Transcript Models that Work: Politics that Don't:

Models that Work: Politics that Don't:
A history of school health in the United States
Julia Graham Lear, Director, Center for Health & Health Care in Schools, The
George Washington University School of Public Health and Health Services, at
the Milwaukee Area Health Education Center, April 29, 2002
Four challenges to building effective,
sustainable school health programs
• Challenge of solidifying a quality
program
• Challenge of implementing
organizational change
• Challenge of securing adequate
funding
• Challenge of building political support
www.healthinschools.org
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The greatest challenge
The greatest challenge is not developing excellent
services, nor finding the best model for delivering
care in schools nor identifying the deepest pockets
to fund those services -The greatest challenge is finding a better model of
political support for any model of health care
delivery in schools.
www.healthinschools.org
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Outline: 100 years of school health
• Where we’ve been and what we’ve learned
• Where we are now: health needs of
students, current programs, potential
barriers
• How to secure more effective school health
programs -- overcoming barriers, building
effective services
www.healthinschools.org
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Where we’ve been: Early days
• 1890s. Boston & NYC: Physicians and nurses hired to
examine children in school & exclude the potentially
contagious.
Message: Protect the school environment.
• Early 1900s. School health services spread. Educators
launch first full-service schools. Early opposition from
immigrant parents, institutions.
Messages: Multiple possibilities; protect the students.
• Post 1910. Conflict between public health & private
medicine. AMA opposition to all publicly-funded treatment
services in schools.
Message: School health
content fixed by external issues. 5
www.healthinschools.org
Where we’ve been: the basics emerge
• 1920s to1950s. School health = health education,
immunization documentation, screenings, treatment for
minor injuries, referrals for problem diagnosis & treatment.
The Astoria plan.
Message: School health contained.
• 1960s & 1970s. New provider types: nurse
practitioners, school-based health centers. New emphasis
on getting health care to poor children. Federal law
mandates health-related services for students with
disabilities.
Message: Increased focus on individual student health,
incorporation of mandated services.
www.healthinschools.org
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Where we’ve been: new directions
• 1980s and 1990s: Spread of school-based health
centers; influence of changes in education (accountability,
testing, success for all) and health systems (accountability,
managed care, outcomes focus).
Message: Importance of external education & health
policies for shaping school health.
www.healthinschools.org
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Where we’ve been:
Strengths and weaknesses
Strengths
• A universal system: all services available to all students
• Developed with attention to what health providers and
parents would support
Weaknesses
• Weak funding base, limited political support
• Arrangements focused on infectious disease, may not be
greatest current threats to child & adolescent health
• Referral strategy for treatment assumes availability of
community-based providers and availability of parents to
take minor children for care
www.healthinschools.org
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Widely shared beliefs about school
health and safety
• Children must be safe when attending school.
• Emergency medical services should be available and urgent
services should be provided for persons in the school
building.
• By law, all communities are obligated to provide the care
needed to enable children with physical or mental health
disabilities to benefit from a free, appropriate public
education.
• Schools should educate children about keeping their bodies
safe and healthy.
www.healthinschools.org
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Beyond the basic components of
school health
Arguments for Expanded School Health
Programs
 That health programs facilitate learning, and may
increase test scores
 That there are gaps in the health care systems
especially for low-income children, those needing
mental health services, and for adolescents
 That there are cost savings to be achieved through
early intervention and treatment
 That children's parents may be inaccessible to
schools and that caring for sick children may fall to
school staff
www.healthinschools.org
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Common Health Problems of
School-Age Children, 5 - 17, 1997
P roblem o r C n
odition
N umb er %
As thma – ver
e to ld had ast hma
6.7m
13.0%
As thma att ack n
i past yea r
3.1m
6%
Hay feve r, r espir ato ry
18.5m
allerg ies, oth er allergies*
Le arn ing disabilities - ever
4.5m
told
At ten tion deficit dsorder
i
3.3m
ever to ld
Medicat ion: Childr en on meds 5.6m
for at le ast 3mos
NA
8.7%
6.3%
10.9&
Sourc e: U S DHHS , CDC , N CHS . S u mmary H e alt h S tisti
a t cs for US
C h ld
i ren: N ati o n a leaHl t h
In t ervie w S ve
u ry, 1 9 9. 7Vit a l a nHe
d alt h
S t atist ics. Series 1 0
, N umb er 2 0 .3Ja n u ay r2 0 0. 2
www.healthinschools.org
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Youth Risk Behavior Survey, 1999
Ri sk Behaviors
1997
1999
Fr equen t cigar ett e us e
16.7%
16.8%
Ep isodic he avy dr inking
34.4%
31.5%
Curr ent coc aine use
3.3%
4.0%
Did not use condom during
las t se xual in ter course
Th rea tened or inju red with
we apon on school prope rty
Fe lt too unsa fe t o go ot school
---
42.0%
4.0%
5.2%
7.4%
7.7%
Sour c e: C D CYouth Risk Behavior Su rveillanc e yste
S m
(YRBSS)
www.healthinschools.org
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Percentage of Schools with Facilities
or Equipment for Health Services
Ty pe o f F ailict y or Equipmen t
% of
Scho o sl
f st aid kit
Po rtable ir
92.7%
Sick r oom or nurse ’s office or other
are a re -se rved for health serv ices
Sepa rat e medicine cabinet with lo ck
81.1%
Re frigerat or rese rved fo r he alth
services
Pe ak f low mete r
57.3%
st for an
Gluc ose me ter, not j u
indiv idual’s use
Nebu liz er, not ju st f or a s pec ific
indiv idual’s use
17.8%
65.4%
27.2%
13.0%
Sour c e: C D C, S chool H ealth Policy &
S y (SHPPS, 2001.
Prog ram s tud
www.healthinschools.org
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School-based providers in the 21st
century
In 90,000 public elementary and secondary schools
attended by 53 million students, there are :
• School nurses -- 30,000 estimated.
• School health assistants or UAPs -- N/A
• School-based health centers -- 1500
• School counselors -- 81,000
• School psychologists -- 20,000-22,000
• School social workers -- 12,000
www.healthinschools.org
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Funding school health
• Primarily local dollars drawn from local tax base
or local allocations of state general fund dollars
• Some states, eg. Pennsylvania & Massachusetts,
provide general fund support for school nurses
• Medicaid reimbursement for special education
health-related services, Medicaid administration,
health services to Medicaid beneficiaries or wraparound services for beneficiaries
• Private philanthropic support, eg. Quantum Fdn,
Duke Endowment, Robert Wood Johnson Fdn
www.healthinschools.org
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Who’s in charge: Traditional school health
funding & management arrangements
Traditional approaches
• School system funding/management
eg. Boston, MA; most New England communities
• School system funding/health department management
eg. Detroit, MI; Milwaukee, WI (?)
Strengths: Institutional understanding of unique
characteristics of health programs in schools; community
good will; support for individual school nurses
Weaknesses: Good managers, but leadership a challenge schools are led by educators; Health must compete with
education for education dollars
www.healthinschools.org
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Who’s in charge: Newer school health
money and management arrangements
Newer approaches
• School system funding/private system management
eg. DCPS/Children’s Medical Ctr, Washington, DC
• School system funding/federal participation via
Medicaid/various management arrangements
eg. Baltimore County PS, Baltimore City
• School system funding plus local-state dollars for
underserved, Medicaid, philanthropy/various management
arrangements
eg. Palm Beach County, Fl; Denver, CO
www.healthinschools.org
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Who’s in charge: Strengths and
weaknesses of newer approaches
Strengths
• Establishes broader funding base and/or political support
• Changes in program management, accountability structure
will strengthen content and outcomes of program
Weaknesses
• Requires on-going collaboration, partnerships
• Requires major changes in management, accountability
measures
www.healthinschools.org
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Barriers to building effective,
sustainable school health programs
• Money: School health programs locally funded,
primarily with education dollars
• Leadership: Few leaders within school boards,
school administrations and state legislatures make
health-in-schools a main focus
• Politics: Public dollars (to support school health)
require public support. Where are the strategies to
build public support?
www.healthinschools.org
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Overcoming barriers: It’s been done
• Money: Seton Health System in Austin documented what
they did with school health dollars,demonstrated their
effectiveness & got additional support. The Detroit SBHCs
organized parents to lobby the state legislature & got
SBHC dollars put back in the budget.
• Leadership: In San Diego, a hospital president, school
superintendent, managed care leaders, and corporate
representatives have joined together to build a common
school health program.
• Politics: In Louisiana and other states, grassroots
organizing at state capital transformed a school health
controversy into just-another-effort to bring “home the
bacon” to local folks.www.healthinschools.org
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Characteristics of Effective,
Sustainable School Health Programs
• Data and epidemiologically-driven program
design
• Transparency: Funding, program goals, staffing
and service arrangements are clear
• Accountability: Reports to institutional leaders
and to the public describe program performance
against program goals
• CQI: On-going efforts to improve performance
and measure the improvement
www.healthinschools.org
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Four challenges to building effective,
sustainable school health programs
• Challenge of solidifying a quality
program
• Challenge of implementing
organizational change
• Challenge of securing adequate
funding
• Challenge of building political support
www.healthinschools.org
22
The greatest challenge
The greatest challenge is not developing excellent
services, nor finding the best model for delivering
care in schools nor identifying the deepest pockets
to fund those services -The greatest challenge is finding a better model of
political support for any model of health care
delivery in schools.
www.healthinschools.org
23