Rhode Island Guidelines: Appendices
Appendix A
RI RULES AND REGULATIONS THAT IMPACT SBHCs
Rules and Regulations for the Licensing of Organized Ambulatory Care
Facilities (OACF) (R23-17-OACF) establishes minimum standards for licensed
organized abulatory care facilties in this state. The regulations define
school-based health centers as an "institution based, non public premises"
- "premises" is defined as where the OACF provides direct care services
solely to individuals who are members of a defined institution as determined
by the Director. This makes it possible for OACFs to sponsor SBHCs without
obtaining a certificate of need. OACFs that wish to sponsor a SBHC should
send a letter of intent to the Director of Health for approval.
Rules and Regulations for the Health Care Accessibility and Quality
Assurance Act (R23-17.13) ensures that those individuals and care entities
involved with the delivery of plan coverage in our state meet the standards
of this chapter to insure accessibility and quality for their patients.
It allows the Department of Health to develop standards for health plans
to ensure quality and accessibility of care.
Rules and Regulation For School Health Programs (R16-21-SCHO) defines
minimum standards for the provision of health services in school.
Rules and Regulations Pertaining to the Reporting of Communicable,
Environmental and Occupational Diseases Communicable Diseases (R 23-5-6,
10, 11, 23-24.6-CD/ERD) (R23-24.5 ASB) establishes standards pertaining
to confidentiality and reporting of communicable, occupational, and
environmentally related diseases in the state. Diseases which much be
reported by licensed physicians to the Department of Health are identified
and the manner in which certain diseases need to be reported are described.
Rules and Regualtions For Determination of Need for New Health Care
Equipment and New Institutional Health Services (R23-15-CON) establishes
minimum standards and procudures regarding the determination of need
for the development of new health care equipment and new institutional
health services. This regulation states that a licensed OACFs or hospitals
providing health care services soley for enrolled students of a recognized
educational faciltiy shall be exempt from certificate of need requirements
for such SBHC premise. Rules and Regulations Pertaining To Immunization
and Testing For Communicable Diseases (R23-1-IMM) establishes standards
pertaining to requirements for immunization and testing of communicable
diseases, including but not limited to tuberculosis for employees, children
and students at any preschool or school in grades Kindergarten -12 in
RI.
Appendix B
A recently published MCH Policy Research Brief summarized research
findings on the strengths of SBHCs to include:
- SBHCs eliminate many access barriers faced by adolescents.
- SBHCs reach under served, low income, and high risk populations.
- SBHCs are often a sole source of care.
- SBHCs involve the community in planning and governance.
- SBHCs meet health care needs specific to children and adolescents
without disrupting everyday functioning of other family members.
- SBHCs provide a variety of services to meet the physical, mental,
and social needs of adolescents.
- Limited data suggest that SBHCs and the services they provide are
very popular with parents and families.
- SBHCs are challenged both to respect the confidentiality of their
clients and to respect the rights of family members to be informed
of a child's or adolescent's well-being.
- SBHCs provide care for culturally diverse populations.
Additionally, data on adolescents prepared by the National Adolescent
Health Information Center at the University of California San Francisco
include:
- White adolescents are more likely to be insured than non-White
adolescents, particularly Hispanics.
- Adolescents without insurance make fewer visits to the doctor than
those with insurance.
- A cost-benefit analysis conducted in San Francisco showed ratios
of $1.38 to $2.00 saved for every dollar expended in SBHCs, based
on estimated reductions in use of emergency rooms, lower pregnancies,
early prenatal care, and diagnosis of Chlamydia.
In Rhode Island from the 1997 Kids Count Fact book :
- As of December 1, 1996, there were 52,238 children under age 18
enrolled in RIte Care, Rhode Island's Medicaid Managed Care program.
Three quarters of all RIte Care clients are children.
- Of the 76,560 RIte Care clients enrolled on December 1, 1996, 46%
were enrolled in United Healthcare of New England; 33% in Neighborhood
Health Plan of RI; 10% in Blue Chip (formerly HMO RI); and 10% in
Harvard/Pilgrim Health Care of New England. t Between 1989 and 1993
in RI, there were 8,486 pregnancies to teens ages 14-18.
- Risk factors for teen pregnancy develop during childhood and include
early school failure, early behavioral problems, poverty, and family
dysfunction. Both male and female teens are less likely to become
teen parents when they have a range of positive life options and economic
opportunities.
- The younger people start smoking cigarettes, the more likely they
are to become strongly addicted to nicotine. Eighty-nine percent of
adult daily smokers tried their first cigarette by age 18.
- Teens who smoke are three times more likely than nonsmokers to
use alcohol, eight times more likely to use marijuana and 22 times
more likely to use cocaine. Smoking is associated with a host of other
high risk behaviors, such as fighting and engaging in unprotected
sex.
- Alcohol is the leading substance of abuse at all grade levels in
RI. The prevalence of alcohol use is higher than national rates.
- The number of RI juvenile arrests for drug abuse violations in
1995 was the highest recorded total since 1977. Drug and alcohol offenses
referred to Family Court increased 50% between 1994 and 1996, from
691 offenses in 1994 to 1,033 offenses in 1996. Ninety percent of
the incarcerated population at the Training School had been regular
abusers of illicit substance and alcohol.
- In Rhode Island in 1994 and 1995, there were 11 gun deaths among
teens ages 15-19. Of the forty eight children hospitalized with gunshot
wounds, one of the victims was younger than age 5, two were between
the ages of 5 and 9, seven were between the ages of 10 and 14, and
thirty eight were between the ages of 15 and 19. Twenty two were intentional
injuries, twenty two were unintentional injuries and four were of
undetermined intention.
According to a 1995 Carnegie Corporation report, Great Transitions:
Preparing Adolescents for a New Century:
- Good schools, caring families, and supportive community institutions
help young people make the transition into adulthood - well-educated,
committed to families and friends, and prepared to be productive workers
and citizens.
- Adolescents need critical life skills such as problem solving,
decision-making, resolving conflict nonviolently, and coping with
stress.
- Adolescents need environments that foster healthy social development,
academic and vocational skills, and offer opportunities for recreation
and community service.
- Adolescents need close, ongoing contact with caring and competent
adults whose judgement they trust.
Appendix C
The components of the Memorandum of Understanding should:
- define the relative roles and responsibilities of the parties specifically
SBHC and school personnel with counterpart responsibilities;
- establish protocols for coordination of services including the
role of SBHC staff in urgent care;
- delineate advisory committee formation, mission, and scope of authority;
- define joint responsibility for planning, priority setting, and
oversight;
- describe methods for resolving differences; and,
- describe procedures to assure a collaborative relationship between
the SBHC staff and school health program staff including health educators,
physical education teachers, school nurse teachers, student assistance
counselors, school psychologists, guidance counselors, and social
workers.
Appendix F
CONFIDENTIALITY LAWS Under RI law, minors can receive care without
parental consent or notification for the following services:
- Emergency Care RI St. 23-4.6-1
Any person 16 years or older or married may consent to routine emergency
medical or surgical care.
- VD/STD Care RI St. 23-11-11
Minors can consent to examination and treatment for any STD.
- Consent to testing and treatment - Reportable communicable disease
- RI St. 23-8-1.1
Persons under 18 years of age may give legal consent for testing, examination
and/or treatment for any reportable communicable disease.
- HIV/AIDS Care RI St. 23-11-17
The physician or health care provider attending any person (with no
reference to age) for a suspected STD shall offer testing for HIV. The
identity of the individuals tested under this section shall not be released
except as otherwise provided by statute. All persons tested under this
section shall be provided pretest and post test counseling.
- RI St. 23-6-12
Unless otherwise expected by the provisions of this chapter, no person
may be tested for the presence of AIDS, where the test can be identified
with a specific individual, unless he or she has given his or her informed
consent by his or her signature or that of a parent or guardian.
- RI St. 23-6-14
Notwithstanding the provision of 23-6-12, a physician or other health
care provider may test for AIDS without informed consent if:
- The person is between one and thirteen and appears to be symptomatic
of AIDS;
- The person to be tested is a minor under the care and authority of the
Department of Children, Youth and Families, and the Director of that Department
certifies that an AIDS test is necessary to secure health or human services
for that person; or
- If an emergency, where due to a grave medical or psychiatric condition,
it is impossible to obtain consent from either the patient or the
parent/guardian.
- RI St. 23-6-17
It is unlawful for any person to disclose to a third party the results
of an individual's AIDS test without the prior written consent of that
individual, or in the case of a minor, the minor's parent or guardian.
- Drug/Alcohol Treatment RI St. 14-5-3
In all treatment of a child for substance abuse or chemical dependency,
the licensed treatment facility shall require the parents to participate
in the treatment. Parental consent is required, except as provided in
14-5-4.
- RI St. 14-5-4
In the event a child refuses permission to contact parents to seek parental
consent and if, in the judgement of a qualified professional, such contact
would not be helpful or would be deleterious to the child who is voluntarily
seeking treatment for substance abuse or chemical dependency, then noninvasive,
noncustodial treatment services may be provided by a qualified professional
without parental consent; provided, however, that during the course
of treatment, the qualified professional shall make attempts to obtain
permission from the child to obtain parental consent for and involvement
in treatment services.
- Confidentiality of Health Care Information Act Chapter RIGL 5-37.3
The purpose of this chapter is to establish safeguards for maintaining
the integrity of confidential health care information that relates to
an individual. Specifically, pursuant to 5-37.3-4 all patient health
care information is confidential and may be released only upon written
consent of the parent with the exceptions noted in 5-37.3-4(b) which
provides that no written consent is required for release of confidential
health care information "Between or among qualified personnel and health
care providers within the health care system for purposes of coordination
of health care services given to the patient..."
There are no specific RI laws regarding:
emancipated minors
minors living apart
pregnant minor
minor in the military
general medical care
family planning
contraceptive care
pregnancy related care
sexual assault
outpatient mental health services
inpatient mental health services.
- Federal laws
Medicaid law prohibits the imposition of parental notification for Medicaid
covered family planning services. This federal law supersedes state
law (however in RI there are no specific provisions for family planning
and contraceptive care).
- 42 Code of Federal Regulations, Part 2 Confidentiality of Alcohol
and Drug Abuse Patient Records
These regulations are stricter than laws regarding confidentiality of
health care information. This law applies to any program which provides
alcohol/drug abuse diagnosis including assessment and evaluation treatment
or referral for treatment.
CHILD ABUSE REPORTING LAWS
- Duty to report-Deprivation of nutrition or medical treatment RIGL
40-11-3
Any person who has reasonable cause to know or suspect that any child
has been abused or neglected as defined herein or has been a victim
of sexual abuse by another child shall, within twenty-four (24) hours,
transfer that information to the Department for Children and their Families
or its agent who shall cause the report to be investigated immediately.
- Immunity from liability RIGL 40-11-4
Any person participating in good faith making a report pursuant to this
chapter shall have immunity from any liability, civil or criminal, that
might otherwise be incurred or imposed. Any such participant shall have
the same immunity with respect to participation in any judicial proceeding
resulting from such report.
- Report by physician of abuse or neglect RIGL 40-11-16
(1) When any physician has cause to suspect that a child, brought in
for examination, has been abused, neglected or if a child under the
age of twelve (12)years is suffering from any sexually transmitted disease,
the physician should report the incident to the Department. (2) An immediate
oral report should be made to both the Department and law enforcement
agency, followed by a written report to explain the extent and nature
of the abuse or neglect the child has suffered. (3) When the department
receives the report from the physician, about the child being physically
abused, they should investigate the oral report. If the investigation
does provide evidence of sexual or physical abuse the department should
have the child examined by a licensed physician. Any child protective
investigator should, with or without the parent(s) or guardian(s) consent
to have the child removed from a place where the child may be to secure
the examination required by this subsection. After the examination is
completed it is mandatory for the physician to make a written report
of his findings to the Department.
- Penalty for failure to report or perform required act 40-11-6.1
Any person, official, physician or institution is required to report
known or suspected child abuse, neglect or to perform any other act
who knowingly fails to do so or who knowingly prevents any person acting
reasonably from doing so shall be guilty of a misdemeanor and conviction
and shall be subject to a maximum of five hundred dollars ($500) or
imprisonment for at least one (1) year or both. In addition these parties
who knowingly fails to perform any act required or who knowingly prevents
another person from performing a required act shall be civilly liable
for the damages proximately caused by such failure.
Appendix G
Model Policy Recommendations on Confidential Health Services for Adolescents
WHEREAS adolescents experiment in behaviors that threaten their current
and future health; and
WHEREAS the timely seeking of necessary medical services is critical to
the health of adolescents; and
WHEREAS both providers and adolescents have identified a lack of confidentiality
as a major barrier to care which leads many adolescents to delay or avoid
medical visits or withhold relevant information form the health provider;
and
WHEREAS confidential health services have long been considered a cornerstone
of the relationship between patients and physicians as well as other health
providers; and
WHEREAS adolescents should receive confidential care consistent with their
developmental and physical needs; therefore be it resolved that:
1. Health professionals have an ethical obligation to provide the
best possible care and counseling to respond to the needs of their adolescent
patients.
2. Providers should allow emancipated and/or mature minors to give
informed consent for medical, psychiatric, and surgical care without
parental consent and notification.
3. Providers should make every reasonable effort to encourage the adolescent
to involve parents, whose support can, in many circumstances, increase
the potential for dealing with the adolescent's problem on a continuing
basis. When, in the opinion of the provider, parental involvement would
not be beneficial, parental consent or notification should not be a
barrier to care.
4. Providers should discuss their policies about confidentiality with
parents and the adolescent patient, as well as conditions under which
confidentiality would be abrogated (e.g. life threatening emergency).
As decision-making responsibility begins to shift between parents and
adolescents the provider should make it clear to parents and adolescents
that adolescents have an opportunity for examination and counseling
apart from parents. The same confidentiality will be preserved between
the adolescent patient and the physician as between the parent (or responsible
adult) and the physician.
5. Parents should be encouraged to work out means to facilitate communication
regarding appointments, payment, or other matters consistent with the
understanding reached about confidentiality, and parental support in
this transitional period when the adolescent is moving toward self-responsibility
for health care.
6. Training programs and continuing education programs in the health
professions should inform their students or parents about issues surrounding
minors' consent and confidential care, including relevant law, and implementation
into practice.
7. Health care payers should be urged to develop a method of listing
services which preserves confidentiality for adolescents.
8. Providers, parents, and adolescents need to be aware of the nature
and effect of laws and regulations in their jurisdiction that introduce
further constraints on the provider-patient relationship.
Some of these laws and regulations are unduly restrictive and in need
of revision as a matter of public policy. Ultimately, the health risks
to the adolescent are so impelling that legal barriers and deference to
parental involvement should not stand in the way of needed care. Gans,
Janet E., Editor, Policy Compendium on Confidential Health Services for
Adolescents, American Medical Association, January, 1993
Appendix H
The following are specific recommendations from SBHC space planners
on how to make a clinic function effectively. This information is from
the Robert Wood Johnson Foundation Publication: The Answer is at
School: Bringing Health Care to Our Students.
|
Laboratory
|
|
|
Environment:
|
Equipment:
|
|
Visually private
space
|
Refrigerator
for specimen
storage
|
|
Adequate counter
space for equipment
|
Sample-taking
chair
|
|
Electrical
outlets
1 outlet for every 18 inches
|
Waste receptacle
with lid
|
|
of counter
space, not over sink
|
Infectious
waste receptacles
|
|
Cabinet/area
to stock daily supplies
|
|
| |
|
|
Exam Room
|
|
|
Environment:
|
Equipment:
|
|
Minimum space
8' X 9'
|
Exam table
and stool
|
|
Exam table
should be
accessible from 4 sides
|
Foot stool
|
|
Private and
soundproof
|
Waste receptacle
with lid
|
|
Door limits
view into exam area
|
Gooseneck lamp
|
|
Cabinet/are
to stock daily supplies
|
|
|
|
|
|
Patient
Waiting Area
|
|
|
Environment:
|
Equipment:
|
|
Chairs that
can be
arranged in various ways
|
Patient education
display unit
|
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Clock
|
|
| |
|
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Receptionist/Records
Storage Area
|
|
|
Environment:
|
Equipment:
|
|
Desk/work counter
and chairs
|
Photocopier
|
|
Telephone
|
Adding machines
|
|
Answering machine
|
Adequate number
of electrical
outlets
|
|
Locked medical
records storage files
|
School Health
On-Line Software
|
|
Fax
|
Computer with
printer
|
|
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