The Center for Health and Health Care in Schools

A Continuous Quality Improvement Tool for School-Based Health Centers

Introduction:

School-based health centers (SBHCs) are designed to detect and address the significant health problems and health risks of each age group among school-age children, i.e. elementary, middle or junior high, and senior high students. A comprehensive annual risk assessment (and biennial physical exam) is essential to detecting and addressing all important health concerns of the students at each level of school. Within each age group there are certain conditions that stand out because they represent typical health risks for that age and because they may serve as a measure of good health care delivered. This chart presents seven "Sentinel Conditions" for each school age group.

It is important to highlight several points about the sentinel conditions. First the sentinel conditions are clinically based. That is, they represent those conditions of health commonly encountered and treatable in a SBHC setting. Next, a limited number of conditions were chosen for several reasons. It allows each health center to focus on a meaningful evaluation. It facilitates local and national comparisons between sites and it allows for additions and changes to the list of conditions in future years as success is achieved with the initial measures.

Thus the list of sentinel conditions is purposefully not comprehensive. Rather, they are intended to be the "core measure" of quality in school-based health centers. It is understood that SBHCs will be subject to quality measures from other sources and agencies and depending on the services provided (e.g. dental, prenatal, well child care). For these added services, additional quality measures will necessarily be developed and applied.

The sentinel condition column identifies the sentinel condition to be monitored. The reference column includes references that support the inclusion of the condition and act as references to access for best practices on diagnosing and treating the condition. Resources are the minimum requirements (policies, equipment, information, relationships) that need to be in place in order to provide clinical services relative to the condition. The markers column describes the data to be collected from the medical record in order to evaluate the quality of care for the sentinel condition. The final column is the marker column and it is the score assigned to the data gathered from the medical record review. The measurement scale from 1 to 5 is designed with a value of 3 as the threshold or minimum standard of care. A score of 1 or 2 is below threshold and 4 or 5 are above threshold.

The foundation for each age grouping is an annual risk assessment and a biennial physical examination for registered students. The risk assessment may be conducted several ways including with student completed paper and pencil assessment forms, computerized assessment forms, interviews by the SBHC staff done separately from the physical examination and interviews done by the provider the time of physical examination. They can be conducted on an individual basis or in as part of classroom screenings. The SBHC may construct its own form or may elect to use forms that have been developed by nationally recognized organizations such as the AMA's GAPS.

Each SBHC will need to determine how it prefers to operate however, there are come guidelines to keep in mind especially for those programs that elect to design their own materials. The biennial history and physical examination should be thorough and should include in addition to a history of current complaints and review of systems, a past medical history, family history, and behavioral/developmental history. The physical should include height, weight, blood pressure, vision screen, physical assessment of all systems, and appropriate laboratory testing. An annual risk assessment that is developmentally appropriate is expected to cover: injury, safety, and violence, diet and exercise, dental, substance use and passive exposure, abuse, family relationships, school, friends, mood and emotional health, and sexuality. The risk assessment can be incorporated into the biennial physical or done separately but should be included in the registrants medical record.

CQI Version 1 September 1, 2001

Sentinel Conditions Elementary School	References	Resources	Markers	Measurement ¹

*Annual risk assessment* ² *Biennial physical exam*	Bright Futures HEDIS AAP USPHSTF PPIP	Physical space is adequate for confidential screening/exams; Medical record forms available Permission by parent or other responsible adult	% of charts with record of both annual risk assessment and biennial physical exam	1= 0-25% of charts with both markers documented 2= 26-50% " 3= 51-75% " 4= 76-95% " 5= >95% "
*Asthma, Chronic*	AAAAI NHLBI AAP	Asthma plan Peak flow meter Primary care physician Parental permission	% of students with asthma plan % of visits in "green zone" or (*) % of students who are stable (no symptoms of cough or wheeze, improved lung function, reduction in number of severe attacks, minimized sleep disturbance, and improved attendance in school, and reduction in number of hospitalizations)	1= 0-40% of charts have asthma plan 2= 41-60% " 3= 61 -100%" 4= Above plus 50-75% of visits show the student in green zone or stable 5= Above plus >75% of visits show student in green zone or stable
*Incomplete Immunizations*	AAP Red Book State Registries Local Health Department	List of required immunization by state Educational material for parents Parent permission Chart form for immunization records Policy for tracking students with incomplete immunizations Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty	% of students behind in recommended intervals for immunizations for school entry who are brought up to date	1= 0-25% of records show that students behind in recommended intervals for immunizations required for school entry are brought up to date 2= 26-50% " 3= 51-75% " 4= 76-95% " 5= >95% "
*High Risk for Unintentional Injury*	Bright Futures AAP CDC Safe Students Children's Safety Network PPIP	Screening questions in history form Primary prevention aides for students, parents List of community resources Planned school-wide health and safety promotional events	% of students at risk for helment and seatbelt injury who have injury prevention materials sent home to family; or documentation that student received instruction regarding risk reduction	1= 0-25% show evidence of prevention materials sent home or student education 2= 26-50% " 3= 51-75% " 4= 76-95% " 5= >95% "
*Poor school performance*	Bright Futures Mental Health DSM-PC	Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty Identified list of performance indicators from school: dropping grades, failing 2 or more classes, suspension from school, skipping school, trouble getting homework done, lack of interest Name of school academic counselor for each student Information regarding absences and discipline	% of students at risk for school failure are assessed for medical and mental health problems % of students with school failure with plan, referral and follow-up	1= 0-50% of charts show record of medical and mental evaluation 2= 51-95% " 3= >95% " 4= Above plus 50-75% have evidence of plan, and referral for academic services 5= Above plus >75% "

Sentinel Conditions

Elementary School

References

Resources

Markers

Measurement ¹

Mental Health ³

Students being treated for ADHD

AAP

AHCPR

DSM-PC

NIMH

Knowledge of treatment plan from provider

Knowledge of student performance

School IEP

Medication log

Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty

% of charts with documentation of treatment plan

% of charts with documentation of compliance with and effectiveness of the treatment plan

1= 0-20% of charts with plan

2= 21-50% of charts with plan

3=>50% of charts with plan

4= Above plus 50% of charts with compliance check and effectiveness evaluation

5= Above plus >50% of charts with compliance check and effectiveness evaluation

Child Abuse

State regulations

School policy

AAP

Guidelines for professional disciplines

Policy regarding reporting suspected child abuse

Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty

Legal reporting requirements

Local resources

Child Abuse Quarterly Medical Update

Institute for Professional Education

% of students at risk are reported to appropriate agencies

% of students who receiving ongoing case management (for those who remain at school)

1= 0-50% of students identified are connected to appropriate agency

2= 51-95% "

3= >95% of students identified are connected to appropriate agency

4= Above plus 50-75% of students remaining in school are receiving ongoing case management

5= Above plus >75% of students remaining "

Sentinel Conditions Middle/Junior High	References	Resources	Markers	Measurement ¹

*Annual risk assessment* 2 *biennial physical exam*	Bright Futures HEDIS AAP USPHSTF PPIP GAPS	Physical space is adequate for confidential screening/exams; Medical record forms available Parental permission documented Parent or other responsible adult present Policy on adolescent confidentiality and receipt of health services	% of charts with record of both annual risk assessment and biennial physical examination	1= 0-25% of charts with both markers documented 2= 26-50% " 3= 51-75% " 4= 76-95% " 5= >95% "
*Tobacco Use*	USPHS Clinical Practice Guideline for Treating Tobacco Use & Dependence in JAMA ALA AMA AAP ETR PPIP	Age appropriate screen Policy on adolescent confidentiality and receipt of health services Treatment plan or referral for treatment Names of school substance abuse resources and community resources Information about prevention for parents Planned school-wide health promotion events	% receiving intervention (treatment or referral) % adherent to intervention plan % cessation	1= 0-50% receive intervention 2= 51-95% receive intervention 3= >95% receive intervention 4= Above plus 50% compliant with plan 5= Above plus 1-20% report smoking cessation
*Risk of Pregnancy*	GAPS Bright Futures AMA Planned Parenthood SEICUS PPIP ETR	Staff expertise with adolescent pregnancy prevention Policy on adolescent confidentiality Patient health education materials Family Planning services on site or referral for service	% of sexually active students with prevention plan % of sexually active students with documented risk reduction	1= 0-50% of at risk students have documented prevention plan 2= 51-95% " 3= >95% " 4= Above plus 1-50% of charts have documented a risk reduction 5= Above plus >50% of charts have documented a risk reduction
*Poor school performance*	Bright Futures Mental Health DSM-PC	Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty Identified list of performance indicators from school: dropping grades, failing 2 or more classes, suspension from school, skipping school, trouble getting homework done, lack of interest Name of school academic counselor for each student Information regarding absences and discipline	% of students at risk for school failure are assessed for medical and mental health problems % of students with school failure with plan, referral and follow-up	1= 0-50% of charts show record of medical and mental evaluation 2= 51-95% " 3= >95% " 4= Above plus 50-75% have evidence of plan, and referral for academic services 5= Above plus >75% "

Sentinel Conditions Middle/Junior High	References	Resources/Tools	Markers	Measurement ¹

*Parent-child conflict*	Bright Futures GAPS DSM-PC	Policy regarding confidentiality List of community resources and agencies for families On-site support for mental health Medical and mental health evaluation for contributing factors (e.g., chemical use, family chemical use, physical abuse, depression, etc.) "Family Conflict Scale" Screen for co-morbidities	% of students with history of parent child conflict are evaluated and assessed for contributing factors and co morbidities % of students with history of parent child conflict have a plan to address problem % of students showing reduction of conflict	1= 0-50% evaluated and assessed 2= 51-95% " 3= >95% " 4= Above plus >75% have a plan 5= Above plus >35% show reduction in conflict
*Mental Health* ³ *Students being treated for ADHD*	AAP AHCPR DSM-PC NIMH	Knowledge of treatment plan from provider Knowledge of student performance School IEP Medication log Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty	% of charts with documentation of treatment plan % of charts with documentation of compliance with and effectiveness of the treatment plan	1= 0-20% of charts with plan 2= 21-50% of charts with plan 3= >50% of charts with plan 4= Above plus 1-50% of charts with compliance check and effectiveness evaluation 5= Above plus >50% of charts with compliance check and effectiveness evaluation
*At Risk for Depression*	GAPS DSM-PC AHCPR SAMHSA	Teen confidentiality Pediatric Symptom Checklist Access to resources for full mental health evaluation Psychiatric referral	% with completed evaluation, referral & plan % of showing improvement	1= 0-50% with completed evaluation, referral and plan 2= 51-95% " 3= >95% " 4= Above plus 25%-%50 show improvement 5= Above plus >50% show improvement

Sentinel Conditions High School	References	Resources	Markers	Measurement ¹

*Annual risk assessment 2* *biennial physical exam*	Bright Futures HEDIS AAP USPHSTF PPIP GAPS HEADSS	Physical space is adequate for confidential screening/exams; Medical record forms available Parental permission documented Policy on adolescent confidentiality and receipt of health services	% of charts with record of both annual risk assessment and biennial physical exam	1= 0-25% of charts with both markers documented 2= 26-50% " 3=51-75% " 4= 76-95% " 5= >95% "
*Alcohol use*	GAPS NIDA SAMHSA AAP ETR PPIP USPHSTF	Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty Policy on adolescent confidentiality and receipt of health services Names of school and community substance abuse Referral relationship with substance abuse programs Information about prevention for parents Screening tool (ie CAGE, AUDIT) Screen for co morbidities	% of students using alcohol who are evaluated for abuse % of students at high risk for abuse with intervention plan, or referral % with reduced risk or reduced abuse	1= 0-50% evaluated for abuse 2= 51-95% " 3= >95% " 4= Above plus 50% of those evaluated with evidence of intervention plan or referral 5= Above plus 10% report drinking cessation
*Risk of Personal Violence*	CDC Hamilton Fish Institute SAMHSA PPIP GAPS	List of categories of violence to be prevented eg, rape, abuse, weapons, fighting, gangs, suspension, arrest Primary prevention aides for students, parents List of community resources	% of those at risk with evaluation and plan % with reduced risk	1= 0-50% with intervention, plan and referral 2= 51-95% " 3= >95% " 4= Above plus 25%-50% reduced risk 5= Above plus >50% reduced risk
*Risk of STI*	GAPS CDC Guidelines IOM PPIP	Protocols for diagnoses and treatment of STIs On site resources for diagnosis & prescription of STI Referral resources for further evaluation & treatment	% with appropriate assessment & treatment % with documented risk reduction	1= 0-50% with appropriate assessment and treatment 2= 51-95% " 3= >95% " 4= Above plus 25%-50% report reduced risk at next visit 5= Above plus >50% report reduced risk at next visit

Sentinel Conditions High School	References	Resources/Tools	Markers	Measurement ¹

*Poor school performance*	Bright Futures Mental Health DSM-PC	Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty Identified list of performance indicators from school: dropping grades, failing 2 or more classes, suspension from school, skipping school, trouble getting homework done, lack of interest Name of school academic counselor for each student Information regarding absences and discipline	% of students at risk for school failure are assessed for medical and mental health problems % of students with school failure with plan, referral and follow-up	1= 0-50% of charts show record of medical and mental evaluation 2= 51-95% " 3= >95% " 4= Above plus 50-75% have evidence of plan, and referral for academic services 5= Above plus >75% "
Mental Health ³ *Students being treated for ADHD*	AAP AHCPR DSM-PC NIMH	Knowledge of treatment plan from provider Knowledge of student performance School IEP Medication log Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty	% of charts with documentation of treatment plan % of charts with documentation of compliance with and effectiveness of the treatment plan	1= 0-20% of charts with plan 2= 21-50% of charts with plan 3= >50% of charts with plan 4= Above plus 50% of charts with compliance check and effectiveness evaluation 5= Above plus >50% of charts with compliance check and effectiveness evaluation
*At Risk for Depression*	GAPS DSM-PC AHCPR SAMHSA	Teen confidentiality Pediatric Symptom Checklist Access to resources for full mental health evaluation Psychiatric referral	% with completed evaluation, referral & plan % showing improvement	1= 0-50% with completed evaluation, referral and plan 2= 51-95% " 3= >95% " 4= Above plus 25%-50% show improvement 5= Above plus >50% show improvement

¹ Scale of markers: 1 and 2= below threshold; 3=at threshold; 4 and 5= above threshold
² Annual Risk Assessment and results of Biennial Physical Exam should be in the chart by the third visit.
³ Each program should choose one of the two Mental Health conditions for evaluation.

Elementary School Data Collection Form | Middle School Data Collection Form | High School Data Collection Form

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