-hours care must be prominently displayed outside the SBHC Site’s entrance(s) and must be printed and made available to patients in the reception area and exam rooms and to parents through the consent form.

4. The SBHC Site must not discriminate or deny access to students enrolled in the school based upon sex, race, color, religion, national origin, age, handicap, sexual preference or ability to pay.

D.Physical Plant

1.The SBHC Site must be located either within the school building or on the school campus.

2.The SBHC Site must have, at a minimum: waiting and reception area, private exam and treatment room with accessible sink, bathroom, clean utility/laboratory space, dirty utility area and secure storage area for pharmaceuticals and medical records.

3. The SBHC Site must have current fire and building safety certificates. If located within a school building or other building with inspection certificates, the SBHC is not required to seek independent certificates.

4. The SBHC Site must have the supplies and equipment necessary for staff to follow universal precautions as defined by OSHA. The SBHC Program must have documentation that all staff has been trained in the use of universal precautions.

5. The SBHC Site must comply with CLIA regulations regarding laboratory operations.

E.Quality Assurance
The SBHC Program must demonstrate evidence of a Quality Assurance Program to include adequate activities in the areas of Quality Management and Improvement, Utilization Management, Credentialing, Patient Rights and Responsibilities, Patient Grievance and Medical Records as defined by the Colorado Association for School-Based Health Care (See Appendix A).

F.Administration

1. There must be a written contract between the SBHC Program and the public school district or private school that delineates the responsibilities of both parties.

2. There must be an organizational chart reflecting clear lines of authority for SBHC Program staff as well as SBHC staff employed by the school district or other agency. There must be one administrator responsible for the SBHC’s overall management, quality of care, and coordination with school personnel.

3. The SBHC Program must have a written policy regarding parental consent for treatment which is available at each SBHC Site for easy reference by staff.

4. The SBHC Program must have written procedures for patient registration which provide for effective collection of demographic, parent contact, third-party billing and previous or current primary care provider information.

5. The SBHC Program must have written job descriptions for all staff including physicians, dentists, dental hygienists, physician assistants, nurse practitioners, nurses, medical assistants, and mental health providers. These documents accurately describe the patient services that may be provided, documentation responsibilities and supervision. The SBHC Program ensures that staff are assigned responsibilities consistent with their education and experience and are periodically evaluated on their performance and trained in areas of weakness or new technologies.

6. The SBHC Program has written clinical protocols for any non-physician providers, including physician assistants and nurse practitioners, that are consistent with the Medical Practice Act and the Nurse Practice Act in Colorado.

7. The SBHC must be in compliance with CLIA, OSHA, pharmacy licensing, child abuse reporting and other laws and regulations governing health care programs.

G. Finance.

1. The SBHC Program must have an annual budget which describes sources and uses of funding.

2. The SBHC Program must have a schedule of standard charges for services rendered, by CPT-IV code.

3. The SBHC Program must have a written policy which describes how services rendered are recorded, charged, billed and collected. If the SBHC Program offers discounts off its schedule of standard charges based on ability-to-pay or other criteria, the process for qualifying for such discounts must be included in the policy. In addition, the procedure for writing off any differences between amounts charged and amounts collected must be included.

4. The SBHC Program must have a computerized system capable of generating a HCFA-1500 or UB-92 billing form with up-to-date CPT-IV and ICD-9 coding either in-house or through a vender. If billing forms are generated by a vender, there must be a written contract between the SBHC Program and the vender delineating the responsibilities of each.

5. The SBHC Program must have an accounting system which uses generally accepted accounting principals to track patient revenue as well as other program revenue.

 

IV.Standards for Level II School-Based Health Center Designation

A.Introduction: The Level II designation is intended for SBHC Sites that are capable of serving as a child’s Primary Care Provider in partnership with another provider who takes over the role whenever the SBHC is closed. A Level II SBHC Site must deliver comprehensive preventive and primary medical care, but may rely on the partner for year-round accessibility and/or twenty-four hour a day coverage. The partnering provider may be another SBHC Site operated by the same SBHC Program, a non-SBHC site operated by the same SBHC Program (such as a community-based site or a hospital-owned outpatient clinic), or another health organization or private practice located nearby.

B. Scope of Services. – Same as Level I above.

C. Availability of Services

1.The SBHC Site must be operational (with a provider present) a minimum of four hours each day that the school within which it is operating is holding regular classes for enrolled students. The SBHC site may be closed during school holidays, teacher in-service and planning days, and extended vacations such as winter, spring and summer breaks.

2.The SBHC Site must provide both scheduled appointments and urgent appointments on the same or next business day.

3.The SBHC Site must have in place a written partnership plan or agreement that provides patients access to urgent appointments on non-holiday weekdays and a 24-hour, seven-day-a-week on-call system of back-up for urgent care and advice when the SBHC site is closed.

Whenever the SBHC Site is closed, the SBHC’s usual published telephone number must either 1) be forwarded to the partner’s telephone number, 2) be answered by a commercial service that is capable of referring the patient to the partner during business hours or contacting the provider on-call within ten minutes during non-business hours, or 3) be answered by a recorded message which gives clear instructions for accessing the partner and back-up system. In addition, instructions for accessing the partner and after-hours care must be prominently displayed outside the SBHC Site’s entrance(s) and must be printed and made available to patients in the reception area and exam rooms and to parents through the consent form.

4. If the SBHC site is to be closed for more than three weeks, medical records must be maintained so that they are accessible to the partner.

5. The SBHC Site must not discriminate or deny access to students enrolled in the school based upon sex, race, color, religion, national origin, age, handicap, sexual preference or ability to pay.

D. Physical Plant – same as II. D. above.

E. Quality Assurance – same as II. E. above.

F. Administration – same as II. F. above.

G. Finance.

1. The SBHC Program must have an annual budget which describes sources and uses of funding.

2. The SBHC Program must have a written agreement with the partner that either:

a) assigns to the partner the responsibility for billing and collecting all patient revenue and includes a methodology for sharing revenue between the partner and the SBHC Program orb) assigns to the SBHC Program the responsibility for billing and collecting all patient revenue and includes a methodology for sharing revenue between the SBHC Program and the partner or

c) specifies that the SBHC Program and the partner will each bill and collect for services it provides or

d) specifies that the SBHC Program and the partner will each bill and collect for services it provides, except for when services are covered under a capitated arrangement with a health plan, in which case there will be a methodology for collecting and sharing the capitation.

3. Either the SBHC Program or the partner must have a schedule of standard charges for services rendered, by CPT-IV code. It must also have a written policy which describes how services rendered are recorded, charged, billed and collected. If the SBHC Program offers discounts off its schedule of standard charges based on ability-to-pay or other criteria, the process for qualifying for such discounts must be included in the policy. In addition, the procedure for writing off any differences between amounts charged and amounts collected must be included.

4. Either the SBHC Program or the partner must have a computerized system capable of generating a HCFA-1500 or UB-92 billing form with up-to-date CPT-IV and ICD-9 coding either in-house or through a vender. If billing forms are generated by a vender, there must be a written contract between the SBHC Program and the vender delineating the responsibilities of each.

5. The SBHC Program must have an accounting system which uses generally accepted accounting principals to track patient revenue as well as other program revenue.

 

V. Standards for Level III School-Based Health Center Designation

A.Introduction: The Level III designation is intended for SBHC Sites that are structured to provide a limited range of services to meet the needs of a given community. A Level III SBHC Site may deliver preventive medical care, reproductive health care, mental health services, dental services, or any combination of these services. A Level III SBHC Site may also have limited hours of operation.

B.Scope of Services

1. A Level III SBHC Site must offer at least one of the following services:

  1. age-appropriate well-child exams consisting of a comprehensive health history, complete physical assessment, screening procedures, anticipatory guidance, and immunizations including:
    • Diphtheria, Tetanus and Pertussis (DTaP or DTP)
    • Polio (IPV or OPV)
    • Hemophilus influenzae type b (Hib)
    • Measles, Mumps and Rubella (MMR)
    • Hepatitis B
    • Varicella (chicken pox)
    • Tetanus and Diphtheria toxoids (Td)
    • Influenza virus
  2. reproductive health services including age-appropriate information on human sexuality, diagnosis and treatment of sexually transmitted diseases, testing and counseling for HIV/AIDS and informing, prescribing, dispensing or referring for birth control.
  3. basic mental health services including mental health assessment; individual, group and family counseling; and consultation with school administrators, parents, teachers and students. Basic mental health services must be provided by a psychiatrist, licensed clinical psychologist, licensed social worker, psychiatric nurse, or master-degreed mental health therapist.
  4. substance abuse services including problem assessment and prevention, intervention and treatment. Substance abuse services must be provided by a specialist certified as a Counselor II or III.
  5. preventive and primary dental care.

C.Availability of Services

1. The SBHC Site must be operational (with a provider present) a minimum of three hours on one day each week that the school within which it is operating is holding regular classes for enrolled students. The SBHC site may be closed during extended vacations such as winter, spring and summer breaks.

2. The SBHC Site must not discriminate or deny access to students enrolled in the school based upon sex, race, color, religion, national origin, age, handicap, sexual preference or ability to pay.

D. Physical Plant

1. The SBHC Site must be located either within the school building or on the school campus.

2. The SBHC Site must have, at a minimum: waiting and reception area, private exam/treatment/counseling room (with accessible sink if medical or dental services are offered), bathroom, and secure storage area for pharmaceuticals and/or medical records.

3. The SBHC Site must have current fire and building safety certificates. If located within a school building or other building with inspection certificates, the SBHC is not required to seek independent certificates.

4. If medical or dental services are offered, the SBHC Site must have the supplies and equipment necessary for staff to follow universal precautions as defined by OSHA. The SBHC Program must have documentation that every employee has been trained in the use of universal precautions.

5. If laboratory services are offered, the SBHC Site must comply with CLIA regulations regarding laboratory operations.

E. Quality Assurance – Same as II. E. above.

F. Administration

1. There must be a written contract between the SBHC Program and the public school district or private school that delineates the responsibilities of both parties.

2. There must be an organizational chart reflecting clear lines of authority for SBHC Program staff as well as SBHC staff employed by the school district or other agency. There must be one administrator responsible for the SBHC’s overall management, quality of care, and coordination with school personnel.

3. The SBHC Program must have a written policy regarding parental consent for treatment which is available at each SBHC Site for easy reference by staff.

4. The SBHC Program must have written procedures for patient registration which provide for effective collection of demographic, parent contact, third-party billing and, if applicable, previous or current primary care provider information.

5. The SBHC Program must have written job descriptions for all staff including physicians, dentists, physician assistants, nurse practitioners, nurses and medical assistants. These documents accurately describe the patient services that may be provided, documentation responsibilities and supervision. The SBHC Program ensures that staff are assigned responsibilities consistent with their education and experience and are periodically evaluated on their performance and trained in areas of weakness or new technologies.

6. The SBHC Program has written clinical protocols for any non-physician providers, including physician assistants and nurse practitioners, that are consistent with the Physician Assistant Practice Act and the Nurse Practice Act in Colorado.

7. The SBHC must be in compliance with applicable laws and regulations governing health care programs.

G. Finance.

1. The SBHC Program must have an annual budget which describes sources and uses of funding.

2. If the SBHC Program charges fees to students or parents for services rendered, it must have a written policy which describes how services are recorded, charged, billed and collected. If the SBHC Program offers discounts off its schedule of standard charges based on ability-to-pay or other criteria, the process for qualifying for such discounts must be included in the policy. In addition, the procedure for writing off any differences between amounts charged and amounts collected must be included.

3. The SBHC Program must have an accounting system which uses generally accepted accounting principals to track revenue and expenses.