School-based health center policy development was
initially the domain of school-based health center sponsors and
funders (i.e. health care organizations and foundations). As states'
financial involvement has grown, their attention to policy and program
issues has increased. Many states have used grant initiatives as
an opportunity to establish program goals, construct global service
and staffing standards, and define prototypes for replication.
Of the fifty states surveyed, 22 have established
state school-based health program guidelines, ranging from suggested
to required program standards. Another nine states reported that
program guidelines were in development this year. The Making
the Grade National Program Office selected a subset of 12 states'
standards judged to be well-defined, comprehensive and utilized
by commun-ities to identify the emerging trends in the development
of school-based health center models (guideline summaries for CO,
CT, DE, LA, IL, ME, MA, NC, NY, OR, PA, and TX can be found in Appendix
B, page 15).
The common denominator across the guidelines is the
states' desire to strike a careful balance between being prescrip-
tive to ensure a standard of care and allowing for
community flexibility in program development. Issues of control
left to community decision-makers tend to center around the designation
of a lead agency, the specifications of the site, and the program's
evaluation and quality assurances. Required components most often
include mandatory parental consent and broad-based community input
into the school-based health center planning and operations.
_ Primary Goal
With few exceptions, states define school-based health
centers as vehicles for coordinating and delivering accessible primary
physical and mental health services to students. For many states,
the vision for school-based health centers extends beyond access;
on-site health care staff would help to assure a medical home for
all students (DE), assess and improve the health status of children
(IL, ME, PA), and enable students to be responsible decision makers
in promoting their own health (TX).
_ Sponsoring Agency
All of the states recognize school-based health centers
as a partnership between school and community health care systems.
States that specifically designate a health care provider as the
lead agency (CT, DE, MA, NY) underscore the importance of generating
a vested interest in the center on the part of school administrators
and require formal agreements between the two. Other states, such
as Pennsylvania, restrict sponsorship to the local educational agency
or the school district. Under this arrangement, the school district
retains control of the school-based health center with services
being provided under contract by an outside health care entity.
_ Site Specifications
Aside from requiring that school-based health centers
be located on school grounds, most states provide minimal specifications
about the site. Where more extensive regulations are in place, some
states, such as Illinois and Texas, incorporate provisions that
allow schools unable to allot physical space within the school building
to establish health center sites adjacent to school property.
Additional specifications for school-based health
centers vary by state. Language includes provisions that school-based
health centers must be: centrally located and convenient for the
students (ME); designed to assure privacy and confidentiality (CT);
able to function as an integral part of the school (LA); accessible
for outreach and summer use (MA); and occupy a minimum of two rooms
if possible (IL).
_ Community Participation
States require active involvement from community
members, parents, and students in the development of school-based
health centers. The required participation includes showing evidence
of relationships with interested and involved community members
and organizations (CO), establishing and maintaining linkages to
providers (CT), and having a school-community advisory group (LA,
IL, MA, ME, NC, TX). Advisory groups, where they exist, are comprised
of parents and students, school staff and administrators, health
care providers, insurers, community and advocacy organizations,
individuals concerned with children's health issues, and business
leaders. The planning and community-level policy decisions regarding
the school-based health centers are influenced and determined, in
large part, by these advisory boards.
_ Continuum of Care
Ten of the 12 states incorporate standards for off-site
referral and community health and social service linkages to ensure
a continuum of care beyond the programs' scope of services and operational
hours. In Delaware, for example, center providers are required to
develop memoranda of understanding for referrals and 24 hour coverage
and to establish a referral network plan with the students' primary
provider.
_ Service Definitions
The states' definition of required or desired services
are fairly uniform. The common service elements to be provided include:
preventive health, acute care, routine examinations, immunizations,
social services, health education and mental health counseling.
Reproductive health services are more frequently suggested, than
required, for centers serving older students.
_ Staffing
State guidelines for school-based health center personnel
are delineated either as recommended (CO, DE, IL, LA, ME, TX), or
required (CT, MA, NY, NC, OR, PA) core staffing patterns. Most states
require that a mid-level practitioner with physician oversight lead
the core staff. In the majority of states, this position is held
by either a nurse practitioner or physician assistant (CO, CT, DE,
MA, ME, NY, NC, OR, PA, TX). Mental health professionals -- either
part-time or full-time -- are required by most states (CT, DE, LA,
ME, NC, OR, TX). Where mental health professionals are not mandated
to be part of the core staff (CO, IL, NY), state guidelines encourage
the provision of mental health services. Several states encourage
the inclusion of additional allied health professionals, including
nutritionists, dentists, psychologists, and violence and substance
abuse prevention specialists, as indicated by the needs of a particular
site (CO, CT, IL, ME, NY, OR).
Illinois, Maine, and Pennsylvania require school
nurses, where present, to be integrated into the school-based center
staff. Other states mandate evidence of collaboration between school-based
health center staff and other health professionals in the school.
Delaware specifies that the school nurse serve as the link between
the health center and the school while Maine states that the school
nurse should serve on the health center advisory committee and assist
in program development.
_ Evaluation and Quality Assurance
The majority of states require that school-based
health center providers define how they will maintain accountability
and assure quality. Suggested mechanisms include internal charts
reviews and audits. Ten of the 12 states monitor health centers
by reviewing performance data and conducting site visits.
In Colorado, the service delivery standards in the
school-based health centers reflect those of the health care entity
affiliated with the school-based health center. In Illinois, the
standards of the service providers' professional organization are
used (e.g., American Academy of Pediatrics and American College
of Obstetricians and Gynecologists).
Standardized data collection is required by 11 states
as a condition of receiving a state grant (CO, CT, DE, LA, MA, ME,
NY, NC, OR, PA, TX). This requirement enables a state-wide quantitative
and qualitative monitoring system. Pennsylvania has contracted with
a local university to conduct evaluations of all state-sponsored
school-based health centers.
In addition to performance monitoring, most state
health departments support quality development through regional
meetings, training workshops, and individual technical assistance.
Medicaid and Medicaid Managed Care
Medicaid support for school-based health centers
has been limited. In a 1991 survey conducted by the Center for Population
Options, Medicaid was found to provide two percent of the operating
costs of school-based health centers. More recently, 1992/1993 data
from 24 school-based health centers receiving support from the Robert
Wood Johnson Foundation reported that 13 percent of their operating
budgets were supported by patient care revenue, primarily Medicaid.
To expand and diversify support for school-based
health centers, some state health departments and providers have
sought school-based health center participation in Medicaid to create
a long-term, viable financing strategy. Twenty-nine states have
established Medicaid reimbursement mechanisms for services provided
in school-based health centers. A few states, including Louisiana,
Texas, and Virginia, require that state-sponsored school-based health
centers become Medicaid providers to ensure maximum recovery of
federal and state dollars for medical and mental health services.
The total amount of Medicaid reimbursement for health
care provided in school-based health centers is unknown at the
state level for several reasons. The states do not fund all
school-based health centers and therefore do not receive revenue
and expense statements that would enable the state offices to determine
the sources of support. Moreover, health care provided in a school-based
setting may be billed to Medicaid by the sponsoring medical institution
with no notation that the care was provided in a school location.
The pursuit of Medicaid reimbursement for school-based
health center services is complicated by the recent growth in Medicaid
managed care programs (see below). With an eye toward reining in
health care costs, reducing unnecessary care, and improving access
to preventive services, states are establishing managed care networks
to regulate Medicaid recipients' health care consumption. School-based
health centers that serve Medicaid beneficiaries must secure a role
within the managed care system if they are to be reimbursed for
services to these patients.
State governments are in the early stages of determining
the appropriate relationship between school-based health centers
and managed care initiatives. For the most part, these relationships
are currently being developed at the local level. Individual health
centers or their institutional sponsors are attempting to negotiate
agreements with the managed care plans concerning services to be
provided managed care enrollees and reimbursement mechanisms. In
some instances, school-based health centers have joined managed
care provider networks and share in the primary care capitation
payments; other school-based health centers have established a reimbursement
relationship for specific services to a managed care provider's
patient; and in still other cases, no relationship has been established.
In response to the survey questions, many states
report limited coordination and negotiations between school-based
health centers and Medicaid managed care programs. This is due either
to a small number of school-based health centers in the state, the
absence of Medicaid managed care programs, or both. States with
extensive Medicaid managed care and school-based health center
activity have been more likely to explore facilitating relationships
by either encouraging or requiring formal arrangements between the
two.
A few states report nascent efforts to explore the
fit between managed care and school-based health centers. State
health care financing administrations in Rhode Island, Oregon and
Connecticut require coordination between the school-based health
centers and managed care plans. Rhode Island's Medicaid managed
care program, RIte Care, requires managed care plans to, at a minimum,
have policies and procedures in place for coordinating service delivery
with school-based health centers as a condition of participation
in the program. The state-level school-based health center program
will explore the possibility of strengthening the contract language
in subsequent RIte Care contracts between the state and the health
plans. At the same time, the state is requiring school-based health
centers to make formal arrangements for the coordination of services
with the managed care plans. Language to this effect is
being added to the contracts between the school-based health centers
chosen to participate in Rhode Island's new school-based health
center project.
Oregon law requires state agencies to mandate that
managed care plans and school-based health centers, among other
organizations, develop agreements authorizing payment for immunizations,
sexually transmitted diseases, and other communicable diseases from
the plans to the providers of these services. The state also encourages
agencies to explore other opportunities for coordination and reimbursement
of services not defined by the mandate.
The state of Connecticut is in the unique position
of developing a Medicaid managed care program in the presence of
an already-established school-based health center network. The request
for proposals being developed to solicit managed care plan participation
in the new program includes a requirement that the plans contract
with the school-based health centers in their catchment area. In
addition, Connecticut's new state-level school-based health center
initiative has a subcommittee devoted to managed care issues. Approval
from the state Medicaid office for reimbursement of services provided
by school-based health centers is pending.
Some states, including Maryland, encourage linkages
between school-based health centers and Medicaid managed care plans
by allowing the centers to serve as primary care providers. The
centers are approved by the state Medicaid plan for reimbursement
for services. Parents have the option of choosing school-based health
centers as their children's managed care sites. Staff from Maryland's
state school-based health center initiative is working with the
state Medicaid administration to develop a "how to" resource
book on obtaining Medicaid reimbursement as well as other approaches
to funding the centers.
In Massachusetts, the Department of Public Health,
which oversees the school-based health center program, has participated
in regional meetings with school-based health staff, Medicaid HMO
providers, and state Medicaid managed care staff to foster communication,
education and linkages among these groups. Participants in the meetings
are working to develop a collaborative strategic plan for improving
health care delivery to children and adolescents.
States that do not attempt to regulate or influence
the relationship between the school-based health centers and the
Medicaid managed care plans leave negotiations to the individual
school-based health centers and the managed care network. The result,
according to survey respondents, is often frustration and fatigue
for school-based health center administrators. Great amounts of
time and energy must be dedicated to cultivating relationships with
managed care organizations. These labor-intensive arrangements drain
programs of scarce human resources already overextended for administration
and program management. Even with contractual relationships, the
outcomes can be disappointing. One state reported that in the first
six months of a Medicaid managed care initiative two school-based
health centers had recovered less than $3,000 each from the managed
care providers, compared to $16,000 - $17,000 received from Medicaid
in the six months prior to the managed care contract.
Failure to develop state-level relationships between
managed care and school-based health centers may have long-term
repercussions. Inconsistent and varied arrangements produce inconsistent
and varied programs, which are difficult to hold accountable to
global standards and quality assurances. Moreover, lack of financial
protection for school-based health centers may render the "primary
care in schools" concept untenable in a managed care environment.
By all reports, the process is complicated; yet states note that
school-based health centers and managed care programs share a mutual
goal of ensuring access to preventive, primary health care, and
that this goal can be met more effectively through collaboration.
Technical Assistance
As state-sponsored school-based health center initiatives
expand, so do requests to state government for technical assistance.
The majority of states, even those without an active state initiative,
report providing some type of technical assistance to interested
communities within the last year. While many states meet technical
assistance needs on a "per request" basis, several have
established on-going efforts to assist communities with grant applications,
Medicaid billing, managed care negotiations, data collection and
evaluation, and needs assessments.
State offices use a variety of strategies to provide
technical assistance. Some states organize regular meetings with
school-based health centers, others use state-sponsored coalitions
and technical assistance advisory groups (AZ, DE, HI, IL, LA, NM,
NY and OR). These activities facilitate continuing clinical education
and professional development, collaborative problem solving, and
statewide networking for school-based health center personnel.
Political Controversy
Nearly all states report some controversy associated
with school-based health centers. Most report, however, that opposition
has been limited and localized. Only a few states indicate that
they have experienced statewide organizing against the centers.
The broad scope of public support for school-based health centers
and the generally modest level of opposition seems an important
contributor to the increases in state support for the health centers.
The most frequently mentioned concerns regarding
school-based health centers are opposition to the provision of family
planning services and apprehension that the centers will interfere
with parental rights and responsibilities. Other concerns include
worries that the school-based health centers will take money from
the schools' education budget, that the health centers will lead
to the elimination or diminution of school nurses' jobs, that the
centers are duplicative of other services readily available in the
community, and that the centers will take patients from private
physicians.
States with school-based health center initiatives,
and even some without, have responded to political controversy with
public education efforts. These include presentations and discussions
at public forums, distribution of printed materials, and creation
of community advisory committees. Involvement of parents in the
planning process and requiring parental consent for students to
use the health centers are singled out as most important in addressing
any concerns. Other frequently cited strategies include presenting
data to the public on student health care needs and on services
offered and utilized at existing school-based health centers. In
general, local communities take the lead in organizing the communications
efforts although one state produced an 8-minute video to introduce
the concept of school-based health centers.
Lastly, several states note that they encourage local
providers to seek news coverage by engaging the media in publicizing
the work of school-based health centers (CO, CT, NJ, OR, PA). These
proactive strategies are credited with minimizing the need for conducting
defensive press relations.
Conclusions
Data from the summer 1994 survey underscore the growth
both in the numbers of school-based health centers and in the state
initiatives to support those centers. Key findings include the following:
School-based health centers have become an
increasingly acceptable vehicle for improving access to health care
for school-age children. By October 1994, the total number of school-based
health centers had reached 607.
State initiatives, which have always played a lead
role in funding school-based health centers, have assumed an even
greater role in the past several years, with state funding increasing
by 140 percent during the past 18 months, reaching a total of $22.3
million.
As funding has increased so has state development
of guidelines for school-based health centers. Twenty-two states
have established guidelines, most of which spell out a commitment
to a comprehensive model of care.
Long-term financing remains the major challenge to
be overcome by school-based health center initiatives. Most school-based
health centers have received limited or no Medicaid reimbursement
for health care provided to poor children; those school-based health
centers which have received substantial Medicaid funds are finding
this source of revenue challenged by Medicaid managed care initiatives.
The sustainability of school-based health centers will depend on
the outcome of efforts to craft a viable long-term funding strategy
in the midst of major changes affecting both the public and private
health care systems.
