School Health & Managed Care In Partnership

This article describes the first two years of a San Diego collaboration among three managed care organizations (MCOs), community health care agencies, and 12 schools with a high enrollment of students with Medicaid in MCO programs. Each school had at least one day of school nurse service weekly. School staff involved in the program included representatives from health services, billing and contracts, and management information.

Building trust was facilitated by MCO visits with school nurses- learning which services were state mandated. MCO staff recognized that school nurses can help families better use their preventive and acute care service benefits, thus reduce misuse of emergency services.

Five principles guided the project: 1) respecting each others’ goals; 2) supporting confidentiality, parent involvement, preventive care orientation, and continuity of care; 3) endorsing the designated provider, not the school, as the student’s "medical home"; 4) writing agreements that could be replicated for diverse populations; and 5) agreeing that any strategy had to make "business sense" for HMOs, providers and schools to be sustainable without other grant or government funding.

To enhance communication, each MCO designated a contact person for the schools to facilitate information exchange. One MCO furnished a FAX machine to each school’s health office to assure confidentiality.

In San Diego, a number of service changes are underway: 1) Reports of services delivered at school and by MCOs to students enrolled in an MCO-Medicaid plan were shared (without revealing student names) to measure service utilization, duplication and gaps. There were no duplicated services. Partners are working toward a standardized services descriptions and better documentation. 2) Vision or hearing screening referral notices to parents include an MCO contact person, and - with parent consent- the MCO is notified of the referral. 3) School nurses read Mantoux TB tests given by MCO providers; reimbursement is being discussed. 4) To reduce unnecessary referrals for attention- or learning-related problems, a multidisciplinary team first reviews the student. If a medical or mental health referral is made, the team furnishes a written report for the parent to deliver at the first appointment. 5) School nurses can initiate head lice treatment under specific arrangements with each MCO. One MCO allows nurses to call for prescription treatment, while another MCO supplies shampoo for its clients. 6) School nurse practitioners continue to perform EPSDT exams if the MCO has been notified but cannot provide the service.

Among the outcomes has been MCO recognition of the value of school nurses’ expertise, access and case management skills. In this project, MCO reimbursement for school services did not lower the capitation rates to assigned providers. It is feasible that future reimbursement may come from the capitation rates since some necessary services can be more efficiently delivered in schools.

(Taras H. et al. The School Health Innovative Programs: integrating school health and managed care in San Diego. J Sch Health 1998;68(1):22-25)

COMMENT: It is not surprising that data collection, securing parental consents, and communication between professionals remain challenges; that occurs in all school health partnerships. The authors stressed the value of the time spent building trust through open discussions about concerns and observing school nurses’ work. One idea to promote understanding about school health would be to invite MCO representatives who have children as Medicaid or commercial clients to observe in the health office in conjunction with national School Nurse Day. -J.O.