Develop Full Service Schools to Provide Access to Health and Social Services for Children and Their Families
School facilities should be more fully used, making them a central location for a broad range of public services. This does not imply a wide range of new responsibilities for schools, but rather greater utilization of campus facilities.


Background
Currently , health and other social services are offered in a fragmented manner. Families must visit multiple agencies and fill out duplicative forms to apply for services. Locating some of these services in public elementary and secondary schools makes sense for se veral reasons: preventive strategies can be targeted to reach the entire family, rather than responding to an individual crisis; school-age children and their families represent a large proportion of state health and human service agencies clients; and school facilities should be maximized. In this case, it is not necessary for districts to assume new responsibilities. Rather, school facilities should be more fully used, making them a central location for a broad range of public services.

Proponents of school-based (or linked) health and social services cite alarming statistics about the health status of children and youth in America. In 1989, the American Medical Association s Council on Scientific Affairs issued a report on comprehensive school-based health programs and estimated that 12 million American children or adolescents were without public or private health insurance coverage. 1 The recent recession has made the problem even worse. One out of five adolescents has at least one serious health problem. An estimated 12 percent, or 7.5 million, of the nation s children suffer from mental disorders severe enough to warrant treatment. While communicable diseases were the common killer of young people a century ago, today nearly three-quarters of adolescen t deaths are due to social causes, many of which could have been prevented. 2

Current interest in education reform has stimulated interest in expanded school-based services as a way to improve student achievement in school. Recent education reforms in Mississippi and Kentucky included school health services as a mechanism to achieve education goals. However, opposition groups have stymied efforts to expand school health services, particularly across the South. Opponents assert that school health programs undermine parental responsibility for managing their children s health care and fear that school health services is a euphemism for contraceptive distribution. (Dissemination of contraceptives is rarely a part of school-based services; only 12 percent of clinics surveyed nationwide provide on-site birth control.) 3

There are an estimated 300 school-based clinics in the U.S. and 100 of these are primary schools in New York. 4 Although the first school-based clinic in the U.S. opened in Dallas in 1970, Texas h as not been a leader in providing expanded school-based services, despite significant need for such services.

Other states have successfully developed school-based programs. Several examples of such programs are described below.

In 1987, New Jersey created the first substantial effort to connect schools and social services to help ensure students success. The New Jersey Department of Human Services (NJDHS) initiated the program to help the state s youth by placing comprehensive social and health services in or very near high schools. There are 30 program sites, with at least one located in each county and most in low-income areas, and are managed by schools, hospitals, social services agencies and community-based organizations. 5 Services are open to any student; the open approach is intended to avoid stigma and encourage students to use the centers before small problems grow into large ones. Parental consent is required for all services.

New Jersey s program does not feature a statewide design, although f unding is provided through an annual $6 million state appropriation. Sites offer at least a core set of services and operate during normal school hours, after school, on weekends and during vacations. 6 Some sites offer recreation as a way to attract youngsters, while other services include child care, services for teen parents, special vocational programs, family planning, transportation and hotlines. NJDHS also provides technical assistance, such as h elping to certify the school-based program as a Medicaid provider so that it can claim reimbursement for services to Medicaid-eligible students. 7

Another successful example is evident in the Walbridge Caring Communities Program (WCCP) in St. Louis, Missouri. Caring Communities is guided by an African proverb It takes a village to rear a child. It seeks to create a village in the midst of the inner city that can nurture its children and help them succeed. The program s objectives are to keep high-risk children performing successfully in school; to help thos e children and their families avoid family dysfunction and separation and to help the children stay out of trouble with the law. 8 The project is sponsored by the Danforth Foundation and four Missouri state agencies the Departments of Elementary and Secondary Education, Mental Health, Health, and Social Services. Most of the project s budget comes from redirected state agency dollars that would have been spent serving children and families in the area. An advisory council composed of parents, community repre sentatives, agency representatives and school personnel decides how the funds should be used and what services should be offered.

WCCP is co-located with Walbridge School (pre-school through grade five) and a community school that offers adult education and after-school programs. The school s principal and the directors of the two programs work together as a team. The facility is open for more than 15 hours a day and offers a range of programs such as family crisis intervention programs (for families at risk of having their children removed from their homes), a daytime in-school treatment program for troubled youth, before- and after-school child care, substance abuse counseling, school nursing services, pre-employment training and job placement for pare nts, academic tutoring, and a food bank. The school features a curriculum that reinforces students self-esteem as a way to prevent substance abuse, as well as monthly parents meetings to keep families informed about what their children are learning.

In Probtsfield Elementary School in Moorhead, Minnesota, students are referred to appropriate services through information provided in the school. All human service agencies were asked to contribute information about their services to a resource manual, a co py of which was given to each teacher. Teachers also received in-service training on how to identify problems and make referrals. Teachers are expected to explore family needs in parent/teacher conferences and to make referrals as needed. A unique feature is that agencies have representatives in school buildings on days when parent/teacher conferences are held. A parent need only walk across the hall to act on a teacher s suggestion.

Finally, in New Beginnings in San Diego, California, school-based services are just one part of a comprehensive community effort to provide services to children and families. New Beginnings involves the leadership of county agencies (the Departments of Social Services and Health and Probation), the San Diego City Schools, the Community College District and several city agencies (the housing commission, the parks and recreation department, library system and police force). The county s chief executive and the city manager also participate.

School-linked services can come in many forms in New Beginnings, including a parent-school communication curriculum for San Diego welfare recipients. Special procedures were developed so that school nurses and the Department of Social Services (DSS) expedi te access to benefits and services for pregnant and parenting teens. The DSS also was actively involved in designing a new middle school, where the staff now includes an on-site family advocate to counsel students and staff and coordinate with other agencies.
New Beginnings is also exploring the potential for using schools as the center of a more comprehensive service delivery. A demonstration center at Hamilton Elementary School, located in an economically depressed area, provides services to the school s 1,300 students and their families. The center offers parent education classes, adult education and health care services such as immunizations and basic physical examinations. In addition to the school-based staff, staff in agencies that receive referrals from the school are part of extended teams that are trained and ready to take referrals from Hamilton Elementary. 9

In Texas, there are a few programs that have established school-service link for schoolchildren and their parents.

The Hogg Foundation for Mental Health is currently spending $1 million over five years on five pilot programs offering in-school social service advocates for the students. The low-cost program, called School of the Future, was designed to be easily duplicated. At elementary and middle schools in Dallas, Austin, San Antonio and Houston, the foundation provides funding for special services coordinators. The coordinator arranges services offered by the state, county or city that may be useful to the student body at the school. These services could include health care, tutorial programs, adult literacy programs, jobs skills training and family counseling. The concept is to bring needed services to students while freeing the classroom teacher for teaching duties. 10

Communities in Schools (CIS) is a nonprofit organization that operates in public schools in more than a dozen Texas cities. CIS is based on a national model (Cities in Schools) which is primarily a dropout prevention program. The program emphasizes a holis tic approach to students needs, using a case managemen t approach to coordinate available resources at the school to provide students with easy access to services. Each local program is autonomous and is responsible for raising its own funds. A state office provides overall direction, an operations manual and suggestions on how to set up new programs.

CIS uses repositioned staff from state agencies to provide on-site services for students. Some of the agencies providing staff include the Department of Mental Health and Mental Retardation, the Texas Departme nt of Health, the Texas Employment Commission and the Department of Human Services (DHS). CIS site teams normally consist of social workers, employment counselors, educators, health professionals and volunteers. Students are referred to CIS from many sourc es, including teachers, counselors, administrators, social service agencies, probation officers and peers. Primary funding comes from state appropriations, private donations and federal Job Training Partnership Act funds.

The School Health and Related Ser vices (SHARS) program is a result of an interagency agreement between the Texas Education Agency (TEA) and the DHS. Texas school districts may receive Medicaid reimbursement for certain education-related health services provided to special education studen ts who are Medicaid-eligible. Initial services to be offered include assessment, audiology, counseling, school health services, occupational therapy, physical therapy, psychological services and speech therapy. Districts are mandated to provide these servi ces; the SHARS program provides a mechanism for reimbursement to school districts for the cost of providing these services. TEA and DHS are studying ways to expand covered services under the program.

Health services provided in Texas schools are covered under the EPSDT (Early Periodic Screening, Diagnosis, and Treatment) program, which provides reimbursement at the rate of $40 per child. Through this program, health needs can be identified and treated early in a child s life. The $40 amount is set by the state, with matching federal funds. Texas has one of the lowest rates in the country, which acts as a disincentive for private physicians to participate. In fact, Texas may have trouble meeting federally-mandated goals. In fiscal 1992, the quota was a mini mum 700,000 participants; as of July 1992, only 300,000 had received services. For fiscal 1993, the quota will be even higher at 1.2 million. 11

Finally, Bright Futures (a program that has been proposed, but not yet implemented) would provide a Medicaid wa iver to all children in predominantly low-income areas (elementary school areas where enrollment is 90 percent or higher low income). The waiver would provide access to universal health care without applications or eligibility determination. If approved, t he project would also have a second phase where the percentage of low-income students would be 75 percent instead of 90 percent. 12

Recommendations
A. The State Board of Education should develop a comprehensive school health policy which sets minimum standards of practice for local school districts.

The policy should ensure that basic health services, such as screenings, health assessments and counseling activities are provided in every school. The policy should cover standards of procedure, medication administration and emergency transportation. The state guidelines should also provide flexible models for delivery which can be adapted to meet local needs.

B. Each local district should conduct a needs assessment in the community, with cooperation and i nput from local health care, child care, recreation and adult education sources, as well as others if appropriate, to determine student needs, identify resources that are currently available and develop a plan for delivering expanded school-based services. The plan should be submitted to the Texas Education Agency (TEA) for approval.

Depending upon local needs and resources, one of several models described above could be adopted. These include basic health (EPSDT screenings, immunizations, health counseli ng), expanded health services (mental health counseling, substance abuse counseling and prevention, case management) and comprehensive health (acute diagnosis and treatment, acute and chronic illness management, laboratory testing, STD testing and treatmen t, family planning information and referrals, prenatal care, and dental screenings and services). Schools should become the focal point for providing services at an expanded level.

In addition to health programs, schools can be the site for other service s such as child care, recreation, adult education and other activities for the students and their families. For example, English as a Second Language could be taught after school or at night for working parents; child care could be provided for younger sib lings of students so parents make one trip during the day; after school recreation programs could be expanded to the needs of latch key children and scout meetings could take place in the school.

Funding for local programs should come from a variety of sources. Whenever possible, Medicaid reimbursement should be sought. In addition, federal compensatory education and child care funds may be available. Schools should establish links with nonprofit community agencies in order to use their resources effect ively. In addition, state health and social service agencies should expand the use of repositioned staff to provide case workers and other personnel for local schools.


Implications
The clear advantage is that the school structure already exists to serve an established constituency. Texas has a large and under-utilized investment in school facilities. Educators recognize the need to adopt preventive strategies to serve the student population. A full range of services may be needed to respond to a student s needs. This proposal would result in a more client-centered approach to service delivery for a large and growing population of disadvantaged Texas students and their families.

Evidence indicates that many students do not receive all the social and heal th services for which they may be eligible. Making the services more accessible would enable more students to receive the services they need. Experience with a similar concept in California found that families in need were less distrustful and open in a sc hool setting.

One roadblock to school clinics is public apprehension about school clinics dealing with issues such as sexuality, pregnancy and contraception. Some parents fear that school-based clinics will lead to free condoms being distributed. It is i mportant to let the public know that mandated school services will include primary health services, not family planning or sex education. Community support for expanded school-based services is essential for their success.


Fiscal Impact
This proposal should be revenue neutral. State resources, including personnel, may be redirected to the school site. Including community and non-profit organizations in the expanded school service array could help reduce costs.



Endnotes
1 Marsha F. Goldsmith, School Based Health Clinics Provide Essential Care, Journal of the American Medical Association , vol. 265, no. 19, May 15, 1991, p. 2458.
2 John J. Schlitt, Bringing Health to School: Policy Implications for Southern States, Issue Brief (Washington, D.C.: Southern Governor s Association and Southern Legislative Conference, June 1991), pp. 1-2.
3 Ibid., p. 4.
4 Goldsmith, School-Based Health Clinics Provide Essential Care, p. 2458.
5 Janet E. Levy and William Shepardson, A Look at Current School-linked Service Efforts, The Future of Children, vol. 2, no. 1, Spring 1992,
p. 47.
6 Core services are defined as mental health and family counseling, primary and preventive health services (on-site or by referral), substance abuse counseling, employment counseling, summer and part-time job development, academic counseling and referral to other health and social services not available on-site.
7 Levy and Shepardson, p. 47.
8 Ibid., p. 50.
9 Ibid., p. 51.
10 Interview with Scott Keir, Study Director for Commissions, Hogg Foundation for Mental Health, The University of Texas at Austin, on May 6, 1992.
11 Interview with Ken Crow, Director of Interagency Coordination, Texas Education Agency, October 22, 1992.
12 Ibid.