Schools and Health Our Nation's Investment (1997) / Chapter Skim
Currently Skimming:
4 School Health Services
4 School Health Services
Pages 153-236
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 153... ...
The National Association of School Nurses has defined roles and standards for school nurses (Proctor et al., 1993) and provides a system for disseminating information and 153
|
From page 154... ...
Similarly, organizations such as the National Association of School Psychologists, the American School Counselor Association, and the National Association of Social Workers have published position statements and standards for their professions. The American School Health Association (ASHA)
|
From page 155... ...
Almost all districts keep student health records on file and monitor student immunization status, and most districts also keep student medical emergency and medical information forms on file. The University of Colorado Health Sciences Center's survey, entitled A Closer Look, examined a systematic random sample of public school districts nationwide for the 1993-1994 school year (Davis et al., 1995~.
|
From page 156... ...
Case management for chronic health problems Provide nutritional counseling 98.7 97.1 86.8 82.8 80.0 77.7 76.8 75.6 58.1 57.5 Provide mental health counseling 56.2 Conduct cardiovascular screenings 49.6 Provide complex nursing care to students with special needs 49.6 Employee wellness programs 48.6 Physical fitness screenings 45.2 Perform urinary catheterizations Conduct health risk appraisals to determine life-style practices Process worker's compensation claims Provide immunizations at school Physical exams Provide family counseling Tube feedings Irrigations Perform dental services Conduct alcohol and drug screenings Health component of Individualized Family Service Plan (IFSP) Administer or monitor oxygen Provide alcohol and drug treatment Provide physicals, other primary health care services for school employees Provide prenatal care Collect and test blood samples Throat cultures Provide prenatal testing Other 40.2 35.7 33.4 33.3 33.1 31.8 28.1 25.3 24.3 23.9 21.4 20.7 16.3 14.4 10.4 9.3 6.6 4.6 16.6 SOURCE: From Davis et al., 1995.
|
From page 157... ...
The school must also provide services to non-special education students with chronic health problems such as asthma, diabetes, and seizures in order that they can be educated. Schools have little or no choice in providing such services, for they are dictated either by legislative mandate or by precautions pertaining to risks and liability.
|
From page 158... ...
Given the above needs and benefits, a basic health services program must be in place in all schools. The issues currently generating much discussion and debate, however, are the role of the school in providing access to primary care, the appropriate lead agency for the more traditional basic school health services, the advantages and disadvantages of a population-focused versus a high-risk approach to the delivery of health services in schools, and the need to develop an integrated system of school health services.
|
From page 159... ...
For example, preventable hospitalizations for pneumonia, asthma, and ear, nose, and throat infections are up to four times higher for poor children than for who are not poor children (Center for Health Economics Research, 1993~. Poor children are also more likely to be limited in school or play activities by chronic health problems and to suffer more severe consequences than their more affluent peers when afflicted by the same illness (Newacheck et al., 1995~.
|
From page 160... ...
Although progress has been made in establishing publicly financed community health centers in inner cities and rural areas, school-age youth rarely visit these facilities until their health problems reach crisis stage. Although Medicaid is intended to provide services for poor children, variations in state Medicaid policies have left almost 40 percent of children who live in poverty without access to basic primary and preventive care (Solloway and Budetti, 1995~.
|
From page 161... ...
The committee has not attempted to assess the professional standards, recommended student-professional ratios, or other issues in this section for validity or adequacy; instead, this section is intended simply to transmit the contributed information. For further details, the professional organizations can be contacted directly.3 Participants in the panel discussion on services at the committee s third meeting included representatives from the National Association of School Nurses, American Acad
|
From page 162... ...
The school nurse typically provides population-based primary prevention and health care services, including · physical and mental health assessment and referral for care; · development and implementation of health care plans for students with special health care needs; · health counseling; · mandated screenings, such as vision, hearing, and immunization status; · monitoring the presence of infectious conditions among students and enforcing public health precautions to prevent spread of infections and infestations; · skilled nursing services for students with complex health care needs; needs; sonnet; · case management of students with chronic and special health care · outreach to students and their families; · interpretation of the health care needs of students to school per · development and implementation of emergency care plans and provision of emergency care and first aid; · serving as liaison for the school, parents, and community health agencies; · collaboration with other school professionals particularly counselors, psychologists, and social workers to address the health, developmental, and educational needs of students; and emy of Pediatrics, National Association of School Psychologists, American School Counselor Association, National Association of Social Workers, and American School Food Service Association.
|
From page 163... ...
The National Association of School Nurses recommends a ratio of one school nurse per 750 students. In recent years, there has been interest in expanding the school nursing function through the use of nurse practitioners, nurses with additional training (generally at the master's level)
|
From page 164... ...
The emergence of the nurse practitioner role has broadened the possible functions of school nurses. However, budget constraints have led to the elimination of school nursing in some school districts.
|
From page 165... ...
Finally, of special concern to school nurses is the tailoring of school health services to local community needs through the formation of school or community planning councils and the use of needs assessments to guide planning efforts. These concerns and other priority issues were the topic of an invitational conference on school nursing in 1994, which called for more appropriate and greater access to educational opportunities for school nurses, the support of additional outcomes-based research, and the need for further policy development regarding the role of the school nurse in supervising unlicensed assistive personnel in the care of students (National Nursing Coalition for School Health, 1995~.
|
From page 166... ...
As described in Chapter 2, physicians have been active in school health programs to varying degrees since the mid-nineteenth century. The boundaries between private medical practice and school health programs, which arose during the period of the National Education Association-American Medical Association alliance from the 1920s to the 1960s, are now beginning to disappear, and schools are receiving increased attention as strategic sites for health promotion and access points for primary care.
|
From page 167... ...
A 1992 survey of 87 school districts selected as exemplary models for school health programs, conducted by the National School Boards Association, revealed that about one-half provided some type of dental services (Poehlman and Manager, 1992~. A follow-up survey (with a 35 percent response rate)
|
From page 168... ...
Congress annually appropriates funds to help state and local education agencies carry out this mandate, but many of the costs for special education services must be financed from state and local government revenues. Examples of professionals providing these specialized services, in addition to school nurses, consulting physicians, and dietitians include the following: · Physical therapists emphasize the remediation of, or compensation for, mobility, gait, muscle strength, and postural deficits.
|
From page 169... ...
There is considerable overlap and collaboration among these fields, with their mutual emphasis on maximizing students' potential and addressing students' academic, psychological, and social problems. School psychologists tend to focus on special learning and behavior problems, school counselors on academic and career-related guidance, and school social workers on family and community factors that influence learning.
|
From page 170... ...
School psychological services are one of the related services designated by the Individuals with Disabilities Education Act to be available to students with disabilities who are in need of special education. School psychologists also work with other targeted school-related groups, such as Head Start.
|
From page 171... ...
School counselors typically advise students in course selections, career options, college application procedures, and school-to-work programs. School counselors are increasingly called upon to work on interdisciplinary teams with school nurses, psychologists, social workers, and other school staff.
|
From page 172... ...
Social workers regularly deal with discipline and attendance problems, child abuse and neglect, divorce and family separation, substance abuse, and issues involving pregnancy and parenting, suicide, and even family finances. Services provided by school social workers include the following: .
|
From page 173... ...
Coordination of social work services provided by outside community agencies with those provided by the school is an important matter. School social workers believe they are better attuned to address situations involving the educational goals of the schools, since they are located within the system.
|
From page 174... ...
School food and nutrition services vary significantly from school to school depending on the perceived needs, resources, and priorities of schools and communities. School food- and nutrition services can be categorized as follows: · federally supported, nonprofit school lunches, breakfasts, and snacks, including those for students with special health care needs; · for-profit food programs, including snack bars, school stores, vending machines, a la carte items sold in school cafeterias, and special functions for students or staff; · nutrition education activities integrated with classroom instruc tion;
|
From page 175... ...
In announcing its "Healthy Kids: Nutrition Objectives for School Meals" initiative in June 1994, the USDA stated that the National School Lunch Program is available in 95 percent of public schools, which are attended by 97 percent of public school children, and that about 59 percent of all public school children participate (USDA, 1994~.
|
From page 176... ...
These are sometimes operated by the school nutrition and foodservice department but are most often operated by the school principal or a school organization designated by the principal. Foods sold outside the reimbursable school lunch and school breakfast are not subject to USDA nutrition standards, with the exception that no carbonated beverages, water ices, hard candies, or chewing gum may be sold in the foodservice area (USDA, 1986~.
|
From page 177... ...
When the National School Lunch Act was passed in 1946 and school foodservice and nutrition emerged as a profession, dietitians and home economists were the early leaders (Frank et al., 1987~. At the present time, USDA has no specific requirements for school foodservice and nutrition program directors or managers.
|
From page 178... ...
Prior to the issuing of the USDA's recommendations, the School Nutrition Dietary Assessment study found that in 44 percent of school lunch programs, students had at least one menu option with no more than 30 percent of its calories from fat, but in only 1 percent of schools did all available school lunch menus have this low fat level. Many intervention studies have focused on environmental changes and have shown promising results in lowering the fat content of meals
|
From page 179... ...
Policy decisions are important to maximizing program influence on current and future eating behaviors of students. Among the policies that local schools and communities must address in order to achieve a school nutrition and foodservice program that meets national goals are those that relate not only to nutrition standards but also to consideration of student preferences, purchasing practices, production methods, professional development of school nutrition staff, team building for school staff and community members, development of eating environments that provide optimum time, space, support for healthful choices, positive supervision, and role modeling (American School Food Service Association, 1994~.
|
From page 180... ...
The degree to which students' nutritional intake and lifelong eating behaviors are influenced by this environment and by the local, state, and federal policies that impact the environment merits further study. Policies that promote universal access to healthful meals are widely viewed as important to the health of children and youth (American Dietetic Association et al., 1995; National Health Education Consortium, 1993; Nestle, 1992~.
|
From page 181... ...
Increased understanding by school administrators and other community leaders of the relationship between the school nutrition and foodservice program and children's health and education will lead schools and communities to establish expectations consistent with community values and resources and to implement policies that maximize outcomes. EXTENDED SERVICES The term "extended services" is used here to refer to the rapidly growing area of services that go beyond traditional basic school health services.
|
From page 182... ...
An SBHC consists of one or more rooms within a school building or on the property of the school that are designated as a place where students can go to receive primary health services. An SBHC is more than a school nursing station; students can receive on-site diagnosis and treatment services from one or more members of an interdisciplinary team of clinicians that may include physicians, nurse practitioners, nurses, social workers, health aides, and similar professionals.
|
From page 183... ...
The National Health and Education Consortium has prepared a report providing information about SBHCs at the elementary school level (Shearer and Holschneider, 1995) and a primer for commu nity health professionals to use in establishing elementary school-linked health centers (Shearer, 1995~.
|
From page 184... ...
A network of school-based mental health programs has been organized by the School Mental Health Project of the Department of Psychology at the University of California in Los Angeles, which is working closely with the Center for School Mental Health Assistance being developed at the University of Maryland at Baltimore. These groups are establishing a national clearinghouse for school mental health that will provide continuing education, research, and technical assistance to enhance local school mental health programs and improve practitioner competence.
|
From page 185... ...
Many of the extended services discussed above are integrated into these efforts. Examples of services include family counseling, case management, substance abuse counseling, student assistance, parenting education, before- and after-school activities, youth programs, health care, and career training.
|
From page 186... ...
. Regional Approaches for Small School Districts Approximately 85 percent of local school districts receive assistance from regional cooperative agencies, thereby allowing them to pool resources for health services, staff development, care of students with special needs, purchase of supplies, and technical assistance.
|
From page 187... ...
However, as increasing numbers of students have come to school in need of primary care and/or with special health needs that require clinical nursing care, the importance of closer links to the established community health system, both private and public, has become more apparent. For example, at least 40 percent of respondents to a survey involving supervisors of school nurses reported that they had no clinical preparation in the delivery of health services although they were expected to supervise complex nursing care, including tracheal suctioning, administration of medications, nasogastric tube feedings, and dressing changes (Igoe and Campos, l991~.
|
From page 188... ...
Another organization and workforce issue concerns the need for integrated school health services in which nurse, social worker, foodservice personnel, and others work together collaboratively as a team. Linked to this issue is the continuing evidence that well-prepared school health assistants paired with school nurses can, under supervision, manage basic services, which frees up nurses for more complex care and responsibilities befitting their preparation (Fryer and Igoe, 1996; Russo et al., 1982~.
|
From page 189... ...
(1974) explored the outcomes in situations in which students were empowered to become active participants in their own care during encounters with school nurses.
|
From page 190... ...
A more complete discussion of selected findings from these initiatives is found in the background paper in Appendix D Much of the research has focused on school-based health centers.
|
From page 191... ...
In a study in Delaware, frequent users (three or more times) of school wellness centers were more likely than nonusers to report having engaged in such high-risk behaviors as suicide attempts, substance abuse, unprotected sexual activity, and eating-related purging (National Adolescent Health Resource Center, 1993~.
|
From page 192... ...
One-fourth of the youths stated that their parents had not completed high school, and another one-third of the students said their parents had no post-secondary education. One in five families was on welfare, and onethird received free or reduced-price school lunches.
|
From page 193... ...
School-Based Adolescent Health Care Program showed that although SBHCs provided access to care and increased students' health knowledge significantly, no reduction in highrisk behaviors could be measured (Kisker et al., 1994b)
|
From page 196... ...
The ratios of savings to costs ranged from $1.38 to $2.00 in savings per $1.00 in costs, suggesting that the school clinic services were a good investment. Potential Strengths and Weaknesses of School-Based Health Centers The Johns Hopkins University Child and Adolescent Health Policy Center has recently published a report that analyzes the existing research on SBHCs and summarizes their strengths and weaknesses in improving access to primary care for adolescents (Santelli et al., 1995~.
|
From page 197... ...
Little research has evaluated the adequacy and quality of the apparently wide range of services provided against the actual needs of the populations served. The scope of provided services is largely a function of funding.
|
From page 198... ...
What are the implications of an SBHC for health programs and health services personnel already at the school? Studying the impacts and outcomes of SBHCs will be a long-term process.
|
From page 199... ...
Florida enacted the Funding for School Health Services Act in 1990. This legislation provides funds for joint projects between county public health units and local school districts, particularly in areas where there is
|
From page 200... ...
! Data Collection and Management Capabilities Demographics Student and parent demographics Usual source of acute, primary, and emergency care Visit Statistics Type of service provided Diagnoses and procedure codes Laboratory tests Morbidity data Prescriptions and other treatments Follow-up and referral dates and comments Productivity Provider mix Complexity of user mix Provider time Follow-up or referral tracking Tickler system for follow-up Referral tracking and completion rates Billing HCFA, Medicaid, private insurance billing Sliding scale and fixed fee Accounting modules Medical Case Management Detailed problem-specific interdisciplinary tracking and follow-up Clinical status and outcome assessment Follow-up prioritization Problem List Active, inactive, and resolved problems and status for problem resolution Health Screening User-defined health screening criteria Reports of normal, abnormal, and follow-up Immunizations Automated immunization capture and documentation Report of recommended and delinquent immunizations Clinical Information Measurements: height, weight, blood pressure Past medical history, allergies Medications prescribed Other treatments Utilities Imports and exports User-defined variables Research statistical package interface Health Education Individual and group health Education interventions NOTE: HCFA = Health Care Financing Administration.
|
From page 201... ...
SCHOOL HEALTH SERVICES 201 Ger~eralized School Health Services Programs Basic services: Health education Nutrition Detection or screenings Prevention Minor health maintenance Intermediate School Health Services Programs Include generalized services and expanded screening services Assessment and management of acute, chronic, and special health care needs On-site immunizations Individual and group counseling and self-care sessions Violence reduction and environmental health activities Primary Health Care Service Programs Include generalized and intermediate services and assessments, diagnostic and treatment services Referrals for specialized services Behavior management programs Day treatment Integration of primary health services into school and community activities FIGURE 4-1 Missouri School Children's Health Services Model Programs Schematic. SOURCE: Missouri School Children's Health Services Committee, 1993.
|
From page 203... ...
A basic health care program for an elementary, middle, and high school feeder system, with trained school health aides in each school, a full-time nurse to supervise the aides in the elementary and middle schools, and one full-time nurse in the high school emphasis is on screenings, assessment, record reviews, and coordinating health services for students with parents or guardians and other agencies in the community.
|
From page 204... ...
Emphasis is on health, behavioral, and learning problems, with referrals made to community providers for serious problems or extended services, such as drug or alcohol abuse and STD treatment.
|
From page 205... ...
Electronic storage and transmission systems raise additional questions about the privacy of student health records and about sharing of information among individual schools, school districts, public health departments, social service agencies, and individual health care providers from both the public and the private sectors. New questions have also emerged since school systems have been authorized to bill Medicaid and private insurers.
|
From page 206... ...
If health records stored at school and health records compiled by outside health care professionals providing school services have the same high level of access as educational records, the privacy of families and adolescents may be compromised. The committee therefore believes that when state law eliminates the parental consent requirement for making specified counseling and treatment accessible to students, access to related medical records at school needs to be held to the same standards of confidentiality observed in other health care settings in communities in that state.
|
From page 207... ...
Department of Health and Human Services (DHHS) ; drug use can be addressed with funds from the Safe and Drug-Free Schools and Communities Act; and model comprehensive school health programs that may include health services may be supported by grants from the U.S.
|
From page 208... ...
Numerous private foundations offer grants to study specific health problems of the school-age population or to provide health services for students. The grants may be given directly to school systems, public health systems, private health care agencies, colleges, universities, academic health centers, or a combination of agencies.
|
From page 209... ...
As required in federal law, all state Medicaid programs cover hospitalization, physician services, laboratory and x-ray services, family planning, and Early Periodic Screening, Diagnostic, and Treatment services for children under the age of 21. In addition to the option of extending coverage to families above the poverty level, states can also provide such other services as prescribed drugs, dental services, inpatient psychiatric care, case management, and transportation.
|
From page 210... ...
As mentioned earlier in this chapter, between one-fifth and onesixth of children under 18 have no health insurance. Nearly two-thirds of these children live in families with incomes above the federal poverty level, making some of them ineligible for government-sponsored health programs.
|
From page 211... ...
The National School Lunch Program is used as a method to verify family income for insurance premium subsidy. Subsidized premiums are based on family income so that families with incomes below 100 percent of the federal poverty level receive fully subsidized premiums; those with incomes between 101 and 135 percent of the poverty level pay $2.50 per child per month; those between 136 percent and 185 percent of the poverty level pay $13 per child per month; and those at 186 percent of the poverty level or above pay the full premium of $46 per child per month.
|
From page 212... ...
Financing for School-Based Health Centers Several recent reports have analyzed financial issues associated with school-based health centers (Brellochs and Fothergill, 1993; Perino and Brindis, 1994; Schlitt et al., 1994; U.S. Department of Health and Human Services, 1993a; U.S.
|
From page 213... ...
Also, many of the services provided by SBHCs, such as mental health counseling or behavior modification aimed at preventing teen pregnancy or AIDS (Acquired Immunodeficiency Syndrome) , have not been reimbursable medical procedures.
|
From page 214... ...
Initially, this legislation contained provisions for funding, but federal funding currently covers less than 10 percent of costs for mandated special education services. Since school districts continue to be mandated to provide these services, most costs are paid out of education funds; this is sometimes called the "encroachment" of special education costs into the general education budget.
|
From page 215... ...
Differentiating health services from educational services is often difficult when a student's health status is interwoven with the necessity for costly and individualized educational services. Both the consolidation of existing health professional staff into a nonprofit corporate unit for contracting services and the negotiation of schoolbased health services delivery through managed care organizations could enhance revenues to school districts, first by offsetting the cost of currently employed health professional services by selling those services to managed care organizations and second by having the cost of schoolbased clinics borne by managed care organizations rather than schools.
|
From page 216... ...
In addition, excise taxes are not as broad and progressive as the system-wide health contribution described in options 1 and 2. FIRST STEPS FOR A COMMUNITY IN ESTABLISHING SCHOOL SERVICES In this section, the committee uses the American Academy of Pediatric's seven "goals" for school health programs, listed at the beginning of this chapter and repeated below, to organize the discussion of specific questions and actions that a community might consider in establishing an appropriate set of school health services within a comprehensive school health program.
|
From page 217... ...
. The National Adolescent Health Resource center of the university of Minnesota, sponsored by the Maternal and Child Health Bureau of the u.s.
|
From page 218... ...
report Emergency Medical Services for Children (IOM, 1993) calls for teachers, coaches, and day care workers, along with parents, to receive the highest 8The survey, A Closer Look, found that exchange of information between school and community providers was inadequate; one out of five referrals from school health personnel failed to produce any response or feedback from the community provider.
|
From page 219... ...
5. How are community providers of emergency medical care services involved in education and training of school-based health personnel and other school staff?
|
From page 221... ...
4. Do other sources private health care, health fairs duplicate school screening efforts?
|
From page 222... ...
In many communities, certain GAPS-recommended procedures might be adapted to local needs and carried out more efficiently by appropriately trained school-based personnel school nurses and nurse practitioners, physicians assistants, school counselors and psychologistsin the school setting. At the time of writing this report, the American School Health Association is working with the American Medical Asso
|
From page 223... ...
What steps have been taken to adapt GAPS to the local community? Provide Comprehensive and Appropriate Health Education Health services personnel can be involved in classroom health education, both in developing the instructional program and perhaps in delivering classroom lessons.
|
From page 224... ...
3. How are health and mental health services personnel involved in the classroom instructional program and in individual and group health education?
|
From page 225... ...
Schools are also required to provide a wide range of health services for students with disabilities and special health care needs. There is agreement that a core set of services is needed in schools, but the topic currently generating a great deal of discussion is the role of the school in providing access to extended services that go beyond traditional basic services, such as primary care, social, and family services.
|
From page 226... ...
The committee also believes that the school foodservice should serve as a learning laboratory for developing healthful eating habits and should not be driven by profit-making or forced to compete with other food options in school that may undermine nutrition goals. Many questions remain unanswered about school services, particularly questions regarding the relative advantages, disadvantages, quality, and effectiveness of providing extended services at the school rather than at other sites in the community.
|
From page 227... ...
1990. Final Report: Study of Income Verification in the National School Lunch Program.
|
From page 228... ...
1995. Joint position of American Dietetic Association, Society for Nutrition Education, and American School Food Service Association: School-based nutrition programs and services.
|
From page 229... ...
1981. The Robert Wood Johnson Foundation National School Health Program: A presentation and progress report.
|
From page 230... ...
1996. Functions of school nurses and health assistants in U.S.
|
From page 231... ...
1994a. Healthy Caring: Outcomes of the Robert Wood Johnson Foundations's School-Based Adolescent Health Care Program.
|
From page 232... ...
1964. An appraisal of the amount of time spent on functions by Los Angeles city school nurses.
|
From page 233... ...
1979. Increasing role effectiveness of school nurses.
|
From page 234... ...
Scarborough, Maine: National Association for School Nurses. Ratchick, I
|
From page 235... ...
School Food Service Research Review 17~2~:103-108. Snyder, M., Obarzanek, E., Montgomery, D., Feldman, H., Nicklas, T., Raizman, D., Rupp J., Bibelow, C., and Lakatos, E
|
From page 236... ...
1993b. Food Assistance: Schools That Left the National School Lunch Program.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.