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 

INTRODUCI’ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...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 CO MMENI?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 CDelivery 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 schoolbased 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-lbfked heauh
M!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 bwdcarq txuuwillrq?r muafmanaguic amfwpwposesofthe~

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 schoolbased 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 nonemergency 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?ssandaoldimwhealf’h 

carq have difiady nuzthg adokscent hedh cm needt 

While managed care plans offer comprehensive health care, most, like their fee-forservice counterparts, offer few counseling sexvices geared to adolescents. According to 

OT& “...Medicaid 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 schoolbased 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 Education’s 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 Medicaid’s 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 Medicaideligible 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 indepth, 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 schoolbased 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 President’s 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 10 health cam 

Overwhehn@ly, State agency respondents (91 percent) feel that school-based health 

centers improve access to health care. Many respondents cite the clinic’s 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) Foundation’s SchoolBased 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 schoolbased 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 practitioner’s actions: ‘W they’re 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 Hcnldt Clhiu Pmvi& Esmuud Car&, J~ Vol 26S,#19,Moy 151991,p.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 dodbased 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 infbnnalio nUkespkhce beZwe4?nmanugdmp* and 

dtool-baxd health C~. 

Most respondents said sharing patient information is not routine. Neither the schoolbased 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 schoolbased 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 

l— 

Patient characteristics 

I 

Services provided 

Hours of seMce 

GoaIa regarding service utilization 

Profit or not-for-profit status 

Funding sources 

All agea


Diverse in race and economic


status


All are insured


Full range of primary,secondary,


and tertiaq serviees


Required to provide 24 hour


acceas to care


Designed to increase primary care


and reduce unneeesary inpatient


hospital and emergency mom


utilization


Can be for-pmtit, or not-for-profit


Billiig of private poliq holdew


Medicaid, and Medicare agenciea


Schooi-based Health Centers 

School-aged, mostly adolescms 

Diverse in race and e.conom]c status 

Medically undeserved, targe 

number of uninsured 

Primary care geared to children 

with emphaais on edueation, 

prewnm, paychc%ocia4and 

mental health seMUsually open school hours with 

backup ffom sponsoring institutions 

Dea@ned to increase appropriate 

seMce utilization 

Not-for-profit 

Multiple funding sources including: 

granta from foundationa, local, 

State, or Federal agencie% thirdparty 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 

! 

~ 

~ 

~ 

I 
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 care pmidem 

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 other’s role and perspective. State and school-based health center respondents 

indicate that each provider “doesn’t 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 provider’s


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


to the patient’s 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-ofpkm 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 schoolbased 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 schoolbased 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 sem’ices: 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, Minnesota’s 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 Ramsey’s 

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 schoolbased 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 schoolbased 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 plan’s 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 schoolbased 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 child’s 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 schoolbased 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 schooibased 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 patient’s 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 HCFA’S 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 

patient’s 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 

Denver School-Based Clinics: a partnership in Health Care for Denver’s Youth 

Universiv of Colorado 

BOXB-206 

4200 E. 9th Ave. 

Denver, CO 80262 

Contact: Bruce 

Department of Health 

Health Sciences Center 

P. Guernsey 

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 

Children’s 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 Dxy’foOS,M.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 Children’s 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


Children’s Service


Massachusetts General Hospital


Boston, Massachusetts


Lydia O’Donnell


Education Development Center, Inc.


Newton, Massachusetts


B-3

Tracey M. Orloff, M.P.H.


Senior Health Associate


Children’s 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). 

Fo~ J+km-ktte B., and Margaret A. McManus, Medicaid Managed Care Arrangemen~ 

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 SI’ANDARDS 

D-1 
Coalition for School-Based Primary Care 

60 Haven 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 

These activities would 

Senior High Schools. There 

- individual student /family both internally a

externally


- SBC within the community


- growth of SBC’S


take place in SBC’S of Elementary, Middle a

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 

SBC’S 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 F1’E -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 ANDTREATINGPAITENI’S 

E-1 
BALTJMOM CITY HEALTHDEPAR=~SH&& TOTALHEALTHCARE HMO CLIENTS 

1 1 m Child needs Child needs

I 

cmergeacy Cafe I

, episodic cue 

. v 

PNP aendareferral currentlybeing 

1. PNPealla911&tK4 with return 

w&a	 . to Emageacy L envelocwtoC7 . 

l<==i--c I 

II n

2. PNP notifies (X hat u -=5$ 

patienton way to c1?


EmergencyRoom L Makesappt. school PNP will


t-n = 3. crw’iunotify@ds 2. Notes %eboolhealth” aue.enebiid&=ad 

CT ails patient’sPCP PCP in eunmenf aeetial of repat&biUto 

w Weksaamc day appt. computes6y- THc

7“— 

“2! 3. Complc4e8

�

b. 

.sadacopyti

Sends copy 

appt.

to 

dip&: 

school 

i-­ L

nume 

c. Ticldem � copy to 

InAeremindadl 

&y before �ppt. I 

u 4. Sends refaml & env. to N Child sent to THC with aebool Numing Managa at 

@ refed & altachedrduxn em. p8tieQt’6PcP de 

Patient seen bv school 1 II 

PNP & Sepott”aento I J[ # v Numing M8n8gcxIiCkkB 

Child seen by P(X & xefaml _ tcfud & amaa ~ 

ldtllld 

attached 

to 

envelope 

add by mad in I?x4ivu rehlrllm 1

_] I ~ @ 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 

SECI’ION 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 Division; 

(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 available 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

................ ..... ..................................

House iuoe

.

.. .....

(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 �.

pprove . agreements between prepaid health plans �nd publicly funded pmviders 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 SUDDOIId cmtzrams �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 bySenate May Z$ 1991 Received by Oovemm

..J.\,.oo ......mM..._Q.m--.!a.._.. -..-.._-...1991 

&“x4a>??A42ff .. ... . . . . Approve&

%.!.%..&.hL-xJY3.% ...=j...........-....-.. !991 

----p@iii: . . . 

Passedby &1991 *-* 

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 

shallexecute agrccmentSwith publicly funded providem for authotition of 

paymentforpointof contactscM= in thefollowingcatcgoriti: 

(1) IfmmmizltiOrlS;


(2) Sexually transmittal di-; and 

(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 PHPshalltakeappropriatemeasu~ 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. 

B. 

c.


D. 

E. 

Describe theagreements andhrsubcontracts youwill-t fm OMAP 

- ~ @reply with MeawememtStandard I.&, or explain steps your 

organization will take to cOmpiy with this statutory requirement. 

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 

Describe any agreements and/or subcontmcts you will have with pubhcly 

funded providers to provide matemity case managemcnq wel.khild care 

ador prenaal are. 

Response due 4/20/92: Attach any agreements andlor subcontracts (or dm 

versions) with publicly fundedprovidexs
toprovidematunitycase

managemea~ wdkhild cam ardor prenatal
cam 

Desde your orpkation’s poliaeswhich addresstk i.ntmt
of Measuremen 

standard
 1.8CL 

Stctioaw -%gt7 

F-5 

— 
APPENDIX G 

HEALTHCARE FINANCING AD~~ON 

RESPONSE TO THE DW REPORT 

G-1 
.

----- -------

.. . *. ;% 

Care C-,Ir.:IrC Admtnfstraf -.” .

& DEPARTMENT OF HEALTH & HLf.MANSER1’!(:ZS Health
 :*


: �


7. “ -. ,..—--—. - ..— .-. .--—— ______ -. % 

FROM:	 Bruce C. VIadec--

SUBJE~ 

Administrator 

Office of Inspector 

-3i’--�

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 schooibased health services ?Imse wntaots should lead the Department’s 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 report’s recommendations. 

Attachment 

G-2

Comxnenrsof the Health Care FinancinizAdministration [HCF~ 

Office of InsO~Or General (OIGI Draft Rent@ 

‘scoo ~ -

EM15-92-00680 

GeneA Comments 

Page 6 states that mosg but not all, of the investigators’discussions with manag 

carerespondents related to Medicaid managed care It m“ghtbe worth 

mentioning here that although the focus of the reportwas the extent to which 

school-based health centers coordinatewithMedicaidmanaged 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 aystenxx“Althoughmany providers are invohwdin the pia

Medicaid recipients may choose a providerand then the prwider’s name and t 

telephone number WINbe included on the recipient’sMedicaid card.” 

On page M, the kzst sentence in the second paragraph should include

acluwwledgement that State Medicaid agenciescan 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 
-..., /’%%.“ DEPARTMENT OF HEALTH & HUMAN WRVKX$ I?wliCHdtl­ a 

;

4 Memorandum 

Qlte yCPlH51993 

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 Nation’s children and youth by the new 

AdauinL,stratLon. 

We generally concur w~h the OIG recommendations. 

(/” a ~�

Philin —. . Lee. — –. M. .


Attachment

c~ s QF THEE!UBuc IW4LTH smwIcE (PHS 1 ON THE O~IC E OF 

~BCT(lR GENEIUL (OIGl RAFT REPORT ON *scxoor4”BAsED 

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) and”the high priority placed on improving the


health status of our NatLon’8 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 S1313CS
fit 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 Cto 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 highrlsk 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&vefi that 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!tznen datlon 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 

Association’s 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


Prevention’s �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 effects of 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 aelfadministered 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 school and 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 AHCPR’S 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 pqograms and 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 SAMHSA’6 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


,The source(s) for the information on the funding estimates ,
 “should be referenced.


H-9

--

--

--

.- uarauxawh uncles“=e m .School-humd Ziql@th -Cers , 

.- The’third 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


ZCS13.“ 

~aue 8, first naraara~


We suggest the statement “Parental consent is the only . . . 

� ‘“ be modified to read “Parental/guardian consent . . . .“ 

.- � at school-bad heal tia Camt@r’s ~ 

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 University’s School of Health 

Policy has convened thmm meetings of the national workgroup 

to recommend national standards for SBHCS.” 

.- ~e 13, 11et “Leua 1~ 

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 sentence r=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.11
et

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