1. 1 School Health Services: Emerging Opportunities for CDC- DASH Julia Graham Lear, PhD The Center for Health & Health Care in Schools School of Public Health and Health Services George Washington University Medical Center May 12, 2005 The Center for Health and Health Care in Schools

2. 2 Overview The Past -- A brief history of school health services and lessons from the past The P resent -- Current models of health service delivery at school and underlying issues The Future -- Potential directions for school health services and opportunities for CDC-DASH

3. 3 The Past: What We Can Learn Those who cannot remember the past are condemned to repeat it. George Santayana, 1905

4. 4 A Brief History of School Health: Important Themes 1890s: Boston & NYC: Physicians and nurses hired to examine children in school & exclude the potentially contagious. Theme: Health professionals conduct surveillance at school and act to protect school community. Early 1900s: School health services spread. Progressive educators launch first full-service schools. Theme: Early introduction of concept that school health services had a role in helping poor children. Post 1910: Conflict between public health & private medicine. AMA opposition to all publicly-funded treatment services in schools. Theme: School health strongly influenced by external issues.

5. 5 School Health Services History: Important Themes 1920s to1950s: School health = health education, immunization documentation, screenings, care for minor injuries, referrals for diagnosis & treatment. The Astoria plan. Theme: Important role of schools in assuring that children were immunized. Screening for select problems (vision, hearing, scoliosis). 1960s & 1970s: New provider types emerge: nurse practitioners, school-based health centers, school-based mental health programs. Federal law mandates school systems assure provision of health-related services to students with disabilities. Theme: Increased focus on individual student health needs, incorporation of federally-mandated services.

6. 6 1980s and 1990s: Continued development of school-based health centers; emergence of coordinated school health programs, changes in education (accountability, testing, success for all), new forces in health care (accountability, managed care, outcomes focus) Theme: Importance of external education & health policies and politics for shaping school health. School Health Services History: Important Themes

7. 7 The Present: School Health Services in 2005 What we have before us are some breathtaking opportunities disguised as insoluable problems. John Gardner, 1962

8. 8 Current School Health Staff Available for 95,000 public schools School nurses -- 30,000 estimated. School health assistants or UAPs -- N/A School physicians -- unknown School-based health centers -- 1,500 School counselors -- 81,000 School psychologists -- 20,000-22,000 School social workers -- 12,000

9. 9 Facilities and Equipment Available for Health Services

10. 10 Snapshot of Two City School Districts and Their School Nursing Programs School system backgrounds AustinTX Boston MA City population680,000589,141 No. of schools103130 No. of students78,00063,024 Limited English Proficiency22%16% Special education12.3%20% Percent of uninsured children note6.3%* Students eligible for free and reduced- price lunch53%71% Students with IHCPs2.3% 3.8% Note: Statewide, Texas children ages 6 - 12 have a 25% uninsured rate; teens ages 13-18 have an uninsured rate of 37%

11. 11 Snapshot of Two City School Districts and Their School Nursing Programs School nursing programs AustinBoston Program Sponsor Children's Hospital BPS School health staff Number of school nurses 65 93.5 FTE Number of health aides52 5.0 FTE * Ratio nurses:students 1:1,200 1:630 *These paraprofessionals provide care to special needs students and do not provide assistance to school nurses

12. 12 Student School Health Encounters, 2001-2002

13. 13 Current Models of School Health Services School nursing –Service provision School nurses only, eg. Boston, MA, Seattle, WA School nurse-UAP combinations, eg. Austin, TX –Sponsorship School system, eg Seattle Health department, eg. Montgomery Cty MD; Community-based organization, eg. Children’s Hospital in Austin, TX

14. 14 Current Models of School Health Services Enhanced school nursing –Enriched service package –May involve advanced practice nurses –Extent of model and numbers of nurses & schools participating unknown. Eg. CT and MA

15. 15 Current Models of School Health Services School-based health centers –1500+ –Staffed by NPs, clinical social workers, mix of other professionals including nurses, nutritionists, dental hygienists depending on needs and resources – Sponsored and managed mostly by community- based organizations, eg. community hospitals, health centers, and health departments.

16. 16 Things to Note Health resources are not spread evenly across school districts or among schools within a district Data systems not in place to document the resources present in individual school districts or schools When school health professionals are present, they are involved in direct service not planning, financing, organizing or evaluation activities

17. 17 Things to Note continued While most parents are typically uninformed about school health & safety arrangements in their school district or in their children’s schools, they support health services at school for their children.

18. 18 Parent Poll Results CHHCS Feb 2003 survey

19. 19 Parent Poll Results

20. 20 The Future: Moving School Health Services Forward It must be remembered that there is nothing more doubtful of success, nor more dangerous to manage than the creation of a new system. For the initiator has the opposition of all who would profit by the preservation of the old and merely lukewarm defenders in those who would gain by the new one. Machiavelli, The Prince, 1513

21. 21 Moving School Health Services Forward: Can We Use the CDC- DASH Four Strategies? Monitoring health behaviors and school policies and programs related to those behaviors Synthesizing & applying research to improve school policies and programs Enabling constituents to help schools implement effective policies and programs Evaluating programs to improve school health policies and services

22. 22 Can We Use the CDC-DASH Four Strategies to Strengthen School Health Services? Monitoring function - YRBSS, SPHPPS have worked well. Synthesizing research Assisting schools in implementing effective policies & programs -- may need more research to action research

23. 23 The Center for Health and Health Care in Schools Contact Information The Center for Health and Health Care in Schools 2121 K Street, NW Suite 250 Washington, DC 20037 202-466-3396 202-466-3467 fax www.healthinschools.org