Introduction

Missouri Department of Health and Senior Services uses public funding to support initiatives that can be accomplished through outcome-based contracting, and those that build and maintain strong systems of care to provide core public health functions.

To be strong, the systems must have six basic components. Those components include the capacity to:

1. Identify problems and solutions;
2. Continually assess and monitor identified problems;
3. Plan and maintain referral systems;
4. Assure people are in place who can effectively address needs and assure that regulations are followed;
5. Provide education in order to identify problems and solutions; and
6. Evaluate how the system is working and use the evaluation information to improve the system.

Core public health functions of assessment, policy development, and assurance are central to developing and maintaining a system to coordinate services to meet the needs of a school community. No matter whether an issue deals with communicable disease, safety, teen pregnancy, physical activity, nutrition, or health care for children, when systems are functioning and working together, issues will be recognized and dealt with appropriately.

Program History

The Missouri School Age Children’s Health Services program began in 1995, when less than 50% of the public schools in Missouri had school health programs. The intended impact of the initiative was to increase access to health care for school-age children, early detection of medical and emotional problems, reduce absenteeism related to health conditions, and reduce dropouts. During the first five years of the program, contractors were required to perform needs assessments, develop unique goals and strategies to address local needs, and collect data. This process made standardized data collection difficult.

In FY 2000, the program was redesigned to a performance-based contract. The performance measures focused on access to health care, services to children with special health conditions, health risks associated with unhealthy eating behaviors and lack of physical activity, and Hepatitis B immunizations for adolescents. Additionally, contractors selected elective measures aligned with the Department’s strategic plan and reflect use of a local needs assessment.

New Direction

Outcome-based contracting is a tool for quality improvement, performance assessment, and accountability. People and organizations with targets tend to outperform those without them.

• Outcome data can assure funders and the public that investments are producing results;
• Agreement on desired results facilitates cross-system collaboration on behalf of children and their families;
• Information about results enhances community and agency capacity to evaluate effectiveness; and
• Assessment of the program by communities.

The Department implemented an outcome-based School Health Services contract model in FY 2005 to reduce the emphasis on process and input, while increasing the focus on outcomes, and a coordinated approach to school health. The guiding principle of a coordinated school health approach is that working in partnership with health agencies, community institutions, and families; schools and communities can create a seamless web of education and services that lowers the barriers to learning.

Program Design

As in past years, contractors continue to develop work plans to address the short-term outcomes related to direct services, enabling services, and population-based services.

• Direct services are described as the services performed to address the needs of children with special health care needs, such as management of acute and chronic health conditions, development of individualized health care plans, asthma action care plans, individualized emergency action care plans, etc.
• Enabling services are activities on behalf of students and families, such as outreach for services, case management, health education, and coordination with Medicaid.
• Population-based services are activities provided to a large segment of the school population, i.e., vision, hearing, spinal, nutrition, oral health screening programs, and additional
• Infrastructure building is demonstrated by the work schools do with the school health advisory council, the school health index, developing and using logic models for program planning and evaluation.

The above services, well known for their role in the Maternal Child Health Block Grant Program, also reflect the basic tenants of the School Health Services program.

Outcomes

The long-term outcomes for the School Health Services program are to promote healthy and safe behaviors of young people, and to improve educational performance. These long-term outcomes are met by addressing the intermediate outcomes of increased access to health care; management of health related barriers to learning; and infrastructure building.

The Department has selected seven short-term outcomes to demonstrate progress toward the intermediate outcomes and ultimately the long-term outcomes for the School Health Services program. The short-term outcomes are:

• Children with access to a regular source of medical care;
• Children with a vision referral completed;
• Children with a hearing referral completed;
• Children with chronic conditions have their health care needs met;
• Children with persistent asthma meet/maintain the criteria for adequately controlled asthma;
• Wellness promotion and disease prevention as evidenced by the school district and community agencies; working together toward common goals utilizing the CDC School Health Index; and
• Reduce the burden of disease through oral health promotion and disease prevention.

Contractors have baseline data for the above short-term outcomes and are expected to collaborate with families, community members, and school staff to develop work plans to increase the number and percent of the short-term outcomes outlined.

The intent of the School Health Services contract is to respond to the needs of children by purposefully integrating efforts and resources of education, health, and social service agencies using a Coordinated School Health Approach. The School Health Services program is based on the following resources: Manual for School Health Programs written by the Department of Health and Senior Services in cooperation with the Missouri Department of Elementary and Secondary Education, and the School Health Advisory Council Guide developed by the Missouri Coordinated School Health Coalition and Health is Academic, A Guide to Coordinated School Health Programs, edited by Eva Marx and Susan Wooley. Guidelines for Vision Screening, Guidelines for Hearing Screening, and Missouri School Asthma Manual. These resources serve as the framework for this program.

The outcomes for the School Health Services program are:

The long-term outcomes are:

a. Schools and Communities promote healthy and safe behaviors;
b. Improve Educational Performance.

The intermediate outcomes are:

a. Increased access to health care;
b. Elimination or management of health related barriers to learning;
c. Reduce the burden of disease through oral health promotion and prevention services; and
d. Wellness promotion and disease prevention.

The short-term outcomes for increased access to health care are:

a. Children with access to a regular source of medical care.

The short-term outcomes for elimination or management of health related barriers to learning are:

a. Children with chronic conditions have their health care needs met;
b. Children with persistent asthma meet the criteria for adequately controlled asthma; and
c. Children receive appropriate referral follow-up related to vision and hearing assessments.

The short-term outcomes for reducing the burden of disease through oral health promotion and disease prevention:

a. Students participating in a external fluoride application program; or
b. Students participating in an oral health curriculum.

The short-term outcomes for Wellness Promotion and Disease Prevention:

a. Demonstrated progress toward goals identified through the SHI action plan.