Abstract
In 1993 the Massachusetts Department of Public Health (MDPH) began defining essential components of school health service programs, consistent with the public health model. The MDPH designed and funded the Enhanced School Health Service Programs to develop 4 core components of local school health services: (a) strengthening the administrative infrastructure; (b) promoting health education, including tobacco control activities; (c) linking school health services with health care providers; and (d) implementing management information systems. Funds were appropriated in 1992 from the tobacco excise tax. With additional funding appropriated in 1999 and 2000 from the Tobacco Settlement Fund, these school nurse–managed programs have increased in number. The goal is to develop a statewide system of high-quality school health service programs responsive to the specific needs of students in each community. To be effective, these programs must be recognized as essential components of the primary health care delivery system serving children.
Keywords
INTRODUCTION
As the demand for school health and school nursing services increases, so too does the need to define these services; their association with other components of a comprehensive health education program; and their relationship to community providers and other local agencies serving children, adolescents, and families. In 1993, the Massachusetts Department of Public Health (MDPH) had a unique opportunity to address these issues when the Commonwealth of Massachusetts increased the state tax on tobacco products by 25 cents. From the resultant revenues, $2 million was allocated for improvements in general school health services managed by professional school nurses. The MDPH designed and implemented the Enhanced School Health Service Program (ESHS) to develop four core functions of local school health services: (a) developing the administrative infrastructure to support high-quality services for children; (b) promoting health education, including tobacco control activities; (c) linking school health services with health care providers and public health insurance programs; and (d) implementing management information systems. The development of the ESHS model is ongoing, having received major support from the Massachusetts legislature through expanded funding of $6.5 million in fiscal year (FY) 2000 and a second additional allocation of $9.6 million in FY 2001. The source of these two increases was the Tobacco Settlement Fund. Currently the MDPH provides a total of $15.5 million annually to 109 school districts for implementation of the ESHS model.
BACKGROUND AND RATIONALE
School nursing has its roots in public health nursing and remains a public health specialty. In 1902, to address the issues of infectious disease in children and resultant high rates of absenteeism, Lillian Wald placed the first school nurse in the New York City schools (Wold, 2001). From these early beginnings in infection control, school nursing has developed into a comprehensive specialty with an array of prevention and treatment responsibilities. Over the past two decades several societal trends have had a profound effect on the demand for school health services:
As medical science and technology advanced, increasing numbers of children with special health care needs were mainstreamed into the public schools. Whereas many of these children may not have survived in previous decades, they are now supported by increasingly diverse and complex services, such as catheterizations and tracheostomy care, which enable them to thrive and be educated (Palfrey et al., 1992; Small et al., 1995). Increases in the number of working parents and in the number of single-parent and low-income households have resulted in more families relying on school nurses for initial assessment of a child’s illness or injury rather than losing time from employment to seek immediate medical attention (Uphold & Graham, 1993; U.S. Bureau of the Census, 2000; Wold, 2001). “Newcomer families” especially look to the school nurse for information on local health resources. Newcomers include families who have immigrated from other countries as well as those who move from city to city for employment or family reasons. In some Massachusetts communities, as many as 40% of the students may fall into this category. The increase of “social morbidities,” such as suicide, adjustment disturbances, and interpersonal violence, have placed additional responsibilities for early identification and referral on school health service programs (Thurber, Berry, & Cameron, 1991). The rapid restructuring of the health care delivery system has shifted many responsibilities for health care from the hospital and clinic to the school. With reduced hospitalizations and reduced lengths of stay, school nurses often supervise the care of children whose illnesses, such as acute asthma and juvenile diabetes, were formerly managed in a hospital or clinic setting (Chabra & Chavez, 2000; Leslie, Sarah, & Palfrey, 1998; Schutte, Price, & James, 1997).
Prior to 1990, school health services in Massachusetts, as in many states, were largely an unrecognized and underresourced part of the health care delivery system serving children and adolescents. A major challenge was interpreting the school nurse’s role in student health and education to local and state leaders responsible for funding decisions (Sheetz, 2002).
SETTING THE STAGE FOR CHANGE
In 1990, recognizing the unique opportunities for quality health services and prevention-focused education offered by school health programs, the MDPH began committing more resources from Title V to school health services. It established the School Health Unit and charged it with improving the standards of school health service practice. Efforts were coordinated with the Massachusetts Department of Education (Sheetz, 2002). By 1993, the School Health Unit had developed the Regulations Governing the Administration of Prescription Medications in Public and Private Schools (Sheetz & Blum, 1998). It also had begun publishing a quarterly newsletter on school health issues and resources, disseminating it to more than 3,500 professionals and parent groups. In 1993, the Massachusetts School Nurse Organization accomplished its goal of adding requirements for school nurse certification to the new state Education Reform Act. This laid the groundwork for a baccalaureate or master’s degree in nursing as the entry requirement for school nursing practice in Massachusetts (Sheetz, 2002) (Table 1).
In 1992 the Massachusetts legislature increased the state tobacco tax by 25 cents and established the Health Protection Fund. Advocates for the tax strongly supported the use of these funds for comprehensive school health education, with tobacco prevention education considered an essential component of the curriculum. Twenty-eight million dollars was earmarked for health education entitlement grants to local school districts (administered by the Massachusetts Department of Education). At the same time, the MDPH received appropriations of $5 million for school health services, approximately $2 million for school-based health centers, and another $2 million for general school health.
THE ESHS MODEL
The School Health Unit staff recognized that if the allocation for general school health services was divided among the Commonwealth’s 351 cities and towns, there would be little impact. However, the MDPH lacked adequate, concrete, “pilot-tested” information about what should comprise a school health service program. Seizing this opportunity, the staff began to develop the broad outlines of a model, which would then be funded at the local level:
The school health service program should be community based and should address the health service needs of all children in a given city or town. It should be formally established and managed by a designated BSN- or MSN-prepared school nursing leader. To address the complexity and diversity of student health needs, the schools should recruit BSN- or MSN-prepared professional nurses to care for students and families on the “front line.” The school health service programs should coordinate their efforts with all aspects of the comprehensive school health education program, as well as local community services.
The goal was to “jump-start” a system of school health services across the Commonwealth—and establish it as a recognized component of the health care delivery system serving children (Table 2).
Based on past experience in working with schools across the Commonwealth, the MDPH’s five master’sprepared School Health Unit staff members identified four general components of a school health service program: (a) strengthening the administrative infrastructure, including qualified nursing leadership, adequate school nurse staffing, and health care policies; (b) promoting comprehensive health education, consistent with the Department of Education guidelines and including tobacco control activities; (c) linking school health services with community providers and public health insurance programs; and (d) implementing management information systems. These components were translated into specific funding requirements (Sheetz, 2002).
Strengthening the Infrastructure of School Health Services
In order to ensure consistent program development and facilitate monitoring, the MDPH defined requirements for the school health service infrastructure. It endorsed the Department of Education’s requirement for a district-wide School Health Advisory Council, reinforcing the notion that this committee should (a) include representation of administrators, school nurses, health coordinators, school physicians, parents, students, boards of health, local providers, and members of community-based tobacco control coalitions; and (b) address both health education and health service issues. Infrastructure requirements also included an identified school nursing leader (with a baccalaureate or master’s degree in nursing, as well as community health, school health, or pediatric experience), position descriptions, a student health needs assessment, health service policies and procedures, emergency care planning, medication administration policies, and individualized health care plans for all children with special health care needs. The MDPH later added requirements for school nursing participation on student support teams, the establishment (at the building level) of an interdisciplinary team to identify students at health or education risk, improvement of the nutritional environment, and a plan to address oral health issues.
Implementing a Tobacco Control Program/Health Education Program
A major requirement was an enforced tobacco control policy for students and staff consistent with the 1993 Massachusetts Education Reform Act prohibiting tobacco use in school facilities and grounds at all times. Tobacco education, in lieu of suspension, was recommended for students in violation of the policy. The school district was required to have a K-12 tobacco prevention and comprehensive health education program. A requirement for a tobacco cessation program was added later.
Linking the School Health Service Program to Community Providers
In order to ensure a “medical home” for all students, school districts were required to identify all students’ primary care providers, with referrals as needed. In 1997, the MDPH added a requirement to identify all students’ health insurance, with referral if necessary to available public health insurance programs. To improve coordination on behalf of child health, school nurses were required to work with community agencies serving families, to become members of local tobacco control coalitions, and to develop “marketing” materials for parents and local providers that described the school health service program.
Implementing Management Information Systems
Recognizing the paucity of data about school health service program activities and services and the health needs of school children, the MDPH began requiring the submission of data. This proved to be challenging. Identifying the data elements and gradually implementing computerized data systems at the school-district level required several years of effort. The first step was to identify frequency of such nursing activities as student and staff health encounters, early dismissals, administration of prescription medications, health screenings, nursing procedures, case management, and referrals and linkages with primary care providers. In 1997, the referrals for health insurance were added. All of these elements were captured on monthly data reports. In order to provide a process measure, programs were also required to submit an annual Status and Measures Report with an update on staffing, policies, and program development consistent with grant requirements. In 1996 completion of a school-based tobacco control program self-evaluation tool was added to the requirements.
Issuing a Request for Response to Local School Districts
In 1993, the MDPH issued a competitive Request for Response for Enhanced School Health Services. The title contains the word enhanced, which indicates that funds are to be used to obtain additional school health resources, building on the existing program. Approximate awards would range from $60,000 to $75,000 per community. The contracts were for 4 years, with the expectation that the local school district would assume the cost at the conclusion of the contract.
Because this was one of the first competitive funding opportunities directed toward school nursing, the MDPH was concerned that communities might not apply. This fear proved unwarranted, because although the applicant numbers were not great, 36 (approximately 10% of the Commonwealth’s cities and towns) received the award. Communities of all sizes and economic levels submitted applications.
Implementation
The School Health Unit staff, originally consisting of a director and four master’s-prepared nurses (School Health Advisors), provided ongoing consultation to the developing ESHS programs. As the School Health Advisors became more familiar with implementing the contracts, several key strategies were developed. Following the Department of Education’s recommendation, the School Health Advisors began conducting “introductory” site visits to the contract recipients. During these site visits, they meet with the superintendent, the school nursing leader, and other administrators. They review the rationale for developing school health services and their role in supporting the educational process and the contract requirements. Administrative support for the school nurse leader as a decision-maker on health issues is emphasized. The school nurse leader is required to sign every budget request or amendment. This not only ensures that the funding will go to the health services but also strengthens the school nurse leader’s management role.
The site visits proved to be a major learning experience for both MDPH staff and local school district leaders. They provided an excellent opportunity to (a) learn the specific student health needs of various communities, (b) discuss ideas for “successful strategies” gleaned from other programs, (c) elicit suggestions from school leaders on ways to move the programs forward, and (d) create a partnership with school administrators.
Recognizing the need to develop the school nurse leaders’ management skills, the School Health Unit began organizing an orientation program. In 1993, also with tobacco excise tax monies, the MDPH started contracting with two collegiate programs, the University of Massachusetts and Simmons College, to develop a School Health Institute charged with providing an annual series of continuing education programs pertinent to school health. The School Health Institute and School Heath Unit jointly developed a 3-day ESHS orientation program designed to foster leadership development, management skills, and networking among the programs. Content areas included program goals, budgeting, skills for navigating the local municipality’s fiscal systems, information technology, team building, and preparation to meet emerging health issues. The sessions proved useful in allaying fears and fostering a sense of camaraderie.
The MDPH also organized four annual statewide meetings of the nursing leaders, offering opportunities to share information and resources. Even more important, the leaders were encouraged to network. To foster their sense of empowerment, they were asked to share successes. As the meetings have progressed, the developing sense of pride and excitement has been palpable. Most of the school nurse leaders and their staff have understood the health needs of their student populations for many years. Support and funding were necessary to put their ideas into action.
MDPH staff implemented several strategies to ensure accountability. As previously discussed, data submission requirements were established. Consistency of reporting has varied with school district size and stage of technology implementation, but this variability is lessening. Reports are used both for program monitoring and for issuing a composite annual executive summary. These yearly summaries have demonstrated the extent and diversity of health service activities occurring in the ESHS schools. They assist in interpreting the need for school health services to a wide variety of stakeholders and advocates. The data also will be used for outcome studies, which are currently being planned.
In 1996, the ESHS data were shared with the Division of Medical Assistance and the University of Massachusetts Center for Health Care Finance, resulting in the implementation of the Municipal Medicaid Administrative Activities Claiming Program in the Commonwealth’s schools. In FY 2001, more than $34.6 million was reimbursed to the Commonwealth’s cities and towns through this program (Sheetz, 2002).
Another strategy for ensuring accountability is the monitoring site visit, using a tool consistent with contract requirements. Although not all sites have been monitored to date, as the School Health Unit staff increases, so too will the biannual site visits. During these site visits, progress in the four content areas is reviewed with both administrators and nurse leaders. The site visits also offer an opportunity for a variety of observations such as school climate, type of meals offered to students, and evidence of tobacco use on school grounds. The staff follow the visit with a written report to the superintendent and nurse leader. The report outlines program strengths and areas for development. Of note is that the MDPH may reduce or terminate a contract if sufficient progress is not made. This has happened only twice since 1993.
PROGRESS IN IMPLEMENTING THE ESHS PROGRAMS
Whereas a formal evaluation is currently being planned, the following examples illustrate many of the initiatives stemming from the program:
Nurse leaders have begun communicating with local emergency medical services to establish school district and building-specific emergency plans. For many communities, this was the first time these groups have collaborated. Many school health advisory committees now include local pediatricians and representatives from other community health agencies, thus fostering the linkage with primary care. Several communities have developed systems whereby, with parental consent and assistance, school nurses may share health information with the child’s primary care provider to facilitate optimal medical management of children with attention deficit disorder or asthma. Some schools are tracking attendance after the implementation of an asthma management program. The ESHS programs provided leadership in implementing the school-based adolescent hepatitis B program in 1996, rather than relying on the primary care providers for this three-injection series. Beginning in the 1997–1998 school year, a total of 232 schools implemented a grade 6 through 12 school-based hepatitis B immunization program. This number rose to 358 by 1999–2000. State regulations now require hepatitis B immunization prior to entry into kindergarten and 7th grade. The ESHS programs were also instrumental in beginning tobacco cessation programs in the schools. Although cessation programs continue to be challenging, the MDPH is now working with nurse leaders and the University of Massachusetts Medical Center to implement a randomized study of individual interventions by school nurses for students who wish to stop smoking. Some ESHS programs requested and received donated services from local dentists and dental hygienists to provide dental sealants and to ensure that children with major dental treatment needs have access to care. The nurse leaders’ comfort level in the use and presentation of data is increasing; all are required by contract with the MDPH to present school health program information to administrators, school committees, or both annually. The number of media events about school health has increased; most major television stations have presented programs on the changing role of the school nurse to meet the changing health needs of students. This publicity has been mirrored in local newspapers.
ADVOCACY EFFORTS
While the ESHS programs were being implemented, statewide and local advocacy for school health was increasing. In 1996 the Massachusetts School Nurse Organization, the Massachusetts Nurses’ Association, the American Cancer Society, and the Parents’ Alliance for Catholic Education were instrumental in encouraging the governor of Massachusetts to appoint a Special Commission on School Nursing. In May 1998 the MDPH issued a report to the legislature, Options for Developing School Health Services in Massachusetts (MDPH, 1998), outlining the following recommendations for certified registered school nurse staffing:
One full-time equivalent (FTE) certified nurse in each building with 250 to 500 students.
For larger buildings, 0.1 FTE for each additional 50 students.
For buildings with less than 250 students, 0.1 FTE for each 25 students. (Sheetz, 2002)
ENHANCED SCHOOL HEALTH SERVICES WITH CONSULTATION
The 4-year funding cycle for the original 36 school districts (total of $ 2 million annually) ended in 1997. In planning to reissue the Request for Response (RFR), the MDPH was concerned that the original ESHS school districts would compete again and receive the grants, and the balance of the 351 cities and towns would not get a chance to benefit from the experience. Therefore, the MDPH created an additional program entitled “Enhanced School Health Services With Consultation” (ESHSC). The original school districts would be eligible to apply for annual contracts of $125,000 to provide consultation for six to eight “recipient” school districts. Each applicant for ESHSC funding would be required to submit for each of the six to eight recipient districts: (a) a memorandum of agreement, signed by the superintendent and a designated nurse leader of the recipient district, stating that the recipient school would agree to requirements for consultation; (b) a brief assessment of the recipient’s health service program; (c) a plan for further developing its health services; and (d) a tobacco control program self-evaluation form.
In this 1997 competitive RFR cycle, eight of the original ESHS programs were awarded ESHSC contracts. These eight districts would provide consultation to a total of 53 recipient school districts. An additional 18 other school districts received the basic ESHS grants.
The ESHSC programs were required to provide the following for the recipient school districts: (a) monthly networking meetings for nursing leaders from recipient schools, (b) consultation on the four ESHS components, (c) site visits to the recipient districts, and (d) telephone consultation. Grant funding paid for substitute nurses in the recipient districts to facilitate the designated nursing leader’s attendance at meetings.
The MDPH began holding quarterly meetings with the ESHSC programs. Although several programs initially reported having difficulty organizing the consultation services, they were soon moving forward and ready to share strategies for developing their recipient school districts.
FISCAL YEAR 2000 EXPANSION
In November 1999, the Massachusetts legislature allocated an additional $6.5 million from the Tobacco Settlement for ESHS programs. At the beginning of 2000, the MDPH again issued a RFR for both ESHS and ESHSC programs totaling $7.5 million.
Nonpublic/Charter Schools
The limited number of health services in nonpublic and charter schools resulted in a major change in grant requirements at this time. In an effort to develop school nursing services in these schools as well, all public school districts funded for ESHS or ESHSC were required to provide beginning health services to the nonpublic and charter schools within their community borders. Applicant public school districts had to approach all nonpublic and charter schools in their city or town and solicit their participation with a memorandum of agreement. Each of the 66 ESHS programs and 11 ESHSC programs were required to provide the following to the nonpublic and charter school with which they had an agreement: (a) a needs assessment; (b) vision, hearing, and scoliosis screening; (c) immunization record system; and (d) identification of each child’s primary care and health insurance provider, with referrals as needed. Funding included a baseline of $75,000 for ESHS and $125,000 for ESHSC, with an additional $2,000 to $6,000 for each nonpublic and charter school, based on enrollment. The goals were to begin to (a) equalize the services provided to both public and nonpublic students, building on the expertise of the health program in the public school; and (b) achieve consistency of school health policies for all children in a given community. In this cohort of grantees, services were initiated in 262 nonpublic and charter schools.
Change From Cost Reimbursement to Grants
A major administrative change also occurred during this expansion. Formerly the programs were funded through cost reimbursement contracts with the MDPH; school districts had to submit bills to the MDPH after monies were expended for school health services. To expedite the distribution of funding in FY 2000, the funding mechanism was changed from cost-reimbursement contracts to outright grants that allowed the MDPH to issue the funding in several lump-sum payments periodically throughout the year. School districts are now required to submit expenditure plans developed by the nurse leader and seek approval prior to spending. Amendments to these budgets are considered when necessary. Documentation for auditing purposes is kept at the local level, and reconciliation is completed by the MDPH at the end of each fiscal year. Unspent funds are returned to the MDPH, which in turn returns them to the Tobacco Settlement Fund.
FISCAL YEAR 2001 EXPANSION
In August 2000, the Massachusetts legislature appropriated an additional $9.6 million for ESHS programs. With these funds, the ESHS program expanded to include:
Increases in grant allocations (from the baseline of $85,000) to cities with more than 5,000 students. Threefold increases for the nonpublic and charter schools ($6,000 to $18,000). The additional funds covered nursing assessment of children on entry into the school and provided on-site school nursing presence for 2 to 3 days per week (by the end of the 2nd year of the grant). Grant awards to 32 additional communities.
By 2001 the MDPH was funding 109 participating school districts, including 11 consultation schools serving approximately 85 additional “recipient” school districts. Thirty of the former “recipient schools” were awarded grants in 2000 and 2001, suggesting that the consultation model was successful in laying the groundwork for recipient schools to compete successfully when funding became available. The combined ESHS and ESHSC programs are now providing certain health services to approximately 296 non-public and charter schools across the Commonwealth. Total enrollment in FY 2002 includes (a) ESHS/ESHSC school districts: 566,801 students; (b) nonpublic and charter schools: 63,103; and (c) recipient schools: 156,243.
ADVANTAGES OF THE INFRASTRUCTURE
As the MDPH introduces or expands its public health initiatives, it utilizes the school health service infrastructure developed by the Enhanced grants. Grant requirements also change and expand:
With the MDPH’s recent focus on oral health, all grantees must develop a plan for (a) assessment of oral health status of the student population, (b) provision of dental sealant programs either directly or through referrals, (c) implementation of school-based fluoride rinse programs in nonfluoridated communities, (d) review of the food service program and vending machines to reduce sugar and starch intake, and (e) implementation of guidelines to ensure mouth-guard use. Consistent with the MDPH’s mental health initiatives, participating ESHS/ESHSC schools are required to develop a plan for identification of students at emotional risk, suicide prevention initiatives, and a referral system for mental health services. Collaborating with the Massachusetts Melanoma Foundation, the MDPH began initiating skin cancer prevention strategies in the Enhanced programs in FY 2002. Implementation of a beginning pediatric asthma surveillance system in the Enhanced programs is planned for the 2002–2003 school year. Many ESHS/ESHSC programs have begun to address the issue of overweight through implementation of nutrition and physical activity programs or involvement in research projects.
WHAT WE HAVE LEARNED
Although the MDPH is planning a formal evaluation of the ESHS programs in the future, the model has been fine-tuned over time through feedback from the nursing leaders. The following are some early generalized findings:
A full-time baccalaureate- or master’s-prepared nurse leader, with full management authority and freed from direct service responsibilities, is essential to the success of the program. Opportunities to share “best practices” are very helpful in developing a statewide system. These may include networking meetings, formal continuing education in the university setting, meetings with the Department of Public Health on a regular basis, or sharing through the e-mail systems. The MDPH maintains an e-mail listing for all nursing leaders and sends important information several times a week. It also has developed a statewide call list whereby each ESHS program has agreed to contact two to three additional school districts should a statewide emergency or bioterrorism event occur. Management information systems are key to providing information to school committees and other stakeholders, as well as facilitating the MDPH’s monitoring of progress, “marketing” the need for school health service programs, and evaluating the effectiveness of the ESHS/ESHSC model. Coordination between school health service and community providers is enhanced when school nurses have access to essential electronic technology, including but not limited to a dedicated outside telephone line, networked computers, facsimile machines, and access to the demographic and attendance data of the school’s management information system. Mechanisms for the school health program to collaborate with community providers and agencies are important. These include but are not limited to a broad-based School Health Advisory Council and local health coalitions with school nurse representation. When school districts use the Enhanced basic infrastructure to address issues specific to the needs of their student populations, such as hunger, depression and suicide, and alcohol abuse, the positive effects may be multiplied exponentially with probable cost savings, which is an area for further study. With a basic infrastructure in place in a variety of school districts statewide, the piloting or implementation of additional MDPH initiatives is greatly facilitated. These may include overweight prevention, immunization programs, and implementation of asthma action plans. A limitation of the Enhanced program is that it affects only approximately half of the Commonwealth’s 351 cities and towns, either directly through the funded programs or through consultation to the recipient schools. However, the lessons learned from the Enhanced school districts may be shared with the nonfunded programs through the school health newsletter and continuing education programs offered by the University of Massachusetts/Simmons College School Health Institute.
School nurses have access to all students, and they are respected and trusted members of the school community. Their educational background (BSN or MSN) typically includes expertise in public health, prevention, health education, and counseling. With appropriate administrative and programmatic support, funding, and decision-making authority, they are uniquely qualified to coordinate a wide spectrum of school and community resources and services. A major accomplishment of the ESHS programs has been to develop the school nursing leadership at the local level, interpret its value to school and community decision-makers, and set the standards for quality health services for the Commonwealth’s children.
NOTE
During the Spring of 2003, the ESHS fnding was reduced as part of the Commonwealth’s emergency budget reductions. Planning for the FY 2004 budget is underway and will determine whether all or part of the ESHS funding will be restored.