The 'School Health Innovative Programs': Integrating School Health and Managed Care in San Diego

Article excerpt

A national trend has developed for both privately insured and Medicaid-insured populations to receive health services through managed care organizations (MCOs). Concomitantly, an unrelated trend to develop school-linked and school-based health services has emerged, which can improve access to medically under-served populations.[1,2] Much of the work to bridge these trends has focused on how MCOs can support services at school clinics and how school clinics can improve access to care for MCO clients.[3-6]

About 600 school-based health centers operate in the United States at this time. This statistic represents an enormous increase from the number of school clinics that existed a decade ago, but it is an insignificant proportion of the schools whose student populations could benefit from such services. School health centers struggle financially to remain open after start-up funds expire. Various experimental agreements among school districts, health departments, and MCOs have helped many school clinics stay open.[3-6] Yet, no master plan addresses the feasibility for MCOs to support school clinics if clinics were to operate in each school that needs one but does not yet have one.

The School Health Innovative Programs (SHIP), developed in San Diego, explored how MCOs and schools can work together to improve the health of students who attend all schools, whether or not a school-based or school-linked clinic exists. This article summarizes the first two and a half years of the project's accomplishments.

BACKGROUND

California's San Diego County enrolls families with Medicaid into MCOs, accounting for a large number of students with MCO-Medicaid insurance in schools. A project was initiated in a cluster of 12 schools (two secondary and 10 elementary) in a region with a high Medicaid-MCO penetration. A school nurse is assigned to each school in this district for at least one day per week. Although other school districts have joined SHIP more recently, this report addresses the initial two years.

SHIP participants met monthly. Schools were represented by district-level staff from three departments: health; billing and contracts; and management information services. School health staff from pilot sites also attended meetings. Three MCOs (Kaiser Permanente, Great American, and Community Health Group) have participated in SHIP since its inception. Others have joined as Medicaid contracts with more MCOs. Each MCO representative has access to the local chief executive officer of his or her organization. To implement pilot collaborative arrangements between MCOs and schools, primary care doctors and school health staff receive in-service training from project representatives at intervals during the course of the project.

The Division of Community Pediatrics at the University of California at San Diego, the local public health department, local community clinics, the local children's hospital, and the local chapter of the American Academy of Pediatrics each send representatives to SHIP's monthly meetings. The initial year's efforts were supported by a grant from the Foundation Consortium of California. The group has since been self-supported.

PROJECT DEVELOPMENT

Establishing Trust: The Initial Six Months

Initially, MCOs and school staff were suspicious of each other's intentions to collaborate. School personnel suspected health plans did not want to encourage service utilization for populations that did not normally seek services. MCO administrators and health providers suspected school health staff were competing with traditional health care providers for the health care dollar.

MCO representatives learned that most school health services -- such as vision screenings, administering medication, and special health care procedures for students with special health care needs -- are mandated by law. By visiting school sites and speaking to school nurses, MCO representatives began to appreciate the utility of school health services. …