SHPPS found that collaboration among the separate disciplines and components of a CSHP exists, by no means was collaboration universal. Interdisciplinary collaboration and communication are likely to be areas requiring constant emphasis and attention.

Perhaps the most difficult issue to resolve before existing programs can be considered "comprehensive" involves the role of the school in providing access to services typically considered the responsibility of the private sector, such as certain preventive and primary health care services. "Providing access" does not necessarily mean that services will be delivered at the school site; rather, it implies ensuring that all students are able to obtain and make use of needed services. Depending on the community, many students may already be receiving such services and be covered through private insurance or Medicaid. However, as mentioned in earlier chapters, increasing numbers of students are uninsured or lack coverage for even the most basic preventive services. Each community must devise appropriate strategies to ensure that all of its students have access to these basic preventive and primary care services.

Even if many students in a community already have access to private care, certain preventive and primary care services might be more efficiently and effectively delivered at the school site, either by school personnel (school nurses, nurse practitioners, psychologists, counselors, or social workers) or community providers, rather than at scattered locations throughout the community. Studies have found that school-based health centers increase access to health care and provide some services more easily and appropriately than other kinds of providers, particularly for adolescents (U.S. Department of Health and Human Services, 1993; U.S. General Accounting Office, 1994b). As discussed in Chapter 4, some of the American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) recommendations might be efficiently and appropriately carried out in schools by school personnel.

Lack of stable and adequate funding appears to be a major obstacle to the development of school-based services, as noted in Chapter 4. Although barriers to cooperation between school health providers and private sector providers are large (Davis et al., 1995; U.S. Department of Health and Human Services, 1993; U.S. General Accounting Office, 1994a, 1994b), some progress is beginning to occur. Examples include the Health Start program in St. Paul, Minnesota (Zimmerman and Reif, 1995), and the program conducted by the Baltimore City Health Department, both of which have negotiated with managed care plans to support the delivery of school-based services. As described in Chapter 4, the Florida legislature has added provisions to the insurance code allowing school districts to become large grouping mechanisms for the purchase of health coverage for students and their families. The state has established a quasi-



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