the whole school , whole community , whole child ( wscc ) model ( figure 1 ) , developed by ascd ( formerly the association for supervision and curriculum development ) and the us centers for disease control ( cdc ) , provides a framework and a call for the health and education sectors to work toward greater alignment and coordination of policy , process , and practice . the wscc model , released in 2014 , was developed to ensure that school - community and education - health sector alignments are front and center . the model expands the traditional 8-component coordinated school health ( csh ) approach and deliberately places it inside the larger community in order to emphasize this connection and role . this includes not only an increase in the number of school health components from 8 to 10 but also the alignment of an education focus with a health focus . the new model calls for a greater collaboration across the community , school , and health and education sectors to meet the needs and support the full potential of each child.8 whole school , whole community , whole child ( wscc ) model . the benefits of collaboration , alignment , and integration between health and education can best be viewed in 3 key areas : leveraging resources , utilizing resources efficiently , and improving both health and education outcomes . a 2010 report from the coalition of community schools cited 5 key ways that schools can efficiently leverage resources.9 this includes collaborative efforts to strengthen the core instructional mission of schools , leveraging community - wide financial resources , developing collaborative leadership structures and ownership , enhancing public / private partnerships , and providing coordination between and across systems . in terms of more efficient utilization , increased integration of health and education can improve usage of facilities and resources . leveraging resources from across the community , as illustrated in the wscc model , can aid both the establishment of school - community connections and health and educational outcomes . examples include shared use agreements that can lead to improved community access to facilities for physical activity10,11 and school - based health centers that have been shown to reduce a community 's inappropriate emergency room use , increase use of primary care , and result in fewer hospitalizations among regular users.1214 finally , strengthening the integration and collaboration between health and education benefits both sectors because research suggests that educational attainment is important to achieving better health outcomes,15,16 and health is key to better educational outcomes.2,3 operationalizing wscc requires moving from theoretical model to practical implementation through the development of state and local school policies and practices . although the model is new , a number of states and local school districts have made significant strides over the last few years in their efforts to better align health and education by building a collaborative , integrated approach . arkansas , kentucky , colorado , maine regional school unit # 22 , and denver public schools ( dps ) all provide valuable examples of states and local districts that embraced wscc 's core vision of aligning health and education through the adoption of integrated policies and initiatives . their trailblazing efforts demonstrate both the feasibility of implementing the wscc model and the visionary leadership required to do so . we conducted a search of the health and education department 's websites in arkansas , colorado , and kentucky , and the school districts ' websites in maine regional school unit # 22 , and dps for materials demonstrating adoption and implementation of csh and its respective components or the wscc model . we also conducted a search of the respective state legislative databases , state health and education department websites , and local school district websites for adopted policy relevant to csh and the wscc model . we searched pubmed , web of science , and academic search premier and for relevant peer - reviewed articles around the implementation of aspects of csh or wscc in the 4 states and 2 local school districts . in addition , we searched online for news articles and gray literature highlighting the implementation of csh or the wscc model , or aspects of them , in each state and local school district . secondarily , we conducted informal reinforcing interviews via phone with 1 person in a key school health leadership role related to the promotion and implementation of the wscc model in each district and state : arkansas , kentucky , and colorado , maine regional school unit # 22 and dps . in arkansas , the state health and education departments have a long history of working collaboratively and with partners to improve the health of students . the 2 agencies have jointly operated the coordinated school health program ( cshp ) for over 2 decades , working together to expand csh in school districts across the state . they have been supported by a series of state laws that have created a strong and long - lasting foundation for their actions . in 2003 , the arkansas legislature adopted act 1220 , landmark legislation addressing multiple areas of a healthy school environment.17 the legislation included requirements for body mass index ( bmi ) screening in schools ; the establishment of a state - level child health advisory committee ( chac ) to develop rules and regulations for school nutrition , physical education ( pe ) , and physical activity , and to make recommendations to the arkansas state board of education and board of health ; and the establishment of a wellness committee in each local school district . act 1220 also created positions for regional community health promotion specialists ( chps ) specifically to assist schools and led to new standards for competitive foods and physical activity in schools , created by the arkansas chac . act 201 followed in 2007 to make modifications to the bmi screening and grade level requirements , provide a parental opt - out clause , and require the department of health to assign regional community health nurse specialists ( chns ) to work with schools to ensure appropriate protocols and follow up . act 317 ( 2007 ) later strengthened the chac recommended physical activity requirements and required a half credit of pe for high school graduation.18 in 2009 , act 180 ( tobacco excise tax ) made possible a state - level joint use agreement grant program collaboratively run by the arkansas department of education ( ade ) , the arkansas department of health ( adh ) , and the arkansas center for health improvement.19 the program assists schools in the adoption and implementation of shared use policies and the formation of collaborative community partnerships to increase opportunities for physical activity . act 180 also provided funding for an annual school - based health center grant , a collaboration among ade , adh , the arkansas department of human services , and medicaid in the schools . this funding led to the establishment of 22 school - based health centers across the state , providing on - site clinical services for students and connecting them with community partners in an effort to meet their needs better . , post - implementation data indicate that act 1220 and the related policies have resulted in substantial positive changes in school health environments , policies , and practices , with widespread parental support and no increase in negative consequences such as weight - based teasing.2022 among the changes are improved nutrition environments in school districts across the state , including reduced access to less healthy competitive foods and beverages and increased access to healthier options , and stronger policies to promote physical activity and recess.20,21,2327 the chps , employed by the state health department but housed in regional educational cooperatives , have worked together with chns to support local school districts , including assisting with the creation of wellness committees and policies , administering the school health index , and developing strategies to improve nutrition , physical activity , and health environment policies and programs . the state health and education departments have worked collaboratively , with initiatives guided by a school health services team comprised of staff from various areas in each agency , including school health services , human immunodeficiency virus infection / acquired immune deficiency syndrome , mental health , arkansas medicaid in the schools , the state school nurse consultant , act 1220 , and csh . team members provide ongoing support , training , and professional development to school districts throughout the state and to the chps and chns on topics such as wellness policies and administration of the school health index . kentucky provides another valuable example of a state that has worked to integrate health and education through the alignment of policy at the state level . kentucky 's state health and education departments have enjoyed a strong , collaborative relationship in recent years . together , staff from each agency have worked together to increase awareness of csh among education leaders across the state , including superintendents , principals , and school board members . they have collaborated with state associations including the kentucky association of school councils , kentucky school nutrition association , kentucky family resource youth service centers , and kentucky association of health , physical education , recreation , and dance to promote understanding , adoption , and implementation of csh at the local level . the state agencies have focused on helping education leaders make the connection between the csh components and educational outcomes of academic achievement , discipline , and attendance . this foundation , along with strong relationships with state - level organizations including the kentucky school boards association and the kentucky superintendents association , has facilitated the adoption of education policies that support healthier schools and students . an example of this can be seen in kentucky 's program review process . in 2009 , the kentucky legislature adopted senate bill 1 , which established program review as a part of a new assessment and accountability model.28 in addition to ensuring district and school accountability for student achievement , the annual program reviews are designed to both audit and provide feedback and recommendations focused on improving the quality of educational experiences available to students . the program review includes a practical living / career studies component , encompassing health education and pe . the state health and education departments worked collaboratively to draft the program review rubric for the practical living / career studies component , setting a high baseline to support and strengthen the integration of health into school - level policies and practices . schools receive one of 4 designations during the program review process : no implementation , needs improvement , proficient , and distinguished . to achieve the proficient level for health education in the practical living / career studies program review , a school must have a csh committee that is used as a support and resource for collaboration and integration of health education instruction in the school environment ( table 1 ) . similarly , to achieve proficient in the practical living / administrative leadership / support and monitoring component , a school must convene its csh committee at least twice a year , implement the district - level wellness policy via a school - level wellness policy reviewed annually , and include goals for school wellness in the comprehensive school improvement plan ( csip ) . for pe , the csh committee of a proficient school must utilize a comprehensive school physical activity program ( cspap ) to increase quality pe and physical activity opportunities , and integrate the pe curriculum , providing opportunities for cross - disciplinary connections ( table 1 ) . whereas schools may go beyond these standards to achieve the distinguished level , setting high requirements for the proficient level has greatly incentivized the establishment of coordinated school health committees in schools across the state , creation of school - level wellness policies , integration of wellness goals into the school improvement plans , and expansion of cspap . using a common sense approach , kentucky has intentionally and thoughtfully woven health into education measures , and in doing so , has taken a major step toward ensuring better integration of health and education at the local level . examples from kentucky practical living / career studies ( plcs ) program review rubric * adapted from the kentucky department of education . in colorado , strong collaboration and leadership between health and education partners , both public and private , have been instrumental in advancing the integration of health and education across the state . cooperative relationships have been created by aligning the priorities of local foundations with state - level initiatives rather than passing policy . in addition to a solid working partnership between the state health and education agencies , the state has benefitted from the strategic support of local foundations and organizations including : the colorado education initiative , rmc health , the colorado health foundation , and kaiser permanente . in 2010 , these partners came together to develop and disseminate the healthy school champion score card , a voluntary online school - level assessment tool and associated statewide recognition program that provides financial incentives for creating healthy schools ( tables 2 and 3 ) . whereas the design is based on the school health index , it also takes into consideration colorado legislation and policies . the use of the score card grew significantly from its initiation in 2010 , when 100 schools participated . in the 20132014 school year , 216 schools , covering over 100,000 students , participated.29,30 colorado healthy school champions score card sections * colorado coalition for healthy schools . score card overview . colorado is working to build on the success of the score card by developing the next phase of a district- and school - level assessment and implementation tool for health policies and practices , called healthy schools smart source . this effort is funded by kaiser permanente , in partnership with the colorado department of education , the colorado department of public health and the environment , the colorado education initiative , and the colorado coalition for healthy schools . the goal of smart source is to create a single assessment tool that will incorporate questions from the score card and other statewide school health assessments , streamlining data collection and submission for schools.31 to create the assessment , partners conducted an extensive literature review and convened over 200 stakeholders in order to determine the correct data points . a pilot of smart source was launched in the 20142015 school year with 90 schools . by the 20162017 school year , smart source will collect and synthesize data about school and district health policies and practices into a statewide system . smart source will provide schools with school - level reports that offer objective , meaningful comparisons to the aggregated results from all respondents statewide . these reports are designed to provide useful , actionable data as well as recommendations for implementing best practices related to health and wellness ( table 4 ) . reports will provide school- and district - level leaders with a more robust picture of the effect their school health efforts have on student performance and classroom behavior , informing the school improvement planning process.31,32 overview of colorado healthy schools smart source * colorado education initiative . in addition to the smart source initiative , collaborating partners have also launched the colorado healthy schools collective impact ( hsci ) , a purposeful and strategic effort to define healthy schools , prioritize school health - related work in the state , minimize duplication of initiatives , and better leverage resources and funding for healthy schools . healthy schools collective impact members include 20 foundations and nearly 100 community organizations , state agencies , school districts and schools , and nonprofits that are all interested in strengthening the school health environment . the 4 focus areas , each represented by a work group that meets monthly , are pe and physical activity , nutrition , behavioral health ( social , emotional , and mental ) , and student health services . healthy schools collective impact 's objectives are to ( 1 ) coordinate efforts and ensure resources are allocated based on identified needs ; ( 2 ) engage those impacted by the work , including districts and schools , parents , students , funders , and organizations that champion healthy schools ; ( 3 ) gather consistent data by coordinating surveys and systems to collect data from schools ; ( 4 ) use consistent communication by creating a shared definition of a healthy school , possibly producing a one - stop shop for data and resources related to priority school health strategies ; ( 5 ) support core capacity for schools and districts ; and ( 6 ) develop shared policy priorities.33 at the local level , many school districts nationally have embraced the importance of addressing the whole child through better alignment and integration of health and education . two districts that provide strong examples of application and implementation of coordinated school health and/or the wscc model include maine regional school unit ( rsu ) # 22 and denver public schools in colorado . both have benefited from the leadership of superintendents and local school boards that have embraced the importance of educating the whole child . maine regional school unit # 22 , located in the hampden area , began to intentionally focus on the health and wellness of students and staff in 1991 . the vision to strengthen school health and wellness has been driven by rick lyons , district superintendent since 1992 . the district began by forming a wellness team long before the concept had gained widespread popularity . the wellness team , comprised administrators , faculty , support staff , and community members , has been a key factor behind the district 's school health achievements since its establishment . in 2001 , the district also founded a school health advisory council ( shac ) comprised of administrators , healthcare professionals , and community members . the shac oversees the cshp , which is headed by a school health coordinator employed by the district . given rsu # 22 's small size ( approximately 2,200 students and 375 employees ) , the financial commitment to support a full - time school health coordinator speaks to the high priority that school health has in this district . over the last 20 years , rsu # 22 has taken many proactive steps toward strengthening school health in each of its 6 schools . it increased the number of positions and staffing time for health education teachers , nurses , and guidance counselors and forged partnerships with behavioral health providers . the district promotes active transport to school with a  walking school bus ,  works with the hampden town council to repair bike lanes and install street lights , and partners with the hampden recreation department to provide before- and after - school programming . regional school unit # 22 implemented a comprehensive k12 health / pe curriculum focusing on lifelong activities ( such as weight training , aerobics , bicycling , and running ) along with activities such as skiing , tennis , snowshoeing , and swimming and uses recess rocks in k2 classrooms . in 2002 , the wellness coordinator and nutrition director worked with students and suppliers to change the content of all food offered in vending machines to healthy choices . regional school unit # 22 's schools offer salad bars at lunch , and the food service director strives to use locally sourced foods as much as possible . in 2010 , parents , students , the district 's food service director , wellness coordinator , and community partners collaborated to plant apple orchards and a vegetable garden . leadership from school board members and the superintendent has been key in rsu # 22 's transformation into a district where health and wellness is a top priority and a value embraced by the school employees and the community . the shac , wellness team , and school health coordinator have also been integral to the process . they have worked together to facilitate the integration of health and education in numerous areas , including the district 's strategic plan and the interview process for prospective employees , which includes questions about their thoughts on the district 's wellness priorities . the district has focused on improving student and staff health and dedicated significant financial resources to both . the local school board allocates approximately $ 40,000 per year for employee wellness incentives for those who did not use more than 3 sick days the previous year , and 60% of staff members have qualified for this reward . regional school unit # 22 promotes periodic wellness challenges for staff and a 7-week  total health track through adult education . in 2012 , it opened a new high school that includes a fitness center , track , and tennis courts open to students , staff , and the community . as a result of these efforts , the wellness council of america awarded the district their gold level workplace wellness award . superintendent leadership also has been critical to the success of dps ' strategic inclusion of student health in the district 's overall priorities and plan . since being appointed to the position by the board of education in 2009 , superintendent tom boasberg has managed the district 's 183 schools , which serve a diverse population of over 90,000 children . seventy - two percent of students qualify for free or reduced - price lunch , and 41% speak a language other than english at home.34 the district has also committed significant resources to student health , and made it a part of the district 's strategic planning process . in 2010 , boasberg oversaw the denver school health advisory council 's creation of the dps health agenda 2015 , which outlines the districts ' health priorities.35 the district has since invested over $ 22 million toward its health goals , including the addition of 6 full - time district - funded employees . some of the significant accomplishments include dramatically increasing the number of schools that serve breakfast after the bell ; adding pe teachers to elementary schools , which has led to an additional 22 minutes per week of pe classes ; and increasing the number of school counselors , which has corresponded with a decrease in expulsion and suspension rates . denver public school has also added a school - based health center every year since 2010 , with a fifth scheduled to open in 2015 . in august 2014 , dps released the current version of its 5-year strategic plan , denver plan 2020 . this version , which was developed with the input of nearly 3,000 educators , parents , students , community partners , and city leaders , includes support for the whole child  as one of 5 goals . using the wscc model as a backbone , an advisory committee is assessing dps ' activities , and will present recommendations for creating a metric to determine future progress in early 2015.36 denver public school is also working on the development of the next generation of their health agenda , dps health agenda 2020 . the district has solicited input from students , parents , and community members through a widely disseminated survey about health issues that most impact students . survey topics include asthma , vision , oral health , nutrition , physical activity , social / emotional health , substance abuse , teen pregnancy , and school culture . denver public school plans to use the results of this survey to improve student health and wellness going forward . in arkansas , the state health and education departments have a long history of working collaboratively and with partners to improve the health of students . the 2 agencies have jointly operated the coordinated school health program ( cshp ) for over 2 decades , working together to expand csh in school districts across the state . they have been supported by a series of state laws that have created a strong and long - lasting foundation for their actions . in 2003 , the arkansas legislature adopted act 1220 , landmark legislation addressing multiple areas of a healthy school environment.17 the legislation included requirements for body mass index ( bmi ) screening in schools ; the establishment of a state - level child health advisory committee ( chac ) to develop rules and regulations for school nutrition , physical education ( pe ) , and physical activity , and to make recommendations to the arkansas state board of education and board of health ; and the establishment of a wellness committee in each local school district . act 1220 also created positions for regional community health promotion specialists ( chps ) specifically to assist schools and led to new standards for competitive foods and physical activity in schools , created by the arkansas chac . act 201 followed in 2007 to make modifications to the bmi screening and grade level requirements , provide a parental opt - out clause , and require the department of health to assign regional community health nurse specialists ( chns ) to work with schools to ensure appropriate protocols and follow up . act 317 ( 2007 ) later strengthened the chac recommended physical activity requirements and required a half credit of pe for high school graduation.18 in 2009 , act 180 ( tobacco excise tax ) made possible a state - level joint use agreement grant program collaboratively run by the arkansas department of education ( ade ) , the arkansas department of health ( adh ) , and the arkansas center for health improvement.19 the program assists schools in the adoption and implementation of shared use policies and the formation of collaborative community partnerships to increase opportunities for physical activity . act 180 also provided funding for an annual school - based health center grant , a collaboration among ade , adh , the arkansas department of human services , and medicaid in the schools . this funding led to the establishment of 22 school - based health centers across the state , providing on - site clinical services for students and connecting them with community partners in an effort to meet their needs better . , post - implementation data indicate that act 1220 and the related policies have resulted in substantial positive changes in school health environments , policies , and practices , with widespread parental support and no increase in negative consequences such as weight - based teasing.2022 among the changes are improved nutrition environments in school districts across the state , including reduced access to less healthy competitive foods and beverages and increased access to healthier options , and stronger policies to promote physical activity and recess.20,21,2327 the chps , employed by the state health department but housed in regional educational cooperatives , have worked together with chns to support local school districts , including assisting with the creation of wellness committees and policies , administering the school health index , and developing strategies to improve nutrition , physical activity , and health environment policies and programs . the state health and education departments have worked collaboratively , with initiatives guided by a school health services team comprised of staff from various areas in each agency , including school health services , human immunodeficiency virus infection / acquired immune deficiency syndrome , mental health , arkansas medicaid in the schools , the state school nurse consultant , act 1220 , and csh . team members provide ongoing support , training , and professional development to school districts throughout the state and to the chps and chns on topics such as wellness policies and administration of the school health index . kentucky provides another valuable example of a state that has worked to integrate health and education through the alignment of policy at the state level . kentucky 's state health and education departments have enjoyed a strong , collaborative relationship in recent years . together , staff from each agency have worked together to increase awareness of csh among education leaders across the state , including superintendents , principals , and school board members . they have collaborated with state associations including the kentucky association of school councils , kentucky school nutrition association , kentucky family resource youth service centers , and kentucky association of health , physical education , recreation , and dance to promote understanding , adoption , and implementation of csh at the local level . the state agencies have focused on helping education leaders make the connection between the csh components and educational outcomes of academic achievement , discipline , and attendance . this foundation , along with strong relationships with state - level organizations including the kentucky school boards association and the kentucky superintendents association , has facilitated the adoption of education policies that support healthier schools and students . an example of this can be seen in kentucky 's program review process . in 2009 , the kentucky legislature adopted senate bill 1 , which established program review as a part of a new assessment and accountability model.28 in addition to ensuring district and school accountability for student achievement , the annual program reviews are designed to both audit and provide feedback and recommendations focused on improving the quality of educational experiences available to students . the program review includes a practical living / career studies component , encompassing health education and pe . the state health and education departments worked collaboratively to draft the program review rubric for the practical living / career studies component , setting a high baseline to support and strengthen the integration of health into school - level policies and practices . schools receive one of 4 designations during the program review process : no implementation , needs improvement , proficient , and distinguished . to achieve the proficient level for health education in the practical living / career studies program review , a school must have a csh committee that is used as a support and resource for collaboration and integration of health education instruction in the school environment ( table 1 ) . similarly , to achieve proficient in the practical living / administrative leadership / support and monitoring component , a school must convene its csh committee at least twice a year , implement the district - level wellness policy via a school - level wellness policy reviewed annually , and include goals for school wellness in the comprehensive school improvement plan ( csip ) . for pe , the csh committee of a proficient school must utilize a comprehensive school physical activity program ( cspap ) to increase quality pe and physical activity opportunities , and integrate the pe curriculum , providing opportunities for cross - disciplinary connections ( table 1 ) . whereas schools may go beyond these standards to achieve the distinguished level , setting high requirements for the proficient level has greatly incentivized the establishment of coordinated school health committees in schools across the state , creation of school - level wellness policies , integration of wellness goals into the school improvement plans , and expansion of cspap . using a common sense approach , kentucky has intentionally and thoughtfully woven health into education measures , and in doing so , has taken a major step toward ensuring better integration of health and education at the local level . examples from kentucky practical living / career studies ( plcs ) program review rubric * adapted from the kentucky department of education . in colorado , strong collaboration and leadership between health and education partners , both public and private , have been instrumental in advancing the integration of health and education across the state . cooperative relationships have been created by aligning the priorities of local foundations with state - level initiatives rather than passing policy . in addition to a solid working partnership between the state health and education agencies , the state has benefitted from the strategic support of local foundations and organizations including : the colorado education initiative , rmc health , the colorado health foundation , and kaiser permanente . in 2010 , these partners came together to develop and disseminate the healthy school champion score card , a voluntary online school - level assessment tool and associated statewide recognition program that provides financial incentives for creating healthy schools ( tables 2 and 3 ) . whereas the design is based on the school health index , it also takes into consideration colorado legislation and policies . the use of the score card grew significantly from its initiation in 2010 , when 100 schools participated . in the 20132014 school year , 216 schools , covering over 100,000 students , participated.29,30 colorado healthy school champions score card sections * colorado coalition for healthy schools . score card overview . colorado is working to build on the success of the score card by developing the next phase of a district- and school - level assessment and implementation tool for health policies and practices , called healthy schools smart source . this effort is funded by kaiser permanente , in partnership with the colorado department of education , the colorado department of public health and the environment , the colorado education initiative , and the colorado coalition for healthy schools . the goal of smart source is to create a single assessment tool that will incorporate questions from the score card and other statewide school health assessments , streamlining data collection and submission for schools.31 to create the assessment , partners conducted an extensive literature review and convened over 200 stakeholders in order to determine the correct data points . a pilot of smart source was launched in the 20142015 school year with 90 schools . by the 20162017 school year , smart source will collect and synthesize data about school and district health policies and practices into a statewide system . smart source will provide schools with school - level reports that offer objective , meaningful comparisons to the aggregated results from all respondents statewide . these reports are designed to provide useful , actionable data as well as recommendations for implementing best practices related to health and wellness ( table 4 ) . reports will provide school- and district - level leaders with a more robust picture of the effect their school health efforts have on student performance and classroom behavior , informing the school improvement planning process.31,32 overview of colorado healthy schools smart source * colorado education initiative . in addition to the smart source initiative , collaborating partners have also launched the colorado healthy schools collective impact ( hsci ) , a purposeful and strategic effort to define healthy schools , prioritize school health - related work in the state , minimize duplication of initiatives , and better leverage resources and funding for healthy schools . healthy schools collective impact members include 20 foundations and nearly 100 community organizations , state agencies , school districts and schools , and nonprofits that are all interested in strengthening the school health environment . the 4 focus areas , each represented by a work group that meets monthly , are pe and physical activity , nutrition , behavioral health ( social , emotional , and mental ) , and student health services . healthy schools collective impact 's objectives are to ( 1 ) coordinate efforts and ensure resources are allocated based on identified needs ; ( 2 ) engage those impacted by the work , including districts and schools , parents , students , funders , and organizations that champion healthy schools ; ( 3 ) gather consistent data by coordinating surveys and systems to collect data from schools ; ( 4 ) use consistent communication by creating a shared definition of a healthy school , possibly producing a one - stop shop for data and resources related to priority school health strategies ; ( 5 ) support core capacity for schools and districts ; and ( 6 ) develop shared policy priorities.33 in arkansas , the state health and education departments have a long history of working collaboratively and with partners to improve the health of students . the 2 agencies have jointly operated the coordinated school health program ( cshp ) for over 2 decades , working together to expand csh in school districts across the state . they have been supported by a series of state laws that have created a strong and long - lasting foundation for their actions . in 2003 , the arkansas legislature adopted act 1220 , landmark legislation addressing multiple areas of a healthy school environment.17 the legislation included requirements for body mass index ( bmi ) screening in schools ; the establishment of a state - level child health advisory committee ( chac ) to develop rules and regulations for school nutrition , physical education ( pe ) , and physical activity , and to make recommendations to the arkansas state board of education and board of health ; and the establishment of a wellness committee in each local school district . act 1220 also created positions for regional community health promotion specialists ( chps ) specifically to assist schools and led to new standards for competitive foods and physical activity in schools , created by the arkansas chac . act 201 followed in 2007 to make modifications to the bmi screening and grade level requirements , provide a parental opt - out clause , and require the department of health to assign regional community health nurse specialists ( chns ) to work with schools to ensure appropriate protocols and follow up . act 317 ( 2007 ) later strengthened the chac recommended physical activity requirements and required a half credit of pe for high school graduation.18 in 2009 , act 180 ( tobacco excise tax ) made possible a state - level joint use agreement grant program collaboratively run by the arkansas department of education ( ade ) , the arkansas department of health ( adh ) , and the arkansas center for health improvement.19 the program assists schools in the adoption and implementation of shared use policies and the formation of collaborative community partnerships to increase opportunities for physical activity . act 180 also provided funding for an annual school - based health center grant , a collaboration among ade , adh , the arkansas department of human services , and medicaid in the schools . this funding led to the establishment of 22 school - based health centers across the state , providing on - site clinical services for students and connecting them with community partners in an effort to meet their needs better . , post - implementation data indicate that act 1220 and the related policies have resulted in substantial positive changes in school health environments , policies , and practices , with widespread parental support and no increase in negative consequences such as weight - based teasing.2022 among the changes are improved nutrition environments in school districts across the state , including reduced access to less healthy competitive foods and beverages and increased access to healthier options , and stronger policies to promote physical activity and recess.20,21,2327 the chps , employed by the state health department but housed in regional educational cooperatives , have worked together with chns to support local school districts , including assisting with the creation of wellness committees and policies , administering the school health index , and developing strategies to improve nutrition , physical activity , and health environment policies and programs . the state health and education departments have worked collaboratively , with initiatives guided by a school health services team comprised of staff from various areas in each agency , including school health services , human immunodeficiency virus infection / acquired immune deficiency syndrome , mental health , arkansas medicaid in the schools , the state school nurse consultant , act 1220 , and csh . team members provide ongoing support , training , and professional development to school districts throughout the state and to the chps and chns on topics such as wellness policies and administration of the school health index . kentucky provides another valuable example of a state that has worked to integrate health and education through the alignment of policy at the state level . kentucky 's state health and education departments have enjoyed a strong , collaborative relationship in recent years . together , staff from each agency have worked together to increase awareness of csh among education leaders across the state , including superintendents , principals , and school board members . they have collaborated with state associations including the kentucky association of school councils , kentucky school nutrition association , kentucky family resource youth service centers , and kentucky association of health , physical education , recreation , and dance to promote understanding , adoption , and implementation of csh at the local level . the state agencies have focused on helping education leaders make the connection between the csh components and educational outcomes of academic achievement , discipline , and attendance . this foundation , along with strong relationships with state - level organizations including the kentucky school boards association and the kentucky superintendents association , has facilitated the adoption of education policies that support healthier schools and students . an example of this can be seen in kentucky 's program review process . in 2009 , the kentucky legislature adopted senate bill 1 , which established program review as a part of a new assessment and accountability model.28 in addition to ensuring district and school accountability for student achievement , the annual program reviews are designed to both audit and provide feedback and recommendations focused on improving the quality of educational experiences available to students . the program review includes a practical living / career studies component , encompassing health education and pe . the state health and education departments worked collaboratively to draft the program review rubric for the practical living / career studies component , setting a high baseline to support and strengthen the integration of health into school - level policies and practices . schools receive one of 4 designations during the program review process : no implementation , needs improvement , proficient , and distinguished . to achieve the proficient level for health education in the practical living / career studies program review , a school must have a csh committee that is used as a support and resource for collaboration and integration of health education instruction in the school environment ( table 1 ) . similarly , to achieve proficient in the practical living / administrative leadership / support and monitoring component , a school must convene its csh committee at least twice a year , implement the district - level wellness policy via a school - level wellness policy reviewed annually , and include goals for school wellness in the comprehensive school improvement plan ( csip ) . for pe , the csh committee of a proficient school must utilize a comprehensive school physical activity program ( cspap ) to increase quality pe and physical activity opportunities , and integrate the pe curriculum , providing opportunities for cross - disciplinary connections ( table 1 ) . whereas schools may go beyond these standards to achieve the distinguished level , setting high requirements for the proficient level has greatly incentivized the establishment of coordinated school health committees in schools across the state , creation of school - level wellness policies , integration of wellness goals into the school improvement plans , and expansion of cspap . using a common sense approach , kentucky has intentionally and thoughtfully woven health into education measures , and in doing so , has taken a major step toward ensuring better integration of health and education at the local level . examples from kentucky practical living / career studies ( plcs ) program review rubric * adapted from the kentucky department of education . in colorado , strong collaboration and leadership between health and education partners , both public and private , have been instrumental in advancing the integration of health and education across the state . cooperative relationships have been created by aligning the priorities of local foundations with state - level initiatives rather than passing policy . in addition to a solid working partnership between the state health and education agencies , the state has benefitted from the strategic support of local foundations and organizations including : the colorado education initiative , rmc health , the colorado health foundation , and kaiser permanente . in 2010 , these partners came together to develop and disseminate the healthy school champion score card , a voluntary online school - level assessment tool and associated statewide recognition program that provides financial incentives for creating healthy schools ( tables 2 and 3 ) . whereas the design is based on the school health index , it also takes into consideration colorado legislation and policies . the use of the score card grew significantly from its initiation in 2010 , when 100 schools participated . in the 20132014 school year , 216 schools , covering over 100,000 students , participated.29,30 colorado healthy school champions score card sections * colorado coalition for healthy schools . colorado is working to build on the success of the score card by developing the next phase of a district- and school - level assessment and implementation tool for health policies and practices , called healthy schools smart source . this effort is funded by kaiser permanente , in partnership with the colorado department of education , the colorado department of public health and the environment , the colorado education initiative , and the colorado coalition for healthy schools . the goal of smart source is to create a single assessment tool that will incorporate questions from the score card and other statewide school health assessments , streamlining data collection and submission for schools.31 to create the assessment , partners conducted an extensive literature review and convened over 200 stakeholders in order to determine the correct data points . a pilot of smart source was launched in the 20142015 school year with 90 schools . by the 20162017 school year , smart source will collect and synthesize data about school and district health policies and practices into a statewide system . smart source will provide schools with school - level reports that offer objective , meaningful comparisons to the aggregated results from all respondents statewide . these reports are designed to provide useful , actionable data as well as recommendations for implementing best practices related to health and wellness ( table 4 ) . reports will provide school- and district - level leaders with a more robust picture of the effect their school health efforts have on student performance and classroom behavior , informing the school improvement planning process.31,32 overview of colorado healthy schools smart source * colorado education initiative . in addition to the smart source initiative , collaborating partners have also launched the colorado healthy schools collective impact ( hsci ) , a purposeful and strategic effort to define healthy schools , prioritize school health - related work in the state , minimize duplication of initiatives , and better leverage resources and funding for healthy schools . healthy schools collective impact members include 20 foundations and nearly 100 community organizations , state agencies , school districts and schools , and nonprofits that are all interested in strengthening the school health environment . the 4 focus areas , each represented by a work group that meets monthly , are pe and physical activity , nutrition , behavioral health ( social , emotional , and mental ) , and student health services . healthy schools collective impact 's objectives are to ( 1 ) coordinate efforts and ensure resources are allocated based on identified needs ; ( 2 ) engage those impacted by the work , including districts and schools , parents , students , funders , and organizations that champion healthy schools ; ( 3 ) gather consistent data by coordinating surveys and systems to collect data from schools ; ( 4 ) use consistent communication by creating a shared definition of a healthy school , possibly producing a one - stop shop for data and resources related to priority school health strategies ; ( 5 ) support core capacity for schools and districts ; and ( 6 ) develop shared policy priorities.33 at the local level , many school districts nationally have embraced the importance of addressing the whole child through better alignment and integration of health and education . two districts that provide strong examples of application and implementation of coordinated school health and/or the wscc model include maine regional school unit ( rsu ) # 22 and denver public schools in colorado . both have benefited from the leadership of superintendents and local school boards that have embraced the importance of educating the whole child . maine regional school unit # 22 , located in the hampden area , began to intentionally focus on the health and wellness of students and staff in 1991 . the vision to strengthen school health and wellness has been driven by rick lyons , district superintendent since 1992 . the district began by forming a wellness team long before the concept had gained widespread popularity . the wellness team , comprised administrators , faculty , support staff , and community members , has been a key factor behind the district 's school health achievements since its establishment . in 2001 , the district also founded a school health advisory council ( shac ) comprised of administrators , healthcare professionals , and community members . the shac oversees the cshp , which is headed by a school health coordinator employed by the district . given rsu # 22 's small size ( approximately 2,200 students and 375 employees ) , the financial commitment to support a full - time school health coordinator speaks to the high priority that school health has in this district . over the last 20 years , rsu # 22 has taken many proactive steps toward strengthening school health in each of its 6 schools . it increased the number of positions and staffing time for health education teachers , nurses , and guidance counselors and forged partnerships with behavioral health providers . the district promotes active transport to school with a  walking school bus ,  works with the hampden town council to repair bike lanes and install street lights , and partners with the hampden recreation department to provide before- and after - school programming . regional school unit # 22 implemented a comprehensive k12 health / pe curriculum focusing on lifelong activities ( such as weight training , aerobics , bicycling , and running ) along with activities such as skiing , tennis , snowshoeing , and swimming and uses recess rocks in k2 classrooms . in 2002 , the wellness coordinator and nutrition director worked with students and suppliers to change the content of all food offered in vending machines to healthy choices . regional school unit # 22 's schools offer salad bars at lunch , and the food service director strives to use locally sourced foods as much as possible . in 2010 , parents , students , the district 's food service director , wellness coordinator , and community partners collaborated to plant apple orchards and a vegetable garden . leadership from school board members and the superintendent has been key in rsu # 22 's transformation into a district where health and wellness is a top priority and a value embraced by the school employees and the community . the shac , wellness team , and school health coordinator have also been integral to the process . they have worked together to facilitate the integration of health and education in numerous areas , including the district 's strategic plan and the interview process for prospective employees , which includes questions about their thoughts on the district 's wellness priorities . the district has focused on improving student and staff health and dedicated significant financial resources to both . the local school board allocates approximately $ 40,000 per year for employee wellness incentives for those who did not use more than 3 sick days the previous year , and 60% of staff members have qualified for this reward . regional school unit # 22 promotes periodic wellness challenges for staff and a 7-week  total health track through adult education . in 2012 , it opened a new high school that includes a fitness center , track , and tennis courts open to students , staff , and the community . as a result of these efforts , the wellness council of america awarded the district their gold level workplace wellness award . superintendent leadership also has been critical to the success of dps ' strategic inclusion of student health in the district 's overall priorities and plan . since being appointed to the position by the board of education in 2009 , superintendent tom boasberg has managed the district 's 183 schools , which serve a diverse population of over 90,000 children . seventy - two percent of students qualify for free or reduced - price lunch , and 41% speak a language other than english at home.34 the district has also committed significant resources to student health , and made it a part of the district 's strategic planning process . in 2010 , boasberg oversaw the denver school health advisory council 's creation of the dps health agenda 2015 , which outlines the districts ' health priorities.35 the district has since invested over $ 22 million toward its health goals , including the addition of 6 full - time district - funded employees . some of the significant accomplishments include dramatically increasing the number of schools that serve breakfast after the bell ; adding pe teachers to elementary schools , which has led to an additional 22 minutes per week of pe classes ; and increasing the number of school counselors , which has corresponded with a decrease in expulsion and suspension rates . denver public school has also added a school - based health center every year since 2010 , with a fifth scheduled to open in 2015 . in august 2014 , dps released the current version of its 5-year strategic plan , denver plan 2020 . this version , which was developed with the input of nearly 3,000 educators , parents , students , community partners , and city leaders , includes support for the whole child  as one of 5 goals . using the wscc model as a backbone , an advisory committee is assessing dps ' activities , and will present recommendations for creating a metric to determine future progress in early 2015.36 denver public school is also working on the development of the next generation of their health agenda , dps health agenda 2020 . the district has solicited input from students , parents , and community members through a widely disseminated survey about health issues that most impact students . survey topics include asthma , vision , oral health , nutrition , physical activity , social / emotional health , substance abuse , teen pregnancy , and school culture . denver public school plans to use the results of this survey to improve student health and wellness going forward . maine regional school unit # 22 , located in the hampden area , began to intentionally focus on the health and wellness of students and staff in 1991 . the vision to strengthen school health and wellness has been driven by rick lyons , district superintendent since 1992 . the district began by forming a wellness team long before the concept had gained widespread popularity . the wellness team , comprised administrators , faculty , support staff , and community members , has been a key factor behind the district 's school health achievements since its establishment . in 2001 , the district also founded a school health advisory council ( shac ) comprised of administrators , healthcare professionals , and community members . the shac oversees the cshp , which is headed by a school health coordinator employed by the district . given rsu # 22 's small size ( approximately 2,200 students and 375 employees ) , the financial commitment to support a full - time school health coordinator speaks to the high priority that school health has in this district . over the last 20 years , rsu # 22 has taken many proactive steps toward strengthening school health in each of its 6 schools . it increased the number of positions and staffing time for health education teachers , nurses , and guidance counselors and forged partnerships with behavioral health providers . the district promotes active transport to school with a  walking school bus ,  works with the hampden town council to repair bike lanes and install street lights , and partners with the hampden recreation department to provide before- and after - school programming . regional school unit # 22 implemented a comprehensive k12 health / pe curriculum focusing on lifelong activities ( such as weight training , aerobics , bicycling , and running ) along with activities such as skiing , tennis , snowshoeing , and swimming and uses recess rocks in k2 classrooms . in 2002 , the wellness coordinator and nutrition director worked with students and suppliers to change the content of all food offered in vending machines to healthy choices . regional school unit # 22 's schools offer salad bars at lunch , and the food service director strives to use locally sourced foods as much as possible . in 2010 , parents , students , the district 's food service director , wellness coordinator , and community partners collaborated to plant apple orchards and a vegetable garden . leadership from school board members and the superintendent has been key in rsu # 22 's transformation into a district where health and wellness is a top priority and a value embraced by the school employees and the community . the shac , wellness team , and school health coordinator have also been integral to the process . they have worked together to facilitate the integration of health and education in numerous areas , including the district 's strategic plan and the interview process for prospective employees , which includes questions about their thoughts on the district 's wellness priorities . the district has focused on improving student and staff health and dedicated significant financial resources to both . the local school board allocates approximately $ 40,000 per year for employee wellness incentives for those who did not use more than 3 sick days the previous year , and 60% of staff members have qualified for this reward . regional school unit # 22 promotes periodic wellness challenges for staff and a 7-week  total health , it opened a new high school that includes a fitness center , track , and tennis courts open to students , staff , and the community . as a result of these efforts , the wellness council of america awarded the district their gold level workplace wellness award . superintendent leadership also has been critical to the success of dps ' strategic inclusion of student health in the district 's overall priorities and plan . since being appointed to the position by the board of education in 2009 , superintendent tom boasberg has managed the district 's 183 schools , which serve a diverse population of over 90,000 children . seventy - two percent of students qualify for free or reduced - price lunch , and 41% speak a language other than english at home.34 the district has also committed significant resources to student health , and made it a part of the district 's strategic planning process . in 2010 , boasberg oversaw the denver school health advisory council 's creation of the dps health agenda 2015 , which outlines the districts ' health priorities.35 the district has since invested over $ 22 million toward its health goals , including the addition of 6 full - time district - funded employees . some of the significant accomplishments include dramatically increasing the number of schools that serve breakfast after the bell ; adding pe teachers to elementary schools , which has led to an additional 22 minutes per week of pe classes ; and increasing the number of school counselors , which has corresponded with a decrease in expulsion and suspension rates . denver public school has also added a school - based health center every year since 2010 , with a fifth scheduled to open in 2015 . in august 2014 , dps released the current version of its 5-year strategic plan , denver plan 2020 . this version , which was developed with the input of nearly 3,000 educators , parents , students , community partners , and city leaders , includes support for the whole child  as one of 5 goals . using the wscc model as a backbone , an advisory committee is assessing dps ' activities , and will present recommendations for creating a metric to determine future progress in early 2015.36 denver public school is also working on the development of the next generation of their health agenda , dps health agenda 2020 . the district has solicited input from students , parents , and community members through a widely disseminated survey about health issues that most impact students . survey topics include asthma , vision , oral health , nutrition , physical activity , social / emotional health , substance abuse , teen pregnancy , and school culture . denver public school plans to use the results of this survey to improve student health and wellness going forward . the wscc model provides a framework for the health and education sectors at the state and local levels to work toward stronger alignment , integration , and collaboration . as lloyd kolbe stated , the wscc model provides a new opportunity , impetus , and sense of purpose for both sectors :  if we prudently could unite the expertise , perspectives , resources , communication , visibility , and political support of national education , health , and related organizations to help schools and colleges implement a wscc approach , we synergistically could increase the impact of each sector , each organization involved ; we could build a lasting national base for new means to improve both education and health ; we could accomplish that which we otherwise cannot.37 whereas the wscc model is new , having been launched in march 2014 , many states and local school districts are already in the process of adapting and adjusting practices and processes to suit the expanded version of csh . the 3 states and 2 school districts highlighted all provide strong examples of implementation of various aspects of the wscc model . they demonstrate that it is possible to prioritize student health within the education system , for the purpose of better addressing the needs of the whole child . they also demonstrate the importance of strategic leadership at the state and local level , including support from policymakers , superintendents , local school boards , and community organizations that recognize and seize opportunities to integrate and better align the health and education sectors . moving forward , state and local health and education agencies should focus greater attention toward ensuring the adoption and implementation of policies that serve both sectors and students , and promote the formation of collaborative partnerships . policymakers need to focus on adoption and implementation of policies and practices that build on the connection between the school health components and educational outcomes , both academic and behavioral . when those in decision - making roles understand and embrace the wscc model , they are able to create programs and policies that lead to collaboration and more effective use of resources , creating healthier school environments that address the needs of the whole child . information contained in this article was not deemed to involve human subjects , and therefore , was considered exempt from institutional review board examination . information contained in this article was not deemed to involve human subjects , and therefore , was considered exempt from institutional review board examination .
backgroundthe whole school , whole community , whole child ( wscc ) model calls for greater collaboration across the community , school , and health sectors to meet the needs and support the full potential of each child . 
 this article reports on how 3 states and 2 local school districts have implemented aspects of the wscc model through collaboration , leadership and policy creation , alignment , and implementation.methodswe searched state health and education department websites , local school district websites , state legislative databases , and sources of peer - reviewed and gray literature to identify materials demonstrating adoption and implementation of coordinated school health , the wscc model , and associated policies and practices in identified states and districts . 
 we conducted informal interviews in each state and district to reinforce the document review.resultsstates and local school districts have been able to strategically increase collaboration , integration , and alignment of health and education through the adoption and implementation of policy and practice supporting the wscc model . 
 successful utilization of the wscc model has led to substantial positive changes in school health environments , policies , and practices.conclusionscollaboration among health and education sectors to integrate and align services may lead to improved efficiencies and better health and education outcomes for students .