School Health Services:

Emerging Opportunities for CDC-

DASH

Julia Graham Lear, P h D

The Center for Health & H ealth Care in Schools
School of Public Health and Health Services
George Washington University M edical Center

M ay 12, 2005

The Center for 1

Health and Health Care in Schools
 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
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The Past: What We Can Learn

Those who cannot remember the

past are condemned to repeat it.

George Santayana, 1905

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A B r ief H istory of School H ealth:
Important T hemes

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.
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 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.5
 School Health Services History:
Important Themes

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.

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The Present: School Health Services in 2005

What we have before us are some

breathtaking opportunities disguised
as insoluable problems.

John Gardner, 1962

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 C ur r ent School H ealth Staff
A vailable 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

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Facilities and Equipment Available
for Health Services

Type of Facility or Equipment % of Schools

Portable first aid kit 92.7%

Sick room or nurse’s office or other 81.1%

area re-served for health services
Separate medicine cabinet with lock 65.4%

Refrigerator reserved for health 57.3%

services
Peak flow meter 27.2%

Glucose meter, not just for an 17.8%

individual’s use
Nebulizer, not just for a specific 13.0%
individual’s use
Source: CDC, School Health Policy &
Programs Study (SHPPS, 2001.

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Snapshot of T wo C ity School Districts and
T heir School Nursing Programs
School system backgrounds
Austin TX Boston MA
City population 680,000 589,141
No. of schools 103 130
No. of students 78,000 63,024
Limited English Proficiency 22% 16%
Special education 12.3% 20%
Percent of uninsured children note 6.3%*
Students eligible for free and reduced-
price lunch 53% 71%
Students with IHCPs 2.3% 3.8%
Note: Statewide, Texas children ages 6 - 12 have a 25% uninsured
rate; teens ages 13-18 have an uninsured rate of 37% 10
Snapshot of T wo C ity School Districts and
T heir School Nursing Programs

School nursing programs

Austin Boston
Program Sponsor Children's Hospital BPS

School health staff

Number of school nurses 65 93.5 FTE
Number of health aides 52 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

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Student School Health Encounters,
2001-2002

Austin Boston
# % # %

Episodic 338,489 57.5 416,650 57.8

Medication 187,897 31.9 227,114 31.4

Procedure Included under 44,369 5.7

episodic &
medication
Screening 61,786 10.5 36,645 5.1

Total 588,172 99.9 721,300 100

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C ur r ent M odels of School H ealth
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

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C ur r ent M odels of School H ealth
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

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C ur r ent M odels of School H ealth
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.

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 T hings 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
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 T hings 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.

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 Parent Poll R esults
C H H C S F eb 2003 survey

Austin Boston
# % # %

Episodic 338,489 57.5 416,650 57.8

Medication 187,897 31.9 227,114 31.4

Procedure Included under 44,369 5.7

episodic &
medication
Screening 61,786 10.5 36,645 5.1

Total 588,172 99.9 721,300 100

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 Parent Poll R esults
Services Strongly Somewhat Strongly or
support support Somewhat
oppose
Providing immediate care in
case of emergencies 88% 8% 4%

Prevention & education about 83% 13% 4%

drugs & alcohol

Caring for children with 70% 20% 10%

chronic problems such as
asthma, diabetes
Providing age-appropriate sex 56% 28% 16%
ed.

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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

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 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

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 Can We Use the CDC-DASH Four
Strategies to Strengthen School
Health Services?
• Monitoring function - YRBSS,
SP HPPS have worked well.
• Synthesizing research
• Assisting schools in implementing
effective policies & programs -- may
need more research to action
research
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C ontact Information
The Center for Health and Health Care in Schools
2121 K Street, N W Suite 250
W ashington, D C 2 0 0 3 7

202-466-3396
202-466-3467 fax

www.healthinschools.org

The Center for 23

Health and Health Care in Schools