QUALITY STANDARDS FOR SCHOOL-BASED HEALTH CENTERS IN NORTH CAROLINA

Background
For many years, public schools have provided important basic health services to students. School- based health centers (SBHCs) represent a relatively new expansion of this concept, offering comprehensive, accessible, primary and preventive physical and mental health services to school-age youth. This evolution is a community based response to the serious health and health-related educational problems faced by many children and their families today.

As recently as 1985, fewer than 50 SBHCs existed in the United States. By the fall of 1995, over 600 were in operation. North Carolina currently has 26 SBHCs in eighteen counties. These were developed through local community collaboration, spurred by the vision of parents, educators, and health providers to improve the health and educational status of North Carolina’s children and teenagers.

The purpose of the Making the Grade in North Carolina project is to increase access to comprehensive health care for school age children and youth of this state through school-based and school linked health centers. Standards have been developed to provide guidance in achieving excellence in care at the centers. These standards will:

  • define and assure an optimal level of quality services in school-based health centers;
  • foster a degree of consistency among centers; and
  • strengthen the center’s ability to contract with managed care organizations and other third party payers.

Use of the Standards

These standards serve as best-practice for existing and developing school-based health centers. They can be adapted to fit local circumstances and may be used to:

  • set quality benchmarks and identify areas for quality improvement for programs
  • communicate with parents, educators and other community members
  • serve as a mechanism for communicating with third-party payers
  • guide communities in establishing new centers
  • promote local agency resource commitments to SBHCs
  • identify SBHC staff development needs

GUIDING PRINCIPLES AND VALUES

These standards were developed with regard to the following principles and values governing school based health centers in North Carolina.

School-based centers:

  • are available for all students
  • recognize diversity
  • link with stable funding, including managed care
  • coordinate with other health services
  • emphasize health promotion and disease prevention
  • involve family and community

STANDARDS FOR SCHOOL-BASED HEALTH CENTERS

I. ACCESS STANDARD:

School-based health centers are easily accessible and designed to eliminate or diminish barriers to care for students. The school-based health center provides age-appropriate primary health, mental health, prevention and health education services. Most care is provided on-site. Some services, based on local need and expertise, may be made available by referral with appropriate follow-up.
A) Access to Services

The centers are located in an area of need in the community and in a location easily accessible to the school age population. The center operates when school is in session at regularly scheduled hours that:

      a. allow for urgent appointments the same day;
      b.allow the scheduling of appointments which do not unnecessarily interrupt the student’s classroom time;
      c. accommodate working parents/guardians who participate in the care of their child; and
    d. are visibly displayed in a public location and in multiple languages if appropriate for the student population.

The center ensures 24-hour access to services for enrolled students. This may include having telephone answering methods and/or distributing information cards which notify students and parents/guardians where and how to access 24-hour back-up services when the center is not open.

When providing services by referral, providers offer options which pose minimal financial or geographic barriers to access. Follow-up involves checking that the appointment was kept, that services met student’s needs, and that the outcome of the referral, including relevant health care findings, was incorporated into the student’s medical record.

The center ensures that staff have education in cultural diversity and that translation services are provided in a way which ensures confidentiality.

Any student enrolled in the center can access services. The center has consent forms available to all enrolling students in order to obtain the informed written consent of the parent or legal guardian. If the individual receiving services is eighteen years of age or older or is otherwise qualified to give consent under G.S. 90-21.5a and is competent to give such consent, such consent will be obtained.

The center does not deny access to care to enrolled students without insurance or other means to pay for services. Enrollment and registration processes provide for effective collection of information regarding third-party billing resources and the identity of primary care providers.

II. Services Provided

A) Comprehensive health assessments

These must include, at minimum:

  1. comprehensive health history:
    -history of present illness
    -past medical history
    -family history
    -review of systems
  2. psychosocial screening for health risks
  3. physical assessment
  4. linear growth and weight relative to height
  5. blood pressure
  6. vision and hearing screening
  7. nutrition assessment/dietary screening
  8. assessment of immunization status
  9. dental screening
  10. care plans and appropriate referrals and follow-up

B) Diagnosis and treatment of medical conditions

On-site diagnosis, treatment (including prescriptions), and appropriate triage and referral mechanisms must be in place for minor and acute problems.

On-site routine management of chronic conditions (asthma, diabetes, etc.) is provided in consultation with student’s primary care provider or specialist as appropriate.

C) Immunizations
Immunizations should be provided, according to ACIP recommendations and local needs, to students who need them.
D) Laboratory tests
School health centers should provide laboratory testing as clinically indicated. Tests may include:
  1. hematocrit/hemoglobin
  2. urinalysis-dipstix
  3. wet-prep
  4. pregnancy testing
  5. tuberculin skin testing
  6. throat culture
  7. HIV/STD testing
  8. other tests according to GAPS and CLIA guidelines

E) Age-appropriate reproductive health care

F) Health Education/Promotion

The center provides health education for the students, their families, and school and health center staff, and where possible supports the provision of comprehensive health education in the classroom. Services include:
  1. one-on-one education
  2. group/targeted education
  3. family and community health education
  4. health education for health center and school staff
  5. support for comprehensive health education in the classroom in such areas as:
  1. substance use prevention/cessation
  2. intentional and unintentional injury prevention
  3. nutrition
  4. social skills development
  5. death and dying issues
  6. physical and emotional development
  7. conflict resolution
  8. child abuse prevention
  9. violence prevention
  10. STD/HIV/AIDS prevention
  11. pregnancy prevention
  12. chronic conditions (i.e. asthma)
  13. general parenting skills
  14. chronic disease prevention (smoking cessation/prevention, heart disease, osteoporosis)
  15. dental health
  16. enhancing family/peer relationships
  17. physical fitness

G) Nutrition

The center provides the following nutrition services on-site:

  1. comprehensive nutritional assessment
  2. weight management counseling
  3. therapeutic diet counseling for chronic disease prevention and treatment
  4. nutrition education and counseling
  5. disordered eating, screening and referral

The following services may be made available on-site or by referral:

  1. consultation to child nutrition/school food service staff on diet modifications for children with special needs
  2. consultation to coaching staff on sports nutrition
  3. nutrition counseling for faculty and staff
  4. WIC Program certification and nutrition education for pregnant and parenting teens
H) Mental Health
The center provides mental health care services on-site. These services include:
  1. immediate response to emergency/crisis situations
  2. physical/sexual abuse prevention/counseling
  3. alcohol/substance abuse prevention/counseling
  4. depression/suicide prevention/counseling
  5. linkage with school and community counseling
  6. short-term counseling

The following services are available on-site or by referral:

  1. group and family counseling
  2. psychiatric evaluation and treatment
  3. long-term counseling
I) Social Services
The center provides initial assessments and referrals to social service agencies to provide the following:
  1. assistance attaining basic needs (food, shelter, clothing)
  2. legal services
  3. referral to Public Assistance
  4. assistance with Medicaid and other health insurance enrollment
  5. employment services
  6. day-care services
  7. transportation
  8. child protective services

J) Other services

Other services provided on-site or by referral may include:
  1. dental care
  2. speciality care
  3. well-child care of students’ children

III. Staffing

The school-based health center services are provided by a multidisciplinary team. It is expected that centers provide appropriate services on site conducted by qualified/licensed providers. Center services are expected to be clearly articulated with the school support staff with defined roles and policies to assure integration of services.

The health center must ensure that staff participate in ongoing professional development and that they are assigned responsibilities consistent with their education and experience, supervised, evaluated, and trained in the policies and procedures of the organization.

Recommended center staff include:

  1. RN for service provision, i.e., assessment, referral, and treatment
  2. Nurse Practitioner/Physician Assistant for service provision, i.e., assessment, referral, treatment.
  3. Physician for back-up, supervision, consultation, or direct service provision.
  4. Mental Health Professional (MSW, CCSW, psychologist, or psych nurse) to provide assessment, treatment, referral
  5. Nutritionist (RD or LDN) to provide individual assessment, treatment, referral
  6. Office Assistant to set appointments, collect insurance and billing information, recall students, collect data, and verify center is meeting state reporting requirements.
  7. Health Center Manager to provide overall management of the center including data collection, budget and finance, preparation of statistical reports and narratives, purchasing, writing grant proposals, staff supervision/scheduling, liaison with school, back-up health care provider, community, and funding sources, advisory committee participation, quality assurance coordination, program development, and program evaluation.

Other staff positions may include:

  1. Health Educator to provide individual, group, and classroom education
  2. Community Outreach Worker to coordinate social service assessments
  3. Mental Health Supervisor
  4. Dentist and/or Dental Hygienist
  5. Substance abuse prevention/intervention specialist
  6. School Nurse (RN) to provide triage
  7. Community Health Assistant
IV. Relationships
The center is organized with regard to family, school, community, and health provider relationships. There should be established relationships with:

1. The Student’s Family

The center providers make every effort to involve the student’s family in regard to the care of the student.

Health center policies regarding access, availability, and flexibility take into consideration the various structures and functions of families in the community being served.

Health center staff understand the nature, role, and impact of a student’s health, illness, disability, or injury in terms of the family’s structure, function, and dynamics.

Policies and procedures assure that there is communication with the student’s regular source of care (if the student has one outside of the center) to ensure that the child obtains all needed service and to prevent duplication. Procedures should be in place regarding the sharing of medical records in accordance with confidentiality laws.

2. The School

The center is integrated into the school environment, and both are committed to operating with mutual respect and a spirit of collaboration. The center cooperates both formally through a memorandum of understanding (MOU) and informally with school personnel. The school assists the health center in many ways, including:

  1. marketing the school-based/school-linked health center
  2. helping to obtain informed parental consent;
  3. helping to obtain information on insurance status and on Medicaid status, including any enrollment in a managed care plan;
  4. providing access to school health records;
  5. maintaining the facility;
  6. providing space (but not necessarily renovations) at no cost; and
  7. collaborating in the establishment of School Health Program Advisory Board

The relationship between the school district and the school health center’s sponsoring agency includes the following:

  1. a current MOU between the sponsoring agency and the school district;
  2. meetings between the school district and/or school building administration and the health care provider are held on a regular basis;
  3. methods for addressing priorities and resolving differences are spelled out in the MOU;
  4. the MOU provides assurances that there will be a collaborative relationship between the center staff and school personnel such as health educators, school nurses, drug abuse counselors, social workers, etc.; and
  5. the MOU describes how the center will provide 24 hour access to services when the center is closed.

The health center’s relationship with the school involves routinely publicizing the centers services to the student body and families. Methods of outreach include:

  1. contacts during school registration
  2. PTA meeting attendance
  3. mail outs/send home notes
  4. bulletin boards/posters
  5. student newspapers
  6. teacher/staff referrals

3. The Community

The center recognizes that it functions within the community and should draw upon and contribute to its resources.

The views of community members are incorporated into decisions involving policies, priorities and plans related to the delivery of comprehensive health care.

The center develops and distributes written materials to the community which define and promote the goals and services of the center. These materials are multi-lingual, if necessary.

The center encourages students to assume responsibility for their own health care through information about the appropriate use of community resources.

The centers have agreements with medical and mental health facilities which provide care when they are not in operation. Procedures should be in place regarding the maintenance of records at these facilities, in accordance with confidentiality laws.

The center consults with and utilizes the services and expertise of the local public health agency to ensure access to necessary services as appropriate.

V. Organization and Function

a. Organizational Structure

The center operates according to an organizational chart and appropriate MOU’s which reflect clear lines of authority for the administration of the SBHC, as well as the roles of the sponsoring agency, the center, collaborating agencies, and the school. This chart should be reviewed periodically and revised as needed.

The health center operates according to written organizational and clinical protocols which ensure that primary care and other health services are delivered to students in an organized manner.

Job descriptions define the qualifications, responsibilities, and supervision of all health center personnel.

The center’s organizational structure includes an administrator or assignment of administrative responsibility. This individual is responsible for overall management of the health center as well as serving as liaison with the health care entity operating the center.

b. Community Advisory Council

The center has a community advisory council which is representative of the community and is oriented to center services. Meetings should be scheduled on a regular basis. Membership includes, but is not limited to, parents, students, school staff, collaborating agency staff, community members, health providers, local public health and social service agency staff.

The Advisory Council may be involved in program planning, development, and evaluation, identification of emerging health issues and appropriate interventions, assisting in identifying funding for the school-based health center, and providing advocacy for the program.

c. Policies and Procedures

A statement or manual describes all clinical and administrative center policies and procedures. Policies and procedures include the following:

  1. employment is without regard to age, sex, race, or sexual orientation;
  2. standards for provider qualifications are reviewed and updated routinely;
  3. job descriptions, curricula vitae, resumes, appropriate licenses, and annual performance evaluations are on file with the program;
  4. orientation and continuing education are offered to all center employees;
  5. protocols and standing orders for clinicians are current and signed by necessary staff members;
  6. all procedures are consistent with the prevailing practice and regulatory guidelines (e.g., Nursing Practice Act, OSHA guidelines);
  7. informed consent is obtained according to a written procedure;
  8. all records and patient information are maintained in accordance with standards and statutes covering confidentiality;
  9. all staff members are trained in emergency care and first aid;
  10. emergency plans for disasters, crisis intervention, suicide prevention are consistent with the school’s plan and available for all staff members;
  11. policies governing the reporting of suspected child abuse and homicidal or suicidal risk are consistent with state requirements.

VI. Fiscal Operations

a. Program
  1. receipts and expenditures should be adequately identified for each contract/source of funds; and
  1. equipment inventories, budget analysis, and total service cost calculations should be completed annually.

b. Medicaid and Other Third Party Reimbursement

For centers which bill for service reimbursement, the following procedures apply:

  1. there are adequate procedures for determining and obtaining information on Medicaid and other third party eligibility, and helping families in the enrollment process;
  2. encounter forms are generated for all billable visits;
  3. procedures adequately address rejected Medicaid or other third party claims;
  4. protocols are developed for working with all sources of primary care, including managed care plans who serve students enrolled in the school-based health centers;
  5. protocols ensure confidentiality for the student and comply with consent agreements consistent with public health statutes regarding exchange of medical information; and
  6. charges for care are based on ability to pay.

VII. Data Management

A record-keeping system provides for consistency, confidentiality, and security of records in documenting student health information and the delivery of health care services.

A single confidential medical record is maintained for each student receiving services at the center. The center may separately maintain medical record afforded a higher degree of confidentiality by law, including, but not limited to, mental health, substance abuse, and HIV testing records, provided there is an effective cross-referencing system.

Written policies dictate access to and use of health center data.

A designated individual is responsible for preparation of state and other reports.

VIII. Facility Requirements

Space must be adequate to accommodate appropriate staffing, to afford client verbal, physical, and visual privacy, and to allow for ease in performing necessary clerical, laboratory, infection control, and clinical activities.

It is recommended that the center include:

  1. private examination and treatment room(s) with accessible sinks
  2. private area(s) for counseling, education, and training
  3. laboratory space
  4. waiting and reception area
  5. secure storage area(s) for pharmaceuticals, supplies, and records
  6. adequate clerical area
  7. patient bathroom

The center is accessible to individuals with disabilities.

The center has current fire and building safety certificates and electrical/mechanical equipment is in safe working order.

The center is equipped with a private telephone line to ensure confidentiality and adequate access to the community and back-up providers.

IX. Quality Assurance Activities

The health center develops and implements a quality management program that monitors and evaluates the appropriateness, effectiveness, and accessibility of the services provided.

The center, with its sponsoring agency, establishes a quality management plan to be reviewed annually. The plan includes clearly defined goals related to improving the health status of enrolled students.

The center develops and/or participates in a program to evaluate the processes and outcomes of care delivered at the center and improves the center operation based on the findings.

There are written specified quality assurance policies and procedures which cover:

  1. provider credentials and maintenance;
  2. professional continuing education;
  3. pre-employment procedures;
  4. staff and program evaluation;
  5. chart review criteria;
  6. selection of clinical issues/investigation;
  7. complaint and incident review;
  8. corrective actions and time frame;
  9. data management/utilization;
  10. staff case conferencing; and
  11. fiscal operations.

The center complies with the data collection requirements of the state.