Service and Targeting Guidelines

RHODE ISLAND'S GUIDELINES FOR
SCHOOL-BASED HEALTH CENTERS, JULY 1998
DEVELOPED BY THE RHODE ISLAND
SCHOOL-BASED HEALTH CENTER NETWORK

Members of the SBHC Guidelines Workgroup of the School-Based Health Center Network include:

Avery Colt* RI Public Health Foundation

Michelle Dair, N.P.*

Central Falls Jr. Sr. High SBHC
Gilson Da Silva United Healthcare of New England
Tracey Dorry, C.S.N.T. Woonsocket Middle School
Diana Hobden, N.P.* Woonsocket High Health Hut
William Hollinshead, M.D., M.P.H. RI Department of Health
Diane Manasian, M.D. Central Falls Jr.-Sr. High SBHC
Rosemary Reilly-Chammat* RI Department of Health
Prudence Robert C.S.N.T. Central Falls Jr.-Sr. High School
Jan Shedd RI Department of Health
Peter Simon, M.D., M.P.H. RI Department of Health
David Tabscott, M.D. Central High SBHC
Lynn Wachtel, F.N.P., M.S.N.* Central High SBHC
Nancy Walsh* RI Department of Health
Pamela Zappardino, Ph.D. RI Public Health Foundation
Harvey Zimmerman RI Public Health Foundation
*Primary authors of the RI's Guidelines for School-Based Health Centers.


FOREWORD

The purpose of Rhode Island's Guidelines For School-Based Health Centers is to provide in one document all the regulatory and best practice information needed for a school community to develop a school-based health center. A variety of Rhode Island's laws, codes and regulations as well as federal laws are cited throughout the document, summaries of which are compiled in Appendix A. All applicable provisions contained in these regulations are mandatory and are enforceable by the RI Department of Health. Regulations pertaining to SBHCs include and are not limited to:

  • Rules and Regulations for the Licensing of Organized Ambulatory Care Facilities (R23- 17-OACF)
  • Rules and Regulations for the Health Care Accessibility and Quality Assurance Act (R23- 17.13);
  • Rules and Regulations for School Health Programs (R16-21-SCHO);
  • Rules and Regulations Pertaining to the Reporting of Communicable, Environmental, and Occupational Diseases (R 23-5-6, 10, 11, 23-24.6-CD/ERD) (R23-24.5 ASB);
  • Rules and Regulations for Determination of Need for New Health Care Equipment and New Instituitonal Health Services (R23-15-CON); and,
  • Rules and Regulations Pertaining to Immunization and Testing for Communicable Diseases (R23-1-IMM).

Best practices are standards adopted by the state to ensure quality and excellence in SBHCs; they are not enforceable by law. Meeting all the state requirements and best practices will ensure optimal use of investments in school based services. In the section entitled "Requirements/Best Practices-Characteristics of Rhode Island's School-Based Health Centers", the statements that contain "must" are requirements by law and statements that contain "should" are best practice standards.

Members of the School-Based Health Center Network can provide technical assistance to schools interested in school based health centers. Contact Rosemary Reilly-Chammat at the RI Department of Health 222-5922 for more information.

INTRODUCTION

School-based health centers (SBHCs) are clinical settings located in schools, which deliver primary preventive care services to students on site. Rhode Island's first SBHC was established in 1987 at Central High School in Providence. Additionally, there are currently SBHCs in Woonsocket High School, Woonsocket Middle School and Central Falls Jr-Sr. High School.

Rhode Island laws have been supportive of the provision of a variety of health services in schools (Appendix A). The Rules and Regulations For School Health Programs (R16-21-SCHO) were established in 1963. These Rules and Regulations describe minimum standards in the quality and quantity of health services provided in schools as defined by existing state law. The school district's certified school nurse teachers are responsible for administering the school health services sections of the Rules and Regulations. The RI Departments of Health and Education jointly promulgate these regulations.

As outlined in Healthy Schools! Healthy Kids!, Rhode Island's Plan for Comprehensive School Health Programs, SBHCs are part of a continuum of providing access to health services in schools. All schools in Rhode Island fall somewhere along this continuum of provision of health services beginning with implementation of requirements in the Rules and Regulations for School Health Programs by the certified school nurse teacher (e.g. on-site screening); identifying a provider and insurer for each child; and linking children without any provider and or insurer to services in the community. As a general rule the greater the physical and behavioral health needs of children and adolescents in a school, the further along the continuum a school community would need to go to adequately address the health needs of children and adolescents.

COZ Family Centers exist in 13 communities throughout Rhode Island and are linked to almost 30 schools. COZs provide an excellent vehicle for a wide range of programs, services, and other initiatives for children and families. The COZ mission is to build capacity to provide an accessible integrated system of resources and supports for families and children to ensure children's success in school. COZs may or may not include the provision of health services depending on the particular needs and resources of a community.

SBHCs should be integrated into the school's Comprehensive School Health Program (CSHP). These components include: health education; physical education; nutrition services; health services; guidance, counseling, and psychological services; school environment; school climate; health promotion for faculty and staff; and family and community involvement. Members of the school's CSHP can support student's health by providing education on healthful behaviors, opportunities to practice healthy behaviors; and by creating environments, policies, and programs that are supportive of healthy behaviors. The SBHC in collaboration with the other members of the school's comprehensive school health team can help students identify, advocate, and take responsibility for their own health needs. See Appendix B for more information on the benefits of SBHCs and information on adolescent health risks.

Finally, SBHCs in coordination with the Multi-Disciplinary Team and Individual Education Plan team can play a vital role in linking special needs students with primary and specialty health care. According to the Regulations of the Board of Regents For Elementary and Secondary Education Governing the Special Education of Students With Disabilities, SBHC staff as providers of "related services" may:

  • Participate directly, or consult as requested or specified, in the evaluation process;
  • Provide direct individual evaluation and/or therapeutic services to students with disabilities as specified by the evaluation process; and
  • Participate in professional, parent, and community education to further coordination of educational, medical, and social concerns regarding students with disabilities.

The purpose of the Guidelines is to define state policy with regard to SBHCs, and to provide guidance to schools and communities for the design and management of SBHCs. These policies and guidelines represent best practice standards based upon applicable laws, regulations, and criterions established by authoritative professional bodies, and the practical experience of an extensive number of SBHCs across the United States. Rhode Island's School-Based Health Center Guidelines are intended to provide uniform guidance for expanding the network of SBHCs in Rhode Island.

MISSION

The primary purpose of the Guidelines is to improve the health of children and adolescents by providing quality health services through SBHCs.

REQUIREMENTS/BEST PRACTICES - CHARACTERISTICS OF RHODE ISLAND'S SCHOOL- BASED HEALTH CENTERS

1. School based health services should be developed based on local assessment of needs and resources.

2. The sponsoring licensed health provider must arrange for 24-hour coverage to ensure access to services when the school or the center is closed, (e.g. through a back-up health facility).

3. The SBHC must be staffed and administered by a qualified, RI licensed, community- based health care provider who is an approved provider for Medicaid and other third party payers, and formal agreements with approved managed care providers under RIte Care must be established to secure reimbursement for school based health services to their enrollees.

4. SBHCs must meet all of the same national and state laws, rules and regulations (e..g. R23-17-OACF) that the sponsoring health facility must meet.

5. SBHC services should be performed by a multi-disciplinary team of credentialed, RI licensed providers which may include, physician, nurse practitioner, dentist, social worker, nutritionist, and other providers. These providers should be eligible to receive reimbursement from third party payers including RIte Care. The SBHC staff should be able to relate to students culturally and linguistically.

6. The SBHC should be integrated into the existing school health program in collaboration with the certified school nurse teacher, school administration, special education, and other members of the school's CSHP.

7. All students enrolled in a school must be eligible for SBHC services.

8. Students must be able to choose the SBHC as their primary care provider. When the SBHC is not the primary care provider, the SBHC must coordinate care with the students' medical homes, including managed care providers, as well as with other medical providers, social service agencies, substance abuse providers, mental health providers, and other agencies, programs and organizations. The SBHC may provide episodic and/or urgent care to students.

9. Each SBHC should form and maintain an advisory committee to provide input into the development and operation of the program.

10. The SBHC partners should be willing to engage in long range planning.

PARTNERSHIP

The health provider, school, and community share responsibility for ensuring successful integration of the SBHC. All need to be committed to operating with mutual respect and a spirit of collaboration. The partnership between school and provider organization should be formalized under a Memorandum of Understanding (MOU) specifying the terms of agreement between the parties (Appendix C). The MOU should describe the relationship between the participating partners and define the roles and responsibilities of SBHC and school counterpart staff. The school and provider organization should jointly establish an on-going relationship with parents and other community representatives through a community advisory committee. In communities with an established COZ, the COZ should be a participant in, the advisory committee. Advisory committee membership should include the certified school nurse teacher and other school staff, community members, health providers, parents, students and other stakeholders.

The partnership role of the school is based on its administration as the host facility, responsibility for educating the student population, and its responsibility under the Rules and Regulations For School Health Programs for the health of the student population. Key partnership functions include:

School's Role

  • Providing and maintaining the physical space of the SBHC;
  • Promoting enrollment in and utilization of, the SBHC to students and their parents;
  • Facilitating collaboration between school personnel, (e.g., school nurse teachers, psychologists, student assistance counselors, social workers, special education personnel, health educators etc.), and staff of the SBHC, (e.g., medical personnel, counselors and administrative staff);
  • Participating in periodic evaluations of SBHC performance;
  • Helping to collect information on insurance status and on Medicaid status, including any enrollment in a managed care plan; and,
  • Providing information to parents of uninsured children about RIte Care and the RIte Care application process.
  • Promoting collaboration and the exchange of information (per confidentiality provisions) related to meeting a student's health needs with the appropriate school staff (i.e. certified school nurse teacher, social worker, psychologist, and guidance counselor).

The partnership role of the health care provider is based on its responsibility for providing high quality primary and preventive health care services. Key partnership functions include:

Provider's Role

  • Providing school physicals, immunizations, and other services for students identified by the school nurse teacher as appropriate;
  • Making referrals to community-based providers for health services beyond the scope of the SBHC, (e.g., specialty medical, substance abuse, mental health, care coordination, and social services, for students enrolled in the SBHC);
  • Organizing outreach efforts to enroll students in the SBHC, especially those students with no regular primary care provider; and,
  • Assuring 24 hour/day, 7 day/week access to primary and preventive health services, including coverage for days and hours when school is closed, for students enrolled in the SBHC.

Health Provider Organization's Role

  • Maximizing revenues from third party payers covering enrolled students to help support SBHC operating costs;
  • Providing in-service training for SBHC staff and cross training opportunities for SBHC partnership;
  • Assisting the school in identifying health related needs and trends of the student population; and
  • Assuring that the SBHC provides quality of care standards as are required of the parent health facility by federal and state regulations, and third party payers, including RIte Care managed care plans, to qualify for reimbursement.

The partnership role of the community, through the SBHC advisory committee, includes the following functions:

Community's Role

  • Participating in oversight of SBHC operations, policy making, and planning;
  • Facilitating information sharing on SBHC activities with the community, and enrollment of students in the SBHC;
  • Advocating for community needs, including family-centered, culturally appropriate, and language-relevant service delivery and communication with parents; and,
  • Planning long term sustainment of SBHC including: tracking and responding to the changing needs of the community; and, planning for changes in federal, state and community resources.

SCOPE OF SERVICES:

A network of SBHCs will target high risk children and youth. SBHCs will bring comprehensive primary medical care, substance abuse treatment, mental health care, dental care and risk reduction services to enrolled students. The emphasis for care is on preventive health services. Community partnerships are encouraged to provide the most comprehensive array of services without duplicating efforts to serve children and adolescents.

1. Basic medical services (e.g. services that can be provided on site) include:

  • Well child and adolescent exams including: Comprehensive health history; Complete physical exam; Screening procedures and laboratory tests; Age appropriate anticipatory guidance; Risk assessment; Special Education Assessment; Immunizations according to RI's Rules and Regulations Pertaining to Immunization and Testing for Communicable Diseases: Sports physicals; Exams required per RI's Rules and Regulations for School Health Programs and the Regulations of the Board of Regents for Elementary and Secondary Education Governing the Special Education of Students with Disabilities; and Disease Reporting according to RI's Rules and Regulations Pertaining to the Reporting of Communicable, Environmental and Occupational Diseases;
  • Services specified by the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program with referrals for specialty care made as appropriate;
  • Diagnosis and treatment of acute illness and injury when referred by certified school nurse teacher as appropriate;
  • Prescriptions and/or dispensing of commonly used medications for identified health conditions, in accordance with medical practice acts and pharmacy acts;
  • Management of chronic conditions, such as asthma, diabetes, seizure disorder, and positive PPD. Coordinate with child's PCP and the school nurse teacher as appropriate.
  • Health education, disease prevention/health promotion and anticipatory guidance to individual students and parents as appropriate;
  • Nutrition and weight management;
  • Crisis intervention related to school emergencies in collaboration with the certified school nurse teacher; and,
  • Reproductive health services including: Information on human sexuality with an emphasis on abstinence; Pelvic exams including pap smears and screening for sexually transmitted diseases; Diagnosis and treatment of sexually transmitted diseases as per CDCs Sexually Transmitted Disease Treatment Guidelines; Testing and counseling for HIV/AIDS as per RI Regulations for Counseling, Testing, Reporting, and Confidentiality; Pregnancy testing; Referral for birth control; and, Referral for prenatal care.

These services must be provided by a RI licensed professional health care provider. The services must be in accordance with The Guidelines for Adolescent Preventive Services (GAPS) of the American Academy of Pediatrics; and the Bright Futures Guidelines for Health Supervision prepared by the Maternal and Child Health Bureau, U.S. Department of Health and Human Services. "GAPS is a comprehensive package of recommendations for primary care physicians and other health providers who see adolescent patients in clinical settings. These recommendations are designed to be delivered during a series of annual preventive service health visits between the ages of 11 and 21." "Bright Futures Guidelines provide health supervision guidance responsive to the current and emerging disease prevention and health promotion needs of infants, children, and adolescents."

  • Behavioral health services may include: Assessment and treatment of psychosocial problems; Coordination with the school's Multi-Disciplinary Team for Special Education; Crisis intervention (as part of a school mental health team); Individual and family counseling; Group counseling; Referral to appropriate mental health agencies for further evaluation and treatment; Outreach to students at risk; Assessment of student's substance abuse problems; Referral/coordination with student assistance counselor; substance abuse prevention, and early intervention services; and, Referral for substance abuse treatment.

    Services will be provided by a RI licensed/certified mental health or substance abuse professional in accordance with standards for mental health or substance abuse practices in a health care setting.

Additionally, SBHCs will provide care coordination services including referral to community-based specialty providers, tracking, follow-up, and co-case management; and make arrangements for coverage during non-school hours, on weekends, and during vacation periods. SBHC staff may provide classroom presentations on SBHC services and or pertinent health topics in collaboration with school health educators and may provide consultation with school staff and parents on issues of adolescent development.

COMMUNICATION WITH PRIMARY CARE PROVIDERS

The SBHC, in order to ensure continuity of care and avoid duplication of services, must assure appropriate communication with each enrolled student's primary care provider (PCP) in the event that the SBHC is not the PCP. Information that is relevant and necessary for quality care must be communicated in writing. If specialty services are required, the SBHC must refer the student to their PCP to obtain a referral to a specialist.

Confidential services, which do not require parental consent (family planning, STD and communicable disease treatment, pregnancy testing, mental health and substance abuse counseling) should only be communicated with the student's written permission to share this information with their PCP. Students should be encouraged to discuss these issues with their PCP at their next visit.

CONFIDENTIALITY AND PROVISION OF SERVICES

SBHC staff make every effort to involve the student's family. However, in the context of adolescent care, the need to provide confidential services is crucial to improve or sustain health. Maintaining confidentiality encourages adolescents to seek treatment for serious health issues for which they might not otherwise be treated because of a requirement of parental consent or notification. Providers should help parents to understand that adolescents are in a transitional period when they are moving toward responsibility for their own health care. Ideally, the goal is to achieve a balance between the rights and needs of the parent or guardian and what is necessary to maintain the health of the adolescent. The nature and limits of confidentiality policies should be explained to the adolescents and their parents prior to the establishment of a provider relationship. Services which may be provided confidentially at the SBHC without parental consent and notification (Appendix F) include:

  • pregnancy testing;
  • reproductive health exams and counseling;
  • screening and treatment for STD's and communicable diseases; and,
  • substance abuse counseling.

Conditions that are reportable by laws include:

  • when the student is suicidal or homicidal; and
  • when abuse or neglect is suspected.

Records which may be shared with school personnel, parents, and other health providers without written consent include:

  • immunizations;
  • school, sports and employment exams;
  • screening exams (e.g. vision, hearing, dental); and,
  • health education services.

Medical Records

All SBHC personnel are responsible for maintaining the confidentiality of all information contained in the medical record in accordance with provisions in the Confidentiality of Health Care Information Act (Chapter 5-37.3 of the RIGL as amended) and 42 Code of Federal Regulations, Part 2 "Confidentiality of Alcohol and Drug Abuse Patient Records." Medical records must be kept locked and secured at all times and only appropriate and necessary personnel should be allowed access to the medical record. Medical records concerned with confidential care may be released only with a signed release by the student. Both the American Academy of Pediatrics and the American Medical Association recommend that policies on confidentiality should be established in conjunction with school authorities prior to the opening of a SBHC. A model policy on confidentiality can be found in Appendix G.

LINKING BEHAVIORAL HEALTH AND PHYSICAL HEALTH SERVICES

Adolescence is a pivotal time in the development of behaviors related to health. The teenager moves from the dependency of childhood to the independence of adulthood during a developmental stage that is characterized by risk-taking behaviors. SBHCs provide unique opportunities for assessment of emerging health habits and for education and intervention when indicated.

Routine annual exams should include a thorough review of health behaviors as recommended by GAPS. Information should be gathered about:

  • diet;
  • exercise;
  • use of safety devices (e.g. seatbelt, helmets, athletic gear);
  • substance use (including tobacco, alcohol and other drugs); and,
  • sexual behavior and interpersonal relationships (with special attention to conflict resolution).

At that time, healthy behaviors should be reinforced, education provided when indicated, and referrals made for mental health, reproductive health, substance abuse, and nutrition counseling when problems are discovered.

Referrals for mental health or substance abuse counseling may be made to a variety of resources depending on the student's individual needs. For some, a referral for substance abuse counseling will be necessary, for others a referral to a community mental health agency and/or psychiatric evaluation for medications may be most appropriate. Some students may benefit most from involvement in group counseling to bolster self-esteem, assist in grief resolution, or to understand the common problems faced by children of substance abusers or mentally ill parents.

SBHC staff must collaborate with, and depend upon the advice and assistance of school personnel with counterpart responsibilities, specifically: school psychologists, school social workers, certified school nurse teachers, health educators, and community health agencies. Consent for communication among this group should be obtained from the student before sharing confidential information that will be needed to make the most appropriate referral. Written protocols should be established for circumstances under which students will be referred, co-case managed, and patient information will be shared, within the limits of confidentiality requirements. In many schools a formal school support team is established as the locus for consultation and co-case management. Written procedures should also specify circumstances under which school personnel may refer non-SBHC enrolled students to the SBHC for services.

FACILITIES

A comfortable, pleasant, and efficiently planned physical facility maximizes client and staff morale and assists in the delivery of a desired standard of care. The SBHC must be compliant with all physical plant requirements of the RI licensed sponsoring health provider facility. All SBHCs should be safe and functionally efficient, with comfort and privacy provided. The SBHC must be accessible to individuals with disabilities and conform to the Americans with Disabilities Act requirements. There should be at a minimum:

  • at least two examining rooms with provisions for hand washing facilities;
  • a counseling room;
  • a small laboratory consistent with the Clinical Laboratory Improvement Act (federal requirements)that contains a refrigerator, a microscope, a place to store blood and other specimens and a sink;
  • adequate lighting;
  • a bathroom with hand washing facilities;
  • separate telephone lines and an answering machine telling students how to obtain emergency services after hours;
  • private areas: rooms where consultations can not be overheard;
  • office and administrative space where staff can work privately with records;
  • secure areas: file cabinets and drawers that lock, to protect medical records;
  • fire protection that meets local codes;
  • water and waste disposal systems provided according to local codes, Narragansettt Bay Commission and OSHA;
  • proper ventilation;
  • comfortable waiting room area;
  • staff room; and, provisions for clients with special needs.

For more specifics from the Robert Wood Johnson Foundation's publication: The Answer is at School: Bringing Health Care to Our Students see Appendix H.

INFORMATION SYSTEMS-MEDICAL RECORDS

Medical care provider organizations operating SBHCs shall maintain comprehensive, computerized management information systems (MIS) sufficient to:

  • manage and monitor patient care;
  • manage administrative and fiscal operations of the Center; and,
  • support quality of care and utilization review functions required by law, third-party payers and HMOs, and good professional practice.

The SBHC MIS shall be maintained on a secure basis to protect patient confidentiality and shall be compatible with the MIS of the parent provider organization. Information regarding SBHC utilization is submitted to the Department of Health three times during the school year. The data will be analyzed and discussed in conjunction with SBHC and school staff.

SBHCs will maintain a behavioral health risk profile on students. This will allow the SBHCs as well as the RI Departments of Health, Education, and Human Services to assess trends in adolescent behavior; and, to plan educational programs and other interventions. These interventions will reduce risks and improve the overall health of the school community and Rhode Island's students. Over time, this information will enable the evaluation of the effectiveness of SBHCs in ensuring the optimal health of our adolescent population.

BIBLIOGRAPHY OF RESOURCES USED AT SBHCS

"American Medical Association Guidelines For Adolescent Preventive Services Recommendations and Rationale", Elster, A.B., M.D., Kuznets, N.J., Ph.D., Williams and Wilkins, 1994.

"Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents", Green, M, M.D. (ED.), National Center for Education in Maternal and Child Health, Arlington, VA, 1994.

"Adolescent Medicine: A Practical Guide", Stasburger, Victor C., M.D., and Brown, Robert T., M.D., Little, Brown and Company.

"Color Atlas and Synopsis of Clinical Dermatology", Fitzpatrick, Thomas B., M.D.et al, McGraw-Hill, Third Edition, 1997.

"Pediatric and Adolescent Gynecology", Emans, Jean H., M.D. and Goldstein, Donald P., M.D., Little, Brown and Company, Third Edition, 1990.

"Primary Pediatric Care", Hoekelman, Robert A., M.D., et al, Mosby Year Book, Second Edition, 1992.

"Red Book-Report of the Committee on Infectious Diseases", American Academy of Pediatrics, Twenty third Edition, 1997.

"Drugs in Lactation and Pregnancy", Briggs, G.G., Freeman, R.K. and Yaffe, S.J. Williams and Williams, Fourth Edition, 1994.

"A Guide to Physical Examination and History Taking", Bates, B., Lipponcott, 1991. Principles of Ambulatory Medicine, Barker, L., Burton, J.R., and Zieve, P.D., Williams and Williams, Third Edition, 1991.

"Manual of Ambulatory Pediatrics", Boynton, R., Dunn, E.S., Stephans, G.R., Scott, Foresman/Little, Brown, Second Edition, 1988.

"Clinical Dermatology", Habif, T.B., Mosby Publishers, Second Edition, 1990.

"Protocols for Nurse Practitioners in Gynecological Settings", Hawkins, J.W., Roberto, D., Stanley, L., Nancy, Tiresia Press, Third Edition, 1991.

"Interpretation of Diagnostic Tests", Wallach, J., Little Brown, Fifth Edition, 1992. Physician's Desk Reference, Medical Economics, Forty ninth Edition, 1995.

"Sexually Transmitted Disease Guidelines", U.S. Department of Health and Human Services, Centers for Disease Control, adapted from Morbidity and Mortality Weekly Report.