A Community Pediatric Prevention Partnership: Linking Schools, Providers, and Tertiary Care Services

By Farrior, Kim Crickmore; Engelke, Martha Keehner et al. | Journal of School Health, March 2000 | Go to article overview

A Community Pediatric Prevention Partnership: Linking Schools, Providers, and Tertiary Care Services


Farrior, Kim Crickmore, Engelke, Martha Keehner, Collins, Catherine Shoup, Cox, Carol Gordon, Journal of School Health


When Lillian Wald began the first school health program in 1902 for New York City children, she began a movement that spread through the country. Though periods of regression occurred, such as the 1970s and 1980s when increasing economic uncertainty and rising costs led to a reduction in school health programs, the general trend has been toward an increasing role for school systems in promoting and protecting children's health.[1]

Recognizing the important role schools play in promoting child health, the American Academy of Pediatrics recommended seven goals for a school health program:[2] assure access to primary health care; provide a system for dealing with crisis medical situations; provide mandated screening and immunization monitoring; provide a system for identification and solution of student health and educational problems; provide comprehensive and appropriate health education; provide for a healthful and safe school environment; and provide a system for evaluating effectiveness of the school health program. Though these goals are admirable, achieving them has proven difficult for many school systems and physicians.

In the past, differences between the health care system and educational system posed a barrier to meaningful dialogue among private providers, hospitals, and school health personnel. School systems focused on the needs of all children, but in the traditional fee-for-service health care system only a small portion of school-aged children received regular, sustained services. These children often had chronic health problems that required ongoing management. In the fee-for-service system, if a school nurse had a concern about a child her only option was to call the child's physician. The treatment plan for a specific category of patients, such as children with asthma, might vary widely between primary care providers.

Response time for the nurse was limited by lack of a standard protocol for handling common problems for chronically ill children. Physicians received few incentives to have school nurses manage these problems because in a fee-for-service system it was easier and generated more revenue to advise the nurse to "send the child to my office after school." Likewise, no economic incentive existed to prevent hospitalization of chronically ill children since insurance companies paid for tertiary care. The traditional system did not result in the highest quality of life for the patient or the family, nor did it consider barriers that families might face in receiving care at a physician's office such as transportation or finances.

In today's managed care system, physicians are often clustered into umbrella organizations that offer incentives for reducing the cost of care. They are encouraged to adopt a standard of care for managing chronic problems such as asthma. Taras[3] suggests several reasons why physicians want to work with schools in managing children with chronic diseases. School systems maintain data that can assist physicians in developing more cost-effective treatment plans. For example, a student's response to medication changes can assist the physician in fine-tuning the medical management of chronically ill children and reduce their use of more expensive health care.

Managed care also increased the focus on primary and secondary prevention. School systems traditionally screen for common problems such as vision and hearing abnormalities. However, with increased emphasis on containing costs, providers need to identify problems early at a point when they are amenable to less-expensive interventions. Altemeier[4] suggests school systems have not begun to reach their potential in delivering preventive services. He suggests schools are ideally suited for prevention education. They cover all children, their primary mission involves education, and they already incorporate age-appropriate information about prevention in the curriculum.

Today's challenge is how to deliver school health services such as chronic disease management and health promotion in a manner that achieves optimal, measurable outcomes. …

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