Resources, Costs, and Efficiency of Training in the Total Army School System

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Increased understanding by school administrators and other community leaders of the relationship between the school nutrition and food-service program and children's health and education will lead schools and communities to establish expectations consistent with community values and resources and to implement policies that maximize outcomes.

The term "extended services" is used here to refer to the rapidly growing area of services that go beyond traditional basic school health services. Extended services often target individual students with limited access to services and students at risk, are usually supported with funds from outside the educational budget, and typically involve collaboration between the school and personnel from community agencies. Much of the information in this section is adapted from a paper on extended services that can be found in Appendix D. Questions are sometimes raised about whether extended services go beyond the basic mission of the schools.

The committee believes that these services should not be the sole—or even major—responsibility of the schools but require leadership and cooperation from other community agencies and providers.


In examples described in this section and in Appendix D , extended services are not another responsibility that must be shouldered by the school; instead, the school is considered by community agencies and providers as a partner and an effective site for provision of needed services—services that will ultimately advance the primary academic mission of the school.

This view is consistent with that of a recent report from the Committee for Economic Development , which states:. Schools are not social service institutions; they should not be asked to solve all our nation's social ills and cultural conflicts. States and communities must lift the burden of addressing children's health and social needs from the backs of educators.

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They must, of course, arrange needed services for children and their families, often in collaboration with the schools. But other state and community agencies should pay for and provide these services so that schools can concentrate on their primary mission: learning and academic achievement. School-based health centers—also called school-based clinics—are a response to the growing health needs and decreasing access to health services of many students. There are now about SBHCs in almost all parts of the country, and the number continues to grow rapidly. SBHCs are most frequently located in inner city high schools, but they are also increasingly found in middle and elementary schools.

An SBHC consists of one or more rooms within a school building or on the property of the school that are designated as a place where students can go to receive primary health services. An SBHC is more than a school nursing station; students can receive on-site diagnosis and treatment services from one or more members of an interdisciplinary team of clinicians that may include physicians, nurse practitioners, nurses, social workers, health aides, and similar professionals.

Examples of provided services include physical examinations, treatment for minor injuries and illnesses, screening for sexually transmitted diseases STDs , pregnancy tests, and psychosocial counseling. Usually outside agencies—health departments, hospitals, medical schools, schools of nursing, or social service agencies—manage the SBHC and employ the practitioners; these agencies often keep the SBHC open or serve as backup after school hours and during weekends, summers, and other vacations.

Service providers in SBHCs are typically selected—often self-selected—for their interest in working with children and young people in such a setting. Studies have shown that SBHCs remove barriers to care and are particularly suited to meet adolescents' needs for trust and confidentiality U. For secondary schools with SBHCs, some of the most frequently provided services to students are listed in Table Santelli et al.

Most SBHCs also provide health education and health promotion in the clinic, the classroom, for staff, and even for the community. A majority of SBHCs offer health education in classrooms in clinic schools, and most run group counseling sessions in reproductive health care, family problems, asthma control, dealing with depression, and other relevant subjects.

It is not always clear how these services interface with the school and whether they complement or duplicate existing school programs. In some communities, a school-based health services program provides care for more than one school. A mobile van is equipped to go from school to school to provide physical examinations, ambulatory services, immunizations, and referrals for more comprehensive medical and dental care.

For example, Baltimore has a mobile van program operated by. Department of Health and Human Services, b. The National Health and Education Consortium has prepared a report providing information about SBHCs at the elementary school level Shearer and Holschneider, and a primer for community health professionals to use in establishing elementary school-linked health centers Shearer, One of the most important unmet needs of young people is mental health counseling. In addition, mental health and behavioral problems are sometimes associated with or aggravated by underlying biomedical factors.

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The demand for mental health services has led to the development of school clinics that have a primary function of screening and treatment for psychosocial problems Adelman and Taylor, In some communities, mental health services are provided in a school center by personnel employed by community mental health agencies. Such a center is usually not labeled a "mental health" facility but is presented as a place where students can go for all kinds of support and remediation. A number of universities also have collaborative arrangements for internship experiences in schools for pre-professional students preparing to enter mental health counseling.

A network of school-based mental health programs has been organized by the School Mental Health Project of the Department of Psychology at the University of California in Los Angeles, which is working closely with the Center for School Mental Health Assistance being developed at the University of Maryland at Baltimore. These groups are establishing a national clearinghouse for school mental health that will provide continuing education, research, and technical assistance to enhance local school mental health programs and improve practitioner competence.

Cities in Schools, a national nonprofit organization that operates in more than communities, brings health, social, and employment services into schools to help high-risk youngsters Cities in Schools, ; Leonard, Each local entity has its own version, but in general the program involves "brokering" community social service and juvenile corrections agencies in the provision of case management services within the school building.

In most programs, a case manager is assigned to each high-risk child, and local businesses arrange for mentoring and apprenticeship experiences. Some centers deliver services on-site whereas others focus on coordination and referral to other community agencies. In , Kentucky's school reform initiative called for the development of youth service centers in high schools in which more than 20 percent of the students were eligible for free school meals.

In New York City, the Beacons program, created by the city's youth agency, supports community-based agencies to develop "lighted school houses" that offer a wide range of activities for young people and are open from early morning until late at night, as well as during weekends and summers Dryfoos, a. Family Resource Centers deliver, either at the school site or by referral to community providers, a set of comprehensive services—including parent education, child care, counseling, health services, home visiting, and career training—to students of all ages and their families Igoe and Giordano, Funds are provided through various federal and state programs and private sources, such as the United Way.

Some centers are located in school buildings; others are based in the community. Kentucky's legislation mandates that every elementary school with more than 20 percent of its students eligible for free lunch must have a Family Service Center Dryfoos, a. A number of school-based interventions have been initiated that address an array of interrelated issues, based on the premise that prevention approaches must be more holistic if they are to be successful.

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Many of the extended services discussed above are integrated into these efforts. Examples of services include family counseling, case management, substance abuse counseling, student assistance, parenting education, before- and after-school activities, youth programs, health care, and career training. Programs are typically put together by an outside organization that provides a full-time coordinator and other services to the school in order to implement all the separate pieces of the package.

Sometimes the term "full-service school" is applied to the most comprehensive models, although the definition of what constitutes full-service varies from place to place. The vision of a full-service school calls for restructured academic programs integrated with parent involvement and.


The term full-service schools is more reflective of an overall philosophy than of a particular type of delivery model or system. Students and families need a variety of services located in a variety of settings, and the key is networking school and community services to form an easily navigated, user-friendly, accessible system. Full-service schools strive to become a ''village hub," in which joint efforts of the school and community agencies create a rich and supportive environment for children and their families Dryfoos, a. Approximately 85 percent of local school districts receive assistance from regional cooperative agencies, thereby allowing them to pool resources for health services, staff development, care of students with special needs, purchase of supplies, and technical assistance.

A report of an investigation of these agencies' involvement in school health indicated considerable interest and activity in the delivery of school health services, including primary care.

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In light of the fact that 76 percent of school districts have a total enrollment of 2, students or less, a regional approach to the delivery of school health-related services is needed in such areas and has already been established in some situations Igoe and Stephens, Over the past three decades, research on traditional basic school health services has focused on four primary areas:.

Department of Health and Human Services, a,b ; and. By far, the largest area of basic school health services research has been related to workforce, organization, and governance issues, particularly to the role, functions, and relationships of school health personnel to school administrators, classroom personnel, and others. Although much of this work has concentrated on nursing services, research has also examined dentists, physicians, school health assistants, counselors, social workers, and psychologists.

Until the passage of the Education of the Handicapped Act later renamed the Individuals with Disabilities Education Act and the introduction of school-based student health centers around the same time, school-employed health service personnel limited their services to case finding and referral.

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Diagnosis and treatment services were the purview of primary care providers located in community health facilities. Consequently, the established line of authority for school health services, which frequently had clinicians reporting to nonclinicians in the school's chain of command, was rarely problematic. For example, at least 40 percent of respondents to a survey involving supervisors of school nurses reported that they had no clinical preparation in the delivery of health services although they were expected to supervise complex nursing care, including tracheal suctioning, administration of medications, nasogastric tube feedings, and dressing changes Igoe and Campos, A nationwide investigation of the experiences of students with special health care needs, The Collaborative Study of Children with Special Needs , funded by the Robert Wood Johnson Foundation in the s, recommended greater involvement of health care professionals in the planning and implementation of services Robert Wood Johnson Foundation, Another nationwide investigation of the needs of children and youth with chronic illness Hobbs et al.

Policies covering the administration of medication and homebound students were given particular attention. Another organization and workforce issue concerns the need for integrated school health services in which nurse, social worker, foodservice personnel, and others work together collaboratively as a team. Linked to this issue is the continuing evidence that well-prepared school health assistants paired with school nurses can, under supervision, manage basic services, which frees up nurses for more complex care and responsibilities befitting their preparation Fryer and Igoe, ; Russo et al.

Traditionally, school health services have been the responsibility of local districts. Given the large number of small- and medium-size school districts—76 percent of districts have a total student enrollment of 2, students of less—a regional plan may potentially even out some of the maldistribution of school health services from one district to the next in a state as well as among states Igoe and Stephens, The feasibility of a regional approach to the organization and delivery of school health services has been investigated by Igoe and Stephens Educational Service Agencies ESAs are intermediate educational agencies that act as cooperatives in approximately 85 percent of the nation's school districts, servicing such needs as staff development, bulk purchasing, and delivery of related services to students with special health needs.

In the study, ESA administrators were contacted to determine their involvement in school health. Although the response rate was only about 50 percent, administrators reported being involved in a wide variety of school health activities, including traditional basic school health services, and they predicted increasing involvement in years to come. Another interesting qualitative finding was that ESA directors had considerable skill in identifying and negotiating financing arrangements for a variety of school services from both state and local education agencies.

Based on the finding, the investigators recommended that ESAs may have untapped potential for devising new plans for financing school health services. The issue of financing for school health services received almost no attention until the introduction of nurse practitioners and primary care into schools in the s. Current efforts in this regard are described later in this chapter. However, one national school health demonstration project conducted from to did investigate financing for school health and primary care in schools and deserves mention DeAngelis, According to Meeker and colleagues , most school health service programs have sole-source financing provided by either a health or an education agency.

An alternative approach recommended by the investigators is multisource financing, which involves both health and education agencies as well as other organizations that provide such services as primary care. Some of the traditional population-focused basic school health services e. Although there has been little debate about the value of school-based screenings for vision and hearing, the value of growth screenings is uncertain.

Furthermore, there is increasing evidence to suggest that scoliosis screening fails to meet the general criteria for screenings and therefore should no longer be recommended Berg, ; Goldberg et al. Remaining to be evaluated with respect to mass screenings are such issues as the market value of these services and the value of a population-based approach versus a high-risk approach in which only those students needing screenings receive them at school. Although investigations of the outcomes of traditional basic services have been limited, some of this work was well designed for its day, and the findings have influenced the development and evolution of school health services.

For example, Basco conducted the first large-scale evaluation of school nurse activities. That study's finding of the need to better utilize the nurse's clinical and managerial skills has been confirmed on numerous occasions. Roberts and colleagues studied absence and attendance patterns of 2, students and developed a statistical model to use in evaluating the effects of changes in nursing practice on the functional state of students. By , the focus of school health services research became further focused on students, and Lewis et al. During the s and s, one principal area of research had to do with the effectiveness of the school nurse as a primary care provider, and another area of research concerned students with special health care needs.

Three large studies during this period yielded valuable results: the Brookline Project, which investigated the developmental readiness of children Levine et al.

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