Department  of Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
SCHOOL-BASED  HEALTH  CENTERS 
AND  MANAGED  CARE 
DECEMBER  1993  OEI-05-92-00680  EXECUTIVE  SUMMARY

PURPOSE 
This  inspection  describes  school-based  health  centers  and  their  degree  of coordination 
with  managed  care  providers. 
BACKGROUND 
According  to sumeys  and  estimates,  there  are  between  200 and  500 school-based 
health  centers  across  the  country,  and  the  number  of school-based  health  centers  is 
increasing  rapidly.  These  school-based  health  centers  vary depending  on the 
community,  but  the  vast  majority  are  located  in middle  or secondary  schools.  Visits 
for  physicals  and  mental  health  needs  are  the  most  common  services  provided  in 
school-based  health  centers. 
This  inspection  focuses  on adolescents  due  to their  unique  health  needs  and  the  fact 
that  most  school-based  health  centers  seine  this age group.  However,  school-based 
health  centers  are  also proliferating  at the  elementary  school  level.  Many  of the  ideas 
discussed  here  are  germane  to elementary  school-based  health  centers  as well. 
School-based  health  centers  often  receive  funding  from  a combination  of public  and 
private  sources.  The  most  common  sources  of private  funding  are  foundation  grants 
and  private  health  insurance.  The  largest  Department  of Health  and  Human  Services 
(HHS)  financial  contributions  come  from  Title  V Maternal  and  Child  Health  Block 
Grants  (providing  an  estimated  16 percent  of school-based  health  centers  funding), 
communi~  health  center  funding  (6 percent),  and  Medicaid  (2 percent). 
At the  same  time  that  HHS  supports  school-based  health  centers  to promote  access  to 
health  care  and  better  public  health,  it also supports  the  growth  of Medicaid  managed 
care  delivery  systems  to promote  better  access  to quality  health  care.  Thirty-two 
States  and  the  District  of Columbia  have  some  type  of managed  health  care  option  for 
Medicaid  recipients.  A common  feature  of managed  health  care  plans  requires 
recipients  to be  locked  in to one  medical  plan  or provider.  Locked  in recipients 
cannot  normally  receive  non-emergency  treatment  from  providers  outside  of the  plan. 
As both  managed  care  and  school-based  health  services  expan4  adolescents  enrolled 
in managed  care  plans  will be  more  likely to have  access  to school-based  health 
centers  and  the  need  for coordination  will grow. 
i  FINDINGS

On-site  school-based  health  centers  increase  access  to health  care  and  specialize  in

providing  semices  aimed  at adolescents.  Staff  at school-based  health  centers  are

trained  in dealing  with adolescents  and  problems  unique  to their  age  group.  By going

where  the  kids are, school-based  health  centers  surmount  a major  barrier  to health

care  access  even  managed  care  providers  cannot  address.

Early  assessments  of school-based  health  centers  are  promising,  and  anecdotal

evidence  supports  the  idea  that  school-based  health  centers  are  an appropriate  way to

deliver  services  to adolescents.  But the  literature  on school-based  health  centers

rarely  gives a national  perspective  and  provides  little  information  about  health

outcomes  for adolescents.

Howeveq  liitk  codhahm   *bezn?t?en  managed mpvtiandscM-bared 
J&?ahhcentas. 
Few  agreements,  formal  or informal,  exist between  managed  care  providers  and 
school-based  providers.  Little  exchange  of medical  information  takes  place  between 
managed  care  providers  and  school-based  health  centers.  k  a result  neither 
managed  care  providers  nor  school-based  health  centers  can  coordinate  or manage  all 
the  care  given  to their  patients. 
Respondents  describe  multiple  barriers  to coordination  between  managed  care 
providers  and  school-based  health  centers.  These  barriers  include  communication, 
finances,  legal  issues, and  confidentiality  of medical  records.  Most  respondents  believe 
there  will be  negative  consequences  if school-based  health  centers  and  managed  care 
providers  do not  coordinate. 
In communities  where  school-based  health  centers  have  agreements  with  local 
managed  care  providers,  all parties  can  benefit  from  increased  capabilities  to deliver 
managed  and  coordinated  care. 
The  HHS  has  a hand  in both  managed  care  and  school-based  health  centers  in a  ~ 
variety  of agencies.  There  is no focal  point  in either  the  Public  Health  Sexvice or the 
Health  Care  Financing  Administration  for  outside  entities  to contact  or to provide  a 
locus  for decisionmaking. 
ii  RECOMMENDATIONS

AGENCY COMMENTS

We  received  comments  from  the  Health  Care  Financing  Administration  and  the  Public 
Health  Service.  Both  agencies  supported  the  recommendations,  suggested  pertinent 
clarifications  and  identified  additional  issues regarding  school-related  and  youth  health 
programs.  The  complete  text  of the  Health  Care  Financing  Administration  comments 
are  included  in Appendix  G.  The  Public  Health  Service  comments  are  included  in 
Appendix  H.  We  made  appropriate  revisions  to the  report  based  on their  comments. 
... 
111  TABLE  OF  CONTENTS

ExEcuTlvE  Sun4MARY 
INTRODUCIION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

School-based  health  centers  increase  access



to health  care  for adolescents  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

However,  little  coordination  exists beween  managed



care  providers  and  school-based  health  centers  . . . . . . . . . . . . . . . . . . .  11

Some  initial  efforts  to coordinate  demonstrate



potential  benefits  for adolescents,  managed  care

providers  andschool-based  health  centers  . . . . . . . . . . . . . . . . . . . . . .  15

Even  though  school-based  health  centers  and  managed

care  are  expanding  rapidly,  HHS  has  no focal  point

coordinating  departmental  programs  and  activities

in these  areas  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...18

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...20

AGENCY  COMMENI?S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...22

APPENDICES 
f%  School-based  health  center  andmanaged  care  respondents  . . . . . . . . . . . . . .  A-1

B:  Other  school-based  health  center,  adolescent  health 
ormanaged  care  contacts  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..s1 
c  Selected  bibliography  on school-based  health  centers 
and  adolescent  health  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..*C-l 
D	 Proposed  New  York  State  school-based 
health  center  standards  andoperations  . . . . . . . . . . . . . . . . . . . . . . . . . . . ..D-l 
E.  Example  of school-based  health  center  and  managed  care  protocols  . . . . . . .  E-1

F  Oregon  lawandimplementing  procedures  requiting  coordination  . . . . . . . . . .  F-1

G  Health  Care  Financing  Administration  response  tothedrafirepofi  . . . . . . . .  G-1

H  Public  Health  Service  response  tothedrafirepofi  . . . . . . . . . . . . . . . . . . . .  H-1
 INTRODUCTION

PURPOSE 
This  inspection  describes  school-based  health  centers  and  their  degree  of coordination 
with  managed  care  providers.l 
BACKGROUND 
Mod-based  hedh  C-
Delivery  of health  care  to children  and  adolescents  poses  a difficult  challenge  to 
communities,  particularly  in low-income  areas  where  access  to care  may  be minimal. 
However,  since  the  mid-1980s,  some  communities  have  addressed  the  problem  by 
setting  up  primary  health  care  for children  and  adolescents  in school-based  health 
centers.  According  to surveys and  estimates,  there  are  between  200 and  500 school-
based  health  centers  across  the  country,  and  the  number  of school-based  health 
centers  is increasing  rapidly.  These  school-based  health  centers  vary depending  on the 
community,  but  the  vast  majority  are  located  in middle  or secondary  schools. 
Nearly  all school-based  health  centers  provide  general,  primary  health  care  ranging 
horn  general  physicals  to chronic  illness management.  2  Many  school-based  health 
centers  also  provide  a health  curriculum  that  is age and  developmentally-appropriate.3 
Visits for  physicals,  acute  illness, psychosocial  and  mental  health  needs  are  the  most 
common  semices  provided  in school-based  health  centers. 
Sthuol-lbhfekaeudhM
!7vkes

In addition  to communities  establishing  school-based  health  center%  many  community 
health  centers  and  hospitals  have  also entered  into  agreements  with  local  schools  to 
provide  children  and  adolescents  access  to comprehensive  health  care.  By November 
1~  240, more  than  one-third  of the  community  and  migrant  health  centers  and 
1  Scmeptopicn$  ??tolhif(ucoard  bwdctaxruq uwillrq?r  muafmanaagmufwipcw posesofthe~
2  Owhaifthcxhoai-lmred  hedh  CcntuSO)qi?the following medical S?wiccs  4#umcntand  r@Yndto  ccmnrAn@M 
Syuemlmdptykim%  chmicilht=tnamzgt?ne?u  diqwi$andueomenl  ofmimorrnjuricg  Edyond  P@iodk  Saeenhg

l)iogwsdcj  and T~  swvicc+ genendp@ica4  &?ucdogicamw  hmdwnk%  inidalandJwow-up  ewhadom@biKh

Columlmelhod% labommy  test$pegna?q  andpmo@cc=  @=4&h  d-gof-d$=@)~d

dise@ed@plir  anduwttnau  2% majotiy of schooL-bad  hcdh  cerum O*  du@%Angc_imd  e&wadonalwvice.t

coun@ngon  binhconudtneth@  drugandsdmance  abuupn+7ams  fatni&coumeling  htxdtheducadom  mental heahhond

pYchmocti  Coulweiing ~  e&otiq  pamuing educ~  pmgnanq  counseling sueducadon  inachsroomseaing  =xal@  .

Cowm?iing and m@t n?tiucdonpm#anu

3 
[nadd&on  to@rtibyxhool-bmuih  edthc~  tnonyschoA  ofer&ahhprograwu  ondacdvidcs  menhancetik& 
of school-aged po~  &  as nwidow  **d@=d~Fwom  m envbvment~  Ofdlug% Vkimc: 
poihuo7wm  There aleaisO adolescent heawl@9rls  oimedataciliOing  Main@dng  andilqmwingth eheahhof  adoksccntsnol 
limited 10 adokxena  autnding school 
1  health  care  for the  homeless  programs  funded  by the  Department  of Health  and 
Human  Smrices  (HHS)  had  arrangements  with local schools  and  school  districts  to 
care  for poor  and  underserved  populations  of school-aged  children. 
For  purposes  of this report,  unless  otherwise  noted,  any further  discussion  of school-
based  health  centers  applies  to school-linked  health  services  as well.  In addition,  we 
will focus  on adolescents  because  most  school-based  health  centers  serve  this age 
group.  However,  school-based  health  centers  are  also proliferating  at the  elementary 
school  level,  and  many  of the  ideas  discussed  are  germane  to these  school-based 
health  centers  as well. 
Mmged  Cm 
At the  same  time  that  HHS  supports  school-based  health  centers  to promote  access  to 
health  care  and  better  public  healt~  it also supports  the  growth  of Medicaid  managed 
care  delivery  systems  to promote  better  access  to quality  health  care.  Thirty-two 
States  and  the  District  of Columbia  have  some  type  of managed  health  care  option  for 
Medicaid  recipients.  Private  managed  care  plans  exist in 46 States  and  the  District  of 
Columbia. 
A common  feature  of managed  health  care  plans  requires  recipients  to be  locked  in 
to one  medical  plan  or provider.  Locked  in recipients  cannot  normally  receive  non-
emergency  treatment  from  providers  outside  of the  plan.  This  lock  in means  that 
managed  care  providers  can  coordinate  the  care  given and  be  certain  of its quality  and 
its cost  effectiveness. 
Managed  care  plans  offer  a wide  range  of medical  specialties  and  semices  for its 
members.  By assigning  each  patient  a primaxy care  case  manager,  patients  should 
have  increased  access  to primary  care.  Managed  care  providers  inform  enrolled 
patients  that  the  plan  is responsible  for all their  medical  care. 
Although  managed  care  can take  different  forms,  generally  managed  care  describes  a 
health  care  deliveg  system where: 
care  is arranged  with  selected  providers  to provide  comprehensive  health  care 
	
services  to members, 
health  care  providers  are  chosen  based  on selection  standards, 
 
plans  have  formal  programs  for ongoing  quality  assurance  and  utilization 
 
review, 
members  have  significant  incentives  to use providers  associated  with  the  plan.4 
 
2
 AU mainstream  health  care  delivery  systems, whether  family physicians,  pediatricians, 
or managed  care  providers,  must  deal  with the  dilemma  of adolescent  health. 
Adolescents  present  special  heaith  needs  to medical  caregivers.  Chief  among  these 
needs  is care  that  is confidential,  convenient,  comprehensive,  and  age appropriate. 
Adolescents  are  generally  perceived  as healthy,  but  this perception  maybe  deceptive. 
In its  1991 study  on adolescent  health,  the  U.S. Office  of Technology  Assessment 
(OTA)  estimated  that  20 percent  of adolescents  have  at least  one  serious  health 
problem.  The  OTA  states  that  many  adolescents  suffer  from  a diagnosable  mental 
disorder.  Prior  studies  have  also described  other  teenage  morbidities  including  youth 
drug  and  alcohol  abuse  and  sexually transmitted  diseases. 
For  myriad  reasons,  most  adolescents  do not  seek  routine  medical  care,  and  often  will 
wait  for  problems  to become  severe  before  soliciting  treatment.  One  consequence  is 
that  adolescents  see  office-based  physicians  less than  any age  group. 5  In some  ways, 
the  nature  of adolescence  may present  a barrier  to health  care.  Adolescents  often  do 
not  keep  medical  appointments.b 
The  OTA  descnies  many  difficulties  adolescents  have  accessing  and  receiving  the 
health  care  they  need.  Among  these  difficulties: 
...access  problems  that  affect  adolescents  particularly  - for example,  lack of 
	
money  to pay for semices  or transportation,  lack  of convenient  hours,  concerns 
about  confidentiality,  and  perceived  lack of approachabili~  of mainstream 
semices. 
...there  is some  evidence  that  many  adolescents  are  unwilling  to visit their 
	
private  physician  for concerns  about  sexuality,  substance  abuse,  or emotional 
upset  and  also would  be  unwilling  to seek  care  for these  problems  with their 
parents  knowledge. 
Primary  care  physicians  appear  to have  difficulty  in ident@ing  adolescents  who 
 
have  behavioral  emotional,  and  substance  abuse  problems. 
...those  adolescents  who seek  health  care  are  likely to see  providers  who  have 
	
not  been  specially  trained  to work  with them. 
5 
Klein Jonahon D., Slap, Gail%  ELua, Anhw  R, schonbus  S. Kcnnc4  ACCU! W Hdh  Can @AdohcuuF,  Jti 
ofAain2scau  Hem  Vo/ 13, #~ Mad  1~~ p.~6t 
6  l%epmaiiing  vielvofmpondumfw  fhissu@  wwLhaiuou  arc"ofrhe?7lowm"  ondthotadoluct??us  donotwalk 
around *  appoinmunt  book 
3  haddition,  health  care  coverage  forteens  is problematic.  Oneinseven  teens  has no 
health  insumnce.  Where  private  health  insurance  covem  adolescents,  restrictions  often 
limit sexvices for teens.  Forexample,  matemi~related  eWenses  arenot  included  for 
one-third  of teens  covered  by their  parents  employment-based  health  plan. 
These  represent  serious  obstacles  that  impede  access  to basic  health  care  for 
adolescents.  Reducing  the  occurrence  of many  serious  adolescent  health  problems 
depends  on overcoming  these  barriers. 
Even ?nana&?tiCWV  dekiv~  syste?n$dai@ed  to incnmse acci?ssandaoldimwhealfh 
carq have difiady  nuzthg  adokscent hedh  cm  needt 
While  managed  care  plans  offer  comprehensive  health  care,  most,  like their  fee-for-
service  counterparts,  offer  few counseling  sexvices geared  to adolescents.  According  to 
OT&  ..M. edicaid  and  many  private  ... insurers  place  limitations  on reimbursement  for 
mental  semices  that  they  may not  place  on semices  for physical  problems.  So drug 
and  substance  abuse,  nutrition,  reproductive,  and  sexuality  counseling  is not  provided 
routinely  through  managed  care  providers. 
Because  adolescents  problems  may be  complez  and  not  strictly  of a physical  nature, 
diagnosis  is difficult.  Because  treatment  of these  problems  may require  dealing  with 
more  than  one  health  or related  system,  case  management  services  and  referrals  for 
social  sexvices may be  necessary.  But managed  care  plans  do not  provide  these 
special  needs  sexvices, and  instead  must  refer  adolescents  for these  sewices. 
Recognizing  the  difficulties  promoting  health  care  and  wellness  among  adolescents, 
some  managed  care  plans  have  developed  special  adolescent  clinics.  Some  have  also 
designed  programs  addressing  a specific  health  problem  (e.g., AIDS).  These 
approaches  have  had  varying  degrees  of success. 
Funding sounxs for school-based  health cemm 
The  school-based  health  centers  often  receive  funding  from  a combination  of public 
and  private  sources.  The  most  common  sources  of private  funding  are  foundation 
grants  and  private  health  insurance.  Public  funding  sources  include:  State  health 
departmen@  city and  county  health  departmen~  school  districts,  and  HHS.  The 
largest  HIIS  financial  contributions  come  from Title  V Maternal  and  Child  Health 
Block  Grants  (providing  an estimated  16 percent  of school-based  health  centers 
funding),  community  health  center  funding  (6 percent),  and  Medicaid  (2 percent). 
School-based  health  centers  have  also been  very creative  in attracting  in-kind 
contributions,  such as mental  health  and  substance  and  alcohol  abuse  services. 
7	 Sources of @nalng rnf~m  Oflce of TKhno@  Assamwu  ~  Adokxau  Hea@  1991, vo&4mcm  p. 4a 
The School-Bared Adokcuu  Health Cam Program ACCCSS~  c~  W Schcwi-lnwd  Hca&h .%nicu  for Adolcscau$ 
F(ZLL1993p.  1. 
4  In the  pasg  HHS,funds  have  comprised  a relatively  small  portion  of funding  for 
school-based  health  centers.  Recently,  however,  there  have  been  efforts  to increase 
HHS  involvement  with  school-based  health  centers.  In  1987, the  Centers  for Disease 
Control  and  Prevention  (cDC)  created  the  Division  of Adolescent  and  School  Health 
to identify  and  monitor  major  health  risks among  youth  and  to implement  national 
programs  to  diminish  these  risks.  In conjunction  with the  Carnegie  Foundation,  CDC 
is funding  an  initiative  at the  Columbia  University  School  of Health  Policy which  has 
brought  together  a national  workgroup  to identify  barriers  to establishing  school-based 
health  centers  and  to develop  recommendations  for a core  set of semices  for school-
based  health  centers. 
In 1991, the  Adviso~  Council  on Social  Security  recommended  that  the  Federal 
Government  help  States  establish  health  clinics in or near  elementary  schools,  and 
share  with  States  the  costs of providing  health  and  dental  semices  for poor  children. 
The  HI-H  and  the  Department  of Education  recently  published  the  Tractical  Guide  to 
School-linked  Service  Integration.  In addition,  the  Interagency  Committee  on School 
Health  was created  under  the  leadership  of the  HHS  Office  of Disease  Prevention  and 
Health  Promotion  as a joint  activity of HHS  and  the  Department  of Education.  Staff 
support  for this  effort  is provided  by the  Office  of Disease  Prevention  and  Health 
Promotion  and  the  Department  of Educations  Office  of Elementag  and  Secondary 
Education.  Representation  from  HHS,  Department  of Education,  the  Department  of 
Agriculture,  and  a number  of other  Cabinet-level  departments  and  Federal  agencies  is 
included  on the  Interagency  Committee  on School  Health. 
Another  effort  demonstrating  HHS  support  for school-based  health  centers  comes 
from  the  Health  Care  Financing  Administration  (HCFA).  The  HCFA  encourages 
schools  to become  providers  for Medicaids  Early  and  Periodic,  Screening,  Diagnostic, 
and  Treatment  (EPSDT)  program. 
EPSDT 
The  EPSDT  program  was created  in 1967 to provide  initial  and  periodic  examinations 
and  medically  necessary  follow-up  care  for Medicaid-eligible  children.  The  Omnibus 
Budget  Reconciliation  Act  of 1989 expanded  EPSDT  coverage  for most  Medicaid-
eligible  children  under  age  21.  In July  1990, HCFA  established  participation  goals  for 
EPSDT  requiring  that  States  screen  80 percent  of eligible  children  by 1995. 
To  help  States  meet  these  goals, HCFA  is encouraging  States  to enroll  schools  as 
EPSDT  providers  and  recently  published  ERSD~  A Guzi.iefor Educational Programs. 
This guide  provides  school  officials with  information  about  State  Medicaid  agencies, 
the  EPSDT  program,  and  the  benefits  of EPSDT  participation. 
5
 METHODOLOGY 
We  conducted  an  extensive  literature  review  on school-based  health  centers  and 
relevant  legislation.  Within  HHS,  we held  discussions  with officials  in HCFA  and  the 
Public  Health  Service  (PHS).  We attended  a Child  Health  Conference  that  addressed 
managed  care  and  child health  issues.  Representatives  from  HCF~  PHS,  managed 
care  consulting  firms, State  Medicaid  agencies,  State  offices  of Maternal  and  Child 
Health,  State  and  local  health  departments,  and  foundations  concerned  with child 
health  attended  the  conference.  In addition,  we attended  the  annual  conference  of 
the  Society  for Adolescent  Medicine  and  a meeting  of the  Ad Hoc  Committee  on 
Health  Promotion  Through  the  Schools. 
Using  HCFA  data  on managed  care  providers  and  from  existing  literature  and  experts 
in the  field  of school-based  or school-linked  health,  we identified  10 communities 
where  both  school-based  health  centers  and  managed  care  providers  exist.  Our 
criteria  for  selection  gave  priority  to communities  where  school-based  health  centers 
and  managed  care  providers  were  working  toward  agreement.  We  also  favored 
communities  that  would  give us a geographically  diverse  sample.  To  obtain  detailed 
descriptions  of how school-based  health  centers  coordinate  with managed  care 
providers,  we used  in-depth,  structured  personal  interviews  with  representatives  of 
both  school-based  health  centers  and  managed  care  providers  in these  communities. 
To  gain  a State  level  perspective,  we contacted  officials  in all States  with both 
Medicaid  managed  care  and  school-based  health  centers.  We  spoke  with  Medicaid 
and  Maternal  and  Child  Health  officials in 32 States  and  the  District  of Columbiaa  to 
discuss  managed  care  coordination  with school-based  health  centers.  We  used  in-
depth,  structured  telephone  interviews  for this purpose.  From  all respondents,  we 
requested  information  on the  barriers  to coordination  between  school-based  health 
centers  and  managed  care  providers  and  the  methods  for  overcoming  these  barriers. 
In total,  we used  structured  interviews  with 88 respondents.  Twenty-two  were  school-
based  health  center  and  managed  care  respondents,  while  66 respondents  were  from 
the  States.  We  also  gathered  information  during  open-ended  discussions  with  27 
others  in the  fields  of adolescent  health,  school-based  health  centers,  and  managed 
care.  No  standards  for measuring  school-based  health  center  processes  and  outcomes 
exish  available  data  varies  by community.  Our  evaluation  is based,  perforce,  on 
qualitative  data.  Such  data  does  not  provide  conclusive  proof  regarding  program 
effectiveness,  but  does  highlight  promising  leads  and  identi~  areas  needing  further 
study. 
Although  we focused  on specific  groups  of respondents,  our  findings  have  much  wider 
implications.  Most  of our  discussions  with managed  care  respondents  related  to 
Medicaid  managed  care,  but  our findings  are  relevant  to all managed  care  plans  whose 
8 
T& Diwict  of Columbia mpondcnn  will be counted witi State respondents in this report 
6  enrollees  can  receive  services  at school-based  health  centers.  Because  the 
preponderance  of school-based  health  centers  are  located  in high schools  and  middle 
schools,  and  the  serious  health  problems  relating  to adolescents,  our  discussions  with 
respondents  focused  on adolescent  health  and  school-based  health  centers  for 
adolescents.  As more  communities  create  school-based  health  centers  to meet  the 
health  needs  of younger  children,  the  many  of the  issues discussed  in this report  will 
apply  at  the  elementary  school  level. 
Appendix  A lists the  managed  care  and  school-based  health  center  sites visited. 
Appendix  B lists other  contacts  in the  fields of school-based  and  adolescent  health, 
and  managed  care.  Appendix  C is a selective  bibliography  which  includes  references 
we found  particularly  valuable  in this study. 
We  conducted  our  review  in accordance  with the  Qualify Standards for Inspechons 
issued  by the  Presidents  Council  on Integrity  and  Efficiency.  FINDINGS

Mainstream  health  care  delivery  in the  United  States  is undergoing  profound  change. 
Managed  care  and  school-based  health  services  represent  some  of this change. 
National  health  care  reform  may include  both  managed  care  and  school-based  health 
centers.  Either  managed  competition  guaranteeing  health  insurance,  or a universal 
health  care  system  increases  the  demand  for access  to primary  health  care  provided  by 
these  current  delivery  systems.  Managed  care  with its aggregate  of physicians  and 
related  services,  and  school-based  health  centers  with their  unique  abilities  to treat 
adolescents,  offer  mechanisms  to provide  this primary  medical  care. 
With  the  health  care  landscape  changing  rapidly,  the  timing  for creating  new, 
productive  linkages  may never  be better.  Although  this report  focuses  on school-based 
health  centers  and  coordination  with managed  care  providers,  it is logical  that  other 
medical  delivery  systems  need  to develop  similar  connections  that  ensure  patient 
access  to services  and  exchange  of medical  information. 
SCHOOLBASED  HEALTH  CENTERS  INCREASE  A-TO  HEALTH CARE 
FOR  ADOLEXENTS. 
on-de  school-based health centem inmase  access 10health cam 
Overwhehn@ly,  State  agency  respondents  (91 percent)  feel  that  school-based  health 
centers  improve  access  to health  care.  Many  respondents  cite  the  clinics location  as 
being  critical  in treating  adolescents.  By going where  the  kids are;  school-based 
health  centers  surmount  a major  barrier  to health  care  access  even  managed  care 
providers  cannot  address. 
Being  physically  located  in the  school  where  adolescents  spend  much  of their  day 
serves  to encourage  clinic usage.  This  access  to health  care  is illustrated  by the  repeat 
visits made  by adolescents.  The  Robert  Wed  Johnson  (RWJ)  Foundations  School-
Based  Adolescent  Health  Care  Program  estimates  that  in the  1990-91 school  year,  87 
percent  of the  visits made  to their  grantee  school-based  health  centers  were  repeat 
visits. 
Parents  of adolescents  in schools with school-based  health  centers  appreciate  the 
health  care  access  provided  their  children.  The  RWJ  reports  71 percent  of parents 
consented  to having  their  child treated  in school-based  health  centers  in  1990-91, an 
increase  from  34 percent  only 2 years  prior. 
8
 Parental  or guardian  consent  is the  only requirement  for students  to enroll  in school-
based  health  centers.  All school-based  health  centers  we visite~  and  all mentioned  by 
State  agency  respondents,  treat  all students  in need  of care  if a parent  or guardian  has 
signed  a consent  form authorizing  treatment.  Without  school-based  health  centers, 
many  adolescents  would  not  receive  health  services  since  they  are  not  covered  by 
private  insurance  or Medicaid.  For  example,  New York  State  estimates  that  in 1992, 
58 percent  of the  students  treated  in their  122 school-based  health  centers  were 
uninsured. 
In addition  to  primary  health  care,  the  school-based  health  centers  provide  specialized 
services  aimed  at  adolescents.  These  semices  include  educational,  preventive,  and 
confidential  services.  The  school-based  health  centers  can  provide  health  and  wellness 
training  in a classroom  setting  to educate  many  students,  or use  individual  counseling 
sessions,  whichever  is appropriate.  The  school-based  health  centers  use  outreach 
approaches  to  attract  students  to their  clinics.  These  outreach  efforts  vary from 
newsletters  to posters  to word-of-mouth. 
One  form  of outreach  school-based  health  centers  use effectively  is follow-up  and  case 
management  for  students.  The  school-based  health  centers,  by virtue  of their  location 
and  ties  to  the  school,  can  call in the  student  for folIow-up  treatment  or to provide 
reminders  to  keep  their  medical  appointments.  According  to school-based  health 
center  respondents,  adolescents  referred  to outside  health  providers  by school-based 
health  centers  have  a high rate  of completion  for referrals. 
Staff  at school-based  health  centers  are  trained  in dealing  with  adolescents  and 
problems  unique  to their  age  group.  The  staffs are  often  multidisciplinary  to deal  with 
more  complex  cases.  Theie  multidisciplinary  teams  draw  providers  from  the  fields  of 
medicine,  nursing,  social work  psychology,  health  education,  and  nutrition. 
One  of the  school-based  health  center  staff becomes  the  case  manager,  directing  the 
patient  to all necessaq  services,  ensuring  appointments  are  kep~  and  following  up on 
any outside  referrals.  In depicting  how this school-based  health  center  case  manager 
functions,  a Journal  of the  American  Medical  Association  article  describes  a Louisiana 
nurse  practitioners  actions:  W theyre  positive  (pregnant)  ... she  immediately  refers 
them  to the  Teen  Advocacy  Program,  and  then  they immediately  hook  up with  the 
nurse  midwife  program  at  the  local hospital,  and  they immediately  begin  good  prenatal 
care  with  close,  ongoing  follow-up  at schoo~  at home  through  the  social  worker,  and  at 
the  hospital.~ 
, 
9 
Go- Marsh  E,  Schd-ik?d  HcnldtClhiu  Pmvi& Esmuud Car&,J~  Vol 26S,#19,Moy 151991p,.2460. 
9  Repn&mh  agree thatschod-based  heaithcen&m  can*someseWiCCs  nmt!dy

thanarnanagui  cmptwidez

All managed  car~,  school-based  health  center,  and  State  agency  respondents  feel  that 
certain  services  can  be  delivered  more  easily by school-based  health  centers.  Some 
respondents  attribute  this ease  to the  school-based  health  centers  physical  proximity 
to the  students,  rather  than  special  expertise  of school-based  health  centers. 
Respondents  disagree  on which  services  are  more  easily provided  in school-based 
health  centers  versus  a managed  care  setting.  Some  of the  differences  are  due  to  local 
variations  in school-based  health  centers  and  the  services  they  offer.  Routine  health 
screenings,  mental  health,  reproductive  counseling,  and  treatment  of psychosocial 
problems  were  most  often  cited  by respondents  as areas  where  school-based  health 
centers  were  able  to provide  services  more  easily to adolescents. 
The  HCFA  encourages  States  to use school-based  health  centers  to perform  EPSDT 
screenings.  Even  though  many  Medicaid  children  are  covered  by managed  care  plaxM 
HCFA  recognizes  that  school-based  health  centers  offer  an  opportunity  to perform 
health  screening  for many  school-aged  children  who might  not  otherwise  be  tested. 
Despite  respondents  perspectives  and  anecdotal  evidence  indicating  school-based 
health  centers  are  responsive  to adolescent  needs  and  increase  access  to health  and 
psychosocial  services,  no national  data  exist that  demonstrate  school-based  health 
center  quality  and  effectiveness.  Early  school-based  health  center  evaluations  focus on 
utilization  of services  rather  than  health  outcomes.  The  few attempts  at  measuring 
school-based  health  center  outcomes  focus on a few clinics in a limited  geographic 
are%  and  their  findings  camot  be  projected  to all school-based  health  centers.  To 
date,  much  effort  has been  expended  to start  and  operate  school-based  health  centers 
rather  than  to define  how school-based  health  centers  should  operate  and  what  they 
should  accomplish.  As a result,  standards  and  outcome  measures  that  recognize 
common  school-based  health  center  functions  and  goals, beyond  local  interests,  have 
not yet  evolved. 
Some  efforts are  underway  to define  broadly  accepted  standards  for school-based 
health  centers.  One  organization,  The  Coalition  For  School-Based  Primary  Care,  has 
proposed  school-based  health  center  Standards  and  Operations  for New York  State 
school-based  health  centers.  (Appendix  D shows the  proposed  standards  developed 
by The  Coalition  For  School-Based  Primary  Care.)  Also, as part  of a CDC-funded 
initiative,  Columbia  University  has convened  three  meetings  of the  national  workgroup 
to recommend  national  standards  for school-based  health  centers. 
10
 HOWE- I.XITLE  COORDINATION EXISTSBEXWEEN  MANAGED  CARE 
PROVIDERS  Ni_D  SCHOOLA%4=D  HEALTH  CENTERS. 
FW  a~  f- or hfond  exist between managed  cm  pmvidm  and dod
based pmdirx 
Few respondents  told  us of any agreements,  formal  or informal,  between  school-based 
health  centers  and  managed  care  providers.  Four  of the  twelve  school-based  health 
center  programs  we visited  have  formal  agreements  with  managed  care  providers. 
State  officials  in 7 of the  33 States  we talked  to think  school-based  health  centers  and 
managed  care  providers  are  coordinating  either  formally  or informally.  In the  other 
26 States,  officials  knew  of no agreements  between  school-based  health  centers  and 
managed  care  providers.  In many  communities,  issues between  managed  care 
providers  and  school-based  health  centers  are  too  new to have  been  addressed. 
Little  tdumge  of medical infbnnalionUkespkhce  beZwe4?nmanugdmp*  and 
dtool-baxd  health C~. 
Most  respondents  said  sharing  patient  information  is not  routine.  Neither  the  school-
based  health  centers  nor  the  managed  care  providers  are  aware  of all the  treatments 
the  students  have  received.  Consequently,  managed  care  providers  camot  coordinate 
or manage  all the  care  given their  patients. 
Respondents  give different  reasons  for the  limited  exchange  of information.  Some 
believe  information  sharing  is only necessa~  on complex  illnesses.  Providers  may only 
share  information  with patient  consent,  and  some  say this has been  a barrier  to the 
exchange  of patient  information.  Some  school-based  health  centers  believe  time 
constraints  prevent  them  from  sharing  information  with other  providers.  Some 
providers  also believe  that  systems  for sharing  information  have  not  been  set  up.  For 
example,  in Baltimore  and  Philadelphia,  school-based  health  centers  share  information 
with providers  where  they  have  established  relationships  or formal  agreements.  But 
there  are  many  providers  with whom  these  clinics have  not  established  relationships. 
Many State  respondents  believe  that  information  sharing  does  not  occur  because  there 
has been  no interaction  between  managed  care  providers  and  school-based  health 
centers.  The  most  common  barrier  to exchange  of patient  information  mentioned  by 
respondents  is that  there  is no system  or history  of relationships  that  foster  the  sharing 
of information. 
11
 W==  betwt?enswuMc-anti?naM@-+~ 
manyofthe  baniemti  codinatk 
When  respondents  told  us why they feel  managed  care  providers  and  school-based 
health  centers  have  difficulty coordinating  medically  and  financially,  many  described 
inherent  differences  between  the  two providers.  Managed  care  providers  and  school-
based  health  centers  have  some  fundamental  differences  in their  approaches  to 
treating  adolescents.  These  opposing  perspectives  are  illustrated  by comparing  some 
defining  features  of managed  care  providers  and  school-based  health  centers  in the 
following  table. 
Definim  Features  of Manamxl  Care  Providers  and  S&c&based  Health  Centers 
II 
Descriptive Feature  Managed Care Providers  Schooi-based Health Centers 
l 
Patient characteristics  All agea
 School-aged, mostly adolescms  ! 
Diverse in race and economic
 Diverse in race and e.conom]c status  ~ 
status
 Medically undeserved,  targe 
I All are insured
 number of uninsured 
Services provided  Full range of primary,secondary,
 Primary care geared to children 
and tertiaq serviees
 with emphaais on edueation, 
prewnm,  paychc%ocia4and 
mental health seM-
Hours of seMce  Required to provide 24 hour
 Usually open school hours with 
acceas to care
 backup ffom sponsoring institutions 
GoaIa regarding service utilization  Designed to increase primary care
 Dea@ned to increase appropriate 
and reduce unneeesary  inpatient
 seMce  utilization 
hospital and emergency mom

I 
utilization

~ 
Profit or not-for-profit status  Can be for-pmtit, or not-for-profit
 Not-for-profit 
Funding sources  Billiig of private poliq  holdew
 Multiple funding sources including: 
Medicaid, and Medicare agenciea
 granta from foundationa, local, 
State, or Federal agencie% third-
party billing and, in-kind 
contributions 
The  table  ex@ins  some  differences  between  school-based  health  centers  and  managed 
care  provide=  in their  approaches  to service  utilization.  While  many  States  told  us 
they are  expanding  managed  care  Medicaid  as a way to increase  access  to a primary 
care  physician  and  to provide  medical  homes  for their  Medicaid  clients,  States  also 
expect  managed  care  providers  to control  utilization  of sexvices.  By requiring  patients 
to go through  their  prirna~  care  physicians  for authorization  of sewices,  managed  care 
providers  reduce  the  likelihood  that  patients  will use inappropriate  or unnecessary 
services.  Managed  care  providers  typically  serve  a more  diverse  patient  population  ~ 
where  concerns  about  overutilizing  services  are  more  relevant  than  with  adolescents. 
In contrast,  because  school-based  health  centers  focus on an  age  group  that 
traditionally  underutilizes  sexvicesj they  approach  health  care  with the  purpose  of 
increasing  appropriate  semice  usage. 
12  Although  both  managed  care  and  school-based  health  centers  offer  primary  care  to 
adolescent  school-based  health  centers  are  able  to attract  adolescents  to use  medical 
services.  The  school-based  health  centers  have  the  advantage  of high visibility to 
adolescents  due  to their  site  location. 
Rquon&m  cite nummiabanim  &CUtW&@ZO  n between school-bad  bed%  ceniim 
and rnunaged carepmidem 
Most  respondents  described  multiple  barriers  to coordination  between  managed  care 
providers  and  school-based  health  centers.  The  two most  commonly  mentioned 
barriers  are  communication  and  financial  barriers.  Respondents  also encountered 
obstacles  related  to issues  of legality  and  confidentiality. 
Communication  Barriers 
 
Forty  percent  of our  respondents  said communication  impedes  coordination.  Many 
State  officials  told  us that  school-based  health  centers  and  managed  care  providers 
have  never  communicated,  and  in some  cases,  managed  care  providers  may not  know 
school-based  health  centers  exist. 
Before  the  two providers  can  effectively  communicate,  they  must  be  able  to appreciate 
each  others  role  and  perspective.  State  and  school-based  health  center  respondents 
indicate  that  each  provider  doesnt  understand  the  other,  there  are  different 
motivations  from  the  two types  of providers,  and  the  providers  face  the  obstacle  of 
overcoming  a perceived  philosophic  difference  of a public  health  versus  a lower 
utilization  outlook  when  communicating. 
Managed  care  respondents  see  communication  as a logistical  obstacle.  They  believe 
there  are  many  parties  involved  in coordinating  with school-based  health  centers.  In 
addition  to coordinating  with  the  school-based  health  center,  a provider  may have  to 
coordinate  with  health  departments,  school  boards,  and  a variety  of agencies  involved 
with the  school-based  health  centers.  Another  problem  cited  was that  school-based 
health  centers  communicating  with some  primary  care  case  manager  plans  may be 
difficult  since  there  are  often  hundreds  of primary  care  case  managers  within  one  plan. 
Financial  Barriers 
 
Thirty-eight  percent  of all respondents  believe  financial  barriers  impede  coordination. 
Financial  barriers  impede  negotiations  between  school-based  health  centers  and 
managed  care  providers  because  the  two providers  must  in some  ways compete  for a 
limited  amount  of funds.  As school-based  health  center  respondents  explain,  managed 
care  providers  are  often  profit  motivated,  so there  is no incentive  to coordinate  with  . 
us, and  providers  do  not  want  to give up care  of their  patients  if it affects  their 
income. 
13
 So while managed  care  providers  support  the  concept  of school-based  health  centers, 
they may have  a disincentive  to forge  formal  agreements  with them  because  it may 
mean  giving up some  funds.  Although  managed  care  providers  were  much  less likely 
to mention  financial  barriers,  some  did admit  that  we might  see  it as a cost increaser 
if patients  got care  at the  school-based  health  centers.  The  State  officials comments 
echo  these  sentiments.  Many  State  respondents  pointed  out  that  the  providers  must 
work  out  who will provide  what  services,  and who will be paid  for these  semices. 
Legal  Barriers 
 
Legal  considerations  represent  a barrier  to coordination  in several  ways.  Managed 
care  providers  are  liable  for their  patients  care.  If school-based  health  centers 
provide  care,  the  managed  care  plan  must  oversee  the  school-based  health  centers  to 
ensure  quality  of care. 
Also, school-based  health  centers  may not  meet  some  of the  qualifications  primaxy 
care  physicians  must  meet  to participate  in managed  care  plans.  Respondents  from 
two States  mentioned  State  laws that  prevent  school-based  health  centers  from 
delivering  Medicaid  semices  because  of the  fact  that  non-physician  professionals 
deliver  most  semices  rather  than  physicians. 
Confidentiality  of patient  records  present  a legal barrier  to coordination.  Patient 
medical  records  must  be confidential,  and  coordination  between  managed  care 
providers  and  school-based  health  centers  could  breach  that  confidentiality.  Many 
providers  told  us they  had  overcome  this problem  however,  with consent  forms 
allowing  release  of pertinent  medical  information  to their  providers. 
Cordldentiality  Barriers 
 
Aside  from  the  legal  issue of confidentiality,  respondents  mention  that  coordination

may jeopardize  adolescents  need  to keep  certain  services  confidential.  Adolescents

may want  to keep  certain  medical  treatment  confidential  horn  friends,  teachers,  or

even  parents.  Without  assurance  that  their  records  are  confidential,  adolescents  may

not  seek  these  services.

Where  school-based  health  centers  coordinate  with managed  care  providers,

adolescents  may have  fears  that  their  medical  records  will be  less confidential  if

school-based  health  centers  bill or notiq  managed  care  providers  about  these  services.

Adolescents  may fear  that  parents  will have  access  to the  managed  care  providers

copy of their  records.  Also, medical  plans  routinely  send  an Explanation  of Benefits

to the  patients  home.  For  these  reasons,  school-based  health  centers  may be

reluctant  to coordinate  with managed  care  providers,  or to bill Medicaid  or managed  ~

care  providers  for these  services.

14
 The  vast  majority  of our  respondents  believe  there  would  be  undesirable  consequences 
if school-based  health  centers  and  managed  care  providers  do not  coordinate  with 
each  other.  Responses  are  similar  for all types  of respondents.  Those  we interviewed 
worry  most  about  how a lack  of coordination  may affect  the  continuity  of health  care 
for patients.  They  wow  one  provider  might not  know about  semices  provided  by the 
other.  Some  believe  that  clients will be confused  about  where  to get  care  because 
no one  is telling  them  when  it is appropriate  to go to a school-based  health  center  and 
when  a managed  care  provider  may be  more  appropriate.  Respondents  feel  lack  of 
coordination  between  the  two types  of providers  can be  disastrous  for  individual 
healthcare,  because  adolescents  may get lost in a maze  of a health  care  system, or 
fall through  the  cracks. 
State  and  school-based  health  center  respondents  are  particularly  concerned  about 
duplication  of payment,  saying school-based  health  centers  in effect  subsidize  managed 
care  providers  when  they  se~e  managed  care  patients.  The  school-based  health 
centers  often  treat  students  enrolled  in managed  care  plans,  but  usually  are  not 
reimbursed  by managed  care  providers  since school-based  health  centers  are  out-of
pkm  providers.  In a sense,  school-based  health  center  sewices  to Medicaid  managed 
care  students  are  paid  tice.  The  State  Medicaid  agency  pays first when  it pays 
managed  care  providers  a fixed rate  for each  patient  enrolled  in its plan.  If managed 
care  providers  are  unwilling  to reimburse  the  school-based  health  center  for  services  to 
its enrolled  patients,  then  the  school-based  health  center  pays for the  semice  a second 
time  from  its own funds. 
Respondents  believe  this duplication  of payment  is serious  because  it drains  school-
based  health  center  resources  and  may force  some  borderline  school-based  health 
centers  out  of business.  In this way, duplication  of payment  may indirectly  limit  access 
to health  care  for  all school-based  health  center  patients,  not just  those  in managed 
care  plans. 
Medicaid  managed  care  providers  face  reduction  in their  Medicaid  cavitation  rate  if 
they  are  not  providing  all services  reflected  in the  cavitation  rate.  These  providers 
could  perceive  the  school-based  health  centers  as removing  patients  from  their  medical 
home  and  draining  funds  from  the  managed  care  system. 
SOME  INITIAL  EFFORTS  TO  COORDINATE  DEMONSITIATE  POTHWWW 
B~  FOR  ~~  MANAGED  CARE PROVID~  AND 
SCHOOLBASED  HEALTH  CENTERS. 
In communities  where  school-based  health  centers  have  agreements  with  local 
managed  care  providers,  all parties  can benefit  from  incre-med  capabilities  to deliver 
managed  and  coordinated  care.  To  understand  these  benefits,  a description  of the 
15  different  models  is helpful.  A companion  report,  School-based  Health  Centers  and 
Managed  care:  Examples  of Coordination  (OEI-05-92-00681)  describes  each  of these 
examples  in greater  detail. 
1.	 State  law recwirirw Medicaid  managed  care  providers  to coordinate  with school-
based  health  centers 
Oregon  is the  only State  with a law requiring  coordination  between  managed  care 
providers  and  school-based  health  centers.  The  law requires  State  agencies  to 
mandate  that  managed  care  providers  and  publicly funded  health  care  providers 
develop  agreements  authorizing  payment  for the  following semices:  immunizations, 
sexually transmitted  diseases,  and  other  communicable  diseases.  Because  all Oregon 
school-based  health  centers  are  operated  by county  governments  or State  agencies, 
they fall under  the  rubrics  for publicly funded  health  care  providers.  The  law also 
requires  State  entities  to encourage  and  approve  agreements  between  managed  care 
providers  and  publicly  funded  healthcare  providers  for  additional  setices  and  to 
develop  agreements  to coordinate  in other  ways.  (Appendix  F contains  a copy of the 
Oregon  law and  the  Medicaid  agency  implementing  procedures.) 
2.  Laal  contract  between  manatzed  care  orovider  and  school-based  health  center 
Only one  community  we contacted  has a formal  contract  between  a managed  care 
provider  and  area  school-based  health  centers.  St. Paul,  Minnesotas  Health  Start 
school-based  health  centers  have  negotiated  a contract  with Ramsey  Hospital,  a 
managed  care  provider  for the  St. Paul  area.  The  six Health  Start  schml-based  health 
centers  are  reimbursed  on a fee-for-service  basis by Ramsey  Hospital  for  all Ramseys 
Medicaid  patients  the  school-based  health  centers  treat.  The  contract  treats  the 
school-based  health  centers  much  like any other  plan  provider,  subject  to the  same 
review  as other  primary  care  physicians  for Ramsey.  Therefore,  the  school-based 
health  centers  must  adhere  to the  quality  standards  other  Ramsey  providers  must 
meet. 
3.	 Formal  nrotocol  for  referral  and  treatment  between  mana~ed  care  provider  and 
school-based  health  center 
Although  no contract  exists, Total  Health  Care,  a managed  care  provider  in Baltimore, 
and  Baltimore  City school-based  health  centers  have worked  out  a detailed  agreement 
to coordinate  sexvices for students  enrolled  in Total  Health  Care.  The  school-based 
health  centers  and  Total  Health  Care  have  agreed  on protocols  that  define  when  a 
child should  be  referred  to Total  Health  Care  and when  it is appropriate  for the 
school-based  health  center  to provide  service.  When  school-based  health  centers 
provide  services  to Total  Health  Care  students,  they are  reimbursed  by Total  Health 
Care  at Medicaid  rates.  The  protocols  require  reporting  any care  given  at the  school-
based  health  center  to Total  Health  Care  so that  the  prima~  care  physician  stays 
informed.  The  school-based  health  centers  often  schedule  and  foUow-up on 
16
 appointments  with Total  Health  Care  primary  care  physicians  for the  students. 
(Appendix  E includes  a chart  depicting  the  protocols  established.) 
4.	 Includim  rnana~ed  care  ~roviders  in coalitions  which  fund  and  develoD school-
based  health  centers 
The  Minneapolis,  Mimesota  Board  of Education  is negotiating  with several  managed 
care  providers  in the  area.  As a result  of these  meetings,  Medics,  a managed  care 
plan,  is underwriting  the  full cost of one  of the  Minneapolis  school-based  health 
centers  for a year.  The  other  managed  care  plans  in Hennepin  County  are 
collaborating  with the  school-based  health  center  program  and  are  considering 
pledging  $1 million  to fund  the  other  Minneapolis  school-based  health  centers.  In 
return,  students  enrolled  in their  plans  will receive  prirna~  care  and  preventive 
semices  through  the  school-based  health  centers.  The  managed  care  plans  will work 
together  with  the  school-based  health  centers  to determine  which  health  services 
should  be delivered  in schools  and  which  should  be delivered  elsewhere  in the 
community. 
5.- Entities  that  administer  school-based  health  centers  also  administer  managed 
care  tians 
In three  communities  we visite~  public  entities  who run  managed  care  plans  also 
operate  school-based  health  centers.  Although  this structure  was not  developed  to 
address  the  conflict  between  managed  care  providers  and  school-based  health  centers, 
this type  of administration  has several  benefits.  For  example,  in Brooklyn,  New York, 
students  enrolled  in Healthcare  Plus, the  managed  care  plan  run  by Sunset  Park 
Family  Health  Center,  can  choose  one  of ten  school-based  health  centers  also  run  by 
Sunset  Park  as a primary  care  provider.  Sunset  Park  has just  developed  a data  system 
for all of its clients  so that  when  a child receives  care  at the  school-based  health 
center,  the  record  of that  visit is available  throughout  the  Sunset  Park  network. 
6.	 Managed  care  nroviders  authorize  school-based  health  centers  to rwovide care 
and  bill Medicaid  directlv  for service 
Another  example  of informal  coordination  takes  place  in several  communities  where

school-based  health  centers  get  an authotition  number  from  a managed  care

provider  to treat  students  and  bill Medicaid  directly  for services.  For  example,  in

Hillsborough  County,  Florida  primary  care  case  managers  sometimes  authorize

school-based  health  centers  to conduct  EPSDT  screening.  Also  in Hillsborough

County,  the  major  managed  care  provider,  Century/PCA  Health  Plans,  has  authorized

a school-based  health  center  located  in an alternative  school  for pregnant  teens  to

deliver  all prenatal  and  postpartum  care  to several  of the  plans  Medicaid  eligible  ~

members.

17
 7.	 Managed  care  rives  exnedited  natient  care  on school-based  health  center 
referrals 
In San Francisco;  the  Balboa  High  School  Teen  clinic has an informal  arrangement 
with Kaiser  Permanence  so students  receive  expedited  appointments  when  the  school-
based  health  center  makes  referrals  to Kaiser  Permanence.  When  a patient  enrolled 
in Kaiser  Permanence  goes to the  school-based  health  center  and  needs  further  care, 
the  clinic telephones  a representative  from  the  managed  care  plan  and  arranges  an 
appointment  for  the  child.  In this case,  the  school-based  health  center  performs  a 
triage  function  when  making  referrals  by assessing  the  urgency  of the  childs problem. 
EVEN  THOUGH  SCHOOLBASED  HEALTH  CENTERS  AND  MANAGED 
CARE ARE EXPANDING RAPIDLY, HHS HAS NO FOCAL POINT 
COORDINA~G  DEPARTMENTALPROGRAMS  AND  A~  INTHE= 
AREAS. 
The  HHS  has a hand  in both  managed  care  and  school-based  health  centers  in a 
variety  of agencies.  Within  HHS,  there  is no locus for decisionmaking  on issues 
affecting  both  school-based  health  centers  and  managed  care.  The  Interagenq 
Committee  on School  Health  offers  a first step  toward  bringing  the  fragmented  players 
in school-based  health  together.  But  no committee  participant  nor  PHS  or HCFA  is a 
focal  point  for outside  entities  to contact.  Therefore,  those  States  new to school-based 
health  centers  or managed  care  may not  know where  to request  information  or 
technical  assistance.  As States  expand  both  managed  care  and  school-based  health 
centers,  the  need  for a focal  point  to bring  together  perspectives  in HHS  will grow. 
Numerous  State  and  local  governments  are  establishing  school-based  health  centers  in 
response  to the  documented  need  of primary  medical  care  for adolescents.  Twenty-six 
of thirty-three  State  Maternal  and  Child  Health  agency  respondents  say their  States 
anticipate  school-based  health  center  expansion  in the  next  several  years.  Also, some 
States  that  currently  do not  have  Medicaid  managed  care,  like West  Virgini~  are 
making  school-based  health  centers  integral  to their  States  health  care  reform. 
Managed  care  plans  may play an increased  role  in health  care  delivery  when  national 
health  care  reform  occurs.  If so, the  number  of managed  care  plans,  providers  and 
patients  covered  by managed  care  will also rise.  In addition,  States  see  managed  care 
as a way to increase access  to care  for Medicaid  patients  as well as contain  health  care 
costs.  Thirty  of thirly-three  State  Medicaid  agency  respondents  say their  States  will 
expand  managed  care  in the  near  future.  Some  of this expansion  will be  massive.  For 
example,  California  Medicaid  covers  600,000 recipients  under  managed  care  plans  and 
is seeking  to expand  coverage  to 3 million  in the  next few years.  In addition,  some   
States  that  currently  do not  have  managed  care  will institute  managed  care  programs. 
18
 As both  managed  care  and  school-based  health  semices  expand,  adolescents  enrolled 
in managed  care  plans  will be more  likely to have  access  to school-based  health 
centers  and  the  need  for coordination  will grow.  The  immediate  need  is to find ways 
for managed  care  and  school-based  health  centers  to complement  each  other  in 
delivering  health  care  to adolescents. 
Conclusion 
At  present,  there  is a dearth  of needed  information  on school-based  health  centers, 
and-in particular,  regarding  coordination  with  managed  care.  Current  literature  on 
adolescent  health  explains  their  health  needs  in great  detail  and  the  consequences  of 
not  addressing  these  needs.  However,  there  is no adequate  assessment  of how 
different  providers  deliver  care  to adolescents.  We  do not  know  how adolescents  are 
being  sewed  by managed  care  organizations.  Early  assessments  of school-based  health 
centers  are  promising,  as shown  by RWJ,  and  anecdotal  evidence  supports  the  idea 
that  school-based  health  centers  are  an  appropriate  way to deliver  services  to 
adolescents.  But  the  literature  on school-based  health  centers  rarely  gives a national 
perspective  and  provides  little  information  about  health  outcomes  for  adolescents,  and 
there  are  no national  school-based  health  center  performance  standards  for process  or 
outcome  measures. 
Both  managed  care  providers  and  school-based  health  centers  argue  that  they  deliver 
services  cheaply.  But,  the  data  showing  the  extent  of semices  provided  to  adolescents 
by managed  care  providers  and  school-based  health  centers  vary by community.  In 
addition,  no one  has  systematically  tried  to assess and  compare  the  cost-effectiveness 
of each  in delivering  primary  and  preventive  care  to adolescents. 
Only a few communities  have  begun  to address  coordination  between  school-based 
health  centers  and  managed  care  providers.  Because  their  efforts  are  new, we cannot 
draw  conclusions  about  their  effectiveness.  With  these  gaps  in our  understanding  of 
managed  care  and  school-based  health  cente~  HHS  has little  information  available  to 
make  policy decisions  regarding  school-based  health  centers  and  managed  care. 
19
 RECOMMENDATIONS

Both  the  PHS  and  HCFA  designated  contacts  should  lead  efforts  to bring  parties  in 
the  Department  together  to resolve  issues between  managed  care  providers  and 
school-based  health  centers.  Both  PHS  and  HCFA  administer  a variety  of programs 
relating  to school-based  health  centers  and  managed  care.  The  designated  contacts 
should  work  to coordinate  these  efforts. 
The  designated  contacts  should  present  a cohesive  view of HHS  activities  on school-
based  health  centers  and  direct  people  to appropriate  sources  of information.  The 
designated  contacts  would  also be  HHS link to other  agencies,  like the  Department  of 
Education,  who  have  also taken  an  active  role  in school-based  health  centers. 
The  designated  contacts  should  work  with national  organizations  and  experts  to 
develop  a strategy  for providing  needed  information  to interested  lo@  State  and 
Federal  parties.  Many  communities  are  new to managed  care  or school-based  health 
centers.  As they  seek  information  regarding  school-based  health  centers,  they  should 
be  able  to access  information  from  someone  with an ovemiew  of school-based  health 
cente~  as well  as an understanding  of issues  relating  to managed  care  and  schooi
based  health  centers. 
The  designated  contact  for school-based  health  centers  appointed  by the  Assistant 
Secretary  for Health  should  work with PHS  to maintain  current  information  about  the 
development  of school-based  health  centers  on a national  basis.  Since  it is likely that 
HI-IS funds  to school-based  health  centers  will increase  as the  number  of school-based 
health  centers  grows, HHS  needs  to be aware  of school-based  health  center  activity. 
%  PH~  HCFA  and the Szates shouki encoumge Wopenlikm  Mweeat  schod-inm?d 
hedhcenrmand  ?nanagedcan?plwvi&% 
Those  HHS  agencies  working  with States  and  communities  on school-based  health 
centers  and  managed  care  should  encourage  States  and  communities  to forge  working 
relationships  between  managed  care  providers  and  school-based  health  centers.  As 
health  care  reform  takes  shape,  this coordination  will be more  important  than  ever. 
Many  treated  at school-based  health  centers  who currently  have  no  health  insurance 
coverage  may soon  be guaranteed  access  to health  care,  and  many  of these  students   
may enroll  in managed  care  plans.  Coordination  between  managed  care  providers  and 
school-based  health-centers  ~ essential  to address  adolescents  special  needs,  like 
20
 expanded  mental  health  services  and  counseling,  and  to overcome  treatment  barriers 
unique  to adolescents,  like patient  confidentiality. 
Examples  of actions  that  could  be undertaken  include  the  following. 
s	 The  PHS  and  HCFA  can work  together  to include  both  managed  care  and 
school-based  health  centers  on issues affecting  child  health,  where  appropriate. 
These  issues  offer  opportunities  to bring  both  managed  care  and  school-based 
health  centers  together  to resolve  problems  or  meet  national  priorities.  The 
PHS  and  HCFA  should  work closely with their  designated  contacts  on issues 
relating  to managed  care  providers  and  school-based  health  centers. 
The  PHS Health  Resources  and  Sem-ices Administratio~  CIX,  and  HCFAS 
 
Medicaid  managed  care  division  can  coordinate  internal  sessions  so those 
working  with managed  care  issues can  have  exposure  to those  working  with 
school-based  health  centers  and vice versa.  These  sessions  can  be  a part  of 
routine  conferences,  or arranged  separately  from  conferences  already 
scheduled.  These  agencies  should  make  attempts  to include  other  agencies 
represented  on the  Interagency  Committee  on School  Health  when  planning 
training  that  focuses  on school-based  health  centers  and  managed  care.  The 
training  should  inform  agencies  working  on school-based  health  centers  and 
managed  care  of the  State  and  national  issues involving  coordination  and  the 
obstacles  to coordination  between  school-based  health  centers  and  managed 
care  providers. 
To  encourage  States  to forge  working  relationships  between  managed  care 
	
providers  and  school-based  health  centers,  HHS  agencies  can  host  several 
regional  meetings  or a national  training  conference  on managed  care  and 
school-based  health  clinic coordination.  Participants  should  include,  but  not  be 
limited  to, representatives  horn  managed  care  systems  and  school-based  health 
centers.  Conference  organizers  should  also bring  together  State  Medicaid  and 
Maternal  and  Child  Health  officials,  and  representatives  from  foundations, 
interest  grou~  and  other  agencies  to discuss issues  and  efforts  related  to 
coordination  between  managed  care  and  school-based  health  centers,  obstacles 
to coordination,  and  strategies  for overcoming  barriers  to coordination.  For 
example,  one  meeting  could  address  the  barrier  created  by the  patients  desire 
for personal  privacy  when  confidential  services  are  provided  (e.g.,  mental  health 
services).  The  need  for privacy  conflicts  with the  need  to exchange  medical 
information  between  the  school-based  health  center  and  the  physician  managing 
the  care  of that  patient. 
The  PHS  and  HCFA  can complement  their  conferences  ad  training  with other, 
	
mechanisms  to share  information  on managed  care  and  school-based  health 
centers.  The  PHS  and  HCFA  can  include  information  on managed  care  and 
school-based  health  centers  in literature  they routinely  send  to S;ate  agencies  to 
keep  them  informed  of new developments  in this area. 
21  Options  that  would  add  to HI-IS informationl  include: 
Within  PHS,  the  Agency  for Health  Care  Policy and  Research  (AHCPR)  could 
	
fund  a study  of utilization  of adolescent  primary  and  preventive  health  care 
setices,  including  mental  health  and  substance  abuse  prevention  and  treatment 
sewices.  The  study should  focus on utilization  in private  and  public  managed 
care  organizations  as well as in school-based  health  centers.  The  study  should 
compare  the  cost-effectiveness  of school-based  health  clinic services  to managed 
care  services  for this age group.  In designing  the  study, AHCPR  should  set 
guidelines  for the  minimum  criteria  that  should  be  included  in comprehensive 
adolescent  primary  and  preventive  care. 
The  PHS  could  work with HCFAS managed  care  division  to provide  small 
	
grants  to communities  to encourage  innovations  that  address  coordination 
between  managed  care  providers  and  school-based  health  centers.  These 
grants  should  include  evaluation  of these  innovations  to look  at what  types  of 
solutions  may be appropriate  for certain  models  of managed  care  providers. 
The  PHS  and  HCFA  could  contract  for a study  on model  performance 
	
standards  for school-based  health  centers.  If HHS  intends  to recognize  the 
value  of school-based  health  centers  in the  health  care  systernj it must  identify 
features  and  practices  integral  to any school-based  health  clinic. 
Within  PHS,  the  Center  for Mental  Health  Services  could  expand  their  current 
	
child studies  that  examine  effective  ways to deliver  mental  health  sewices  to 
adolescents  in school  settings. 
AGENCY COMMENTS

We  received  comments  from  the  Health  Care  Financing  Administration  and  the  Public 
Health  Service.  Both  agencies  supported  the  recommendatio~  suggested  important 
clarifications  and  identified  additional  issues regarding  school-related  and  youth  health 
programs.  The  complete  text  of the  Health  Care  Financing  Administration  comments 
are  included  in Appendix  G.  The  Public  Health  Sexvice comments  are  included  in 
Appendix  H.  We  welcome  the  HCFA  and  PHS  support  for the  recommendations  in 
22
 our  draft  report.  We  made  appropriate  revisions  to the  report  based  on their 
comments 
In response  to PkIS comments  and  suggestions,  we revised  the  Background  section  to 
reflect  the  differences  belween  health  education  curriculum  and  health  service% both 
of which  a school-based  health  center  may provide,  and  the  Methodology  section  to 
describe  the  qualitative  data  we collected.  We clarified  the  need  to collect  data  on 
both  the  processes  of delivering  setices  in a school-based  health  center  as well as 
developing  outcome  measures  for these  services.  In addition,  we expanded  the 
options  for conferences  for school-based  health  centers  and  managed  care  providers. 
We  now provide  an  option  to deal  with overcoming  the  barriers  presented  by the 
patients  need  for personal  privacy when  it conflicts  with the  need  to exchange  medical 
information.  We  also acknowledged  current  research  undenvay  in the  Department. 
The  PHS  suggested  revising  the  recommendation  to name  designated  contacts  in PHS 
and  HCFA  for school-based  health  center  issues since  they  perceived  it primarily  as an 
option  to enhance  information  exchange  with HCFA  on these  matters.  InsteaG  we 
refocused  this recommendation  to emphasize  the  importance  of a designated  contact 
for coordination  on school-based  health  center  issues.  The  designated  contacts  should 
first serve  as a focal  point  in their  agencies  in resolving  issues  involving  school-based 
health  centers  and  managed  care.  In additio~  they should  work with  the  other 
designated  contact  when  cross-cutting  measures  are  needed  to resolve  these  issues.  To 
help  share  information  with communities  and  other  agencies,  the  designated  contacts 
can work with  existing bodies  like the  Interagency  Committee  on School  Health. 
23
 APPENDIX  A 
SCH~LBN~  HEALTH  CENTER  AND  MANAG~  CARE  RESPO~E~ 
A-1  School-bud  HeaUh Cetier  RqPo@m 
Adolescent  Health  Program 
Minneapolis  Public  Schools 
254 Upton  Avenue  South 
Minneapolis,  MN  55405-198 
contact:  &me  St. Gerrnaine 
Comprehensive  School  Health  Services  Program 
Baltimore  Health  Department 
303 E. Fayette  2nd Floor 
Baltimore,  MD  21202 
Contact:  Bemice  Rosenthal 
a partnership  in Health  Care  for Denvers  Youth 
Denver  School-Based  Clinics: 
Universiv  of Colorado  Health  Sciences  Center 
BOXB-206 
4200 E. 9th  Ave. 
Denver,  CO  80262 
Contact:  Bruce  P. Guernsey 
Department  of Health  and  Rehabilitative  Services 
Hillsborough  Coun~  Public  Health  Unit 
PO  Box 5135 
Tampa,  FL  33675-5135 
Contact:  Mary  Emma  Howard 
Family  Health  Bureau

San  Francisco  Dept.  of Public  Health

101 Grove  St. Room  115

San Francisco,  CA  94102

Contact:  Stephen  Purser 
Far  Rochwy  High  School-Based  Clinic 
821 Bay Mth  St. 
Far  RocMwy,  NY  11691 
Contact:  Linda  Jusczak 
Health  Start 
640 Jackson  St. 
St. Paul,  MN  55101 
Contact:  Donna  Zimmerman  North  East  Medical  Sexvices 
1520 Stockton  St. 
San  Fran*,  CA  94133 
Contacc  Sophie  Wong 
Spectrum  Health  Services

5619 Vine  St.

Philadelphia  PA  19139

Contact:  Karolyn  Baxter 
The  Teen  Health  Center 
2016 43rd  Street 
Galveston,  TX  77550 
Contact:  Stephen  Bamet~  M.D. 
School  Health  & Community  Pediatrics 
Department  of Pediatrics,  C-19 
University  Texas  Medical  Branch 
Galveston,  TX  77550 
Afanuged Care Reirpondenls 
The  Bronx  Health  Plan 
1 Fordham  Plaza 
Suite  1000 
Bronx,  NY  10458 
Contact:  Maura  Bluestone 
Childrens  Medical  Center 
1575 Vine  St. 
Denver,  CO  80206 
Contact:  Jules  Amer,  M.D. 
Kaiser  Perrnanente 
10350 East  Dakota  Avenue 
Denver,  CO  80231-1314 
Conta@.  Kristin  Paulson  Snyder 
Kaiser  Perrnanente 
1950 Franklin  St. 3rd Floor 
Oakland,  CA  94612-2998 
Contact:  Jean  Nudelman 
A-3
 Kaiser  Permanence 
7201 N. Interstate 
Portland  OR  97217 
contact  Anne Plunkett 
Medics

PO  Box  1587, Route  7780

Minneapolis,  MN  55440-1587

Contact:  Lais  Wattman 
PCA  Health  Plans 
8303 Mopac,  Suite  450 
Austin,  TX  78759 
Contact:  Jan  Scott 
PCA  Health  Plans  and  Century  Medical  Health  Plan,  Inc.

2002 N. Lois Avenue

Suite  100

Tampa,  Florida  33607

Contact:  Steve  Gritin 
Total  Health  Care 
1501 Division  St. 
Baltimore,  MD  21217 
Contact:  Joan  Phillips 
ReqxmdeM  Opemting Both Mmnged  Care Planr and School-based  Health  CerUm 
Greater  Philadelphia  Health  Action,  Inc. 
Executive  Offices:  4510 Frankford  Ave. 
Philadelphia  PA  19124 
Contact:  Ronald  E. Heigler 
Multnomah  County  Health  Department

426 SW Star&  8th Floor

Portland  OR  97204

Contact  for  managed  care:  Mary  LOU  I+enrich 
Contact  for school-based  health  centers:  Billie Carlson 
Sunset  Park  Family  Health  Center 
The  Lutheran  Medical  Center 
150 55th  St. 
Brooklyn,  NY  11220 
Contact:  Jim  Stiles 
A-4
 APPENDIX  B 
OTHER  SCI-KXLBASED  HEALTH  ~  ADOLESCENT  HEALm 
OR  MANAGED  CARE  CONTACI% 
B-1  Robert  Blum,  M.D.

University  of Mimesota

Minneapolis,  Minnesota

Claire  Bnndis,  Dr.  P.H.

Center  for  Reproductive  Health  Policy Research

University  of California

San Francisco,  California

Christel  Brellochs

Columbia  University  School  of Public  Health

New York,  New  York

Stu Cohen,  Deputy  Director

Health  & Human  Development  Programs

Newton,  Massachusetts

Debra  Delgado,  Associate  Director

The  School-Based  Adolescent  Health  Care  Program

Robert  Wood  Johnson  Foundation

Washington,  D.C.

Joy DxyfoOMS,.A. 
Hastings-on-Hudson,  New York 
Tim  Dunn,  Associate  Center  Director

Center  for  Health  Promotion  & Education

Newton,  Massachusetts

Florence  Frucher,  Director

Office  of Medicaid  Managed  Care

New  York  City Department  of Health

New York,  New  York

Holly  Allen  Grason,  Deputy  Director

Association  of Maternal  and  Child  Health  Programs

Washington,  D.C.

Karen  Hacker,  M.D.

Director  of Adolescent  Services

Division  of Public  Health

City of Boston,  Department  of Health  & Hospitals

Boston,  Massachusetts
 Debra  Hauser,  M.P.H.

Director,  Suppti  Center  For  School  Based  health  Centers

Center  For  Population  Options

Washingto~  D.C.

Vince  Hutchins,  M.D.,  M.P.H.

Executive  Director,  National  Ready  To  Learn  Foundation

Bethesda,  Maryland

Renee  Jenkins,  M.D.

Director  of Adolescent  Medicine

Howard  University  Hospital

Washington,  D.C.

David  Kaplan,  M.D.,  M.P.H.

Chief,  Adolescent  Medicine

The  Childrens  Hospital,  Department  of Pediatrics

University  of Colorado  Health  Sciences  Center

Denver,  Colorado

Jonathan  D. Klein,  M.D.,  M.P.H.

Assistant  Professor  of Pediatrics

Division  of Adolescent  Medicine

University  of Rochester  Medical  Center

Rochester,  New  York

Christine  Layton,  M.P.H.

Maternal  and  Child  Health  Project

National  Association  of County  Health  Officials

Washington,  D.C.

Julia  Graham  Lear,  Ph.D.,

Co-Director,  The  School-Based  Adolescent  Health  Care  Program

Robert  Wood  Johnson  Foundation

Washingto~  D.C.

Manette  Murphy,  M.D.

Adolescent  .Medicine

Childrens  Service

Massachusetts  General  Hospital

Boston,  Massachusetts

Lydia  ODonnell

Education  Development  Center,  Inc.

Newton,  Massachusetts

B-3
 Tracey  M. Orloff,  M.P.H.

Senior  Health  Associate

Childrens  Defeqse  Fund

Washingto~  D.C.

J.P.  Perino,  Director

Training  & Support

Q.D.  Systems

Berkeley,  California

Phillip  J. Porter,  M.D.

Healthy  Children  Program

Division  of Health  Policy Research  and  Education

Hamard  University

Brookline,  Massachusetts

Howard  Spivak,  M.D.

Chief,  Division  of General  Pediatrics

New England  Medical  Center  Hospitals

Boston,  Massachusetts

Rebecca  Stone,  Senior  Consultant

Ounce  of Prevention  Fund

Chicago,  Illinois

Michael  D. Usdan,  President

The  Institute  For  Educational  Leadership

Washington,  D.C.

Ann  Delisi  Vetter,  R.N.,  M.S.N.

Child  Health  Program  Coordinator

Travis  County  Health  Department

Austin,  Texas

Bobbie  Wunsch

Health  Care  Consulting  & Management  Semites

San  AnsehnQ  California

B-4
 APPENDIX  C 
sELEcrED BXBLXOGRAPWON SCHOOI=BN~  HEALTH 
AND  ADOLESCENT  HEALTH 
c-1  Bibliography   
Brindis,  CIaire,  School-Based  Health  Clinics,f chapter  for Maternal and ChiZdHealth 
Practices, Third  Party  Publishing,  (available  September,  1993). 
Center  for  the  Future  of Children,  7he Future  of Chikfren,  Volume  2, Number  1, (Spring 
1992) 
Congress  of the  United  States,  Office  of Technology  Assessment,  Adolescent Heahh 
Volumes ~ IL and /11, (November  1991). 
Dryfoos,  Joy G., Adolescents  at Risk  A Summation  of Work  in the  Field  - Programs 
and  Policies,  Jouma! of Adolescent Health, (December  1991) 
Fox, Harriette  B., Lori  Wicks,  and  Debra  J. Lipson,  ImprovingAccess to Cornprehen.s~e~ 
Heaith Care Z%roughSchool-Based Programs,Fox Health  Policy Consultants,  Inc., 
(January  1992). 
and  Margaret  A. McManus,  Medicaid Managed  Care Arrangemen~ 
Fo~  J+km-ktte  B., 
and Z7zekImpact on Children and Adokscents:  A briefing reprt,  The  Child  and 
Adolescent  Health  Policy Center,  (November  1992). 
Igoe,  Judith  B., and  Beverly  P. Giordano,  Expanding School Health Senices  to Serve 
Families in the 21sr Century, American  Nurses  Publishing,  (1992). 
King, Martha  P., Healthy Kids:  State Initiatives to Improve ChiZdrenh Health, National 
--
Conference  of S~ate Legislatures,  (April  1993). 
Klein,	 Jonathan  D., et. al., ComprehensiveAdolescent health Services in the United 
S(ates, 1990, The  Cecil  G. Sheps  Center  for Health  Services  Research,  the  Center 
for  Early  Adolescence,  and  the  Center  for  Health  Promotion  and  Disease 
Prevention  University  of North  Carolina  at Chapel  Hill,  (June  1992). 
Kolbe,	 Lloyd  J., An Essential  Strategy  to  Improve  the  Health  and  Education  of 
Americans;  unpublished  paper  presented  at  1992 American  Academy  of 
Pediatrics  Annual  Meeting,  (October  1992). 
School-Based  Adolescent  Health  Care  Program,  The,  ACCESS  to Comprehensive 
School-Based  Health  Sem-ices for Adolescents,  Journal  published  quarterly  by The 
George  Washington  University. 
Wasza~  Cynthia,  and  Shara  Neidell,  School-Based  and  School-Linked  Clinics:  Update 
1991Y The  Center  for  Population  Options  (1991). 
U.S.  Department  of Health  and  Human  Services,  Health  Care  Financing  Administration, 
Medicaid  Bureau,  EF?SDE  A guide for educational programs, (September  1992). 
c.~  APPENDIX  D 
PROPOSED NEW YORK STATE 
SCHOOLEBMED HEALTH CENTER SIANDARDS 
D-1  Coalition for School-Based  Primary Care 
60Haven Avemc.  8-3 
tiew  Yom< NY  10032   
Phone:  212-304-5248 
fax  2,2.305.7024

RECOMMENDED  GUIDELINES 
FOR 
STANDARDS AND OPEIUTIONS 
OF SCHOOL-BASEDCLINICS 
IN NEW YORK 
STA~ 
PREPARED  BY 
THE  STANDARD  AND  OPEIUTIONS  COMMI~E 
DORIS  PASTORE,  M.D.,  CHAIR 
N(X  TO BE REPRODU~  WITHOUT THE PERMISSION OF THE COAIJTIONFOR 
SCHOOL-BAS~  PRIMARY CARE. MAY, 1993. 
D.~  Guidelines  for Standards  and Operations 
In  an  effort  to  develop  consistent  standards  to  assure  program 
quality,  assist  in program  evaluation,  and provide  guidelines  for grantors, 
the ideal  standards  for a model  school-based  clinic  (SBC) are proposed. 
These  discussions  were about an hypothetical  urban school with 2,000 
students  where  the SBC  would  have  60-707i0 of the student  body  enrolled 
or  formally  registered  for  services.  SBC  enrollment  currently  requms 
parental  consent.  These  guidelines  aim  to  describe  what  core  services  a 
student  and  his /her family  enrolling  in the SBC  can  expect,  what  staii  or 
staffing  patterns  these services  would require,  as well as what space would 
be needed  to provide  comprehensive  school-based  clinic  health  care. 
The  S13C model  is  one  model  for  delivering  school  health  services. 
The  WC  model  includes  several  essential  components:  providing 
comprehensive  primary  care;  inter-relating  with  the  family,  school, 
community  and medical  facility;  providing  the identified  core services;  and 
being  located  on  the school  site. 
I. Mission  Statement 
The  goal  of the SBC  is to provide  or make  available  comprehensive 
primary  medical,  social  and mental  health  and health  education  services  to 
enrolled  students.  Primary  care includes  first contact care, preventive  health 
care  and  longitudinal  care  over  time. 
By  comprehensive  care  we  mean  that  not  only  will  the  students 
medical  needs  be  met but  the  student  would  be assessed  for any social  or 
mental  health  concerns.  For  teenagers  this  means  not  only  a  complete 
medical  history  and  exam  but  also  an  assessment  in  the  areas  of  home, 
school,  fa.miIy, friends,  depression/suicide,  sexual  activity,  physical/sexual 
abuse,  violence.  For  elementary  students  this  would  include  a 
developmental  assessment  if  appropriate,  addressing  behavioral  issues, 
school  problems  and being  a resource  for parents.  These  areas  need  to be 
addressed  in  an  age  appropriate  manner  and  where  needs  are  identified 
1

D-3
 sefices  must  be  provided  or  referrals  made.  Follow-up  of problem  areas 
must  take place.  The SK  must  actively interact with not only  the student 
as a patient,  but  also  the family,  communi~  and educators. 
These  services  are  to  address  the  health  and  behavioral  needs  of 
students.  They  are  to include  health  screening,  treatment  and  prevention; 
counseling  and  crisis  intervention;  social  service  needs;  sexuality  and 
reproductive  health  care;  and dental  needs. These  are to be provided  by a 
multidisciplinary  team. 
II.  Concept: 
The approach  to the delivery  of this type of health care  recognizes  the 
school-based  clinic  to be multifaceted  in its roles  and responsibilities.  The 
school-based  clinic  inter-relates  with  the  family,  host  school,  local 
community,  as well  as the back-up medical  facility: 
.  Family  - The  enrolled  student  is viewed  in the context  of &/her 
family.  The  involvement  of the family  will be enlisted  as it pertains  to the 
care  of  the  student  and  as  appropriate  to  the  age  of  the  student.  This 
would  be an  especially  crucial  aspect  of providing  care in the  Elementary 
programs. 
.  Schcx)l  - The  SBC  is a functional  component  of  the school  and  as 
such  not  only  delivers  direct  care  but  aims  to  work  cooperatively,  both 
formaLly  and  informally,  with  school  administration,  faculty  and  staff. 
However,  the  confidentiality  of  the  provider-patient  relationship  and  of 
medical  records  is fully  maintained.  Both the SBC and the school  maintain 
separate  but  interdependent  roles. 
Programma tically,  the  school  assists  in obtaining  informed  parental 
consent,  obtaining  insurance  or  medicaid  information,  in  follow-up  of 
broken  appointments,  marketing  the SK,  and giving access to school health 
records.  The school  is responsible  for maintenance  of the facility,  including 
providing  a clean,  safe,  secure  environment. 
2

D-4
 .  Community  - The  SBC  recognizes  that  the school  functions  within 
a community  and therefore  wants  to draw upon its resources  and establish 
mutually  dynamic  relationships. 
. Medical  facility  - The back-up institution  operates  the school-based 
clinic  and  has  the duty  and responsibilityy to ensure  program  quality.  This 
is  to  include  but  is not  limited  to  an  appropriate  referral  system,  qua litv 
assurance,  continued  medical  education,  and  contractual  compliance.  The 
organization  sponsoring  the SBC must ensure  that this linkage  takes place. 
Specifically,  the  medical  facility  is  also  to  provide  billing  support, 
availability  of  in-patient  care  if  needed,  continuity  of  care  including  ~24 
hours/7  days),  and  training  if an academic  program. 
III.  Activities 
Involvement  of  the  SBC  with  the  family,  school,  community  and 
medical  facility  in  the  goal  of  providing  comprehensive  primary  care 
necessitates  that  the SBC  undertake  the following  activities: 
.  direct  services	 - medical 
- mental  health 
- sexuality  and  reproductive  health 
.  health  education	 - students 
- parents  and community 
- school  faculty 
.  training	 - medical  students/residents/fellows 
- NP/PA  students 
- social  work/ health  education  students 
- health  professionals 
3

D-5
 .  advocacy  - individual  student /family both internally a

externally

- SBC  within  the community

- growth  of SBCS

These  activities  would  take place in SBCS of Elementary,  Middle a

Senior  High Schools.  There  would be a Particular  emphasis  in meeting  t

needs  of parents  among  the  Element&  programs  by  making  avai~a 
referrals  f~r direct  servi=es,  providing  health  education  and advocacv. 
IV. Services 
All school-based  clinics  should  provide  the following  core service 
.  Comprehensive  medical  and  psycho-social  histories  and 
individual  assessment  of strengths  and risk 
.  Physical  examinations 
.  Behavioral  and developmental  assessment  as age 
appropriate 
.  Diagnosis  and  treatment  including  the prescribing  of 
medications  of minor  and  acute  problems 
.  Case  management  including  utilization  of back-up  medical 
facility  and  community  resources  for speaalty  seMces 
.  Dental  health  assessment  and  referral 
.  Family  planning  and  reproductive  health  services  as 
age  appropriate 
.  Health  education,  promotion  and  prevention 
.  Laboratory  testing 
4

D-6
 .  Immunizations 
.  Management  of chronic  problems 
.  Mental  health  and social  service  assessment,  treatment  or 
appropriate  referral 
.  Nutrition  counseling 
Outreach 
Physical/sexual  abuse  identification  and referral 
.  STD/ HIV/AIDS  education  and HIV pre/post-test  counseling  or 
appropriate  referral 
.  Substance  abuse  assessment  and referral 
.  24 hour  medical  coverage 
Additionally,  optional  services  could  be  provided  dependent  up 
community  need  and  funding  resources.  These  would  include  classroo 
education,  dental  seMces  on-site,  health  care  for  siblings  of  enroll 
students,  health  education  for  family  membem,  pm-natal  care,  te 
parenting  programs,  risk  behavior  modification  programs  such  as  tho 
addressing  smoking  and  obesity. 
V. Staffing 
In  order  for  the  SBC  to  function  in  a  multifaceted  mann 
appropriately  deliver  medical,  mental  health  and  reproductive  servic 
provide  health  education,  trainin~  and  partiapate  in  advocacy,  the  S 
must  be staffed  by a multidisciplinary  team.  The staff needs  to be flexib 
Sources  of support  for staff might include  the sponsoring  facility,  the Boa 
of Education,  or an community  agency. 
5

D-7
 Based on the  collective  experience  of  the Coalition  and  the services 
SBCS are to provide,  a staff of 7-8 full-time  persomel  is recommended  for 
a typical  urban  school  of 2,000  enrolled  students. 
This  staff is to include  but  not limited  to: 
Nurse  Practioner/Physician  Assistant  - providing  direct service and 
program  management,  where  appropriate.  It is felt  that  each  NP/PA  can 
provide  care  for 700 enrolled  students.1 
.  Mental  health  provider  - the SBC must be able to address  differing 
needs,  including  group,  individual,  family  counselin~  crisis  intervennon; 
short-term  counseling,  long-term  counselin~  case  management;  as well as 
make  referrals  where  appropriate.  Consultative  and  supervisory  serwces 
must  involve  a  doctorate  Ievel  prof-sional  and  be  staff  appropriate.  To 
provide  for the mental health needs of 700 enrolled  students  a minimum  1.3 
mental  health  providers  would  be required. 
.  Physiaan  - there  are different  models  for physician  presence  in the 
SK  and range  from a minimum  supervisory  presence  to full-time  primary 
provider.  Minimum  supervision  would require presence  for one three-hour 
session  (chart  review,  supervision,  consultation)  per  week  for  the  first 
NP/PA,  adding a session for each additional  one or two NP/PAs  (i.e., two 
sessions  for 2-3,  three  sessions  for 4-5,  etc). 
.  Program  Manager  - for  large  programs  of  greater  than  2,000 
enrolled students, there needs to be at least one full-time program manger 
who  is  not  a  provider.  Alternatively,  these  duties  can  be  fulfilled by 
appropriately  qualified staff or assumed by the back-up institution.  The 
SK  is  accountable  to  the  responsible  physiaan  of  their  agency  e.g. 
Division of Adolescent Medicine;  Department  of Pediatrics;  Department  of 
1  mm  m?/PA  :  Student  ratio  of  1:700  was  tirivml  frout  the, 
collective experionca of thosa involved  with  tha  Coa%itioa  and  from 
review  of  tha  Fodoral  guitilinas  set  forth  fox  C-unity  Haalth 
Centers. 
6

D-8
 Family  Practice.  These  duties  include:  budget  and finance;  data collection, 
statistical  reports  and narratives;  purchastig  writing  grant proposals;  staff 
supervision/scheduling;  liaison  with  schooL  back-up,  community,  and 
funding  sources;  seek  out  funding  sowces;  advisory  committee 
participation;  quality  asswance  coordtiation;  program  development  and 
program  evaluation. 
.  Health  Educator  - to provide  individual  and classroom  information 
on family  planning  issues,  nutrition  and  weight,  etc. 
The Coalition  recommends  one full-time  health educator  be part of the staff 
providing  care  for 700  enrolled  students. 
.  Clerical/School  HeaIth Aide -to  work closely  with school staff and 
ST3C team  in  such  areas  as  clinic  patient  flow,  appotitment  making, 
checking  insurance, recalling students, immunizations, data collection  and 
state reporting  requirements,  supervision  of other students  in the clinic, etc. 
It is felt  that  one  full-time  aide  is needed  in a program  providing  care  to 
700  students.  These  responsibilities  may  also  be  fulfilled  by  a  medical 
assistant /receptionist. 
In a school  where  there  are 400  enrolled  students  the responsibilities 
of SK  program  management  can  shared  across  disciplines.  For example, 
an SK  might  be  staffed  by  a NP/PA  .75 ITE  -1.0  FIE  (dependent  upon 
exact  duties),  Mental  health  provider  .75  F1E -1.0  lTE  (dependent  upon 
exact  duties),  clerical/school  health  aide  1.0  ITE,  and  Physician  .10 -1.0 
(dependent  upon  SK  stmcture). 
7

D-9
 IV.  !%ace 
The space for the SBC must be adequate  to accommodate  appropriate 
staffing.  For a school  with  an SBC  enrollment  of 700, approximately  2,000 
Sq.  Ft. would  be  required  and  would  include  2 exam  rooms  per  full-time 
provider  (with  sinks),  1  counseling  room,  1  laboratory  area,  1  patient 
bathroom,  1 waiting  room,  1 storage  room,  1 clerical  area.  The actual  floor 
plans  need  to  provide  for  patient  privacy  and  be  functional  in  allowing 
good  use  of  clinic  space.  The  SBC  also  needs  a private  telephone  line  to 
ensure  confidentiality  and adequate  access to the community  and back-up 
institution.  Additional  space  would  be  required  should  the  SBC  be  a 
training  site. 
a 
D-10
 APPENDIX  E 
EXAMHE  OF SCHOOI/BASED HEALTH CENTER AND MANAG~  CARE 
PROTOCOLSFOR REFERWNG ANDTREATINGPAITENIS 
E-1  BALTJMOM CITYHEALTHDEPAR=~SH&&  TOTALHEALTHCARE HMO  CLIENTS 
m 
1  1 
Child needs  Child needs I
episodic cue  cmergeacyCafe 
I  , 
.  v 
PNP aendareferral 
currentlybeing 
withreturn 
1.  PNPealla911&tK4  l<==i--c 
w&a	 to Emageacy  L envelo.cwtoC7  .  I  n
uII   
-=5$ 
2. PNP notifies (X  hat 
c1?

patienton way to  L
EmergencyRoom  L  Makesappt.  school PNP will

t-n  =  3. crwiunotify@ds  2. Notes %eboolhealth  aue.enebiid&=ad 
wI   CT ails  patientsPCP2  !  PCP  cino meupnumteesn6fy -aeetial of  rTeHpact&biUto 
Weksaamcdayappt. 
3. Complc4e8appt.dip&: 
7   .sadacopytii-
b. Sends copy to school 
nume 
c. Ticldem  copy to 
InAeremindadl 
 I 
&y before  ppt. 
u 
4.  Sends refaml & env. to
N 
Child sent to THC with aebool  Numing Managa at 
@  refed  & altachedrduxn em.  p8tieQt6PcP de 
Patient
seen bv school  1  II 
PNP & Sepottaentto  I  J[  # 
v  Numing M8n8gcIiCxk1kB 
Child seen by P(X & xefaml  _ 
tcfud  & amaa  ~ 
ldtllld to add  by mad in  I?x4ivu  rehlrlml
attached envelope  _]  I ~  @  I  APPENDIX  F 
F-1  .. 
. 
66th OREGON  LEGISLATIVE  ASSEMBLY-1991  Regubr  Session 
Enrolled 
Senate  Bill  760 
Sponsored  by  Senator  KENNEMER;  senators  BRENNEMAN,  CEASE,  COHEN,  GOLD,  HAMBY, 
McCOY,  TROW,  Re  resentatives  BARNES,  BAUMAN,  CARTER,  CLARK,  HAYDEN,  MASON, 
McTEAGUE.  MEE~,  MILLER,  SHIPRACK,  SOWA,  STEIN  (at  the  request  of  Clackarnas 
County,  Coalition  of  Local  Health  OfIicials) 
...  G37

CHAPTER ............ . ..... ........... ....... ....... 
AN  AtX 
. Relating  to  poverty  level  medical  programs. 
Be  It  Enacted  by  the  People  of  the  State  of  Oregom 
SECIION  1.  It is  the  purpose  of this  Act  to take  advantage  of opportunities  to:

(1) Enhance  the  state  and  local  public  health  partnership;

(2)  Improve  the  accesa  to  care  and  health  status  of women  and  children;  and

(3) Strengthen  public  health  programs  and senices  at  the  county  health  department  level,

SECTION  2.  The  Adult  and  Family  Services  Division,  the  Ofllce  of  Medical  Assistance  Pro.

grams  and  the  Health  Division  shall  endeavor  to develop  agreements  with  local  governments  to  fa. 
cilitate  the  enrollment  of  poverty  level  medical  assistance  program  clients.  Subject  to  the 
availability  of  funds  therefor,  the  agreement  shall  be structured  to allow  flexibility  by the  state  and 
local  governments  and  may  allow  any  of  the  following  options  for enrolling  clients  in poverty  level 
medical  assistance  programs: 
(1)  Initial  processing  shall  be  done  at  the  county  health  department  by employees  of the  county, 
with  eligibility  determination  completed  at  the  local  orlce  of  the  Adult  and  Family  Services  Divi
sion; 
(2)  Initial  processing  and  eligibility  determination  shall  be done  at the  county  health  department 
by employees  of the  Adult  and  Family  Services  Division;  or 
(3)  Application  forms  shall  be  made  available  at  the  county  health  department  with  initial 
processing  and  eligibility  determination  shall  be  done  at  the  local  office  of  the  Adult  and  Family 
Services  Division. 
SECXION  3.  To  capitalize  on  the  successful  public  health  programs  provided  by  county  health 
departments  and  the  sizable  investment  by tmate and  local  governments  in the  public  health  system, 
state  agencies  shall  encourage  agreements  that  allow  county  health  departments  and other  publicly 
supported  programs  to  continue  10 be  the  providem  of  those  prevention  and  health  promotion  ser. 
vices  now  available,  plus  other  maternal  and  child  health  services  such  as  prenatal  outreach  and 
care,  child  health  services  and  family  planning  services  to women  and  children  who  become  eligible 
for poverty  level  medical  assistance  program  benefits  pursuant  to  section  4 of this  Act. 
SECTION  4.  [n  order  to  make  advantageous  use  of  the  system  of public  health  services  avail-
able  through  county  health  departments  and other  publicly  supported  programs  and  to insure  access 
to  public  health  services  through  contract  under  ORS chapter  414,  the  state  shall: 
(1)  Unless  cause  can  be  shown  why  such  an  agreement  is  not  feasible,  require  and  approve 
agreements  between  prepaid  health  plans  and publicly  funded  providers  for authorization  of payment 
for point  of contact  services  in  the  following  categories: 
F-2
 (a)Immu?tiZatiOW,

(b) SeXudly  transmitted  diseases;   nd 
(c) Other  communicable  diseases; 
(2) Continue  to  now   nrollees  in prepaid  health  plans  to  receive  family  planning  services  from 
fee.for.semice  providem, 
(3)  Encourare  and   .pp. rove  agreements  between  prepaid  health  plans   nd publicly  funded  pm
viders  for  uthorization  of  nd payment  for services  in the  following  categories: 
(a)  Maternity  case  management; 
(b] Well-child  care;  and  . 
(c)  Prenatal  care;   nd 
(4)  Recognize  the  social  value  of  partnerships  between  county  health  departments  and  other 
mbliclv  SUD.D. OIId  c.-mtzrams   nd other  health  provide=,   nd ~ke  appropriate  ~a~u~s  to  involve 
publicly  supported  health  care   nd  service  programs  in  the  development   nd  implementation  of 
managed  health  care  programs  in  their  areas  of responsibility. 
Pmaed  bySenateM ayZ$1991  Received  by Oovemm
..J.\,..o...o... mM..._Q.m--...!.a_-... .-..._-...
1991 
&x4a>??A42ff 
........................... .......... ........................... 
Approve&
%.!.%..&....=hjL..-..x.J..Y...3.-..%...-.. 
!991 
----p@iii: 
Hoiuu&s1oe9e91  .  ......... 
*-* 
Passebdy 
Filed by Office  of Secretasy  of State: 
......................... .c........ ............... . 
../.f.2.!..-(?M..M..-- ....-JLLM.JG...-_..-.  ,99, 
Speaker of House 
3  ....zti  ............ ................/ &..................................
Secretary of SLa 
5 
Enrolled  Senate  Bill  760  Page  2 
F-3
 1.8  Masu-ti  Standd 
LI ~  tO ma  ~vantagcous  usc of the system of public health  senciccs available 
tiUgh  county  health departmen~ and Otk  publicly  SU~ti  prOgIamS  and to 
ensure  access to public health  semke+  through contract  under ORS Chapter  414: 
a.	 Unless  cause can be shown why such an agreement  is not feasible,  the PKP 
shalelxecute agrccmentSwith publicly  funded providem for authotition  of 
paymenftorpointofcontactscM=  inthefollowingcatcgoriti: 
(1)  IfmmmizltiOrlS;

and 
(2)  Sexually transmittal  di-; 
(3)  other  @mmuni*le  diseaSU. 
b.	 Pm  mem- may receive  family ptig  services  ffom appropriate  non-ph 
providcm.  . 
c.	 The PHP is cncouE@  to exccutc agrcemas  with publicly funded protidm 
for autho~tion  of and payment  for services  in the follotig  catcgoria: 
(1)  Maternity  case managemen~ 
(2)  Well-child  ~,  md 
(3) Prenatal care. 
d.	 Rcco-g  the social value of piulnefi~  betw=  county  hcalti 
deptmm~  and other publicly suppoti  programsand other health protidm, 
the PHPshalltakeappropriatmeeasu~  to involve  publicly  suppoti  halth 
~  ~  -CC  -S  in the dcvelopmClltand implemCntitim of you 
In.am@healthcare programs. 
(
 OU4?Obwgon H&  ma  m?  A$@&Wu@n 
La  ReqUkd  Respoase 
A.  Describe theagreemenatsn dhrsubcontracytosuwill-t  fm OMAP 
- ~  @reply with MeawememtStandard I.&,  or explain steps your 
organization  will take to cOmpiy with this statutory  requirement. 
B.  Response  due 4/20/92:  Unless exemptedfrom complian~  with Measurement 
Standard  1.8a, attach any agreements and/or submntracts (or draft versions) 
you are submitting for apprwal  to OMAP to mmply with this statutory 
requi.mrnak 
c.
 Describe any agreements and/or subcontmcts you will have with pubhcly 
funded providers  to provide  matemity  case managemcnq  wel.khild  care 
ador  prenaal are. 
D.  Response due 4/20/92:  Attach any agreements andlor subcontracts (or dm 
versions)  with publiclyf undedprovidexst
oprovidematunitycase
managemeaw~d khild cam ardor prenatacla
 m 
E.  Desde  yourorpkations poliaeswhichaddresstk i.ntmto
f Measuremen 
standa1r.8dC
 L 
Stctioaw  -%gt7 
F-5 
  APPENDIX  G 
HEALTHCARE  AD~~ON 
FINANCING 
RESPONSE TO  THE  DW  REPORT 
G-1  ....
*.  ;% 
& 
-. . DEPARTMENT  OF HEALTH  &  HLf.MANSER1!(:ZS  HealtCha
re  C-,Ir.:IrC  Admtnfstraf
:*

:  

7.    -.  ,..--.  - ----- ..  .-.  .--  ------- ______  -. 
% 
-3i--
FROM:	 Bruce  C. VIadec--
Administrator 
SUBJE~  Office of Inspector General (OIG) Draft Repor& School-BasedHealth 
Centm  and Managed Health Care,  (OEI-05-92-00680) 
TO:	 Bryan  B. Mitcheil 
Prjncipal  Deputy  Inspector  General 
The Health Care Financing Administration  (HCFA)has reviewed the subject draft 
report which reveals that school-based health centers increase access to health care for 
adolescents. 
We supportthe  three  recommendations  contained  in the report.  We agree  that more 
information about school-based health centers is needed inorder to improve the 
coordination be~een  managed care and better serve the health care needs of 
adolescents.  In particular, we believe the Public ?ieaIth Semite and HCFA should each 
designate a contact to coordinate on issues involvingboth managed  care  and schooi
based health services  ?Imse wntaots should lead the Departments efforts in this area 
and work with appropriate agenoies to study the issues desd%ed  in the repot% The 
number of school-based health centers and managed care plans are incr~~  and 
linkages between these wo  qp  of providers will be essentiai to both Medicaid and the 
entire hea[th care system. 
Thank you for the opportunity to review and comment on this draft report  Additional 
comments are attached for your consideration.  Please advise us if you would like to 
discuss our position on the reports recommendations. 
Attachment 
G-2
 Comxnenrsof the Health  Care  FinancinizAdministration [HCF~ 
Office of InsO~Or  General (OIGI Draft Rent@ 
~sc oo  -
EM15-92-00680 
GeneA  Comments 
Page 6 states that mosg but not all, of the investigatorsdiscussions with manag 
carerespondents related to Medicaid managed care  It mghtbe worth 
mentioning here that although the focus of the reportwas the extent to which 
school-based  healthcenterscoordinatewithMedicaidmanaged care programs, 
the findings are relevant to managed care plans in general.  Also, throughout t 
repor$  it would be useful if any of the tidings  that might be uniqueto Me&lc 
managed care were separately highlighted. 
On page 1% after the Iast seatence in the Communication Barriers sectio~  we 
suggest adding the folkwing to include ISmherinformation about primarycare 
case management aystenxxAlthoughmanyprovidersare invohwdin the  piau 
Medicaid recipients  may choose a providerand then the prwiders name and t 
telephone  number WINbe included on the recipientsMedicaid card. 
On page M, the kzsste ntencien  the second paragraph should include
acluwwledgemetnhtat  State Medicaid  agenciecsan also pay twice  through 
duplicative claim  We suggestthe followingas an addition to the last sentenc 
w 
a second time from its own fun~  or bills Medicaid  and the  State pays fo 
tie  Ace. 
G-3
 APPENDIX  H 
PUBLXCHEALTH SERW=  RESPONSE  TO  THE  D~  REPORT 
I-I-l  -...,
%/ %
4
.  DEPARTMENTOFHEALTH& HUMAN WRVKX$  I?wliCHdtl
a 
;
Memorandum 
yCPlH51993 
Qlte 
AaaLstant  Secretary  for  Health 
Subjecc	Office of Inspector General (OIG) Draft Report$  School-Based 
Health Centers and Kanaged  Care?  OEI-05-92-00680 
To  Acting  Inspector  General,  OS 
Attached  are  the  PHS comments on the subject draft report. 
Tho OIG report is very tinaely,especially in light  of  health 
care reform and the high priority placed on tiprovinq the 
health status of  our Nations children and youth  by  the  new 
AdauinL,stratLon. 
We generally concur w~h  the OIG recommendations. 
(/  a ~
Philin.   . Le e..  M. .

Attachment
 c~  s  QF  THEE!UBuc IW4LTH smwIcE (PHS1 ON THE O~IC E OF 
~BCT(lR  GENEIUL (OIGl  RAFT REPORT ON  *scxoor4BAsED 
CENTERS  AND MAHA@  HEAIITHCM  ~, o~z-~5-92-00680 
We commend the OXG for recognizing the importance of examining

the issues addressed in this study more closely.  Their effort

reflects  one  of  the  earliest  attempts to do so and~ as such~

offers useful and important directions for  further study.  The

report is very timely, especially in light of health care

reform  (HCR) andthe high priority placed on improving the

health status of our NatLon8 children and  youth  by  tlw  new

Administration,  the  Assistant  Secretary  for  IWalth,  and  our

new  Suxgeon  General.

PHS generally concurs with  the  three  OIG  recommendations,

although  there are a number  of specific comments that pertain

to the recommendations.  PHS balieves, howwor,  that the body

of the report can be strengthened by$  (1) making  clearer the

unique  contribution that school-based or linked health

centexs (SBHCS) can make; (2) explaining  how S1313CSfi
t  into 
the  broade~  context of school health  and adolescent 
health;  (3) clarifying and improving understanding of these 
concepts and terminology; and (4) ackmwledging  and build~ng 
upon tho limitations of  the study as a basis for further 
xeseaech.  Some guidance  in  this regard in provided below. 
  Ca of  .  Because they are located in or near 
oux  schools,  where most of our children and youth C-
to ether on a regular basis,  SBHCS can provide an 
et$ective means for  improving access to health sem?ices 
and  a  tremendous  opportunity to reach tlmse vulnerable 
populations in an attempt to pzevent or minimize high
rlsk behaviors that  ndanges health status.  Coordination 
of  se~ice~  provided by SBHC8 with those of managed care 
systems in the coamunity offers yet another opportunity 
to enhance  effeotiveness~  efficiency, and the health of 
school-aged  populations. 
	   SBHCS or semices  a~e not 
necessarily synonymous or interchangeable (nor.should 
they be) with school health  issues,  adolescent  health 
concorns,  or with semices  geared only to children and 
youth who are medically undeserved,  economically 
disadvantaged, uninsured, or  in urban settings.  The 
report needs to acknowledge a broader understanding and 
appreciation  of  these  concepts  and  place  the  study  and 
its  findings within this bxoader context. 
H-3
 Specifically, it is important to make distinctions

between school-based/ltiked health centers (essential

health caze aemices  delivered in and/or near school.

settings), S*OO1  h-lti  prov~a  and activities

(which, if comprehendive~ may include not only health 
serwLces, but other elements provided in schools to 
enhance tho health of  school-aged populations~ such as a 
age- and d=elopnentally-appropriate  health education 
framework or classroom  curriculum,  nutxLtiou8  meals, 
physical  fitness  and  sports  progzama,  an  envirotint  fr 
of dregs, violence, pollutants,etc.) and adolescent 
health efforts (which are aimed at achieving,

maintaining, and improving the health of adolescents

specifically and are not limitad only to adolescents in

school or to what can be done in schools).

On a related note, while the report indicates that the 
SBHC8 in the study and, most SBHCS  currently in 
existence, emphasize senices  to adolescents and includ

family planning, care needs to be taken not to rebf=ce

fears  or wrongful notions that school-based/link~ 
health centers or sezwices are geared only to 
adolescents and/oz  xist to provide se~ices  related to 
teenage sexual behavior.  It would be useful, therefore 
to reference  the  range  of health services that SBHCs ca 
or do provide (L.e.~immunizations, nutritional/dietary 
counseling, substance abuse--inc~udlng alcohol  ~d 
tobacco--an  d  mental  health  counseling  and  referral, 
treatment  of tinox fnjuries, safety education, etc.) 
It would also be useful to present SBHCa  within the 
context of comprehensive school health programs which 
offer benefits to ALL school-aged (including elementary 
and perhaps, post-secondary) populations and those in 
rural as well as urban areas.  The issues of  coordinati 
with community semices  ar. applicable to the other 
components (twch  as a health education curriculum or a 
healthy school eny$xonment) of such a comprehensive 
program as well.  ~xthennore,  the ~rtance  of the

family, home, and neighborhood environments also needs

be dcnowledged,

	   In the section on mainstream 
medical delivery systems (pages 3-4), a stronger case 
could be made regarding the need to address adolescent

health care concerns through means that complement

traditional delivery systems.  What is the  dilemma

posed in trying to promote adolescent health?  What is

the nature and extent of the health problems faced by

unique to adolescents (including but not limited to se

and drug-related issues)?  How are such problems

H-4
 3

8%aC8Zbat~  by the social, emotional, and developmental

issues most adolescents experience? What is the critical

role that primary  and secondary prevention can play for 
adolescents?  How do  mainstream  systems fail adolescents 
us  compared  to  other  populations  and  why  are  school- , 
based/lhlced  health  centora  most  suited to filling the 
gap?

w	 st~~-ffqg.  The report states that school-based/ 
linked health centem increase acc8ss, provido some 
se=ices  more easily than  managed  care  systems,  and  offer 
other significant benefits if coordinated with local 
managed cars providers and/or systems.  It also 
LdentLflea  a number  of  barriexu  to coordlnat~on  and 
cooperation. However,the data to auppo- oonclualonO 
regarding  benefits  and  barriers  are  largely  anecdotal~ 
reflecting  respondent  perceptions  and feelings rather 
than hard evidence.  It may be useful to mention the 
limitations of tho study based on the methodology and to 
specifically propose  studies regarding actual benefits 
and barriers under the last recommendation. 
Another Mmitatlon  of the study  that  may  be  worth  noting 
1s in the nuaber  and types of respondents inte~iewed.

Given  that  State 14edicaid  agencies, State Maternal and 
Child Health (%CH) offAces,  and  Community  Realth Centers 
wece ~asizdr  the rasults will naturall  nfleot  a

heavier focus on se=ices  to the economicsILy

disadvantaged and &ically  undeserved  and to

populations seeking psenatal and other MCR-related care.

  den~tv  ~- &rr  fer#*  Page 10 of the draft 
presents a number of reasons for Mm.ited  coordination  and 
exchange  of  medical  information  betwaen  managed  care 
=ymtems  and  school-based/linked  health centeru, but does 
not include the critical issues of personal privacy, 
conficientiallty,and security of informatf.ontechnology

systems.  On page.19, it is stated that coordination I.s

essential to overcoming treatment barriers; howummr, it

might be argued that overcoming cefiain barriers,

including  iasuea  of privacy and confidentiality, is 
eeuentlal to coordination.  ~U8,  it might be WOXth

conaidoring a reoosunendationto fo~  some sofi of

mechanism (e.g., task force, working groups) for

addressing these and  other actual or potential barriers 
to coordination.

  mlth  0ut4xUeS WrSuS  Uti*  tial.  The report 
states that there axe few, if any, attempts to measure 
health outcomes xelatad to school-based/linked senrices, 
and stresses the need to move beyond utilization 
H-5
 4

asuessmenta to  measures of quality and effectiveness. 
G&vefithat a major justification for such se~ices  is to 
improve access and delivery, the inqo~ance  of 
utilization data should not be  minimized.  We believe 
that more and better efforts need to be made in both 
utilization assessment and measurement of quality and 
effectivene66. 
OIG RECOMM=DATIOll

The Assistant Secretary for Health and the Administrator for

Health Care Financing should each designate a contact to

coordinate school-based health center issues in their 
agencies.  Thesa contacts should provide a point-of-entry for 
those outside HIM who need information about  school=ba8ed 
health centara.

JMUxUUX  s

We genezally agree with the OIG recommendation.  Ik3w0verr  we 
believe the thrust of the reco!tzndeantlon is information 
sharing.  For  that reason, OIG may wish to consider changtig 
the word issues in the first sentence of  the  recommendation 
to information. 
We agree that designating single points of contact in P13S and 
the Health Care Financing Administration (IXCFA)  fOr 
information exchange on SBHCS and managed cam  1s one possible

way to enhance cocmlination.  within PM,  however, there are

many possibil~ties regarding the manner in which efforts 
related to SEHCS, school health, and adolescent health can  be 
coordinated, managed, or addressed.  All of these 
possibilities will be considered by  the new Surgeon General as 
she assumes responsibilities relative to those efforts. 
Consequently, we suggest that this recormnendationbe modified 
to r~flect the need for the heads of  PM  and HCPA tOl  (1) 
identify means by which  to  effect coordination within and 
between their agencies.on issues related to SBRCS and managed 
care and (2) enable outside parties to more easily obtain 
accuzato, adequate, and up-to-date information on SBHCS.

Designating points  of contact  could then be presented as one

of many possible ways in which these needs might be met. 
The PHS, HCFA and the States  should encourage cooperation

between school-based health centers and managed caze

providers.

H-6
 We  support  this  recommendation, especially its intent to

address treatment barriers.  However, as mentioned in our

gensral comments, while coordination is essential to 
overcoming tseatment barriers~ it might be argued that the 
reverse is also *ef  i.e.~ that  overcoming certain barriers, 
such as confidentiality, is essential to coordination. 
Studios  of  these  barriars  8hould  precede any Federal mandates 
for racord @baring and other coordination fo~ all treatment 
populations  including adolescents.

The PHS and HCFA should work with HHS agencies to fund 
approp~iate studies and grants that will add to HIM knowledge 
on school-based health centers and managed care providers. 
We agree that more studies are needed to add to our knowledge

regting  SB8CS and managed care systems and/oc pxwidarsr

particularly in light of lxcR. Identifying the priority i86ues 
to be utudied and the research  questions to be answered IS a 
loglcal  step  to ensuring the implementation of a  cw~tion 
resoasch agenda.  Coordinative bodies such as the Interawcy 
Committee on School Health (ICSIi)ox the National Coordinating 
Committee on School Health (NCCSH)--both recently established 
by the Office of  Disease Prevention and Health Promotion on 
behalf of DHM--may  ba able to assist Ln this regard. 
With reference to specific studies, it is critical that 
studies be proposed and conducted to provide more solid 
evidence  of  actua~  benefits and  barriers  and  data  upon  which 
to  base  our  policy  and  progmm decisions relative to 
coordination of SBHCS and managed care systems.  studies to 
provide more Information,about effects on access and 
utilization, and research on quality cuntrols and standards 
are a180 needed.  The Eealth Resources and Se-ices

Ad.Uthi8t%&ti0nsuggested an expansion of the OIG study to full

case studiee and evaluating these caaeziin order to obtain

greato~ hsight  into the local conditions which make SBHC8,

managed care syutm,  and coordination Posuible and 
succeaeful In all instances, great cake must be taken in the 
 
design etudLe8.  For example, strictly comparing utilization

patterns 02 cost effectiveness of  managed  care  organizations 
and 6BHCa may not be appropr~ate since it 16 likely that  many 
adolescents will use both semice  delivery systems for

diffe~ent purposee.

While our knowledge in these areas is rather limited, care-

wU1  need to be taken not to duplicate existing efforts which

address adolescent health needs, such as the American Medical

H-7
 6 
Associations GuidelQes  of Ad lescent Preventive s~i

Care will also be needed  to  co~duct  atudias  within  the  ~=~ext

of  othor  DHHS and/oz  PHS activities  that  address  adolescent
access  to  care,  such as the  guicielties  of the U.S. Pr-tive

Servic_ Task Force  and  the  Centers  for  Disease Control and

Preventions  valuations  relative  to  SBHCSand  comprehensive
school  health  education. 
The  OIG may wish to recognizethe fact that the Agency for 
Health Care Policy  and Research (AHCPR), the Substance Abuse 
and Mental ?IeulthSe~ices  Administration (sAHHSA) and  perhaps 
others in PM  already have existing grant programs which could 
expand our knowledge bases vis-a-vis SBHCS and managed care 
providers.  For example, AHCPR recognizes that our lack of 
national data regarding the effectsof SBHCS and  managed  care 
providers on the health outcomes of adolescents is due,  in 
part, to the absmce  of  good  measures of  health status for 
th$s age group.  Xn Febnary  1992, the AECPR began funding a 
3-year grant  project which is validating  and  refining  a  aelf
administered instrument to  measure the health statuu  of 
adolescents whu were drawn from school and cllnlc populations 
(including managed care organizat$on6).  If this project  La 
successful, the instrument could be used to asaist in 
determining the effects of schooland managed care programs on

the health status of adolescents and generally assist in

planning, developing, and evaluating health ptograms.

The AHCPR also sponsors gxanta related to managed care. 
Although  the  AHCPRS  current  portfolio does not contain 
projects that focus specifically on the coordination of 
managed  care and SBRC8, several of these studies examine other 
coordination of care issues.

Within SAMHSA, the Center for Substance Abuse Prevention has

numerous demonstration grants that are evaluating prevention

and early intexwention pqogramsand policies in schools.

Also, the SAMHSA Center for Substance Abuse Treatment

explicitly targets substance-using adolescents as one of the

critical populations for  its  demonstration grants. 
Furtlmrmxe,  the SAMHSA6 Centez for Mental Health Se-ices 
develops and test comprehensive child and adolescent mental

health se~tces  programs,

TECRHICaL C~

--Paue 1. S- ~

We suggest the following paragzaph be added;

Community support in all stages of  the  planning, 
development, and implementation of school-based 
health care systems is critical to the success and 
---F-77
 7

longevity of such systems.  Effortsmust be a  direct

response to the policies,conatxaintst and concerns of

the community*  It is essential that active solici=tion

of input  and  involvement  of  community and  business 
leaders, haalth care  and  social  semice  providers,  SChOOl 
administrators/kard  Iuembers/teache=s? chu.rches~

parents, and youth be obtained in this partnership

effort.

, 
--Paue  1.  thd D~~a=  aD~

We suggest that the statement ViBits for physicals and mental 
health , . . . be  modified to read as follows; 
visits for physicalat acute illness, psychosocial?

and mental health meads are the most common se=ices

providd  in SBHCS.

- -J?aae 3* first 
We suggest that the statement Chief among these needs is

care. . . . be revised to read;
Chief among these nSK$dS is care  that  is 
confidential, convenient, comprehensive, and age 
appropriate. 
We suggest the second paragraph under this section be  revised 
to read as follows: 
Because  the problems of adolescents are often 
complex and not strictly of a physical natuxe~ 
diagnosis may be difficult.  Treatment of these 
prableaaemay requir$ outside referrals for special

needs o= auxiliary services.  In medically

undeserved  or ruxal areas, such outside se=ices 
may not  exist,  leaving  many  adolescents  unable  to 
attain  needed  care.  SBHCSwhich  are  dependent  upon 
outs~de  referrals  for  needed  sezw~ces  will  not  X 
successful  without  first  developing  a  strategy fox the 
provision of these uemices.  -
-- far Srhcu~-based h- m  tersm4

,Thesource(s) for the information on the funding estimates  ,

should be referenced.

H-9
 .- uarauxawh  uncles=e 
m
.School-humd  Ziql@th  -Cers  , 
.- Thethird  sentence  should  read that  In 1987 not 1988

the Centers for Disease Control and Prevention created

the Division of Molescent  and School Health.

-- We suggest that the last sentence be revised to read:

In conjunction with the Carnegie Foundation,  CDC  is
funding an initiative at the Columbia University

School of Health Policy which has bxought together a

national workgroup to identify barriers to

establishing SBHCS and to develop recommendations

for a core set of services for SBHCS.

We  reconmmnd  that  the  statement  In  addf.tion,  the  H13S Office 
of oiseane Prevention . . . . be revised to reads 
In addition, the Interagency Committee on Schwl  Health

(ICSH] was created under the leadership of the lXIXS

Office of Disease Prevention and Health Promotion (ODPHP)

as a joint activ~ty of  DHHS and the Department  of 
Education (DEd).  StAff SUppOfi fOr this effOfi i8 
provided by ODPI?Pand the Dad Office of  Blumentary  and 
Secondary Education.  Representation from  DXHS, DEd, the 
Depar-ent of Agriculture,and a number of other Cabinet

lwel  departments and Federal  agencies  is  included  on  the

ZCS1.3 
-- ~aue  8, first naraara~

We suggest the statement Parental consent is the only  . . . 
 be modified  to  read  Parental/guardian  consent  .  .  .  . 
 
.-   at school-bad  heal tiaCamt@rs 
~ 
We  recoamend that the second paragraph under this section be

modifLed to read%

School-based health semices  are provided by a 
multidisciplinary team consisting of providers fmm 
the fields of medicine,  nursing,social work, 
.  psychology, health education, and nutrition.

-- me  9. Last D~  a 
We recommend that the statement . . . a CDC-fundeci

initiative. , . . be modified to read *A9 part of a CDC-

H-10
 9 
funded initiative, Columbia Universitys School of Health 
Policy has convened thmm  meetings of  the national workgroup 
to recommend nationalstandardsfor  SBHCS. 
.- ~e  13,  11et Leua1~ 
We recommend that the statement Respondents from two States

mention State Laws. . . . be revised to xead as follows:

Respondents from two States mentioned that State law=

p=event SBHCS from being reimbursed by Medicaid fOr

services provided by non-physician health care

professionals (ite., nurse practitioners).

.

.- cre19, fxst  ret=-d@u!u

The last sentence of the first paragraph states that . . . 
the Department of Education, who have also taken an active 
role in school-based health activiti~s.  We suggest  that  the 
-yord activities be changed to centers since SBFICSand

school-baaed health activities are not synonymous.

.- 20* Seco&  ball et

The Bu~eau of Primary ~ltQ  Care (BPHC)  is  inco~rectly cited 
as tho Bureau of Primary Ca2Q.  Also, both the BPHC  and the 
Bureau of  Maternal and Child Health should be identif~ed as 
paxt  of  the Health Resources and Services Administration

(HRSA),

--~w  bum

-- The first sentence states that . . . HHS agencies  can

host several regional ox a national training conference

on managed care . . . . we suggest the word meettigs

be  added  after  regional so the sentencer=ds  D s s

can host several regional meetings or a national training

conference. . . .!.

-- We suggest the remaindec of the paragraph be modified to

read:

These meetings or conferences should include a focus on

team building at the local level with an emphasis on 
community  collaboration.  participants should include~ 
but not be limited to, repr~sentatives from managed care 
systems and SBHCS.  Organizers should also brhg  together

State Z4edicaidand MCH officials, and representatives

from Foundations, interest groups, and other aaencies to  ~

discuss issues and efforts related to coordina~ion

-TFii-

  10 
between managed care and SBHCa, obstacles to

coordination, and strategies for overcoming barriers to

coordination.

--Pa9e  21.  ffiti  let *first eentence 
Given the effects of  substance  abuse (including tobacco and 
alcohol abuse) on health care  costs,OXG may wish to consider 
modifying  mental  health  aamices  to  mental  health  and 
aubatance  (including  tobacco  and  alcohol)  alnma  prevention  and 
txeatmonc  Se=icea. 
.- Paae  21. foumlm bu.11e
 t
We  suggest this bullet be revised to read$  Within PHS, the

Center for Mental Health Senices  could expand their current

child studies that examine effective ways to deliver mental

health services to adolescents in school settings.

--Paae  ~

Since coalition building is a crucial and integral part of the

implementation process for SBHC8, w. recoxmnendadding another

option  for  PHS,  especially HRSA and  CDC, through tholr gxant 
prog=ams~ to support the capacity of the States to build the 
linkages and infrastructures supportive of SBHCS within their 
local communities.

H-12