DOCUMENT RESUME

ED 401 507 CG 027 109

TITLE Issues in Financing School-Based Health Centers: AGuide for State Officials.

INSTITUTION George Washington Univ., Washington, D.C.; Rosenberg& Associates, Point Richmond, CA.

PUB DATE Sep 95NOTE 38p.

PUB TYPE Guides Non-Classroom Use (055) ReportsDescriptive (141)

EDRS PRICE MF01/PCO2 Plus Postage.DESCRIPTORS *Child Health; Elementary Secondary Education;

*Health Facilities; *Health Programs; *HealthServices; *School Health Services; State Aid; StateFederal Aid; State Programs

ABSTRACTDespite the recent, unprecedented growth of

school-based health centers and the related increased support fromstate government, the future of school-based health centers isuncertain. Since they can no longer rely on federal support, privateinsurance, or other commercial sources, each state must develop itsown approach to supporting the centers. A critical precondition forcreating a financial strategy is for each state to address thefollowing questions: (1) What is a school-based health center? (2)Whom should the school-based health center serve if the center is tosecure public funding? (3) What specific services must be provided?(4) How will these services be paid for and who will receive payment?This paper discusses approaches to answering these questions. Topicsinclude difficulties related to financing school-based health centersthrough third-party payments, recent events which have had a majorimpact, the essential step of defining a school-based health center,and alternative reimbursement models as funding strategies. Sixfigures and three tables present data and statistical analysis. Anappendix presents 1994 state guidelines for school-based healthcenters. Contains 37 references. (RB)

***********************************************************************

Reproductions supplied by EDRS are the best that can be madefrom the original document.

***********************************************************************

21- GRADE

24

C

CDCDC.)

STATE AND LOCAL PARTNERSHIPS TO ESTABLISH

SCHOOL-BASED HEALTH CENTERS

O

Issues in Financing School-Based Health Centers:

Prepared by:

A Guide for State Officials

September 1995

Making the Grade National Program OfficeThe George Washington UniversityWashington, DC

Rosenberg & AssociatesPoint Richmond, California

EST COPY AVAILABLE,

U.S. DEPARTMENT OF EDUCATIONOffice of Educational Research and Improvement

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

This document has been reproduced asreceived from the person or organizationoriginating it.Minor changes have been made toimprove reproduction quality.

"PERMISSION TO REPRODUCE THISMATERIAL HAS BEEN GRANTED BY

(; Leap

Points of view or opinions stated in thisdocument do not necessarily represent TO THE EDUCATIONAL RESOURCESofficial OERI position or policy. INFORMATION CENTER (ERIC)."

Issues in Financing School-Based Health Centers:A Guide for State Officials

Despite the recent, unprecedented growth of school-based health centers and

the related increased support from state governments, the future ofschool-

based health centers is uncertain. Proposed cut-backs in government

spending may limit previously available public health dollars and state

governments that intend to include school-based health centers in their

health care networks for school-age children must now determine how to

ensure financing for those centers.

Given the fiscally conservative climate in Washington, DC., states cannot

rely on federal grant initiatives, federal protectionfor cost-based

reimbursement, or federal mandates for inclusion of school-basedhealth

center programs in Medicaid managed care arrangements. Nor can the

states rely on private insurance or other commercial sources to support the

centers. The expansion of privately financed managed care and the

continuation of ERISA exclusions has eroded opportunities to enlist private

dollars in support of school-based health centers. Each state must develop

its own approach to supporting the centers. A critical precondition for

creating a financial strategy is for each state to address the following basic

questions:

What is a school-based health center?

Whom should the school-based health center serve if the center is to

secure public funding ?

What specific services must be provided?

How will these services be paid for and who (or what) will receive

payment for the services?

This paper discusses approaches to answering these questions.

3

Issues in Financing School-Based Health Centers:A Guide for State Officials

Background 4

Difficulties in financing school-based health centers through third- partypayments 7

Recent events that have had a major impact on funding strategies for school-based health centers 9

Defining a school-based health center: An essential step towards a financingpolicy 14

(1) Options for targeting criteria: defining the communities to beserved by state-supported school-based health centers 14

(2) Defining school-based health center services 17

Strategies to fund school-based health centers: Alternative reimbursementmodels 11

A regulatory approach 11

A market approachA "pooled fund" approach

Appendix: State Guidelines for School-Based Health Centers, 1994 26

Background

Since the first comprehensive school-based health centers were established in theearly 1970s, states and localities have increasingly looked to schools as reasonableand innovative sites for assuring access to health care for children and adolescents.Between 1985 and 1992, the number of such programs around the nation grewfrom 40 to more than 400. According to a national survey conducted by theMaking the Grade National Program Office, by 1994 there were 607 school-basedhealth centers in 41 states and the District of Columbia (see figure 1, page 6).Nearly half of these programs are located in high schools and over one quarter arelocated in elementary schools (Schlitt, et. al., 1995). Fueling the recent exponentialgrowth of the centers has been the development of a number of state governmentinitiatives to support school-based health center programs.

At present, most states fund school-based health centers through grant programsthat draw from either Maternal and Child Health (MCH) block grant dollars or stategeneral funds. The Making the Grade survey found that in school year 1993-1994,32 states allocated an estimated $38.8 million to local governments or health careinstitutions to support the centers. Twenty-five states allocated $12 million in MCHdollars to school-based health centers, while another group of 25 statesappropriated $22.3 million in general fund support for the centers (see figure 2,page 6). Three states designated funds from the US Department of Education's"Drug Free Schools and Communities" program. Illinois is the only state thatcommits a portion of its federal Social Services block grant, Title XX, to its school-based health center program. Several states, including California, Florida,Louisiana, Massachusetts, and Missouri, fund their school-based initiatives throughspecial taxes, such as supplemental sales taxes and tobacco excise taxes.

Other major funding for school-based health centers comes from federal grants,private foundations, and local dollars. Since the Making the Grade survey, 27centers have received grants from the federal Bureau of Primary Care. Privatefoundation initiatives in Connecticut and Michigan are investing an additional $6million in centers in those states.' The Robert Wood Johnson Foundation willprovide nearly $18 million for school-based health centers through its nationalprogram, Making the Grade: State and Local Partnerships to Establish School-Based Health Centers.2

I School-based health centers are rarely supported by a single source of funds. In addition to stategrants, most centers or their sponsoring institutions pay their expenses through a combination ofresources: local health department grants, in-kind contributions from the host schools, supportfrom their sponsoring agencies, and corporate contributions. A number of school-based healthcenters receive no state grant support. Among the 41 states with school-based health centers, eightstates report that fewer than half their school-based health centers receive state support, and elevenstates provide no funding to the centers.

2 Under the Making the Grade initiative, 12 states received planning grants to create long-termfunding strategies for school-based health centers as weil as develop or expand local school-basedhealth center programs. To date, three states, Colorado, Connecticut, and New York, have received

implementation grants.

5Draft manuscript for review and comment, 9/13/95 4

Local support remains vital. All school-based health centers receive help from theirhost schools; other local agencies contribute varying levels of support. Twenty-three school-based health centers supported by the Robert Wood JohnsonFoundation, through its previous grant program the School-Based AdolescentHealth Care Program, reported that one-third of their budgets were provided in-kind by local sources. In Oregon's Multnomah County, in Fiscal Year 1995, localtax dollars provided $1.4 million or 64 percent of the total operating budget for theten school-based health centers in Portland.

States that have initiated funding for school-based health center initiatives, in mostcases, have asked their health departments to take the lead in program and policydevelopment. In response, the health departments have organized the state grant-making process -- writing the grant application guidelines, developing servicestandards and quality assurance measures, and determining staffing requirements.Within the health departments an individual or office generally has responsibility forproviding technical assistance to local programs as well as facilitating thedevelopment of state policies to support the centers.

During the early phase of state support for school-based health centers, the stateshave considered these initiatives small-scale pilot programs whose characteristicswere hand-tailored to fit the small number of communities in which the centers werelocated. However, as demand for the centers increases and they become part of thestate's larger strategy of assuring health care for all children, the policy questionsbecome more complex and require more detailed responses. How should statesdetermine the need for such centers? How can start-up funds for the centers besecured? How will on-going support be obtained? Fundamental premisesunderlying such questions must be tested: Are the centers to serve all children oronly some children? Are there spending priorities for public dollars?

If a state is to assure the availability of school-based health centers as a componentof its health care system for school-aged children, the state will need to establishfunding priorities by defining where they wish to locate school-based health centers(targeting criteria) and by establishing the services the school-based healthcenters will provide (service criteria). This paper reviews possibilities fortargeting and service criteria and articulates the financing issues that states mustconfront as they move to fit school-based health center programs into an on-going,soundly-financed system of health care for children.

Sources:Dryfoos, JG. Full-services schools: A revolution in health and social services forchildren, youth, and families. San Francisco: Jossey-Bass, 1994.

Schlitt, JJ, Garfinkel, S. Where the kids are. State government news 1995;38(6):20-24.

Schlitt. JJ, Rickett K. Montgomery L. Lear JG. State initiatives to support school- basedhealth centers: A national survey. J of Adolesc Health 1995; 17:68-76.

6

Draft manuscript for review and comment. 9/13/95 5

600

500

400

300

200

100

0In00ON11

Fig. 1. School-Based Health Centers, 1985-1994

40.00

35.00

30.00

25.00

20.00

15.00

10.00

5.00

0.00

NO t% 00 ON 000 00 CO 00 OS

ON ON as ON ON

...1 ..4 1ml 11 11

...4 NION ONON ONv i

MOsas....1

Fig. 2. State Financing of SBHCs, 1992, 1994

1992 1994

Sources:Figs 1. and 2. Schlitt et. al. State initiatives to support school-based health centers. J ofAdolescent Health, 17(2), 1995.

7

Draft manuscript for review and comment, 9/13/95 6

Difficulties in financing school-based health centers through third-party payments

Most school-based health centers have been started and sustained with private andpublic grant dollars. Funds from patient care reimbursement, whether throughprivate insurance or Medicaid, have only recently contributed measurably to thecenter budgets (see Table 1, page 8). This limited support from patient carerevenues has been due to several factors:

Initially, school-based health centers were considered experimental projects thatwere more appropriately funded by grant dollars.

If privately insured students use the health centers, they are likely to havepolicies with large deductibles and limited coverage for primary health care andmental health services. While nine states and the District of Columbia havepassed the Child Health Insurance Reform Plan (CHIRP), which requiresinsurers to provide coverage for complete preventive health services for children0 - 19, to date few health centers are reporting significant revenues from privateinsurance. The potential gains from CHIRP may be offset by the movement ofprivately-insured families to ERISA-protected, self-insured plans, which neednot comply with CHIRP requirements.

Adolescents from low-income families are less likely than their youngercounterparts to be Medicaid insured. As a result, school-based health centerslocated in high schools have high rates of uninsured patients (see figure 3, page9).

Not all services provided to Medicaid-insured students are reimbursable due tostate-specific Medicaid plan limitations or exclusions.

Because patient care revenue potential is perceived as minimal, many school-based health centers have elected not to bill either patients or their insurers forservices provided. These school-based health centers and their sponsoringorganizations conclude that the cost of billing would exceed the revenuesgenerated.

Despite barriers to billing, those who organize school-based health centersincreasingly believe that patient care revenues are essential to funding the centers.Health care reform discussions have contributed to a perception that in the very nearfuture all personal health services even those targeted to low-income students --will be paid for through a patient care funding mechanism, whether by fee-for-service or pre-paid arrangements. Thus, the critical question: Can these centers fitinto the emerging system of health care financing?

The shift from a grants-based strategy towards a greater reliance on patient carerevenues is complicated by a concern that a billing or service-focused financingstrategy may threaten the unique set of services currently offered by the centers.The centers were established to provide a comprehensive mix of medical and mentalhealth care, health education and preventive services. Health center professionalsprovide clinical care, sponsor counseling groups, provide classroom education andwork with parents, athletic staff and students to encourage a healthier school

8Draft manuscript for review and comment, 9/13/95 7

environment. Many of these activities are not billable, but most health centersbelieve these activities are among the most important things they do. To tie thework of the center to a traditional reimbursement system is to risk forcing the healthcenter to alter its package of care from a multi-faceted social model to a medicalmodel of care that de-emphasizes mental health and other less billable services.

Sources:Lear JG, Schlitt, JJ, Rickert K. Medicaid, managed care and school-based health centers:Report from a Conference. Washington, DC, Making the Grade, The George WashingtonUniversity, 1995.

Massachusetts Department of Public Health, Bureau of Family and CommunityHealth. School-based health centers: Medicaid standards. Boston, MA: Author, 1994.

Newacheck PW, McManus MA, Gephart J. Health insurance coverage of adolescents:A current profile and assessment of trends. Pediatrics 1992: 90(4):589-596.

Perino J, Brindis C. Payment for services rendered: Expanding the revenue base ofschool-based clinics. Center for Reproductive Health Policy Research, University ofCalifornia, San Francisco, Report to the Stuart Foundations, 1994.

Table 1. Current Funding Sourcesfor SBHCS

State Health Departments 24%Private Foundations 18%MCH Block Grants 17%

Local government 12%School Districts 8%Community Health Centers 7%State human services 3%Title XX (AFL) 3%Medicaid 2%Other 7%

Source:Table 1. Center for Population Options. School-based and school-linked clinics: Update 1991.

Author: Washington, DC.

9

Draft manuscript for review and comment, 9/13/95 8

Fig. 3. Health Insurance Status of SBHC Users

PrivateInsurance

Uninsured

Source:Fig. 3. The School-Based Adolescent Health Care Program, The George Washington University.

Washington, DC.

10Draft manuscript for review and comment, 9/13/95 9

Recent events with major impact on funding strategies for school-based health centers

State and federal governments have utilized a variety of strategies to support healthprograms targeted on specific populations. These include funding multi-sitedemonstration programs, establishing preferential payment-for-service formulae,and promulgating rules and regulations that create a favorable environment for thedesired services. A number of recent events affect the ability of federal or stategovernments to use these approaches for the benefit of school-based health centers.

The federal government role in long-term funding strategies is constrained bythe collapse of health care reform at the federal level and election of a fiscally-conservative Congress. One component of the proposed Health Security Act thatreceived bipartisan support in both the House and Senate was a section providingfor a large-scale federal grant initiative for school-based health centers.3 Fundingfor this initiative was to come from cost-saving changes in the plan. Failure of theoverall plan eliminated projected savings and the likelihood of a large federal grantinitiative. The post-election anti-Washington sentiment and the impact ofpresidential campaign politics on the Congressional legislative process onlyincreases the difficulties confronting federal efforts. As a result, there is increasedpressure on the states to solve their own health care funding crises.

States are facing continued fiscal pressures due to explosive Medicaid growth.In the post-Clinton reform environment, states are facing continued Medicaidbudget pressures. In five years state Medicaid expenditures more than doubled,growing from $22.5 billion in 1988 to $53.6 billion in 1993 (see figure 4, page12). Now many state Medicaid offices no longer have the flexibility to initiate orexpand innovative access programs, including school-based health care.Congressional proposals to reduce federal public health dollars and curb Medicaidspending either through block grants or federal spending caps will exacerbate thestates' financial difficulties.

States are responding to fiscal pressures by developing Medicaid managed careprograms. As Medicaid spending has accelerated, politically-sensitive stategovernments are targeting their Medicaid cost-savings on AFDC clients. Thesebeneficiaries are being enrolled in Medicaid managed care plans, primarily throughthe creation of Section 1115 and 1915(b) waiver programs that, with HCFAapproval, permit mandatory assignment of Medicaid beneficiaries to managed care(see figure 5, page 13). Thus, those school-based health centers that have learned

3 Title HI (SubtitleG, Part 5) of the Health Security Act called for investment of $100 million inFY 1996 in school-related health services, growing to $400 million in FY 1999 and 2000, withsupport totaling $1.525 billion over five years. The Education and Labor Committee of the Houseof Representatives reported out its version of health care reform with a similar level of support forschool health services. In its version of Title III, the Senate Labor and Human ResourcesCommittee increased support for school-related health services to $2.35 billion over six years.The Senate committee unanimously approved this section of health care reform legislation.

Draft manuscript for review and comment, 9/13/95 10

how to implement fee-for-service billing systems may find themselves unable tocollect payment for services because their Medicaid patients are now enrolled inmanaged care.

Federal eligibility standards for cost-based reimbursement are increasinglyrestricted and reduce revenue potential for school-based health centers. Onemethod some school-based health centers have used to increase reimbursementfrom Medicaid has been to enter into contractual relationships with federally-qualified health care (FQHC) clinics. These clinics receive cost-basedreimbursement under both Medicare and Medicaid because they serve communitiesfederally-designated as "medically underserved." As FQHC satellite facilities,school-based health centers may receive cost-based reimbursement for careprovided to Medicaid beneficiaries. With the federal government facing budgetlimitations, the identification of communities eligible for "medically underserved"status has become more restrictive. Expansion, and indeed, retention of the FQHCprograms is increasingly uncertain as managed care programs have spread.Currently, litigation (NACHC v. Shalala) is challenging the right of the USDepartment of Health and Human Services to waive FQHC entitlements underMedicaid managed care programs.

School-based health centers have not been defined as "Essential CommunityProviders" and are therefore not automatically entitled to any special treatment thatmay be accorded "safety net" services. In an effort to retain cost-basedreimbursement for programs targeted on the underserved, a number of health careproviders have been identified at the federal or state level as "Essential CommunityProviders" (ECPs). School-based health centers have not been included in anyfederal or state definition of "essential community provider," nor are designatedessential community providers such as community health centers required tocontract with the school-based health centers. Given the legislative and regulatoryenvironment, expansion of ECP designations at the federal and state levels may bedifficult.

HCFA appears to be narrowing FQHC and ECP protections. Pending a decision inthe NACHC v. Shalala case, the agency maintains that while cost-basedreimbursement for FQHC providers is protected under 1915(b) waivers, 1115waivers give states broader authority to waive all protections for FQHC providers.Moreover, even under a 1915(b) waiver, the state need not protect all FQHCs orECPs but need only assure that Medicaid beneficiaries retain access to one suchprovider. Thus, contracts between a school-based health center and a FQHC mightnot assure participation in a managed care plan or cost-based reimbursement.

The Employee Retirement Income Security Act (ERISA) exempts large numbersof employers from complying with state laws regulating health insurance.ERISA, the federal law governing self-insured employers, precludes states fromplacing any requirements on self-funded health insurance programs, includingmanaged care. Increasing numbers of employers are self-insuring their employeesso that nationally almost half of all privately insured workers come under self-insured plans. As a result, there is a shrinking private insurance market from whichstates might seek support for school-based health centers via sales or other taxes.While school-based health centers may well be viewed positively by the private

12Draft manuscript for review and comment, 9/13/95 11

sector, ERISA legislation may limit a state's ability to require its participation inschool-based health center initiatives or to control how that participation takes place.Cooperation among private insurers, major employers and government agenciesmay bring about a partnership to support school-based health centers, but the state'srole in such efforts at this point appears likely to be advisory rather than directive.Note, however, that the April 1995 decision in the New York Conference of BlueCross and Blue Shield Plans et al. v. Travelers Insurance Co. et al. may increasethe ability of states to finance and regulate health care.

Sources:Iglehart, JK. Health policy report: Medicaid and managed care. NEJM 1995;332(25):1727-173I.

National Health Policy Forum, Issue Brief No. 656. ERISA and state flexibility:Exploring options from a state perspective, Fall 1994.

Rosenberg & Associates. Financing adolescent school-related health centers under theproposed National Health Security Act. Author, Point Richmond, CA, January 1994.

140

120

100

80

60

40

20

Fig. 4. Federal and StateMedicaid Expenditures, 1988-93

88 89 90 91

State 113 Federal

92 93

Source:Fig. 4. J. Iglehart. Health policy report: Medicaid and managed care. NEJM, 332(25), 1995,

1727-31.

13Draft manuscript for review and comment, 9/13/95 12

8.000

7.000

6.000

2 5.000

4,000H

.2. 3.000

m 2,000

80%

70%

60%

50%

40%

30%

20%

10%

0%

1,000

0

Fig. 5. Medicaid Managed Care Enrollment, 1984-1994

84 85 86 87 88 89 90 91 92 93 94

Fig. 6. Health Insurance Status of Children Under AgeEighteen1988-92

88

Private

89 90 91

Public Insurance 111 Uninsured

92

Sources:Fig. 5. DHHS Health Care Financing Administration, Medicaid Managed Care Office.

Fig. 6. Newacheck et al. Children and health insurance: an overview of recent trends. HealthAffairs, Spring 1995, 244-54.

14Draft manuscript for review and comment, 9/13/95 13

Defining a school-based health center: An essential step towards afinancing policy

Because federal Medicaid regulations do not define school-based health centers asparticipating entities within the program, if a state is to develop special Medicaid-related funding strategies for the centers, the state Medicaid program needs to definethe centers as a reimbursable ambulatory care provider-type, that is, a particularhealth care delivery system unit that can be shown to meet specific standards.Examples of ambulatory care provider types include hospital or health department-sponsored out-patient clinics; federally qualified health centers (FQHC), ruralhealth centers, physicians and physician practice groups, and certified nursepractitioners.

There are advantages, particularly related to reimbursement, to designating school-based health centers as a specific provider type. For example, federal law stipulatesthat FQHCs and rural health centers (RHC) are entitled to reimbursement for thefull cost of providing services to both Medicare and Medicaid beneficiaries. Thisarrangement allows the centers to include in their payment rate the costs ofproviding non-medical health services (social work and mental health services, casemanagement, outreach, transportation, community health education, etc.) that arenot typically reimbursed in a private medical practice. School-based health centersaffiliated with FQHCs and RHCs have the potential for realizing cost-basedreimbursement through their sponsor.

States as regulators of Medicaid rate payments can also establish a specialreimbursement rate for school-based health centers that, similar to the FQHCs,compensates school-based providers for a broad scope of services to Medicaidbeneficiaries. To pursue such a strategy, however, the State Medicaid programmust define a school-based health center -- both by identifying the population to beserved and by delineating the specific services to be provided.

(1) Options for targeting criteria: defining the communities to beserved by state-supported school-based health centers.

Limited resources preclude the expansion of centers into every community thatmight desire one. Decisions must be made. Priority-setting among communities(i.e. targeting) might utilize one or a combination of the following factors: income,age, insurance status, and health care access.

(a) Low-income

While all school-age children need a broader set of services than is covered undermost health insurance, upper-income communities appear more able to finance theirown needs. Parents may be more likely to have full-family employer-based healthinsurance coverage, as well as the time and money to coordinate the different needsof their children. However, working families with low to moderate incomes mayhave more limited resources, in terms of both time and money. A state may wish tolocate centers in those communities with a significant proportion of poor and near-poor households.

15Draft manuscript for review and comment, 9/13/95 14

A rationale for using low-income as a targeting criterion is that health servicesresearch has documented that low income children experience greater healthproblems than children as a whole.

Children with emotional or developmental problems are likely to be poor, tohave multiple persistent problems. to live in identifiable underserved neighbor-hoods, and to face particular barriers to needed services (Starfield B, 1992).

The high child poverty rate in the United States substantially increases the healthproblems of children. The frequency rates for many medical problems aredouble to triple the norm among low-income children. Child deaths due todiseases are triple to quadruple those of other children, and low-income childrenhave much greater percentages of conditions limiting school activity, lost schooldays, and severely impaired vision (Starfield B, 1992).

(b) Age

Age may be used as a targeting criterion to improve health care access for aspecifically-defined age group that experiences greater access barriers than other agegroups, or may have greater needs. Historically, adolescents ages 10-19 havebeen a primary target group for school-based health care because national datasuggest that, as a whole, adolescents are less healthy and utilize health services lessfrequently than their pre-adolescent peers.

As more communities place school-based health centers in elementary schools,states must carefully assess the political ramifications of targeting populationsgenerally thought to be less in need and better served by traditional health caresystems.

Some of the data confirming the health needs of adolescents are as follows:

At least 20 percent of adolescents have one serious health problem. Theseinclude visual, auditory and dental problems that can seriously impede theability to perform well in school. Many adolescents also suffer from adiagnosable mental disorder (Office of Technology Assessment, 1991). Mentalhealth problems increase with age: while 12.7 percent of 6-11 year olds arereported as having emotional or behavioral problems, 18.5 percent of 12-17year olds have these same problems. The highest frequency of problems isreported among males ages 12-17. The most common problems includeattention deficit disorders, phobias and anxiety disorders, depression, andlearning disabilities (Zill and Schoenborn, 1990).

In addition to chronic physical and mental health problems, adolescents haveexperienced some striking increases in behavior-related problems. Suicide andhomicide rates have tripled among young people aged 15-19. One in fiveadolescents acquires a sexually-transmitted disease by age 21, and teenpregnancies continue at a rate of one million teenage girls becoming pregnanteach year (Lear, 1995).

Mainstream delivery systems are not geared to adolescents. Adolescentspresent special problems to caregivers given that their care needs to beconfidential, convenient, comprehensive and age-appropriate (Office of theInspector General, 1993).

16Draft manuscript for review and comment. 9/13/95 15

Adolescents see office-based physicians less frequently than other age groups(Klein et al, 1992).

Many primary care physicians do not feel comfortable with adolescents, whoare seen as not fitting into a pediatric or an adult care model (Klein et aL, 1992).

Young people are often "of the moment." They are likely to seek care at thetime it is needed. If medical attention must be scheduled at a later time, abroken appointment is likely to result (Office of the Inspector General, 1993).

In many states, Medicaid and other public assistance programs cover fewadolescents.

Uninsured adolescents are reluctant to burden fmancially-struggling familieswith health care costs (Feiden, 1993).

(c) Insurance Status

As employer-based health insurance declines and children of working parentsbecome increasingly less likely to be insured, states may choose to targetcommunities with significant numbers of uninsured school-age children. Recentpublications have documented the increased numbers of uninsured children and theimplications for health care access:

An article in the New England Journal of Medicine showed that uninsuredchildren aged 6-17 were significantly less likely to see a physician for fourcommon conditions for which medical care is considered necessary(pharyngitis, acute earache, recurrent ear infections, and asthma), even whensocioeconomic conditions were taken into consideration (Stoddard et al., 1994).

Children's employment-related insurance coverage declined from 64.1 percentin 1987 to 59.6 percent in 1992 (Teitelbaum, 1994).

Lack of health insurance crosses boundaries of race, family status and familyincome. In 1992, almost 8 3 million children were uninsured for the entireyear, of whom 6.4 million were white (12 percent of all white children), 1.4million were black (13.5 percent of all black children), and about 2 million wereLatino (25.7 percent of all Latino children, noting that persons of Latino originmay be of any race) [Teitelbaum, 1994].

In 1987, most uninsured children lived in poor or near-poor families. Almosthalf of children from families with incomes below the federal poverty level(FPL) was uninsured for all or part of the year, almost 35 percent of children infamilies between 100 percent and 200 percent of the FPL was uninsured for allor part of the year (Monheit, 1992). In 1991, the highest percentage ofuninsured children was from families with incomes between $10,000 and$19,000 (Kogan, 1991, cited by Teitelbaum).

d) Inadequate primary care access

Barriers to ambulatory care due to inaccessible or limited numbers of primary careproviders may constitute another criterion for community selection. Evidence ofaccess problems for school-age children have been reported in leading medicaljournals.

17Draft manuscript for review and comment, 9/13/95 16

Investigations by the United Hospital Fund in New York City, which reportson City programs providing innovative AIDS and health care services to high-risk adolescents, indicate that adolescents have problems in accessing care inunderserved areas (Feiden, 1993).

Hospital admissions in New York City for ambulatory care-sensitiveconditions, which suggest inappropriate emergency room utilization andinadequate primary care availability, are significantly associated with area andincome for children aged 6-17 (Billings et al. 1993).

A recent article in the New England Journal of Medicine by the Medicaid AccessStudy Group points out that for Medicaid beneficiaries, obtaining ambulatorycare outside of emergency rooms is difficult (Medicaid Access Study Group,1994).

In summary, it might be argued that the children for whom school-based healthcenters are most useful are adolescents, ages 10 19, from low-income families.Many of these young people are without health insurance, and even for those whohave Medicaid or some other form of coverage, access to care may be limited bysocial conditions including the absence of appropriate providers in their community.In addition, the range of care for chronic physical, mental health and behavioralconditions, and the social support to help them manage ongoing problems, is notroutinely available through existing health care provider organizations.

States will likely have many more needy communities than can be served by a state-sponsored program. Therefore, it may be important for a state to add additionalcriteria, such as community support or evidence of parental leadership. States mayalso choose to rank-order communities in terms of variables such as the availabilityof local matching dollars, or the perceived likelihood of success. The viability of astate-sponsored school-based health center program will be significantly enhancedby the development of explicit criteria for the kinds of needy communities where theprogram is most likely to be effective.

(2) Defining school-based health center servicesTo determine the costs of operating a school-based health center as well as to lay thegroundwork for discussions with managed care plans, states must define therequired components of school-based health care and identify standards for howservices are to be rendered. The School Health Policy Initiative at MontefioreMedical Center, in collaboration with groups of national experts, has developedboth a set of operating principles for school-based health centers and an outline ofrecommended services to be provided by the centers (Brellochs, 1995).

Service criteria typically include a statement of program objectives. An example fora school-based health center might be: "to assist students to function appropriatelyin their social and educational environment by meeting their physical, social andbehavioral needs in a comprehensive primary care center with-in a school-basedhealth program." Services to achieve this objective can include:

preventive and primary care, including health education.diagnosis and treatment of illness and injuries, including referral to linkedpartners, follow-up care, and longitudinal management of chronic problems,limited on-site laboratory capability;

Draft manuscript for review and comment, 9/13/95 17

radiology service through linked providers.access to appropriate mental health resources.behavioral health care and social support.coordination of health and educational concerns.

State standards for school-based health centers are spelled out in documentssupporting a number of state grant initiatives. While state Medicaid programs havenot yet become involved in the definition of school-based health centers, state healthdepartments have become increasingly so. In the process of initiating grant pro-grams for school-based health centers, the health departments have establishedprogram goals, described service and staffing standards, and defined prototypes forreplication. Of the 50 states surveyed by the Making the Grade National ProgramOffice, 22 have established state school-based health program guidelines, rangingfrom suggested to mandated program standards (see Table 2 below). Twelve ofthese standards, judged by the Program Office to be well-defined and comprehen-sive, are summarized in the appendix. Nine states reported that program guidelineswere under development. With few exceptions, states define school-based healthcenters as vehicles for coordinating and delivering accessible primary physical andmental health services to students. The states' definition of required or desiredservices are fairly uniform. The services to be provided include: preventive healthcare, acute care, routine examinations, immunizations, social services, healtheducation and mental health counseling. Reproductive health services are morefrequently suggested than required for centers serving older students. Whatbecomes clear from conversations with state officials is that the process of definingthe school-based health center service package is difficult given the value attached toa strong programmatic role for local officials and community groups. Extensivediscussions involving a mix of state and local representatives are essential toestablish consensus on the service package (Schlitt JJ, et al).

Table 2. State Guidelines For School-Based Health Centers'Required/Suggested ::

Guideline2: ',,, 1

Development 3"Gilidelinee!

Colorado Michigan Arkansas Alabama NevadaConnecticut Nebraska Iowa Alaska New HampshireDelaware New Jersey Maryland Arizona North DakotaFlorida New Mexico Missouri California OklahomaGeorgia New York Rhode Island Idaho South CarolinaHawaii North Carolina Tennessee Kansas South DakotaIllinois Ohio Utah Kentucky WashingtonIndiana Oregon Vermont Minnesota WisconsinLouisiana Pennsylvania West Virginia Mississippi WyomingMaine Texas MontanaMassachusetts Virginia

1 With many states developing new school-based health center initiatives and other states assessingand re-assessing their preferred models, all state guidelines might be considered "works in progress."2 States in this category have either issued guidelines which must be complied with as a condition ofstate funding or have developed guidelines that are recommended to communities but are not arequirement for funding.3 Some states that have funded school-based health centers using general guidelines are nowclarifying their service standards and staffing requirements. These states are moving towards anexplicit comprehensive model. A number of states are elaborating several models for health servicesin school, ranging from limited services to comprehensive health centers. States that have recentlyfunded school-based health centers are developing their initial standards by drawing upon theexperience of older programs.4 States that have not developed guidelines for school-based health centers either do not supportcenters or have a total commitment to local control.

II; EST COPY AVAILABLE,

19Draft manuscript for review and comment, 9/13/95 18

Sources:Billings, JD, Zeitel, L, Lukomnik, J, Carey, T. Blank. A. Newman. L. Impact ofsocioeconomic status on hospital use in New York City, Health Affairs, Spring 1993.

Brellochs C. Fothergill K. Ingredients for success: comprehensive school-based healthcenters. A special report on the 1993 national work group meetings. Bronx. NY: SchoolHealth Policy Initiative, Montefiore Medical Center. Albert Einstein College of Medicine.1995.

Cart land, JD, Yudkowsky, B. State estimates of uninsured children, Health Affairs. Spring1993.

Feiden. K. Health Care for Adolescents: Developing Comprehensive Services, UnitedHospital Fund, April 1993.

Klein, JD, Slap, G, Elster, A. Schoenberg, SK. Access to health care for adolescents. Journalof Adolescent Health, Vol. 13, No., March 1992.

Klein. JD, Slap, G, Elster, A, Cohn, S. Adolescents and Access to Health Care, Bull. NY.Acad. of Medicine, New York, NY., Winter, 1993.

Klein, JD. Adolescents, Health Care Delivery System Issues and Health Care Reform,Center for Reproductive Health, University of California at San Francisco, 1994 (in press).

Kogan, M. Unpublished data from the 1991 longitudinal follow-up to the 1988 NationalMaternal and Infant Health Survey, National Center for Health Statistics, Hyattsville, MD.

Lear, JG. Health care goes to school: an untidy strategy to improve the well-being of school-age children. In: Social policies for children, Garfinkel I. Hochchild J. McLanahan S, eds.Washington, DC: Brookings Institution, in press.

Leibowitz, A, Manning, WG, Keeler, EBB, Duan, L, Lohr, KN. Effect of cost-sharing on theuse of medical services by children: interim results from a randomized controlled trial.Pediatrics, 1985; 75.

Monheit, AC, Cunningham, P. Children without health insurance, The Future of Children.The David and Lucille Packard Foundation, Winter, 1992.

Office of the Inspector General, Recommended guidelines for the standards and operations ofschool-based clinics in New York State, in School Based Health Centers and Managed Care.Department of Health Services, Office of the Inspector General. December, 1993.

Schlitt JJ et al. State initiatives to support school-based health centers: a national survey.Journal of Adolescent Health.

Starfield B. Child and adolescent health status measures. The Future of Children: US HealthCare for Children, vol., no. 2(Winter 1992), pp. 25-39.

Stoddard. J, St. Peter, R, Newacheck, P. Health insurance status and ambulatory care forchildren", NEJM, Vol. 330, No. 20, May 19, 1994.

Teitelbaum, MA. The Health Insurance Crisis for America's Children, Children's DefenseFund. March 1994.

The Medicaid Access Study Group. Access of Medicaid recipients to outpatient care, NEJM.Vol. 330. No. 20, May 19, 1994.

Draft manuscript for review and com20ment, 9/13/95 19

US Congress, Office of Technology Assessment. Adolescent Health, Volumes I, IIand III, Washington, DC.: US. Government Printing Office, 1991. OTA-H-466.

Zill, N, Schoenborn, CA. Developmental, learning and emotional problems, Advanced Datafrom Vital and Health Statistics of the National Center for Health Statistics, Hyattsville, MD:US DHHS, November 16, 1990.

21

Draft manuscript for review and comment, 9/13/95 20

Strategies to fund school-based health centers: Alternativereimbursement models.

Once the state has defined a school-based health center provider-type by identifyingthe community to be served and the services to be provided, the state must thenaddress how the school-based health centers will be paid for their services. In sodoing, the distinction between local and state perspectives must be considered. Theindividual school-based health center or its sponsor is responsible for covering itsoperating costs; the full range of alternatives from contracts with managed careplans to fee-for-service billing to categorical grant initiatives and in-kindcontributions must be explored. Regardless of its creativity and energetic pursuit offinancing, however, the health center's access to financial support will bedetermined, in great part, by decisions at the state level.

The level of state support for school-based health centers is a function of thecombined decisions of all the state agencies that agree to participate in supportingcare provided by the centers. It is therefore important that the broadest range ofdecision-makers sit at the table when determining what resources can be applied toschool-based health centers. In general, the key participants will include theMedicaid director, the Commissioner of Public Health, the Superintendent ofSchools, the Commissioner of Mental Health and, perhaps, the InsuranceCommissioner. If special health care reform offices have been established, theirinvolvement is essential as well.

To assure stable long-term financing for school-based health center programs,resolution of the following issues is critical: Should payment to the centers be on afee-for-service basis? How are uninsured students to be covered? How can thisprogram fit with managed care? Should state-supported programs be paid onlythrough Medicaid, and if so, should they serve only the Medicaid-eligiblepopulation? Experience has shown that whichever model the state chooses to adoptmust be accepted and supported at every level of state government.

There are a limited number of approaches for paying school-based health centers forthe care they provide to designated populations. These include a regulatoryapproach, a market approach, and a "pooled fund" approach.

A regulatory approachUnder this approach, the state through its regulatory process defines the school-based health center provider-type, including the establishment of targeting criteriaand services to be provided, and mandates that Medicaid managed care plans (and/or potentially all licensed insurers in the state) pay the provider-type for servicesprovided to their enrollees at a stipulated rate determined to cover the costs ofproviding that care.

This approach is not dissimilar to some existing provisions under managed care.For example, family planning services are often "carved out" from the primary carecontracts of Medicaid managed care providers. That is, although family planning isa covered benefit for which the managed care plan is responsible, enrollees mayobtain family planning services outside the plan without going through their

22Draft manuscript for review and comment. 9/13/95 21

primary care "gatekeeper." The managed care organization excludes familyplanning services from the per capita payment to the primary care provider, andpays the family planning organization on a fee-for-service basis. This is donebecause all parties want enrollees to have free access to family planning services,which would be less likely to occur if pre-approval were needed from the primarycare gatekeeper.4

The regulatory approach has several benefits: it provides stable funding; it definesand codifies the school-based health care model; and it allows the state to determinethe scope and breadth of the program. It also fits well within the traditional role ofgovernment in serving the low-income population. The necessary technologyexists to implement the approach, since the centers will be serving in an establishedrole, that is, they will operate as vendors to managed care plans.

There are also drawbacks: The percentage of school-age children for whom aschool-based health center would receive payment under such an approach must becarefully assessed. Because states may lack adequate regulatory authority over self-insured plans (approximately half of all insured employees and dependents areinsured through self-insured plans), the financing of school-based health centerswill be largely dependent on Medicaid and other insurance plans regulated by thestate. If only a small number of students are covered under Medicaid and otherstate-regulated plans, funding for the centers from this source will necessarily belimited.

From the perspective of the school-based health center, the regulatory approachcalls for considerable administrative effort. The center will need to identify themanaged care plan in which the student is enrolled (in general it is the parent, ratherthan the child, who is the direct enrollee, making identification sometimes verydifficult). The center must then obtain all necessary billing numbers and generate abill that meets the needs of the managed care plan. The problems faced by Medicaidmanaged care programs in managing the Medicaid population will be passed on tothe center, and are likely to become magnified in the process. Notification of planenrollment change by the parent may not be accomplished smoothly, and theproblem of eligibility may become even more difficult. Representatives of Medicaidmanaged care plans complain that their greatest problem arises from involuntarydisenrollment through loss of eligibility, which often affects 50 percent of theircovered population annually.

Other complex problems may arise in a Medicaid managed care plan, includingpossible limitations on mental health services providers, and an unwillingness toreimburse for services of clinical social workers, who often play a major role inschool-based health care. Moreover, the managed care plan may limit the numberof outpatient mental health visits, or may require (as in New York State) that after10 such visits the patient's care is shifted to a mental health managed care provider.

4 By a 1986 amendment to Title XIX of the Social Security Act., Congress "carved out" familyplanning from the Medicaid managed care programs under the 1915(b) waiver process to assure thatMedicaid beneficiaries had broad access to family planning services. However, the carve out is notapplicable to Medicaid managed care programs operating under Section 1115 waivers. See P.L.99-509, Section 9508. Sara Rosenbaum et al., Beyond Freedom to Choose: Medicaid ManagedCare and Family Planning, Center for Health Policy Research, The George WashingtonUniversity, Washington, DC.

23Draft manuscript for review and comment, 9/13/95 22

Lastly, to participate efficiently within a managed care system, school-based healthcenters will need medical billing capability and full understanding of thecomplexities of health care accounting practices.

A market approachUnder the market approach, rather than identifying and certifying the school-basedhealth center as an essential provider-type, the state would define the function of theschool-based health center as an essential service. That is, the state would specifythat if a managed care organization is authorized to serve an area with more than acertain percent of Medicaid enrollment, it must provide school-based health careservices as part of its Medicaid contract.

Using this approach, it would be possible for managed care organizations to workcollaboratively with community schools to ensure a sound, well-organizedprogram. Collaboration, however, is by no means guaranteed. Several centersmight be organized by competing plans in schools that are in close proximity to oneanother. Will the centers serve students who are not enrolled in the sponsoringplan? Indeed, there are a number of potential problems, including neglecting thesensitivities of the school itself. Some schools may not want a center either forpolitical reasons or due to space scarcity. The issue of governance is also likely tobe problematic: who would own the center and could it be owned by one plan, orby several together?

The question of accountability also arises. To whom would the managed careorganization be accountable, and for what? Could students vote with their feet andobtain services elsewhere? Hypothetically, unless the managed care organization isheld accountable for the services it provides via school-based health centerstandards, the plans may find it in their best interest to limit resources and make theprogram extremely unattractive. Without accountability, there will be limitedacceptance of responsibility for the needs of the student, and an idiosyncraticprogram may well develop.

A "pooled fund" approachUnder the pooled funding approach, the state assumes direct responsibility for theprogram, and funds it via a global budget paid directly to each center. The statedetermines the centers' operating cost and creates a fund to pay for a specificnumber of centers by pooling money from a variety of sources. These includeMedicaid funds obtained under 1115 waivers, federal maternal and child healthfunds, state general revenue support, foundation grants, and other related fundsavailable through education and human services. By the state pooling these fundstogether, matching federal Medicaid funds under the terms of the 1115 waiver couldbe obtained. The project could then be administered by an appropriate state agencyin accordance with defined targeting criteria and service levels as previouslydiscussed.

In 1991, the New York legislature considered a variation of this approach. Asreported by Christel Brellochs, proposed legislation sought "to take advantage ofdisproportionate share allowance provisions of the federal Medicaid program bydesignating the $3 million in State funds allocated to school-based health centers asthe state contributions to Medicaid. If this amount were matched by local (25%)and federal (50%) shares, approximately $10 million would be generated for theschool-based health centers. Combined with the Title V allocation of $3.5 million,

24Draft manuscript for review and comment, 9/13/95 23

a total of $13.5 million would be available to fund school-based or school-linkedservices." The proposal was rejected by the New York Senate as a result of end-of-session politicking, but the New York experience suggests the possibility of thisapproach (Brellochs, 1992).

The model, however, has not been implemented in any state. As a result, there area number of issues that will need to be resolved. The state must be able to monitorthe management of global budgets by the centers to assure efficient operation.Incentives for optimum utility must be incorporated so that if a center's utilizationrate is lower, it receives a smaller budget. At present, there are limited dataavailable to inform the establishment of an appropriate budget based on utilization(that is, we don't currently know, in a high school of, for example, 1,000 students.what the normative budget for a school-based health center should be, or whatmight impact on that budget in terms of making it larger or smaller ).

A major attraction of this approach is that currently-available funds, such as theMaternal and Child Health block grant program and private foundation grant awardssuch as those from the Robert Wood Johnson Foundation, the Kellogg Foundation,and the William Caspar Graustein Memorial Fund could be used to learn moreabout how to organize this kind of program and manage global budgets efficiently.It would then be possible to "carve out" the services and finances from state-sponsored Medicaid managed care programs, and continue the program as a directstate-supported operation with an appropriate global budget. The learning periodcould also be used to continue to build solid community support for the program.This includes working with the schools to assure their perception of ownership andworking with community providers to develop sound referral relationships, anessential requirement for collaborating with managed care programs.

It seems as if we can see the future for school-based health center programs, as forall other health care endeavors, only in a glass darkly. Nonetheless, it seemspossible that this kind of globally-budgeted program, funded by the state throughpooling a variety of resources, may provide a sound interim step in learning notonly how to fund the program for the longer term, but also how to implement iteffectively through well-developed targeting and service criteria.

A comparative analysis of the three long-term financing approaches is summarizedin Table 3 on the next page.

O

25Draft manuscript for review and comment, 9/13/95 24

Table 3. Alternative Reimbursement Models For State-SponsoredSchool-Based Health Center Programs

RegulatoryModel

Market Model PooledFund

Accountability Must meet state-defined criteria -

Unclear Managed by statedept. of health

PaymentMechanisms

State-stipulatedper-unit rate (fee-for-service)

Determined bymarket

State-determinedglobal budget

AdministrativeBurdens

High for allparties: state,centers andmanaged careplans

Low for states;marketdetermines formanaged careplans

. Mid-level forstates; minimalfor centers andmanaged careplans

StudentEvaluation

_

Choice limited toenrollmentopportunitiesunder Medicaidmanaged care

Unclear Stateaccountabilityprocess mustinclude studentassessment

Sources:Brellochs, C. Initial report: School health Medicaid project. Center for Population andFamily Health, Columbia University School of Public Health, New York, Report to the NewYork Community Trust, January 1992.

Rosenberg, S, et al. Beyond the freedom to choose: Medicaid managed care and familyplanning, Center for Health Policy Research, The George Washington University, 1994.

26Draft manuscript for review and comment. 9/13/95 25

STA

TE

GU

IDE

LIN

ES

FOR

SC

HO

OL

-BA

SED

HE

AL

TH

CE

NT

ER

S 19

94Pr

imar

y G

oal

Spon

sori

ngA

genc

ySi

teSp

ecif

icat

ions

Serv

ice

Def

initi

ons

Staf

fing

Com

mun

ityPa

rtic

ipat

ion

Pare

ntal

Con

sent

Con

tinuu

m o

fC

are

Eva

luat

ion

& Q

ualit

yA

ssur

ance

Info

rmat

ion

on th

equ

antit

y an

d 9u

ality

of s

ervi

ces

deliv

ered

will

be

colle

cted

by

site

s us

ing

Scho

olH

eal t

hCa

re O

n-L

ine!

!;

Dat

a an

d ou

tcom

eac

coun

tabi

lity

requ

irem

ents

will

be

defi

ned.

c __.

U L BD ip A Dca

re1-

' o

To

rem

ove

fina

ncia

lId

eally

, SB

HC

s w

illL

ocat

ed o

n th

eV

arie

s ba

sed

onan

d or

gani

zatio

nal

be li

nked

with

scho

ol s

ite.

scho

ol ty

pe:

barr

iers

that

inhi

bit

Com

mun

ity H

ealth

esta

blis

hing

and

Cen

ters

, loc

al h

ealth

Ele

men

tary

: wel

lsu

stai

ning

sch

ool-

depa

rtm

ents

, and

child

car

e;ba

sed

heal

thco

unty

nur

sing

serv

ices

whi

ch w

illse

rvic

es w

hich

are

Mid

dle

scho

ol: w

ell

ultim

atel

y fa

cilit

ate

perm

itted

child

/ ado

lesc

ent

univ

ersa

l acc

ess

tore

imbu

rsem

ent

care

, rep

rodu

ctiv

eba

sic

prim

ary

with

out a

phy

sici

anhe

alth

, and

opt

iona

lpr

even

tive

phys

ical

on-s

ite.

cont

race

ptiv

ean

d m

enta

l hea

lthse

rvic

es;

serv

ices

for

the

scho

ol-a

geH

igh

scho

ol: w

ell

popu

la H

on.

adol

esce

nt a

ndpr

even

tive

heal

thse

rvic

es a

ndsu

bsta

nce

abus

ese

rvic

es.

All

cent

ers

offe

rac

ute

care

, lab

test

s,.

med

s, a

cute

car

e fo

rch

roni

c co

nditi

ons,

dent

al c

are,

men

tal

heal

th, a

nd h

ealth

educ

atio

n

Sour

ce:

Mak

ing

the

Gra

de A

pplic

atio

n, 1

993

and

Qua

rter

ly R

epor

t, 19

94.

Gui

delin

es s

ugge

stsc

hool

nur

sepr

actit

ione

r or

phys

icia

n as

sist

ant,

men

tal h

ealth

prac

titio

ner,

stud

ent h

ealth

tech

nici

an (

orse

cret

ary)

, and

heal

th e

duca

tor;

At t

he m

iddl

e an

dhi

gh s

choo

l lev

els,

subs

tanc

e ab

use

and

viol

ence

pre

vent

ion

spec

ialis

ts m

ay b

ead

ded.

Mus

t pro

vide

Pare

nts

shou

ld-

beev

iden

ce o

fal

low

ed to

cho

ose

rela

tions

hips

with

whe

ther

thei

r ch

ildpu

blic

and

pri

vate

may

use

the

SBH

Che

alth

pro

vide

rs,

serv

ices

by

havi

ngte

ache

rs, s

choo

lth

e op

tion

to s

ign

ahe

alth

per

sonn

el,

cons

ent f

orm

.co

mm

unity

-bas

edor

gani

zatio

ns,

serv

ice

club

s an

dot

her

com

mun

itygr

oups

, par

ents

,st

uden

ts, a

nd o

ther

sde

term

ined

to h

ave

ast

ake

in th

e he

alth

of

the

com

mun

ity's

child

ren.

'

Cas

e m

anag

emen

tan

d fo

llow

-up

toen

sure

that

all

heal

th c

once

rns

are

adeq

uate

lyad

dres

sed;

Aft

er h

ours

cove

rage

and

linka

ges

with

all

appr

opri

ate

leve

lsof

car

e is

req

uire

d.

N E C T C U

T1

To

expa

ndA

med

ical

pro

vide

rO

n-si

te a

vaila

bilit

yPr

imar

y he

alth

car

e,In

clud

es a

cen

ter

com

preh

ensi

vew

ho d

eliv

ers

of a

dequ

ate

clin

icso

cial

ser

vice

s,m

anag

er w

ithhe

alth

ser

vice

s fo

rse

rvic

es a

t the

spac

e is

man

dato

rym

enta

l hea

lth, h

ealth

trai

ning

in m

enta

lsc

hool

age

d ch

ildre

n co

mm

unity

leve

l will

The

SB

HC

sho

uld

be e

duca

tion,

pre

nata

lhe

alth

/hea

lthan

d ad

oles

cent

s.be

sel

ecte

d by

the

loca

ted

in a

fai

rly

and

post

- pa

rtum

syst

ems

man

agem

ent,

com

mun

ity a

dvis

ory

visi

ble

area

of

the

refe

rral

and

fol

low

-at

leas

t one

nur

se.

boar

d ba

sed

onsc

hool

. It m

ust b

eup

;pr

actit

ione

r w

ithab

ility

to m

eet s

tate

mad

e ap

peal

ing

toad

oles

cent

hea

lthag

ency

and

RW

Jth

e st

uden

ts, b

oth

inE

ncou

rage

den

tal

expe

rien

ce, o

nem

odel

req

uire

men

ts,

term

s of

aes

thet

ics

serv

ices

whe

re n

eed

MSW

with

will

ingn

ess

to f

orm

and

acce

ssib

ility

is in

dica

ted.

cons

ulta

nt b

acku

p,a

part

ners

hip

with

The

cen

ter

mus

t be

addi

tiona

l alli

edth

e sc

hool

sys

tem

,de

sign

ed to

ens

ure

heal

th p

rofe

ssio

nals

and

abili

ty to

mee

tpr

ivac

y an

das

nee

ded,

and

stat

e lic

ensu

reco

nfid

entia

lity

and

cler

ical

sup

port

.st

anda

rds

for

anm

eet s

tate

lice

nsin

gou

t-pa

tient

clin

ic.

stan

dard

s.

Sour

ce:

Sta

ndar

d M

odel

for

Sch

ool-B

ased

Hea

lth C

ente

rs, C

T D

epar

tmen

t of H

ealth

Ser

vice

s, 1

993

Lin

kage

s to

the

Pare

ntal

con

sent

isco

mm

unity

med

ical

requ

ired

to r

ecei

vean

d so

cial

ser

vice

cent

er s

ervi

ces

prov

ider

s (l

ocal

heal

th d

epar

tmen

ts,

com

mun

ity h

ealth

clin

ics,

med

ical

scho

ols/

hosp

itals

),m

ust b

e es

tabl

ishe

dan

d m

aint

aine

d.

Mus

t def

ine

back

-up

Bot

h co

mpo

nent

s ar

efo

r ce

nter

non

-si

te s

peci

fic

and

site

-op

erat

ing

hour

s an

dde

term

ined

;lin

kage

to s

ervi

ces

beyo

nd c

linic

sco

pei'l

ans

and

outc

omes

thro

ugh

lette

rs o

far

e m

onito

red

byag

reem

ent.

stat

e de

part

men

t of

heal

th s

ervi

ces.

Idea

lly, t

he c

ente

rst

aff

wou

ld h

ave

priv

ilege

s at

the

back

-up

site

(s)

inor

der

to e

nhan

ce th

eco

ntin

uity

of

care

.

27

26B

EST

CO

PY A

VA

ILA

BL

E,

28

STA

TE

GU

IDE

LIN

ES

FOR

SC

HO

OL

-BA

SED

HE

AL

TH

CE

NT

ER

S. 1

994

Prim

ary

Goa

lSp

onso

ring

...

Age

ncy

Site

.

Spec

ific

atio

ns .

Serv

ice

Def

initi

ons

-',',

Staf

fing

Com

.

mun

ityPi

rtic

lPili

Ori

Pare

ntal

Con

sent

Con

tinuu

m o

fC

are

Eva

luat

ion

&Q

ualit

yA

ssur

ance

t, IC I, A w A R

Pro

ves

prim

ary

Hea

litea

re d

eliv

ery

open

5 d

ays

a w

eek

All

serv

ice

Rec

omm

ende

d co

repr

even

tion

and

orga

niza

tion;

and

oper

atio

nal

com

pone

nts

will

be

staf

f: nu

rse

early

Inte

rven

tion

year

rou

nd (

with

appr

oved

by

loca

lpr

actit

ione

r, w

ithfo

r he

alth

pro

blem

sLo

cal s

choo

l dis

tric

tpr

ovis

ions

for

scho

ol b

oard

bas

edph

ysic

ian

back

-up,

amon

g th

e st

uden

tan

d bo

ard

ofre

duce

d su

mm

eron

nee

ds o

f stu

dent

a m

inim

um o

f 3 d

ays

popu

latio

n;ed

ucat

ion

mus

tho

urs)

.po

pula

tion;

a w

eek;

phy

sici

anap

prov

e th

e pr

ojec

t'sav

aila

ble

a m

inim

umA

ssur

e th

at e

ach

plan

ning

and

Ser

vice

s to

be

of 2

day

s a

wee

k;st

uden

t has

aim

plem

enta

tion.

prov

ided

incl

ude

mas

ters

pre

pare

dm

edic

al h

ome.

med

ical

hea

lthso

cial

wor

ker

aas

sess

men

ts,

min

imum

of 2

day

s a

diag

nosi

s an

dw

eek;

nut

ritio

nist

atr

eatm

ent,

soci

alm

inim

um o

f 1 d

ay a

serv

ices

, hea

lth a

ndw

eek;

cle

rical

nutr

ition

edu

catio

n,su

ppor

t on

daily

and

com

mun

ityba

sis;

one

pro

ject

serv

ice

refe

rral

;co

ordi

nato

r (m

ay b

eS

TD

and

HIV

the

resp

onsi

bilit

y of

serv

ices

may

be

prof

essi

onal

sta

ff).

prov

ided

;.r

epro

duct

ive

heal

thS

choo

l nur

se s

erve

sca

re is

pro

hibi

ted.

as li

nk b

etw

een

the

cent

er a

nd th

esc

hool

.

Sou

rce:

Rep

ort o

n S

choo

l-Bas

ed H

ealth

Cen

ters

in D

elaw

are,

Del

awar

e H

ealth

and

Soc

ial S

ervi

ces,

Dec

embe

r,19

93

Loca

l adv

isor

yW

ritte

npa

rent

alco

unci

l for

boa

tpe

rmis

sion

req

uire

dpl

anni

ng a

ndpr

ior

to p

rovi

ding

impl

emen

tatio

n is

med

ical

ser

vice

s.re

quire

d.

Pla

ns fo

r pr

ovis

ion

of s

ervi

ces

durin

gno

n-op

erat

iona

lho

urs

and

redu

ced

hour

s du

ring

sum

mer

mon

ths

mus

t be

clea

rly id

entif

ied;

Mem

oran

da o

fun

ders

tand

ing

requ

ired

for

refe

rral

s, s

uppo

rtse

rvic

es a

nd 2

4 ho

urco

vera

ge;

Ref

erra

l net

wor

k/pl

an b

etw

een

fam

ilyph

ysic

ian,

HM

O, o

rot

her

med

ical

gro

upm

ust b

e st

ated

.

Sta

te p

ublic

hea

lthdi

visi

on s

erve

s as

man

ager

to a

ssur

eco

mpl

ianc

e w

ithac

cept

ed m

odel

and

stan

dard

s.

Pro

gram

s ar

ere

quire

d to

part

icip

ate

inS

choo

l Hea

lthC

are

On-

Line

!! da

taco

llect

ion

syst

em.

L U I S I A N A

Mee

t the

phy

sica

lS

hall

be p

rivat

e or

Mus

t fun

ctio

n as

Sho

uld

incl

ude

but

and

emot

iona

lpu

blic

Inst

itutio

nin

tegr

al c

ompo

nent

not l

imite

d to

:he

alth

nee

ds o

flo

cally

-sui

ted

for

of s

choo

ls)

and

prev

entiv

e he

alth

adol

esce

nts

atad

min

istr

atio

n/w

ork

coop

erat

ivel

yca

re a

nd m

edic

alsc

hool

s.op

erat

ion

of S

BH

C;

with

sch

ool n

urse

s,sc

reen

ings

, tre

atm

ent

clas

sroo

m te

ache

rs,'

for

conu

non

sim

ple

(i.e.

, hea

lth c

ente

r,co

ache

s, c

ouns

elor

s,ill

ness

es, r

efer

ral

hosp

ital,

med

ical

and

scho

olan

d fo

llow

up

for

scho

ol, h

ealth

prin

cipa

ls;

serio

us il

lnes

s an

dde

part

men

t, yo

uth

serv

ing

agen

cy,

Loca

l gra

ntee

s ar

eem

erge

ncie

s, m

enta

lhe

alth

, alc

ohol

and

scho

ol o

r sc

hool

subj

ect t

o 20

%dr

ug a

buse

ser

vice

s,sy

stem

);fin

anci

al m

atch

;im

mun

izat

ions

, and

prev

entiv

e se

rvic

esN

on m

edic

alM

ust b

ecom

e a

for

high

-ris

kag

enci

es m

ust

Med

icai

d pr

ovid

er.

beha

vior

s su

ch a

sco

ntra

ct m

edic

alpr

egna

ncy,

ST

Ds,

com

pone

nt w

ithdr

ug a

nd a

lcoh

olqu

aTifi

ed m

edic

alab

use,

vio

lenc

e an

dpr

ovid

er.

inju

ries.

Sou

rce:

Ado

lesc

ent S

choo

l Hea

lth In

itiat

ive

Req

uest

for

Pro

posa

ls. 1

992

Sho

uld

incl

ude,

at a

min

imum

a nu

rse

(or

nurs

epr

actit

ione

r or

phys

icia

n as

sist

ant)

,on

e or

mor

e pa

rt-

time

phys

icia

ns, a

soci

al w

orke

r or

men

tal h

ealth

prof

essi

onal

at l

east

part

-tim

e, a

nd a

med

ical

offi

ceas

sist

ant.

The

sch

ool n

urse

shou

ld w

ork

with

the

Sill

IC p

erso

nnel

to d

evel

op h

ealth

educ

atio

n m

essa

ges.

Mus

t pro

vide

Mus

t ass

ure

pare

nts

evid

ence

of p

lann

ing

exec

ute

writ

ten

proc

ess

invo

lvin

g a

cons

ent f

orm

broa

dly

appr

oved

by

scho

olre

pres

enta

tive

auth

oriti

es.

com

mun

ity g

roup

;

Mus

t for

mco

mm

unity

adv

isor

ybo

ard.

Req

uire

d to

sub

mit

plan

for

mon

itorin

gan

d ev

alua

tion

Req

uire

d to

part

icip

ate

inS

choo

l Hea

lthca

reO

n-Li

ne!!

data

colle

ctio

n sy

stem

.

.

29

17

30

STA

TE

GU

IDE

LIN

ES

FOR

SC

HO

OL

-BA

SED

HE

AL

TH

CE

NT

ER

Prim

ary

Goa

lSp

onso

ring

Age

ncy

Site

.

SPec

ific

atio

nsSe

rvic

eD

efin

ition

s.

Staf

fing

Com

mun

ityPa

rtic

ipat

iOn

Pare

ntal

Con

sent

Con

tinuu

m o

fC

are

Eva

luat

ion

& Q

ualit

yA

ssur

ance

I L L I N 0 I S

Impr

ove

the

over

all

May

be

in o

r...

devo

ted

prim

arily

phys

ical

and

adja

cent

to a

to p

erfo

rman

ce o

fem

otio

nal h

ealth

of

scho

ol...

prev

entiv

e m

edic

al,

stud

ents

.ed

ucat

iona

l,A

min

imum

of t

wo

coun

selin

g an

d/or

exam

inat

ion

room

sdi

agno

stic

Is d

esira

ble;

proc

edur

es;

Sta

te p

rovi

des

spec

sM

ay in

clud

e ro

utin

efo

r cl

inic

equ

ipm

ent

med

ical

car

e, e

xam

s,an

d la

b ut

ility

roo

m.

lab

scre

enin

gs, S

TD

and

repr

oduc

tive

heal

th s

ervi

ces.

Sou

rce:

Sch

ool B

ased

Hea

lth C

linic

Gui

delin

es, I

llino

isD

epar

tmen

t of P

ublic

Hea

lth

Min

imum

sta

ff sh

all

incl

ude

a m

edic

aldi

rect

or (

prim

ary

care

phy

sici

an),

are

gist

ered

nur

se, a

scho

ol n

urse

, and

acl

eric

al s

uppo

rtpe

rson

;

May

incl

ude

OB

/GY

N, A

RN

P,

RN

, sch

ool

coun

selo

r, a

nd/o

rde

ntis

t.

Eac

h cl

inic

sha

ltha

ve a

n ad

viso

rybo

ard

cons

istin

g of

scho

olad

min

istr

ator

s,m

edic

al c

omm

unity

,sc

hool

nur

se,

pare

nts,

cle

rgy,

yout

h ag

ency

rep

s,co

mm

unity

lead

ers;

Sha

ll ha

ve a

writ

ten

plan

for

com

mun

ityin

volv

emen

t.

Mus

t pro

vide

pare

ntal

con

sent

For

m in

clud

ing

desc

riptio

n of

the

clin

ic, s

cope

of

serv

ices

offe

red,

and

optio

n to

sel

ect

whi

ch s

ervi

ces

are

to b

e pr

ovid

ed.

To

Fur

ther

bro

aden

Inte

rnal

rev

iew

team

reso

urce

s, s

choo

l-is

res

pons

ible

for

base

d cl

inic

s sh

ould

cont

inua

llin

k se

rvic

es w

ithm

onito

ring

ofot

her

heal

th a

ndso

cial

ser

vice

s in

serv

ices

;

thei

r ar

ea.

May

be

perf

orm

edth

roug

h ra

ndom

A c

omm

unic

atio

nsa

mpl

e of

mon

thly

syst

em fo

r em

erge

ncy

char

t aud

its;

and

non-

emer

genc

yse

rvic

es r

efer

ral

Ser

vice

sta

ndar

dssh

all b

e av

aila

ble

mus

t mee

t tho

se o

fdu

ring

non-

clin

icA

AP

and

AC

OG

.ho

urs.

' M Ahe

alth

I E

Est

ablis

h st

rong

Elig

ible

spo

nsor

Mus

t be

conv

enie

ntC

ore

serv

ices

Rec

omm

end

nurs

eco

mm

unity

, sch

ool,

incl

udes

sch

ool

and

cent

rally

dete

rmin

ed b

ypr

actit

ione

r or

and

pare

nt s

uppo

rtsy

stem

or

med

ical

loca

ted

to th

eco

mm

unity

phys

icia

n's

and

invo

lvem

ent i

npr

ovid

er.

stud

ents

. Spa

ce m

ust i

ndic

ator

s in

clud

eas

sist

ant,

phys

icia

nS

BH

Cs;

to a

sses

sbe

ade

quat

e in

siz

eph

ysic

al e

xam

s,co

nsul

tant

, aan

d ev

alua

te th

eto

pro

vide

suf

ficie

ntdi

agno

sis

and

coun

selo

r or

soc

ial

care

nee

ds o

fro

om fo

r a

wai

ting

trea

tmen

t of m

inor

wor

ker,

and

the

stud

ents

; to

area

and

priv

acy

for

inju

ries

and

rece

ptio

nist

.co

ordi

nate

del

iver

yph

ysic

al e

xam

ina-

illne

sses

,of

com

preh

ensi

velio

ns a

nd c

ouns

el-

imm

uniz

atio

ns,

The

sch

ool n

urse

prim

ary

heal

th c

are

ing.

Spa

ce is

EP

SD

T s

cree

ning

s,sh

ould

be

serv

e as

with

in a

n ed

uca-

requ

ired

for

lab

test

s, c

hron

iclia

ison

on

the

tiona

l fra

mew

ork

labo

rato

ry s

ervi

ces,

Illne

ss m

anag

emen

t;ad

viso

ry c

omm

ittee

and

scho

ol s

ettin

g;eq

uipm

ent,

secu

rean

d pe

diat

ric c

are

of a

nd a

ssis

t in

to m

onito

r th

e he

alth

stor

age

for

supp

lies,

stud

ents

' inf

ants

.pr

ogra

m d

evel

op-

care

pro

vide

d to

and

plac

emen

t of

Den

tal,

repr

oduc

tive

mea

tst

uden

ts; a

nd to

reco

rds.

The

floo

ran

d m

enta

l hea

lthev

alua

te th

e he

alth

plan

sho

uld

bepr

imar

y ca

reO

ther

alli

ed h

ealth

stat

us o

f stu

dent

s by

abou

t 260

0 gr

oss

serv

ices

may

be

prof

essi

onal

ssp

ecifi

c ou

tcom

e.

squa

re p

er 4

000

offe

red

but a

re n

otsh

ould

be

part

of t

hecr

iteria

.sc

hool

pop

ulat

ion.

requ

ired.

.ce

nter

sta

ff as

need

ed (

e.g.

nut

ri-tio

nist

, psy

chol

ogis

t,cl

inic

ass

ista

nt).

Sou

rce:

Dev

elop

ing

a S

choo

l-Bas

ed H

ealth

Clin

ic, A

n A

ssis

tanc

e M

anua

l, M

ED

epar

tmen

t of H

uman

Ser

vice

s, 1

992

A c

omm

unity

-bas

edad

viso

ry c

ounc

ilsh

ould

incl

ude

cons

umer

and

prov

ider

gro

ups,

prof

essi

onal

s w

ithsp

ecia

l ski

lls,

com

mun

ity g

roup

sw

ith c

lout

, sch

ool

adm

inis

trat

ion,

scho

ol s

taff,

stud

ents

and

oth

ers.

Par

enta

l con

sent

form

mus

t be

sign

ed,

retu

rned

, and

on

file

in o

rder

for

ast

uden

t to

rece

ive

all o

r in

dica

ted

cent

er s

ervi

ces.

.

Med

ical

con

sulta

ntP

artic

ipat

e in

Sch

ool

or p

rovi

der

grou

pH

ealth

Car

e O

n-w

ill b

e av

aila

ble

for

Line

!!fo

llow

-up

serv

ices

afte

r ho

urs.

Prim

ary

outc

ome

indi

cato

rs in

clud

em

enta

l hea

lth s

tatu

s,ch

roni

c or

acu

teill

ness

, inj

urie

s,nu

triti

onal

pro

blem

s,pr

egna

ncy,

dru

g an

dal

coho

l abu

se, a

ndto

bacc

o us

e.

The

sta

te c

ondu

cts

site

vis

its a

ndpr

ovid

es in

stru

ctio

n-al

wor

ksho

ps.

Per

iodi

c ch

art

revi

ews

are

cond

ucte

d to

ass

ure

adhe

renc

e to

prot

ocol

s an

dpo

licie

s.

31B

EST

CO

PY A

VA

ILA

BL

E,

32

STA

TE

GU

IDE

LIN

ES

FOR

SC

HO

OL

-BA

SED

HE

AL

TH

CE

NT

ER

S. 1

994

Prim

ary

Goa

"Sp

onso

ring

Age

ncy

Site

SPeC

ific

atio

nsSe

rvic

eSt

affi

ngD

efin

ition

s

/17i

-0er

Und

er m

edic

alco

mpr

ehen

sive

supe

rvis

ion

ofpr

imar

y ca

re.

phys

icia

n;

Serv

ice

elem

ents

On-

site

sta

ff m

ust

incl

ude:

scr

eeni

ngin

clud

e on

e of

the

and

asse

ssm

ent,

follo

win

g:pr

even

tive

heal

thph

ysic

ian,

nur

sese

rvic

es, e

xam

s,pr

actit

ione

r or

diag

nosi

s an

d tr

eat-

regi

ster

ed n

urse

;m

ent,

heal

thed

ucat

ion,

sub

stan

ce M

ust a

lso

incl

ude

aab

use

serv

ices

,st

uden

t hea

lthm

enta

l hea

lthse

rvic

es, a

ndto

ser

veco

ordi

nato

rse

ryrv

e as

cas

ere

prod

uctiv

e he

alth

.m

anag

er.

The

Sill

-IC

pro

gram

is m

eant

to e

nhan

ceth

e ex

istin

g sc

hool

nurs

ing

staf

f.

of P

ublic

Hea

lth, A

ugus

t, 19

93.

Com

mun

ityPa

rtic

ipat

ion

,.

Shal

l est

ablis

h an

advi

sory

com

mitt

eew

ith s

tude

ntre

pres

enta

tion.

--Pa

rent

alC

onse

nt

Wri

tten

pare

ntal

cons

ent,

usua

llyob

tain

ed a

tbe

ginn

ing

of s

choo

lye

ar, i

s re

quir

ed f

oral

l ser

vice

s ex

cept

thos

e de

emed

emer

genc

y;

Con

tinuu

m o

fC

are

Shal

l inc

lude

str

ong

refe

rral

sys

tem

s to

ensu

re s

tude

nts

rece

ive

a co

ntin

uum

of h

ealth

car

e;

A li

nkag

e pl

ansh

ould

be

esta

blis

hed

with

clea

r id

entif

icat

ion

of w

hat w

ill b

epr

ovid

ed o

n si

te a

ndw

hat w

ill b

ere

ferr

ed;

Mus

t be

able

to o

ffer

24 h

our

back

-up.

Eva

luat

ion

& Q

ualit

yA

ssU

ranc

eM

ust p

artic

ipat

e in

stat

ewid

e SB

HC

data

col

lect

ion

syst

em ;

Mus

t use

stan

dard

ized

regi

stra

tion

and

enco

unte

r fo

rms

topr

ovid

e co

re d

ata

set;

Stat

e he

alth

depa

rtm

ent c

ondu

cts

peri

odic

site

vis

itsto

mon

itor

qual

ity.

M A S A H U S E T T S

Ens

ure

that

chi

ldre

nJo

int v

entu

re};

inM

emon

stra

te a

and

adol

esce

nts

will

bet

wee

n pr

imar

yfl

oor

plan

for

clin

icha

ve a

cces

s to

ear

ly,

care

pro

vide

r (e

.g.,

loca

tion;

com

preh

ensi

ve a

ndco

mm

unity

hos

pita

l,co

mpe

tent

hea

lthne

ighb

orho

od h

ealth

Mus

t be

licen

sed

byca

re.

cent

er)

and

host

stat

e he

alth

scho

ol;

depa

rtm

ent;

Hea

lth c

are

Mus

t be

acce

ssib

lepr

ovid

er s

erve

s as

for

outr

each

and

lead

age

ncy;

afte

r-sc

hool

and

sum

mer

use

.M

ust h

ave

form

alag

reem

ent w

ith h

ost

scho

ol d

istr

ict.

Sou

rce:

Sch

ool H

ealth

Ser

vice

s, R

eque

st fo

r P

ropo

sals

, MA

Dep

artm

ent

N E W l' 0 R K

Bri

ng d

irec

t acc

ess

Prov

ider

mus

t be

Clin

ics

mus

tto

com

preh

ensi

vece

rtif

ied

unde

r th

epr

ovid

e:pr

imar

y an

dpu

blic

hea

lth la

w o

rm

ass

scre

enin

gpr

even

tive

heal

thbe

a p

riva

te a

nd/o

rse

rvic

es, p

h si

sal

care

to m

edic

ally

-gr

oup

phys

icia

nex

ams,

hea

lth a

ndun

ders

erve

dlic

ense

d to

pra

ctic

eps

ycho

-soc

ial

child

ren.

med

icin

e in

New

coun

selin

g,Y

ork;

diag

nosi

s an

dtr

eatm

ent o

f m

edic

alM

ust e

nter

into

aco

nditi

ons

both

mem

oran

dum

of

acut

e an

d ch

roni

c,un

ders

tand

ing

with

imm

uniz

atio

ns, l

absc

hool

, sch

ool

test

s, a

nddi

stri

ct o

r bo

ard

ofre

prod

uctiv

e he

alth

educ

atio

n.ca

re o

n si

te o

r by

refe

rral

.

Sou

rce:

Req

uire

men

ts fo

r N

on-F

unde

d C

hapt

er 5

3 S

choo

l Witi

th D

emon

stra

tion

Pro

ject

s

Prov

ider

s m

ust b

ePa

rent

al c

onse

nt is

mid

-lev

elre

quir

ed u

nles

spr

actit

ione

rs w

ithst

uden

t is

18 y

ears

phys

icia

ns a

sor

old

er, o

rsu

perv

isor

s;ot

herw

ise

qual

ifie

dto

giv

e co

nsen

t.M

ust m

eet s

tate

DO

E r

equi

rem

ents

for

prof

essi

onal

licen

sure

and

expe

rien

ce;

.

Add

ition

al s

taff

may

incl

ude

soci

alw

orke

r,ps

ycho

logi

st, a

ndnu

triti

onis

t.

Mus

t agr

ee to

prov

ide

follo

w-u

pse

rvic

es f

or c

hild

ren

in n

eed

of h

ealth

care

who

lack

apr

imar

y ca

repr

ovid

er;

Req

uire

s lin

kage

with

hos

pita

l or

diag

nost

ic a

ndtr

eatm

ent c

ente

r fo

r24

hou

r, 7

day

-a-

wee

k co

ntin

uous

com

preh

ensi

ve c

are.

Req

uire

d to

part

icip

ate

inSc

hool

1 le

alth

Car

eO

n-L

ine!

! da

taco

llect

ion

syst

em;

Req

uire

d to

part

icip

ate

in s

tate

-w

ide

qual

ityas

sura

nce

prog

ram

,Pr

ogra

mE

ffec

tiven

ess

Rev

iew

Too

l(l

'ER

T)

3334

STA

TE

GU

IDE

LIN

ES

FOR

SC

HO

OL

-BA

SED

HE

AL

TH

CE

NT

ER

S. 1

994

:,"::.

.,

Prim

ary

Goa

l-.

1',.'

.,'..,

:-.,.

.-:,:

-_-

..,-.

Spon

sori

ngA

geO

ef".

:',X

,'.,;:

.-:-

Site

,..,,

-;.-

..1,..

'.::.:

-1-:

,;..

Spec

ific

atio

nsSe

rvic

e-J.

:.4'

befl

niel

OU

Sz(,

,St

affi

ng'

'..:-

...,:

.-0

:1'-'

1:i..

-"1

.'1

.:.:,!

:

Com

tnun

ity,-

:;;,.

:.

Part

icip

atio

n-P

aren

tal,

.....:

.. C

onse

nt',

Con

tinuu

mof

Car

e' :

-..,

..:.

.: .

Eva

luat

ion

&Q

ualit

y',:

Ats

tiran

ceN ,..

,.., V K T 7.

7,.

...,

.;:

:.f,: A.

.1%

.13 '.'..L

'

.1 ..

:.

N A

Incr

ease

stu

dent

sIn

cas

es w

here

Prim

ary

site

mus

t be

Mus

t be

Mus

t be

prov

ided

by

acce

ss to

hea

lthap

plic

ant I

s no

t alo

cate

d w

ithin

the

com

preh

ensi

ve in

a m

ulti-

disc

iplin

ary

care

;he

alth

ser

vice

ssc

hool

set

ting

and

natu

re, i

nclu

ding

team

incl

udin

gin

stitu

tion,

aop

erat

e fu

ll tim

epr

imar

y ca

re, m

enta

lnu

rses

, phy

sici

ans,

Pro

vide

ear

lyqu

alifi

ed m

edic

alw

hile

sch

ool i

s in

heal

th, p

reve

ntiv

eph

ysic

ian

exte

nder

s,id

entif

icat

ion

ofpr

ovid

er m

ust b

ese

ssio

n,he

alth

car

e an

dcl

inic

al s

ocia

lhe

alth

pro

blem

s an

did

entif

ied

tohe

alth

ris

kw

orke

rs a

ndon

-goi

ng tr

eatm

ent

cont

ract

for

the

redu

ctio

n se

rvic

es,

nutr

ition

ists

;an

d pr

even

tion

ofde

liver

y of

med

ical

dise

ase

and

Inju

ry;

serv

ices

;M

ust I

nter

face

with

At a

min

imum

, on-

exis

ting

heal

th a

ndsi

te s

taff

mus

tE

ncou

rage

stu

dent

sLe

tter

of c

omm

itmen

thu

man

ser

vice

s an

din

clud

e a

regi

ster

edto

take

per

sona

lfr

om s

uper

inte

nden

tre

sour

ces

in th

enu

rse

(thi

s m

ay b

ere

spon

sibi

lity

for

and

boar

d of

scho

ol.

the

scho

ol n

urse

),th

eir

heal

th c

are.

educ

atio

n re

quire

d.nu

rse

prac

fi B

oner

/ph

ysic

ian'

s.

assi

stan

t with

phys

icia

n ba

ck u

p,m

enta

l hea

lthpr

ofes

sion

al, a

ndcl

eric

al s

taff.

Sou

rce:

Gra

nt A

nnou

ncem

ent,

Req

uest

for

Pro

posa

ls, N

C D

ept.

of E

nviro

nmen

t, H

ealth

and

Nat

ural

Res

ourc

es, 1

994

Mus

t be

gove

rned

Inco

ncer

t with

form

alco

mm

unity

adv

isor

ybo

ard

com

pris

ed o

fpa

rent

s, c

omm

unity

lead

ers,

hea

lth c

are

prov

ider

s, a

ndyo

uth

agen

cyre

pres

enta

tives

for

the

purp

ose

ofpl

anni

ng a

ndov

ersi

ght;

Mus

t dem

onst

rate

high

deg

ree

ofco

nunu

nity

owne

rshi

p an

dsu

ppor

t.

Mus

t ass

ure

that

no

stud

ent w

ill r

ecei

vese

rvic

es w

ithou

t aw

ritte

n pa

rent

al/

guar

dian

con

sent

form

on

file.

Mus

t cle

arly

iden

tify

plan

for

prov

isio

n of

serv

ices

whe

n th

ece

nter

is n

ot in

oper

atio

n to

ass

ure

cont

inui

ty o

f ser

vice

deliv

ery

and

aco

ntin

uum

of c

are.

Mus

t est

ablis

hcr

iteria

for

eval

uatio

n an

dm

easu

ring

succ

ess

and

impa

ctex

pres

sed

as p

roce

ssan

d ou

tcom

em

easu

res;

Req

uire

d to

part

icip

ate

inS

choo

l Hea

l thC

are

On-

Line

!!

:. : .., ....:

.

..-,-

.-.

.:,..:

...

:,..

.

..:;., .....

..,:.:

,

::.

All

site

s w

illO

n th

e sc

hool

esta

blis

h a

cam

pus.

part

ners

hip

with

the

loca

l sch

ool d

istr

ict

and

the

loca

l hea

lthde

part

men

t;

Oth

er p

artn

ersh

ips

may

hvi

ude:

psyc

holo

gist

s, s

ocia

lw

orke

rs, p

ublic

and

priv

ate

heal

th c

are

prov

ider

s, fa

mily

plan

ning

clin

ics,

and

.

hosp

itals

.

Sou

rce:

Mak

ing

the

Gra

de A

pplic

atio

n, 1

993.

A m

odel

cen

ter

will

prov

ide

acce

ssib

le,

com

preh

ensi

ve,

cultu

rally

-sen

sitiv

ese

rvic

es to

stu

dent

s,In

clud

ing

age-

appr

opria

teph

ysic

al a

nd m

enta

lhe

alth

pro

mot

ion,

prev

entio

n,in

terv

entio

n, a

ndtr

eatm

ent s

ervi

ces,

Ref

erra

ls to

appr

opria

te s

ourc

esw

ill b

e m

ade

for

serv

ices

that

can

not

be p

rovi

ded

on-s

ite.

One

full-

time

nurs

epr

actit

ione

r or

phys

icia

n's

assi

stan

t, an

MD

as

med

ical

dire

ctor

and

cons

ulta

nt, n

urse

with

ado

lesc

ent

expe

rienc

e, c

linic

also

cial

wor

ker,

adr

ug a

nd a

lcoh

olsp

ecia

list,

and

are

cept

ioni

st a

nd/o

rhe

alth

ass

ista

nt.

Oth

er a

llied

hea

lthpr

ofes

sion

als

asne

eded

.

Mus

t dem

onst

rate

evid

ence

of

com

mun

ity in

put

from

par

ents

,te

ache

rs, s

tude

nts,

heal

th c

are

prov

ider

s, b

usin

ess

lead

ers,

man

aged

care

and

priv

ate

Insu

rers

, and

com

mun

ity r

elig

ious

lead

ers

for

SB

HC

plan

ning

and

Impl

emen

tatio

n

The

SB

HC

s w

illco

llabo

rate

with

the

scho

ol d

istr

ict

pare

nt-t

each

eror

gani

zatio

ns, a

ndth

e lo

cal s

choo

l site

to e

stab

lish

SB

HC

role

with

in th

esc

hool

sys

tem

.

Stu

dent

s ag

ed 1

5an

d ol

der

can

cons

ent t

o re

ceiv

ehe

alth

car

e se

rvic

esan

d pe

rson

s of

any

age

can

obta

infa

mily

pla

nnin

g an

dS

TD

rel

ated

ser

vice

sw

ithou

t par

enta

lco

nsen

t.

Som

e lo

cal

com

mun

ities

hav

ede

velo

ped

enro

llmen

t pol

icie

sth

at r

equi

repa

rent

al c

onse

nt fo

rsp

ecifi

c se

rvic

es.

Pro

vide

inte

grat

edse

rvic

es to

dec

reas

efr

agm

enta

tion

and

assu

re th

at s

tude

nts

rece

ive

care

and

guid

ance

.

At t

he lo

cal l

evel

,24

-hou

r co

vera

gem

ust b

e pr

ovid

ed b

ya

com

mun

ity h

ealth

care

pro

vide

r/sp

onso

r.

Cha

rt a

udits

of

pres

entin

g pr

oble

ms

and

prob

lem

reso

lutio

n ar

esu

gges

ted

by th

eS

tate

.

Site

vis

its a

reco

nduc

ted

by th

est

ate

thro

ugh

the

coun

ty h

ealth

depa

rtm

ents

eve

rytw

o ye

ars.

Sta

te H

ealth

Div

isio

n A

nnua

lR

epor

t is

prod

uced

annu

ally

with

dat

aco

llect

ed b

y th

eS

BH

Cs.

35

30

BE

ST C

OPY

AV

AIL

AB

LE

36

STA

TE

GU

IDE

LIN

ES

FOR

SC

HO

OL

-BA

SED

HE

AL

TH

CE

NT

Prim

ary

Goa

l''

Spon

sori

ng,'

genc

yA

Site

Spec

ific

atio

ns'

Serv

ice

,''

Def

initi

ons '

Staf

fing

,

-,C

omm

unity

.-P

aren

tal

Part

icip

atio

nC

onSe

n,

Con

tinuu

m o

fC

are

. .

Eva

luat

ion

& Q

ualit

yA

ssur

ance

vp r, E N N Spi

lot

.`" Y i a V A N I A

refe

rral

s

Impr

ove

the

heal

thS

choo

Tdi

stric

tsO

n th

e si

Roo

l site

.us

t pro

vide

ast

atus

of c

hild

ren

serv

e as

the

lead

pack

age

of p

rimar

yth

roug

h th

eag

ency

inpr

even

tive,

chi

ld/

expa

nsio

n of

hea

lthco

ordi

natio

n w

ithfa

mily

hea

lthse

rvic

es c

urre

ntly

the

com

mun

ity-b

ased

serv

ices

incl

udin

gav

aila

ble

in s

elec

ted

prim

ary

heal

th c

are

phys

ical

ass

essm

ent,

scho

ols

and

syst

em.

imm

uniz

atio

ns,

impr

oved

grow

thin

tegr

atio

n of

sch

ool

mea

sure

men

ts,

hear

th s

ervi

ces

deve

lopm

enta

l and

with

in a

com

mun

ity-

beha

vior

alba

sed

prim

ary

care

scre

enin

g, c

linic

alsy

stem

.sc

reen

s, r

outin

ecu

lture

s an

d la

bte

sts,

chi

ld/fa

mily

heal

th e

duca

tion

serv

ices

, and for

spec

ialty

car

e.

Sou

rce:

Req

uest

for

App

licat

ion.

Sch

ool-B

ased

Prim

ary

Hea

lth S

ervi

ces

Pilo

t Pro

ject

s.19

92.

Req

uire

cer

tifie

dre

gist

ered

nur

sepr

actit

ione

r,ph

ysic

ian'

sas

sist

ant o

rph

ysic

ian.

Sch

ool n

urse

invo

lvem

ent I

sen

cour

aged

. Sch

ool

nurs

e m

ay s

erve

as

the

cent

er m

anag

er.

Enc

oura

ges

the

invo

lvem

ent o

f oth

erco

mm

unity

-bas

edhe

alth

and

soc

ial

serv

ices

pro

vide

rsin

pro

gram

pla

nnin

gan

d im

plem

enta

tion.

Req

uire

writ

ten

pare

ntal

con

sent

for

all e

nrol

lees

.

Pro

vide

car

eco

ordi

natio

n fo

rfo

llow

-up

and

refe

rral

s; a

ssis

t in

acce

ssin

g ne

eded

heal

th, s

ocia

l,nu

triti

onal

or

othe

rse

rvic

es; t

rack

refe

rral

s to

dete

rmin

e se

rvic

est

atus

; con

duct

hom

evi

sits

whe

nne

cess

ary;

guar

ante

e as

sura

nce

of 2

4-ho

ur o

n-ca

llse

rvic

es a

ndco

nsul

tatio

n fo

rre

ferr

al o

f pro

blem

sno

t tre

atab

le o

n-si

te.

Req

uire

col

lect

ion

ofen

coun

ter

and

enro

llmen

t dat

a to

part

icip

ate

inst

atew

ide

eval

uatio

n sy

stem

;

Ass

ure

mec

hani

sms

are

in p

lace

toev

alua

te th

e qu

ality

and

appr

opria

tene

ssof

pat

ient

car

e.

T Efo

rX

Est

ablis

hE

ligib

le p

rovi

ders

At a

site

on

or n

ear

colla

bora

tion

ofm

ay b

e ci

vic

orsc

hool

gro

unds

.fa

mili

es, s

choo

ls a

nd c

harit

able

com

mun

ity;

orga

niza

tion,

com

mun

ity h

ealth

Ass

ure

med

ical

hom

e ce

nter

s, p

ublic

stud

ent;

heal

th a

genc

ies,

hosp

ital d

istr

icts

,P

rovi

de a

cces

s fo

rsc

hool

dis

tric

ts,

spec

ializ

ed m

edic

alm

edic

al s

choo

ls, o

rca

re;

priv

ate

prov

ider

s;

Pro

mot

e he

alth

and

Ful

l sup

port

of

use

of h

ealth

scho

ol d

istr

ict m

ust

syst

ems.

be e

vide

nt.

Sou

rce:

Sch

ool H

ealth

Pro

gram

s R

eque

st fo

r P

ropo

sals

, 199

4.

Cor

e se

rvic

es, w

hich

mus

t be

mad

eav

aila

ble,

incl

ude:

mai

nten

ance

of

heal

th r

ecor

d an

dhe

alth

pla

n,sc

reen

ings

, exa

ms,

imm

uniz

atio

ns,

diag

nosi

s an

dtr

eatm

ent o

f sim

ple

illne

ss a

nd m

inor

inju

ries,

edu

catio

nan

d co

unse

ling,

and

men

tal h

ealth

.

May

be

sche

dule

dfu

ll or

par

t-tim

e:ph

ysic

ian/

med

ical

dire

ctor

or

an a

ppro

pria

tely

trai

ned

licen

sed

nurs

e pr

actit

ione

run

der

phys

icia

ndi

rect

ion,

men

tal h

ealth

coun

selo

r;so

cial

wor

ker,

regi

ster

ed n

urse

, and

cler

k.

The

exi

stin

g sc

hool

heal

th p

erso

nnel

and

the

SB

HC

sta

ffw

ork

as a

team

.

Adv

isor

y co

unci

l of

pare

nts,

you

th,

chur

ches

, you

th a

ndfa

mily

ser

vice

s,ph

ysic

ians

, nur

ses,

and

othe

r he

alth

care

pro

vide

rs,

busi

ness

, sch

ool

nurs

es, s

choo

lad

min

istr

ator

s, a

ndfa

culty

to: s

et p

olic

y,id

entif

y se

rvic

es,

over

see

budg

et,

eval

uate

pro

gram

;as

sist

in g

ener

atin

gco

mm

unity

reso

urce

s.

Gen

eral

con

sent

form

that

iden

tifie

sal

l of t

he s

ervi

ces

avai

labl

e;

Par

ent m

ust b

eof

fere

d op

port

unity

to id

entif

y sp

ecifi

cse

rvic

es th

at th

ey d

ono

t con

sent

to b

eing

prov

ided

.

Mus

t pro

vide

writ

ten

agre

emen

tfo

r pr

ovis

ion

ofaf

ter

hour

s an

dsu

mm

er c

are;

Mus

t pro

vide

prot

ocol

for

com

mun

icat

ing

with

child

's m

edic

al/

heal

th p

rovi

der;

Mus

t des

crib

em

echa

nism

s fo

rex

chan

ge o

f med

ical

,so

cial

and

fina

ncia

lel

igib

ility

info

rmat

ion.

Mus

t par

ticip

ate

inst

atew

ide

data

colle

ctio

n;

Mus

t pro

vide

prot

ocol

for

phys

icia

nin

volv

emen

t in

reco

rd r

evie

w a

ndco

nsul

tatio

n.

Sta

te h

ealth

depa

rtm

ent c

ondu

cts

tech

nica

l ass

ista

nce

and

qual

ityas

sura

nce

site

vis

its.

38

3i

U.S. Department of EducationOffice of Educational Research and Improvement (OERI)

Educational Resources Information Center (ERIC)

REPRODUCTION RELEASE

I. DOCUMENT IDENTIFICATION:

(Specific Document)

0

Title: Issues in Financing School-Based Health Centers: A Guidefor State Officials

Author(s): Making the Grade/Rosenberg Associates

Corporate Source: Making-the- Grade-National. Program OfficeThe George Washington University

Publication Date:

Fall 1995

II. REPRODUCTION RELEASE:In order to disseminate as widely as possible timely and significant materials of interest to the educational community, documents announced

in the monthly abstract journal of the ERIC system, Resources in Education (RIE), are usually made available to users in microfiche, reproducedpaper copy, and electronic/optical media, and sold through the ERIC Document Reproduction Service (EDRS) or other ERIC vendors. Credit isgiven to the source of each document, and, if reproduction release is granted, one of the following notices is affixed to the document.

If permission is granted to reproduce and disseminate the identified document, please CHECK ONE of the following two options and sign atthe bottom of the page.

Check hereFor Level 1 Release:Permitting reproduction inmicrofiche (4" x 6" film) orother ERIC archival media(e.g., electronic or optical)and paper copy.

Signhereplease

The sample sticker shown below will beaffixed to all Level 1 documents

PERMISSION TO REPRODUCE ANDDISSEMINATE THIS MATERIAL

HAS BEEN GRANTED BY

TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)

Level

The sample sticker shown below will beaffixed to all Level 2 documents

PERMISSION TO REPRODUCE ANDDISSEMINATE THIS

MATERIAL IN OTHER THAN PAPERCOPY HAS BEEN GRANTED BY

TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)

Level 2

Documents will be processed as indicated provided reproduction quality permits. If permissionto reproduce is granted, but neither box is checked, documents will be processed at Level 1.

El

Check hereFor Level 2 Release:Permitting reproduction inmicrofiche (4" x 6" film) orother ERIC archival media(e.g., electronic or optical),but not in paper copy.

"I hereby grant to the Educational Resources Information Center (ERIC) nonexclusive permission to reproduce and disseminatethis document as indicated above. Reproduction from the ERIC microfiche or electronic/optical media by persons other thanERIC employees and its system contractors requires permission from the copyright holder. Exception is made for non-profitreproduction by libraries and other service agencies to satisfy information needs of educators in response to discrete inquiries."

Signature:

ss:

Making the Grade: State & Local

Partnerships to Establish School-BasedHealth Centers1350 Connecticut Ave NW 1505Wachingtnn DC 20036

Printed Name/Position/Title:

Julia Graham Lear, Director

Telephone:

202-466-3396FAX:202-466-3467

E-Mail Address:jgl@gwis2.circ.gwu

@edu

Date:

7/9/96

(over)

III. DOCUMENT AVAILABILITY INFORMATION (FROM NON-ERIC SOURCE):

If permission to reproduce is not granted 'to ERIC, or, if you wish ERIC to cite the availability of the document from another source,please provide the following information regarding the availability of the document. (ERIC will not announce a document unless it ispublicly available, and a dependable source can be specified. Contributors should also be aware that ERIC selection criteria aresignificantly more stringent for documents that cannot be made available through EDRS.)

Publisher/Distributor:

Address:

Price:

IV. REFERRAL OF ERIC TO COPYRIGHT/REPRODUCTION RIGHTS HOLDER:

If the right to grant reproduction release is held by someone other than the addressee, please provide the appropriate name and address:

Name:

Address:

V. WHERE TO SEND THIS FORM:

Send this form to the following ERIC Clearinghoude:

ERIC/CASSSchool of EducationPark 101, UNCGGreensboro NC 27412

However, if solicited by the ERIC Facility, or if making an unsolicited contribution to ERIC, return this form (and the document beingcontributed) to:

ERIC Processing and Reference Facility1100 West Street, 2d Floor

Laurel, Maryland 20707-3598

Telephone: 301-497-4080Toll Free: 800-799-3742

FAX: 301-953-0263e-mail: ericfac@inet.ed.gov

WWW: http://ericfac.piccard.csc.com(Rev. 6/96)