Managed School Health Program

State: FL Type: Model Practice Year: 2006

Federal and state laws, coupled with increasing numbers and complexity of health conditions among school-aged children have created a demand for expanded capacity and a higher level of professional health services to meet this demand. Brevard County’s Managed School Health Program serves approximately 85,000 students, renders health assistance to over 3,600 children a day, and directly or indirectly addresses the needs of 15,700 total reported health conditions. The overall goal was to provide a safe and healthy school environment. Objectives included: safe medication administration, reduced numbers of students reporting illness, increased health interventions to support overall student and school performance, appropriate health protocols, and appropriate first aid and emergency responses. Managing resources by striking a balance between demand and level of care represents a true collaboration between the school district and health department. This successful and innovative school health program has enjoyed an ever-increasing demand for continued and expanded services every year. As a concept, rather than a concrete plan, it provides a flexible methodology and solution to providing quality school health services while maximizing available resources.
Brevard’s school children reflect national trends for chronic disease, numbers of daily medications and chronic disorders. In Brevard, 22 percent of school children report having some type of chronic health condition and 25 percent visit school clinics weekly. Within the last five years, the average number of medication doses per year within Brevard County schools has increased from 161 to 1280 and complex medical procedures have increased from 3,000 to over 27,000. About 2,075 students received care for intentional injuries and 200 medical calls to 911 were placed from schools in 2005. Additionally, parent consults on health issues have increased from 177,000 to 314,000 and education plans involving children with complex health care needs have increased from 108 to 617. The need for early interventions, prevention, and lifestyle modifications were, and still are, great. This program emulates NACCHO’s model for “Building Healthy Schools” by approaching the school district with respect for their educational agenda, beginning with a pilot program, gaining stakeholder support through positive outcomes, and expanding over time with the guidance of a community-based advisory board. It goes a step further, and beyond models based on ratios, by distributing responsibilities in a manner that assures autonomous, flexible, well-coordinated, and professional health care. CHD nurse managers are autonomous practitioners dedicated to health department guidelines and professional standards. They have full authority and accountability to provide managerial oversight and supervision of school-based health services and personnel. They address the needs of the whole child, provide a safe environment, provide health education, and implement programs to support healthy lifestyles that impact the entire community. They serve as a valuable and objective expert, advocate, and resource by working in collaboration with schools and recognizing and supporting the priorities of an educational agenda. Program leadership is provided by the two major stakeholders, the school board and the health department with the guidance of an advisory board. From partner to the provider levels, respect for adherence to professional standards and decision-making as well as clear and consistent policies have resulted in the cohesiveness and flexibility necessary to manage resources effectively and respond quickly and appropriately to unexpected challenges.
Agency Community RolesCommunity involvement has resulted in well-coordinated, safe, and effective school health services. Leadership and management responsibilities are shared between the health department and the school board. The advisory committee consists of local physicians, nurses, private schools, school board programs, health department programs, and health organizations such as mental health, and disability and diversity groups. This committee sets goals, evaluates programs, and recommends policy to the school board. Local colleges assist in annual health screenings. Specialized private and public programs include: teen health, school-based physicals, school-based nutritional counseling, dental health, physical and occupational therapy, vision /hearing screening and treatment, and referrals to Medicaid, insurance and social programs. Health organizations, such as the American Lung Association, Juvenile Diabetes Association, and American Heart Association, provide curriculum and school-based interventions to address specific risk factors. Together in Partnership and Community-based Care provide services in the areas of mental health, justice, and child protection. Special grants have provided for student referrals for mental health counseling. Volunteer nurses cover personnel shortages in exchange for license cost reimbursement and free continuing education credits.  Costs and ExpendituresFunding of this program is the shared responsibility of the school board and the health department through local, state, and federal funding sources and is supplemented through a variety grants, such those that address nutrition and physical activity, and mental health. In-kind hours, donated by local agencies, have increased from $1,223 to $13,244. Students receiving mental health interventions have increased from 42 to over 1200 in just the last year. Over the past five years, the School Board has approved increased funding of over $300,000 and has absorbed 70% of the total budget for school health services. This program demonstrates the power of community partnerships as it evolves and expands to create a network of health and wellness throughout the school system and community.  ImplementationTwo pilot projects resulted in overwhelming support for school-based health services and garnered the trust and respect necessary to build and solidify a partnership between the school board and the health department. Together they negotiated financial and oversight responsibilities and established agreements regarding program structure, management, and funding. School-based health personnel became employees of the health department, working in cooperation with schools. Nurse supervisors provide medical and managerial oversight to school-based personnel within geographic regions, typically consisting of 8-9 elementary schools, a middle school, and 1-2 high schools.The CHN Supervisor is a constant source of guidance, information, support, and supervision by phone, during scheduled visits or impromptu visits and audits. Off-site monitoring, reviews of medication administration and documentation, and continuous close contact with school administration also assures tight monitoring and compliance. The CHN supervisor is also a medical resource, an educator, and a student advocate by identifying and correcting health barriers to education and providing care plans for medically-complex children.
Goal: Provide a safe and healthy school environment.Objective: Safe medication administration: Performance measures: Missed medications, medication errors, and adverse events.  Data collection: Numbers of medications administered per day, numbers of medication errors, and numbers of adverse events.  Outcomes: Compared to national rates of medication errors of 5 per 100 among licensed professionals: 5 or less missed meds per month over 5 year period; 5 or less actual wrong doses – med errors – annually; Zero adverse events due to missed med or med error over 5 year period.  Objective: Reduced numbers of students reporting illness: Performance measures: Students reporting to school clinic with illness.  Data collection: School clinic visits per student collected by school-based health personnel, manually on paper forms.  Outcomes (long-term): Ear/nose/throat complaints to school clinic reduced (2,389 complaints from 2000-2001 vs. 1,503 complaints from 2003-2004); Scabies and lice complaints to school clinic reduced (3,724 from 2000-2001 vs. 2,046 from 2003-2004); Lowest rate of absenteeism among peer counties and one-half of the average for the state.  Objective: Increased health interventions to support student and school performance: Performance measures: Numbers of students receiving direct/indirect nurse intervention, advice, or assistance with education plan.  Data collection: Numbers of Individual Education Plans and other educational plans with nursing interventions to remove health barriers to education. Outcomes (short & long term): Educational plans, removing health barriers (108 from 2000-2001 vs. 615 from 2003-2004); Increase in student mental health interventions and referrals (42 from 2000-2001 vs. 1,200 from 2003-2004); Increase in health screenings (38,000 from 2000-2001 vs. 98,000 from 2003-2004); Placement of in-school nutritionist – overall steady decline in % children overweight by BMI; Sustained high rate of immunization (avg. 98%); Average lowest number of repeat births to teens for region. 
State and federal programs, grants associated with Healthy People objectives, and Medicaid reimbursement of health services also provide for financial sustainability. Careful evaluation of policies by an advisory board of community members provides equitable solutions for all parties and garners the respect and support of the public. Adding to public support has been the establishment of this infrastructure to provide a mechanism for disaster/hurricane response by establishing medical needs shelters within schools, staffed and managed by the school-based personnel. Thus, a dual-use of health care personnel is realized to the benefit the community. This program supports the concept of schools as a touchstone of health and wellness within the community without competing with private providers, as is the case with models utilizing school-based providers. Overall, this program has demonstrated sustainability and has proven to be a win-win partnership that can be replicated within any community.