The Center for Health and Health Care in Schools

Quality Guidelines, Standards of Care, & Certification Requirements

State Resources - Vermont
INTRODUCTION -- VT MAKING THE GRADE

The Vermont School Based Health Center Quality standards are the recommended guidelines for the operation of all state designated school based health centers in Vermont. The Agency of Human Services School Based Health Center Assistance Program shall be responsible for program effectiveness reviews of all state designated centers. The Standards are the criteria for designation and review.

The Vermont School Based Quality Standards have been developed and reviewed by:

The Vermont Agency of Human Services school Based Health Center Assistance Program will conduct a biennial review of the Standards. Recommendations for revision may be submitted to the School Based Health Center Assistance Program at any time.

VERMONT SCHOOL-BASED HEALTH CENTER QUALITY STANDARDS AND GUIDELINES

1.0 ACCESS STANDARD: School-based health center services are easily accessible and designed to eliminate or diminish barriers to care for students and to participation by parents or guardians.

A) Availability of Services

1.1 The center shall operate when school is in session at regularly scheduled hours that:

include some before or after school hours at least one day a week;
to the maximum extent possible, accommodate working parents/guardians who participate in the care of their child;
allow for urgent appointments within the same day;
to the extent possible, schedule appointments that do not unnecessarily interrupt the student's classroom time; and
are displayed in a public location, and in multiple languages, if appropriate to the student population.

1.2 The center shall have in place telephone answering methods that notify students and parents/guardians where and how to access 24-hour back-up services when the center is not open.

1.3 The center shall provide mental health and substance abuse services, on-site and through referral arrangements that offer:

immediate response to emergency/crisis situations
urgent appointments whenever possible within the same day and no later than three calendar days after the request for service is made; and
non-urgent appointments within seven calendar days.

1.4 The center, in response to the cultural and language needs of the student body, shall ensure that center staff has education in cultural diversity, and that translation services, appropriate to the major school population(s), are provided by staff or interpreters in a manner that ensures confidentiality.

1.5 Enrollment and registration processes shall provide for effective collection of information regarding third-party billing resources and the identity of primary care providers. The center may not deny access to care to students without insurance. The center will assist the family in identifying a primary care provider (medical home) when needed. The center will facilitate enrollment in Dr. Dynasaur/Medicaid.

1.6 The center shall conform with anti-discrimination laws.

1.7 The center shall provide services to students in a manner which ensures the student's and his/her family's right to privacy.

B) Physical Plant

1.8 The center shall be accessible to individuals with disabilities.

1.9 The center shall include waiting and reception areas, office space, private examination and treatment room(s), sink(s), bathrooms(s), and secure storage area(s).

1.10 The center shall have current fire and building safety certificates, and electrical/mechanical equipment shall be in safe working order.

1.11 The center staff shall have the training, supplies and equipment necessary to follow infection control practices (including environmental sanitation, cleaning and sterilization of equipment and supplies, and the disposal of hazardous and medical waste) and to comply with laws and regulations regarding reportable diseases and employee health policies.

2.0 PROFESSIONAL QUALIFICATIONS STANDARD: School-based health center services are delivered in accordance with professional standards and by qualified licensed and/or registered staff.

2.1 All professional staff who provide care through a school based health center shall meet all applicable state practice requirements, be trained and experienced in community and school health, and have knowledge of health promotion and illness prevention strategies for children and adolescents.

2.2 If the center contracts with an outside agency or practitioner for the provision of substance abuse services, the contracted agency or practitioner shall be state approved/certified.

2.3 The center shall ensure that staff participate in ongoing professional development programs to update and enhance their knowledge of child and adolescent health and public health.

2.4 The center shall ensure that staff are assigned responsibilities consistent with their education and experience, supervised, periodically evaluated, and trained in the policies and procedures of the organization.

2.5 Center staff shall be currently trained in emergency care, including general first aid, cardiopulmonary resuscitation, and the Heimlich maneuver. The health center shall have a written emergency care plan for disasters and for crisis intervention, including suicide prevention and intervention, that is consistent with the school's plan and coordinated with the community emergency response system. Staff shall be trained in implementing the plan.

3.0 ORGANIZATIONAL STRUCTURE STANDARD: The school-based health center operates according to written organizational and clinical protocols that ensure that primary care services are delivered to students in an organized manner.

3.1 The center shall operate under written administrative policies and procedures. Policies shall accurately describe the services provided. Job descriptions shall define the qualifications, responsibilities and supervision of all health center personnel.

3.2 The center's organizational structure shall include an administrator responsible for the overall management of the health center as well as serving as a liaison with the health care entity operating the center, and sufficient support and clerical staff to carry out required administrative functions, including the collection of insurance and billing information.

3.3 To the maximum extent possible, the center shall bill third party insurers for covered services.

3.4 School-based health centers shall not operate in schools which do not meet state requirements for school health services. (Standards for Approving Vermont's Public Schools, Section 2192)

3.5 Medical services shall be provided under the medical direction of one or more designated physicians knowledgeable in child and adolescent health, public health, and school health practices.

3.6 The center shall offer a comprehensive range of primary care services. Services provided on-site shall include: Preventive health care services; mental health services; substance abuse services; and age appropriate anticipatory guidance delivered in conjunction with the VT Department of Health Early Periodic Screening, Diagnosis and Treatment (EPSDT) periodicity schedule; diagnosis and treatment of acute illness; and health education including injury and violence prevention. If not provided on-site, the center shall arrange for the provision of nutrition services, reproductive health services, sexually transmitted disease services, human immunodeficiency virus (HIV) services, dental health services.

4.0 CONTINUITY OF CARE STANDARD: The school-based health center develops a collaborative relationship with the student, his/her parent or guardian, the school health program, and other health care providers in the child's community.

4.1 The center shall coordinate care and the exchange of information necessary for the provision of proper health care of the student, between the school-based health centers and a student's primary care clinician or managed care organization. Written policies which recognize and support the role of the student's medical home shall address obtaining student and/or parental consent to share information regarding a student's health care. Policies shall comply with the AHS Rule 96-1. Access to Information.

4.2 The center shall operate in accordance with a systematic process for referring students to community-based health care providers when the center is not able to provide the services required by the student. The center shall refer a student who requires specialty medical and/or surgical services to his/her primary care clinician or HMO to obtain a referral to a specialist. The center shall document in the student's record that the referral was made and follow-up on the outcome of the referral.

4.3 The center shall promote collaboration and the exchange of information related to meeting a student's health needs between the school health staff and relevant school staff and community providers. This collaboration and exchange shall be consistent with all applicable confidentiality and consent requirements.

4.4 The center shall obtain consent for treatment. Written protocols shall (1) require the written permission of a parent/guardian, except where minors are authorized by law to provide consent (2) incorporate the rights of minors to consent to their own treatment as provided for by law, including consent for testing and treatment of STDs and diagnosis and treatment of substance abuse, and 3) establish a timeframe for renewing written permission.

4.5 The center and the sponsoring agency will establish and participate in a community advisory board to assist the center in the integration of services with the community resources and to advise the school based health center on policy and program matters. The board will at a minimum include: the center staff, the school nurse, a school administrator, students, parents, a community physician, local public health and social service representatives, mental health and substance abuse personnel, and other individuals in the community involved with youth, health and education. The board will coordinate with a comprehensive school health program advisory group where one exists.

4.6 The center shall develop and distribute to the community written materials that define and promote the goals and services of the center. Such materials shall be multi-lingual, if appropriate to the community.

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

5.0 QUALITY MANAGEMENT STANDARD: The school-based health center develops and implements a quality management program that monitors and evaluates the appropriateness, effectiveness and accessibility of the services provided.

5.1 The center, with its sponsoring agency, shall establish a quality management plan to be reviewed annually by the Agency of Human Services School-Based Health Center Workgroup and participating AHS departments. The plan shall include clearly defined goals related to improving the health status of enrolled students.

5.2 The school-based health center shall develop and/or participate in a program to evaluate the processes and outcomes of care delivered at the center and improve the center operation based on the findings.

5.3 The school-based health center shall comply with data collection requirements of the Agency of Human Services and have in place a method to collect and aggregate data on the student population enrolled in the health center. The data may include, but not be limited to: access to and utilization of services; continuity of care and followup to referrals; delivery of preventive health care services; absenteeism; rates of student drop-out; as well as behavioral outcome indicators e.g., substance abuse, pregnancy.

6.0 MEDICAL RECORDS STANDARD: The health center establishes a record-keeping system that provides for consistency, confidentiality, and security of records in documenting significant student health information and the delivery of health care services.

6.1 The center shall maintain a single confidential medical record for each student receiving services at the center. The center may separately maintain medical records 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.

6.2 The center shall develop policies and procedures regarding the security and confidentiality of records.

6.3 If the center is closed during school and summer vacations, the center shall transfer student health center records to the agency operating the center within an established timeframe that ensures continuity of care.

6.4 The center shall maintain records and copies of records in a secure manner that protects them from unauthorized use. The center shall develop policies for identifying who shall have access to records. Center records shall be maintained separately from school records and are in no way a part of the school records. The center shall follow procedures outlined in the SHO training manual for security of electronic files.

6.5 When the center is contracted to deliver a school service (e.g. special education, health screenings, etc.) to all eligible students the records of that service shall be incorporated into the student's school record.

6.6 The center shall assure timely access to the comprehensive record by those with the need to know. The transfer of information shall abe consistent with all applicable consent and confidentiality requirements.

6.7 The center shall ensure that the records contain sufficient information to justify the diagnosis(es) and treatment, and accurately document all health needs and services provided to the student.

6.8 Each entry into the student's health center record shall be dated and authenticated by the staff member making the entry, indicating full name and title.

6.9 The center participates in state projects to establish a common, computerized student health information system.

7.0 RELATIONSHIP STANDARD: School-based health centers are organized with regard to family, school, community and sponsoring agency/health provider relationships.

A) The Student's Family

7.1 School based health center providers shall make every effort to involve the student's family as age appropriate and with consent as necessary, in regard to care of the student.

7.2 The center shall abide by two principles governing the disclosure of information revealed by students in confidence:

in cooperation with the student, parents will be informed except where prohibited by law
the safety and well-being of the child shall be protected at all times.

In any situation where these principles conflict, the second principle takes precedence over the first

7.3 School based health center policies regarding access, availability, and flexibility shall accommodate the needs of families to the maximum extent possible.

7.4 School based health center staff understand the nature, role and impact of the child's health, illness, disability, or injury in terms of the family structure and dynamics and the care plan shall consider the needs and capabilities of the family.

B) The School

7.5 The SBHC is integrated into the school environment and both are committed to operating with mutual respect and a spirit of collaboration. The health center cooperates both formally through a memorandum of understanding (MOU) and informally with the school administration, faculty and staff.

7.6 Center staff are encouraged to participate in school efforts, such as health fairs, classroom presentations and special events, to provide comprehensive health education to students.

C) The Community

7.7 The SBHC recognizes that it functions within the community and shall draw upon and contribute to its resources. Views of community members shall be incorporated into decisions involving policies, priorities and plans related to the delivery of school based care.

7.8 The SBHC shall consult with and utilize the services and expertise of, the Vermont Department of Health as appropriate. The Community Public Health District Office will support SBHC activities as needed e.g., with immunizations, epidemiological consultation on infectious diseases, help with access to health care and dental care, services for children involved with the Health Department Children with Special Health Needs program and linkages to community services offered by other state agencies.

D) Organization and Function

7.9 The SBHC will operate according to an organizational chart and appropriate MOUs which reflect clear lines of authority for the administration of the SBHC, as well as the roles of the sponsoring agency, other agencies with whom the center contracts for services, the SBHC and the school. This chart should be reviewed periodically and revised as needed.

APPENDIX TO SCHOOL-BASED HEALTH CENTER QUALITY STANDARDS: SUGGESTED POLICIES & PROCEDURES RE: SECURITY/CONFIDENTIALITY OF SBHC RECORDS

Modern health care requires a collaborative effort of a multi-disciplinary team relying on accurate information about the patient/client. However, the registry and sharing of such information also raises potential risks.

These policies and procedures are designed to minimize the potential risks associated with SBHC records in general, and with SBHC electronic records specifically. The risks include both the loss of records, and compromised confidentiality of records; thus, these policies and procedures address the security/integrity both of computers (or other "hardware") and of the information.

Although no policies and procedures can entirely eliminate risks, patients, potential patients, providers, and the community have a right to expect that all information concerning a patient's medical care shall be confidential; that personally-identifiable information shall be used only for purposes for which informed consent is given (unless otherwise specifically required by law); and will be protected from loss and from any unauthorized use.

All use of SBHC records shall be governed by generally-accepted principles of "informed consent" and "strict need-to-know" access, as defined here and in AHS Rule 96-1, "Access to Information." "Informed consent" is defined as follows: The individual understands who is collecting what infomation, for what purpose, and who will have access to the data and how it will be used; and actively consents to providing the requested information for the specific purpose(s). "Strict need-to-know" is defined as follows: The information is requested by a professional provider because it has direct relevance for understanding a patient/client's illness or condition, or has a direct bearing on the treatment services that should be provided.⁽¹⁾
The SBHC shall obtain, from the enrolled student or his/her parent/guardian, prior written consent for release of specific information beyond the SBHC. AHS Rule 96-1 (Section IV.) provides guidelines, including a release form.
All staff having access to SBHC records shall have on file signed confidentiality agreements, which bind them to generally accepted confidentiality principles, with the understanding that breach of those principles may be cause for dismissal. AHS Rule 96-1 (Sction V.) provides guidelines. SBHC staff shall devleop specific protocols around handling of SBHC records, that are consistent with these confidentiality principles.
Access to SBHC records shall be limited to the fewest personnel possible. An original, licensed version of the software, "SHO," shall be installed, according to the vendor's instructions, on a single, desktop PC. The PC shall be dedicated for this purpose alone.
The software shall not be installed on additional machines (e.g., laptops, provider's office PC), unless security equal to that described here can be assured. The SHO PC shall not be electronically linked to any other device (printer, modem, fax, etc.) unless security equal to that described here can be assured. When necessary, the preferred, most secure method of data transfer is by diskette.
The SHO PC shall be stored in a room which will be locked whenever it is unattended. Storage of hard-copy (paper) records, and records on diskette or any other portable storage medium, shall be similarly secured. Regular electronic backups of data files shall be created according to the instructions in the SHO manual. Back-up data shall be stored with the same degree of security as the original data. Disposal of records--paper or electronic--shall be carried out in such a way that no substantive information could be reconstructed from them.
Users of the SHO software shall be assigned passwords by the system administrator; passwords should include a non-alphabetic character. Users shall be instructed on generally accepted practices regarding password security. Passwords shall be changed on a monthly basis, or whenever there is reason to believe that security has been compromised. The system administrator shall designate one or more backup personnel who will have access to the SHO system if regular personnel are unavailable.
Users shall have access only to the level of use necessary for their assigned role (e.g., system administration, data-entry, reporting, etc.). Any use resulting in a change to records shall be tagged with a valid "user of entry" identification. SBHC staff shall develop a protocol to include security audits to track multiple failed logins, since a pattern of these could indicate an attempt to break into the system. The system administrator shall ensure that access to SHO is denied to persons who lose their access authorization through re-assignment, retirement, dismissal, etc.

1. It is useful to distinguish between "need-to-know" and "strict need-to-know" criteria for access to data. "Need-to-know" defines purchasers and policy makers, or health plan and school administrators' access to anonymous, aggregated data. "Strict need-to-know" governs personally identifiable information required to understand or treat an individual's condition.

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