Models that Work: Politics that Don't : A history of school health in the United States Julia Graham Lear, Director, Center for Health & Health Care in Schools, The George Washington University School of Public Health and Health Services, at the Milwaukee Area Health Education Center, April 29, 2002

Four challenges to building effective, sustainable school health programs Challenge of solidifying a quality program Challenge of implementing organizational change Challenge of securing adequate funding Challenge of building political support

The greatest challenge The greatest challenge is not developing excellent services, nor finding the best model for delivering care in schools nor identifying the deepest pockets to fund those services -- The greatest challenge is finding a better model of political support for any model of health care delivery in schools.

Outline: 100 years of school health Where we’ve been and what we’ve learned Where we are now: health needs of students, current programs, potential barriers How to secure more effective school health programs -- overcoming barriers, building effective services

Where we’ve been: Early days 1890s. Boston & NYC: Physicians and nurses hired to examine children in school & exclude the potentially contagious. Message: Protect the school environment. Early 1900s. School health services spread. Educators launch first full-service schools. Early opposition from immigrant parents, institutions. Messages: Multiple possibilities; protect the students. Post Conflict between public health & private medicine. AMA opposition to all publicly-funded treatment services in schools. Message: School health content fixed by external issues.

Where we’ve been: the basics emerge 1920s to1950s. School health = health education, immunization documentation, screenings, treatment for minor injuries, referrals for problem diagnosis & treatment. The Astoria plan. Message: School health contained. 1960s & 1970s. New provider types: nurse practitioners, school-based health centers. New emphasis on getting health care to poor children. Federal law mandates health-related services for students with disabilities. Message: Increased focus on individual student health, incorporation of mandated services.

Where we’ve been: new directions 1980s and 1990s: Spread of school-based health centers; influence of changes in education (accountability, testing, success for all) and health systems (accountability, managed care, outcomes focus). Message: Importance of external education & health policies for shaping school health.

Where we’ve been: Strengths and weaknesses Strengths A universal system: all services available to all students Developed with attention to what health providers and parents would support Weaknesses Weak funding base, limited political support Arrangements focused on infectious disease, may not be greatest current threats to child & adolescent health Referral strategy for treatment assumes availability of community-based providers and availability of parents to take minor children for care

Widely shared beliefs about school health and safety Children must be safe when attending school. Emergency medical services should be available and urgent services should be provided for persons in the school building. By law, all communities are obligated to provide the care needed to enable children with physical or mental health disabilities to benefit from a free, appropriate public education. Schools should educate children about keeping their bodies safe and healthy.

Beyond the basic components of school health Arguments for Expanded School Health Programs  That health programs facilitate learning, and may increase test scores  That there are gaps in the health care systems especially for low-income children, those needing mental health services, and for adolescents  That there are cost savings to be achieved through early intervention and treatment  That children's parents may be inaccessible to schools and that caring for sick children may fall to school staff

Common Health Problems of School-Age Children, , 1997

Youth Risk Behavior Survey, 1999

Percentage of Schools with Facilities or Equipment for Health Services

School-based providers in the 21st century In 90,000 public elementary and secondary schools attended by 53 million students, there are : School nurses -- 30,000 estimated. School health assistants or UAPs -- N/A School-based health centers School counselors -- 81,000 School psychologists -- 20,000-22,000 School social workers -- 12,000

Funding school health Primarily local dollars drawn from local tax base or local allocations of state general fund dollars Some states, eg. Pennsylvania & Massachusetts, provide general fund support for school nurses Medicaid reimbursement for special education health-related services, Medicaid administration, health services to Medicaid beneficiaries or wrap- around services for beneficiaries Private philanthropic support, eg. Quantum Fdn, Duke Endowment, Robert Wood Johnson Fdn

Who’s in charge: Traditional school health funding & management arrangements Traditional approaches School system funding/management eg. Boston, MA; most New England communities School system funding/health department management eg. Detroit, MI; Milwaukee, WI (?) Strengths: Institutional understanding of unique characteristics of health programs in schools; community good will; support for individual school nurses Weaknesses: Good managers, but leadership a challenge - schools are led by educators; Health must compete with education for education dollars

Who’s in charge: Newer school health money and management arrangements Newer approaches School system funding/private system management eg. DCPS/Children’s Medical Ctr, Washington, DC School system funding/federal participation via Medicaid/various management arrangements eg. Baltimore County PS, Baltimore City School system funding plus local-state dollars for underserved, Medicaid, philanthropy/various management arrangements eg. Palm Beach County, Fl; Denver, CO

Who’s in charge: Strengths and weaknesses of newer approaches Strengths Establishes broader funding base and/or political support Changes in program management, accountability structure will strengthen content and outcomes of program Weaknesses Requires on-going collaboration, partnerships Requires major changes in management, accountability measures

Barriers to building effective, sustainable school health programs Money: School health programs locally funded, primarily with education dollars Leadership: Few leaders w ithin school boards, school administrations and state legislatures make health-in-schools a main focus Politics: Public dollars (to support school health) require public support. Where are the strategies to build public support?

Overcoming barriers: It’s been done Money: Seton Health System in Austin documented what they did with school health dollars,demonstrated their effectiveness & got additional support. The Detroit SBHCs organized parents to lobby the state legislature & got SBHC dollars put back in the budget. Leadership: In San Diego, a hospital president, school superintendent, managed care leaders, and corporate representatives have joined together to build a common school health program. Politics: In Louisiana and other states, grassroots organizing at state capital transformed a school health controversy into just-another-effort to bring “home the bacon” to local folks.

Characteristics of Effective, Sustainable School Health Programs Data and epidemiologically-driven program design Transparency: Funding, program goals, staffing and service arrangements are clear Accountability: Reports to institutional leaders and to the public describe program performance against program goals CQI: On-going efforts to improve performance and measure the improvement

Four challenges to building effective, sustainable school health programs Challenge of solidifying a quality program Challenge of implementing organizational change Challenge of securing adequate funding Challenge of building political support

The greatest challenge The greatest challenge is not developing excellent services, nor finding the best model for delivering care in schools nor identifying the deepest pockets to fund those services -- The greatest challenge is finding a better model of political support for any model of health care delivery in schools.