A three-year demonstration project in Cincinnati used a quasi-experimental design to test different levels of school-linked health care: 1) continuing part-time school nurse services (control), 2) enhanced model with the addition of a full-time data clerk, computerized method of tracking activities, and a referral system for external services, and  3) comprehensive model with half-time nurse practitioner employed by the health department added to the enhanced model schools.  The collaborative project partners included the public school system (42,000 students) from which six elementary (grades K to 8) schools participated, the local health department which historically provided school nurse services, the children’s hospital which hired data clerks and conducted project evaluation, a university policy research center which administered surveys, and a local foundation which funded the project.

The project included a year for planning and baseline data collection followed by two years for implementation.  The planned outcomes and data sources were: health-related quality of life (PedsQL© questionnaire), school connectedness (ADD Health survey), school absences (school data), children’s hospital non-urgent emergency department visits, and completed referrals for vision, hearing, dental, behavioral or medical care (Welligent [version 3] referral module).

At project completion, the school and health department did not change their original service model; the health department did not want to compromise the school nurses’ role by adding a health clerk within their existing budget. One project school with “comprehensive” services partnered with a local health center to sustain services for families.

The authors summarized key issues and recommendations from “lessons learned.”  Most should be considered by other districts planning similar projects.

1) Involve staff at all levels, including information technology and staff nurses, in planning; reward nurses who participate and permit reassignment for those who are reluctant.
2) Focus the first few years on implementation and process evaluation; limit outcome evaluation to one or two measures, and control the amount and complexity of data needed; define data needs in writing.
3) All services staff (nurse practitioner, school nurse, clerks) should be employed by the same organization; define roles and reporting in writing; review objectives when there is turnover in leadership.
4) Provide a computer for each nurse and each health clerk so that they can enter data concurrently; this project recommended a district-wide system (due to high student mobility which was not considered in the planning phase).
5) Prioritize nurse practitioner time for direct primary care rather than health promotion, case management, and school committee activities.
6) Communicate liberally with frequent, concise documents to school personnel and regular letters to families.

(Rose BL, Manour M, Kohake K. J Sch Health. 2005;75(10):363-369)