Articles

A Community Pediatric Prevention Partnership: Linking Schools, Providers, and Tertiary Care Services Kim Crickmore Farrior, Martha Keehner Engelke, Catherine Shoup Collins, Carol Gordon Cox

ABSTRACT: Integrated school health services traditionally have been provided through the local board of education or health department. However, increased competitiveness in the health care arena has challenged providers to find innovative models to deliver health services to school-aged children. This article describes a partnership among a hospital, a university, private providers, and a local school system and health department to provide school health services. Noteworthy aspects of the project include the organizational structure and funding of the program, implementation of a case management model, and a focus on documenting outcomes. This program has been successful in building local alliances to provide health care services to school children. Implications for other school systems struggling to fund health services for school-aged children are discussed. (J Sch Health. 2000;70(3):79-83)

hen Lillian Wald began the first school health W program in 1902 for New York City children, she began a movement that spread through the country. Though periods of regression occurred, such as the 1970s and 1980s when increasing economic uncertainty and rising costs led to a reduction in school health programs, the general trend has been toward an increasing role for school systems in promoting and protecting children’s health.’

Recognizing the important role schools play in promot- ing child health, the American Academy of Pediatrics recommended seven goals for a school health program:2 assure access to primary health care; provide a system for dealing with crisis medical situations; provide mandated screening and immunization monitoring; provide a system for identification and solution of student health and educa- tional problems; provide comprehensive and appropriate health education; provide for a healthful and safe school environment; and provide a system for evaluating effective- ness of the school health program. Though these goals are admirable, achieving them has proven difficult for many school systems and physicians.

In the past, differences between the health care system and educational system posed a barrier to meaningful dialogue among private providers, hospitals, and school health personnel. School systems focused on the needs of all children, but in the traditional fee-for-service health care system only a small portion of school-aged children received regular, sustained services. These children often had chronic health problems that required ongoing manage- ment. In the fee-for-service system, if a school nurse had a concern about a child her only option was to call the child’s physician. The treatment plan for a specific category of

Kim Crickmore Farrior, RN, MSN, Coordinator, Pediatric Prevention Programs; and Catherine Shoup Collins, BSN, CSN, Senior School Health Specinlist, University Health Systems; and Martha Keehner Engelke, RN, PhD, Professor, or <Engelkem@mail.ecu.edu>; and Carol Gordon Cox, RN, BSN, MS, M P H , C S N , Assistant Professor, East Carolina University School of Nursing, 216 Rivers Bldg., Greenville, NC 27858-4353. This article was submitted June 8, 1999, and revised and accepted for publication January 5, 2000.

patients, such as children with asthma, might vary widely between primary care providers.

Response time for the nurse was limited by lack of a standard protocol for handling common problems for chronically ill children. Physicians received few incentives to have school nurses manage these problems because in a fee-for-service system it was easier and generated more revenue to advise the nurse to “send the child to my office after school.” Likewise, no economic incentive existed to prevent hospitalization of chronically ill children since insurance companies paid for tertiary care. The traditional system did not result in the highest quality of life for the patient or the family, nor did it consider barriers that fami- lies might face in receiving care at a physician’s office such as transportation or finances.

In today’s managed care system, physicians are often clustered into umbrella organizations that offer incentives for reducing the cost of care. They are encouraged to adopt a standard of care for managing chronic problems such as asthma. Tarass suggests several reasons why physicians want to work with schools in managing children with chronic diseases. School systems maintain data that can assist physicians in developing more cost-effective treat- ment plans. For example, a student’s response to medica- tion changes can assist the physician in fine-tuning the medical management of chronically ill children and reduce their use of more expensive health care.

Managed care also increased the focus on primary and secondary prevention. School systems traditionally screen for common problems such as vision and hearing abnor- malities. However, with increased emphasis on containing costs, providers need to identify problems early at a point when they are amenable to less-expensive interventions. Altemeiei‘ suggests school systems have not begun to reach their potential in delivering preventive services. He suggests schools are ideally suited for prevention educa- tion. They cover all children, their primary mission involves education, and they already incorporate age-appropriate information about prevention in the cumculum.

Journal of School Health March 2000, Vol. 70, No. 3 79

Today’s challenge is how to deliver school health services such as chronic disease management and health promotion in a manner that achieves optimal, measurable outcomes. The advent of managed care resulted in a sensi- tivity to documenting outcomes of school health services in a way that has not existed. However, school systems often lack resources to provide data about health utilization and cost. Lack of such data puts them at a disadvantage in the managed care arena. If school health care providers can demonstrate that their services improve health outcomes, then their services are more likely to be included in contracts negotiated between managed-care organizations and providers5

Creative solutions are needed for school systems to become part of children’s health services. In particular, school systems in underserved areas must participate in coalitions with health care providers to offer a coordinated school health program. This paper describes a program developed by a tertiary care hospital, health care providers, and a school system to deliver health services to school- aged children. Noteworthy aspects of the project relate to organizational structure, implementation of a case manage- ment model for children with health and social problems, and development of an evaluation plan that documents outcomes for students, the school, and the tertiary care facility.

THE COLLABORATIVE MODEL FOR SCHOOL HEALTH:

ORIGINS AND ORGANIZATION The Collaborative Model for School Health6 was devel-

oped in a rural county in the Southeast. For several years the school system and the public health department strug- gled to fund the school health program. Limited funds and pressing needs for more school buildings, more school teachers, and more direct services to residents with acute health and social problems such as AIDS and unintended pregnancy led to chronic underfunding of the school health program. In 1995, funds for the school health program were eliminated from the health department budget.

Subsequently, representatives of the school system, health department, a university-based nursing school, and private providers entered into discussions with the hospital that served the community to explore the possibility of having the hospital fund the school health program.

Background University Health Systems of Eastern North Carolina

includes Pitt County Memorial Hospital (PCMH), a 731- bed tertiary care center. The hospital has a Department of Community Health dedicated to fostering collaborative projects to improve the health of residents in the region.

There were many reasons for PCMH to become involved in the school health program at this time. In particular, the lack of school health services contributed to inappropriate use of the hospital. Children with chronic illnesses such as asthma and diabetes were being seen in the emergency department and admitted to the hospital for acute exacerba- tions of illnesses that could be prevented. These repetitive admissions were no longer cost-effective for the hospital, particularly when the repetitive admissions for a child might occur at frequent intervals. The school system was

eager for the hospital to assume oversight of the school health program since they saw their primary mission as education rather than health care. The hospital administra- tion petitioned the board of trustees to fund six nurses for the elementary schools in the county. Later, the program was expanded to the middle schools through a grant from the Duke Endowment. Next, an event occurred that led to long-term funding of the school health program. The hospital administration petitioned the county to change its status from a publicly-owned county facility to a private non-profit institution. This would give the hospital more flexibility in contract negotiations with managed care companies and other external groups. Several county commissioners were ardent supporters of the school health program. As a part of the transfer agreement, the hospital agreed to continue to fund the school health program indef- initely as a part of its commitment to maintaining a high level of community service.

Initial development of the school health program was facilitated by the director of the hospital’s Department of Community Health Programs. A steering committee was formed to provide guidance on policies and procedures. The committee included providers such as pediatricians in the community and at the medical school, community lead- ers involved in care of the pediatric population at school, the health department, and other health service agencies.

Pilot Project The school health program began as a pilot project in

January 1996 with five objectives: design and implement a

Figure 1 Organization of Community

Pediatric Prevention Services

I Community Pediatric Prevention

I 1 1 I I

-7-1’ I

r - - - - - l I I - Senior School Immunization

Health Specialist Initiative

1 11 School 1 1 Case 1 1 Adolescent 1 Health Specialists Managers Risk Reduction

1 Telemedicine 1

80 Journal of School Health March 2000, Vol. 70, No. 3

comprehensive health program in 19 county elementary schools; establish interagency collaboration among the hospital, school system, and health care providers and resources in the county; establish a baseline for evaluation to document the health status of K-5 children attending county schools; reduce school absenteeism caused by pedi- atric asthma, ADHD, and diabetes; and reduce inappropri- ate use of the health care system.

During the first six months, the project coordinator, the program consultant from the school of nursing, and the school health coordinator met to establish specific assign- ments for the school nurses, goals for staff orientation and training, development of policies and procedures, and data- base content and management. Activities moved quickly during this phase. The normal period for planning was condensed and occurred simultaneously with implementa- tion as the group struggled to get the program operating before the end of the school year. Long hours and heavy work schedules were the norm during the initial phase. When the school year ended, staff used the summer months to refine policies and procedures and to provide further training to staff so the program could continue and expand during the next academic year.

The pilot project demonstrated that health services to school-aged children were needed and valued by students, families, and teachers. The program affected 25% of the K- 5 population. Primary prevention services included facili- tating administration of immunizations and health teaching through group sessions and healthhafety fairs. Secondary prevention services included vision and scoliosis screening as well as staff consultations and development and imple- mentation of a manual for medication administration. Tertiary preventive services were provided to children with chronic illnesses and special needs. School nurses became involved in developing and implementing Individual

Education Plans (IEP), Individual Health Plans (IHP), and Emergency Action Plans (EAP).

After the pilot, the program was evaluated and strategies for the future were identified. Three important considera- tions emerged for expanding the program. First, a need existed to focus on more specific outcome measures that documented both quality and cost. Outcomes during the pilot phase relied heavily on evaluating how satisfied school personnel, students, and families felt about the services provided. This outcome was important during the initiation phase as the staff sought to stabilize the program within the school system. However, if the program was to grow, staff needed to identify the desired program outcomes for the children, school, and hospital.

Second, a need existed to focus more time and resources on children with chronic illnesses, so a more realistic plan for secondary prevention, particularly screening services, was developed. Instead of providing direct vision screening to students, school nurses needed to focus on training volunteers or enlisting student nurses to complete the initial screening. School nurses then could become a back-up for identified problems. This approach would allow school nurses to focus time on services for chronically ill children.

Third, a need existed to expand services to other rural counties served by the hospital and to expand the program to middle schools. With the goal in mind a master’s- prepared nurse was hired to oversee expansion of the project. The leadership team developed four new objectives to guide the expansion: link children with health care resources for preventive care, and reduce inappropriate use of the health care system; reduce absences among children with chronic illness; improve the health status of students in grades K-8 through primary, secondary, and tertiary preven- tion strategies; and expand the school health program to a neighboring county.

Figure 2 Case Management Model

Referral for Service

I Initial Interview I Assessment

I Determination of Resource Intensity I Needs J I

Complex Intermediate Non-acute co-morbid conditions co-morbid conditions Stable medical psychosocial issues no major psychosocial problems and social

frequent exacerbations no repetitive medical needs situation

Enroll in Program Develop Action Plan Minimal Services

Comprehensive assessment Individualized care plan

Care coordination Reassessment/ monitoring Evaluation of outcomes

Re-evaluate at three, six and nine month Close case at one year if stable

Enroll in program if needed

Initial education Referral to other sources

Journal of School Health March 2000, Vol. 70, No. 3 81

To achieve these objectives, a need existed to explore avenues for external support. Using data from the pilot project that demonstrated the quality of services provided, the leadership team successfully obtained support from the Duke Endowment. This funding allowed for expanding health services to middle schools and to a neighboring rural county. Figure 1 contains the current organizational struc- ture for the pediatric prevention model.

A CASE MANAGEMENT MODEL A major challenge for school health programs involves

developing plans of care for children with chronic disease. The National Association of School Nurses (NASN)’ proposed that the role of case manager be intrinsic to school health services. Specific skills needed by school- based case managers include knowledge of available services; experience in collaboration of service plans; skills to assure continuity of services; ability to help students and families understand, select, and obtain services; and exper- tise to evaluate outcomes. School nurses are logical choices for this role. However, it is unrealistic for school nurses to serve as case managers for all children with chronic disease. A case management model must be developed that focuses on providing services to children with the greatest need.

The school nurses adopted a case management model developed by the pediatric asthma program at PCMH (Figure 2). Children are referred for case management services by school personnel, parents, or a physician. The hospital discharge planner also makes referrals for school- aged children with needs after hospitalization. Any child who misses more than 10 days of school receives an auto- matic referral.

Children with complex health needs often have complex social and educational needs. They may have an established relationship with a guidance counselor or a social worker. Interventions by the school nurse should complement rather than compete with other school personnel so the family will not feel overburdened. To prevent duplication of services, each school has a communication log with names of active caseloads for the nurse, social worker, and guidance coun- selor. The log led to a coordinated approach in which fami- lies do not become overwhelmed with too many providers, and the school nurse can provide case management services to children truly in need.

One issue that arises with case-managed children involves integrating case-management services with medical management. Physician response to the school nurse program was positive, and physician referrals continue to increase because school nurses provide consis- tent feedback to the child’s physician. A computerized progress note that includes problems identified and an update on the child’s progress is faxed to the physician every three months. Frequent telephone contact also is maintained and, if needed, the nurse may accompany the child to a physician visit.

As nurses became more involved in schools, a signifi- cant level of morbidity was detected among school person- nel including teachers, assistants, secretaries, and housekeepers. Diabetes, hypertension, and other chronic health problems were common concerns. School nurses suggested that wellness contracts be developed to assist personnel in health promoting behaviors. Data are being

collected to confirm the need for a wellness program for staff at public schools in the two counties.

DEVELOPING AN EVALUATION PLAN The American School Health Association and the

National Association of School Nurses8 have recommended evaluating school health services. These two groups estab- lished a priority rating of issues to be systematically evalu- ated, including the need to document the effect of school nursing services on attendance, student achievement, dropout rates, school behavior, safety, and absenteeism. Determining what services are valued by parents, adminis- trators, and teachers also is critical. Further, there is a need to determine what services the nurse provides and what impact these services have on student health.

At the onset of the project, it was recognized that the development of an evaluation plan would be essential to ensure the success of the program and secure future fund- ing. Therefore, a data analyst was hired. The data analyst has experience in spreadsheet and statistical software and helps with preparation of evaluation reports as well as monitoring of ongoing data collection.

The evaluation plan documented the effect of the program on health care utilization, student health and qual- ity of life, and value of the program to school health personnel and families. Health care utilization is docu- mented through linkages with other providers. Since the school nurses are actually hospital employees, access to hospital and emergency department is more accessible than if they were county employees. Charges for inpatient admissions and emergency department visits are tracked for case-managed children. Case management services offered by school nurses reduced hospital and emergency depart- ment utilization for several children with chronic illness.

Quality of life for students is monitored through school- based measures. The Student Health Profile, a form completed for all children, includes information on chronic health conditions, health insurance, medications, and peri- odic health exams. Responses are entered into the Student Information Management System maintained by the school system. These data for all children are useful in evaluating activities of the school nurses in relation to the total student body profile.

As part of the evaluation plan, a database on client outcomes is used when students receive services. The nurs- ing outcomes classification (NOC) identifies outcomes along a continuum, and each outcome includes an associ- ated group of indicators to determine that outcome. This system allows evaluation of specific outcomes and quanti- fies types of interventions provided by the nurse. Of chil- dren referred to the nurse during the 1998-1999 school year, 863 children (87%) demonstrated improvement in health status, 1 12 children (1 1%) maintained their health status, and 18 children (2%) showed a slight decline in health status. The leading nursing diagnoses were altered health maintenance, health seeking behaviors, impaired skin integrity, ineffective breathing pattern, and ineffective airway clearance.

To evaluate program impact on the school system, administrators, teachers, counselors, special education teachers, social workers, and psychologists are surveyed annually. Last year, the survey documented a need for additional school health services. Teachers and counselors

82 Journal of School Health March 2000, Vol. 70, No. 3

encouraged expanding school health services to include more children, and they wanted increased contact time between staff and students. In particular, school personnel recognized the nurse’s importance in consultation and plan- ning to meet the needs of chronically ill children.

FUTURE ACTIVITIES The Community Pediatric Prevention Program

embarked on a new initiative this year by partnering with an affiliated home health care agency that provides tele- homecare. Funding from the Children’s Miracle Telethon provided resources to begin a teleschool project in the county school system. A telemedicine unit is placed in the school and children can be seen by the nurse located in the home care agency. This agency has extensive experience with telehomecare and has found it to be both cost-effective and valued by patients and families.

School units are used for physical exams, medication monitoring, and patient education. Operation is simple and easily can be completed by the child or school personnel. Using this equipment provides an opportunity to maximize school health resources. In this rural area, any technology that reduces travel time can increase effectiveness of care. The first children enrolled in the teleschool program had chronic problems, and they are seen by the nurse on a planned schedule. Over time, staff hopes to extend the program to all children with health concerns that do not require “hands-on” care.

A report from the Institute of Medicine’ suggested that, for school health programs to reach their potential,

concerted action and departure from “business as usual” will be needed. A coordinated effort among major stake- holders is essential to ensure that schools provide a coordi- nated school health program. Rather than asking individual schools to do more, hospitals, providers, and affiliated agencies need to take advantage of the key role that schools can play in promoting the health of children.

References 1. Pigg RM. The school health program: historical perspectives and

future prospects. In: Wallace HM, Patrick K, Parcel GS, Igoe JB, eds. Principles and Practices of Student Health Volume 11. Oakland, Calif: Third Party Publishing Co; 1992;247-261.

2. American Academy of Pediatrics. School Health: Policy and Practice. 5th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1993.

3. Taras HL. Managed health care and school health. Pediarr Ann. 1997;26( 12):733-736.

4 . Altemeier W. Does school health have a place in this era of managed care? Pediatr Ann. 1997;26( 12):7 14-716.

5. Gaffrey EA, Bergren MD. School health services and managed care: a unique partnership for child health. J Sch Nurs. 1998; 14(4):5-21.

6. Cox C. The Collaborative Model for School Health in Pitt County: Program Development and Evaluation. 1997.

7. National Association of School Nurses. Unpublished survey. Scarborough, Maine: National Association of School Nurses; 1997.

8. Bradley BJ. Establishing a research agenda for school nursing. JSch Nurs. 1998; 14( 1 ):4-13.

9. Institute of Medicine. School and Health: Our Nation’s Investment. Washington, DC: National Academy Press; 1997.

A S H A P A R T N E R S

These institutions and corporations have expressed their commitment to and support of coordinated school health programs by joining with the American School Health Association as an ASHA Partner.

Platinum Endowment Partner + + + +

Glaxo Dermatology, 53 Leonard St., 5th floor, New York, NY 1001 3 Kansas Health Foundation, 1845 Fairmount, Box 16, Wichita, Ks 67260-001 6 Merck 6r Co., Inc., 770 Sumneytown Pike, P.O. Box, West Point. PA 19486-0004 McGovern Fund for the Behavioral Sciences, 22 1 1 Norfolk, Suite 900, Houston, TX 77098-4044

Gold Endowment Partner + + Consumer Health Care Division of Pfizer, Inc., New York, NY 1001 7 Tampax Health Education, 1500 Front St., Yorktown Heights, NY 10598

Silver Endowment Partner + + + +

Center for Mental Health in Schools, University of California, Los Angeles. Box 95 1563, Los Angeles. CA 90095-1563 Dept. of Health Science Education, University of Florida, Gainesville, FL 3261 1 Midland Dairy Council, 10901 Lowell, #135, Overland Park, KS 66210 School Health Corporation, 865 Muirfield Drive, Hanover Park, IL 60103

Century Partner + + Health Wave, Inc. 1084 St., Stamford, CT 06907 William V. MacGill6r Co., 720 Annoreno Drive, Box 369, Addison, IL 60101

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Journal of School Health March 2000, Vol. 70, No. 3 83