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2001 National School-Based Health Care Conference

This workshop focuses on assessing the quality of clinical services in School-Based Health Centers (SBHCs) through a Continuous Quality Improvement (CQI) tool. Learn about tool development, strengths, struggles, and resources available to meet care standards. Discover the criteria for evaluating sentinel conditions in different age groups and how to improve performance based on markers of care. Join experts in evaluating and enhancing clinical care in SBHCs.

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2001 National School-Based Health Care Conference

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  1. 2001 National School-Based Health Care Conference Workshop B8: A Method of Evaluating Clinical Services in School-Based Health Centers Monday, June 25, 2001 9:30 – 10:45 am

  2. Assessing the Quality of Clinical Services in SBHCs (CQI Tool) • Tool Development • Strengths of the SBHC model • Struggles facing the SBHC model • Resources available • Meeting a standard of care • Agreement from experts that conditions were the right ones

  3. Assessing the Quality of Clinical Services in SBHCs (CQI Tool) • Tool Characteristics • Sentinel conditions as a marker of the quality of clinical care • The foundation is an annual risk assessment and biennial physical exam • Limited number of conditions allows for meaningful evaluation • Intent is for the tool to be flexible

  4. The SBHC CQI Tool - Characteristics • Six clinical conditions per age group (choose one of two mental health conditions) • References to support the inclusion of the condition and to use to improve performance • Resources necessary to provide quality care relative to that clinical condition • Markers of care for that condition • Measurement of the markers on a scale of 1 to 5 with threshold at 3

  5. Sentinel Conditions for Elementary School • Annual risk assessment and biennial physical exam • Asthma,chronic • Incomplete immunizations • High risk for unintentional injury • Poor school performance • Mental health • Students being treated for ADHD or • Child abuse

  6. Sentinel Conditions for Middle School • Annual risk assessment and biennial physical exam • Tobacco use • Risk of pregnancy • Poor school performance • Parent child conflict • Mental health • Students being treated for ADHD or • At risk for depression

  7. Sentinel Conditions for High School • Annual risk assessment and biennial physical exam • Alcohol use • Risk of personal violence • Risk of STI • Poor school performance • Mental health • Students being treated for ADHD or • At risk for depression

  8. SBHC CQI Tool • http://www.healthinschools.org/home.asp • The tool • Data collection forms • Instructions • Resources/glossary/directory • FAQ’s

  9. Beta Test • Selected 20 sites from larger group of volunteers • Spread among the age groups served by SBHCs • BPHC grantees and non BPHC grantees • Geographic diversity • Computer, Internet access, MIS system, scheduled chart reviews

  10. Beta Test • Some sites selected because they were thought to represent best practices related to a sentinel condition • 2 scheduled conference calls to explain purpose and orient participants to use of the tool • Sites in Connecticut, New York, Georgia, Illinois, Texas, California, Oregon, Arizona,Tennessee, Indiana, Michigan, Alabama, Colorado, Illinois, New Mexico

  11. Data Collection • Data collection began 2/01 ended 3/01 ( 6 wks), 2 sites entered data 4/01 • 17 completed data entry; 7 elementary, 4 middle, 6 high school • Sites had access to technical assistance • Data from chart reviews entered on the web • Sites completed the NASBHC 2000 survey for background information on SBHC operations and staffing

  12. FAQ’s - Beta Test How is a complete history and physical defined? When are immunizations considered to be complete? How do we find the population to be studied (poor school performance, at risk for injury/personal violence)?

  13. The Data Collection Web Site and Materials

  14. Key Screens • Login screen • Add a student screen • Survey summary screen • Sentinel condition marker screen • Supplemental entry screen • Results screen

  15. TechnicalRecommendations for Data Entry • Improve access to instructions for each field and screen. Create an icon such as a question mark. • Written policies and procedures on administrative issues such as issuing site Ids, passwords, establishing student Ids and providing technical assistance. • Add demographic questions to the software. • Training - identify individuals from each state or region to conduct a hands-on training of the software.

  16. Technical Recommendations for Data Entry • Convert the Web-based data collection tool to a CD-Rom application. • On-going communication with the software designer

  17. Results • 17 sites completed data entry: 7 elementary, 4 middle, 6 high school • A total of 1563 records were reviewed: 627 elementary, 281 middle, and 655 high school • Gender: 56.6 % female and 43.4 % males

  18. Beta Test Sites (N=15) • 53% sponsored by hospital/academic medical center • 80% in urban areas • 100% open for > 2 years

  19. Beta Test Sites (N=15) • 13.3% school enrollment is < 500 students • 13.3% school enrollment is 500 –999 students • 40% school enrollment is 1000 –1499 • 33.3% school enrollment is >1500

  20. Primary Care Staff in Beta Test Sites (N=15) • 13.3% had primary care staff (NP,PA,MD) 8-30 hours a week • 86.6% had primary care staff >30 hours a week

  21. Mental Health Staff in Beta Test Sites (N=15) • 13.3% had no mental health staff (SW, drug and alcohol counselor, psychiatrist, psychologist,) • 20% had mental health staff 8-30 hours a week • 66.6% had mental health staff > 30 hours a week

  22. Estimate of Use of SBHC As a PCP in Beta Test Sites (N=15) • 6.6 % report <25 % of enrollees use the SBHC as the PCP • 53.3% report 26-50 % of enrollees use the SBHC as the PCP • 20% report 51-75 % of enrollees use the SBHC as the PCP • 20% report 76-100 % of enrollees use the SBHC as the PCP

  23. Condition Mean Range of Scores RA & PE (n=7) 2.71 1-4 Asthma (n=7) 3.57 1-5 Immunization (n=7) 3.71 1-5 Injury ( n=4) 4.0 3-5 School (n=7) 2.33 2-3 ADHD (n=4) 4.43 3-5 Abuse (n=3) 2.75 2-3 Mean Scores- Elementary SBHCs

  24. Condition Mean Range of Scores RA & PE (n=4) 3.25 1-5 Tobacco (n=4) 3.75 3-5 Pregnancy (n=4) 2.75 1-5 School (n=4) 2.75 2-4 Parent-Child (n=4) 4.00 1-5 ADHD (n=4) 3.50 1-5 Depression (n=4) 3.25 3-4 Mean Scores – Middle Schools

  25. Condition Mean Range of Scores RA & PE (n=6) 3.33 1-5 Alcohol (n=6) 4.50 2-5 Violence (n=6) 2.67 2-3 STI (n=6) 2.67 2-4 School (n=6) 3.17 2-4 ADHD (n=0) 0 0 Depression (n=6) 3.17 3-4 Mean Scores – High Schools

  26. Annual Risk Assessment and Biennial PE Poor School Performance Students Treated for ADHD Treated for Depression Elementary SBHCs 2.71 4.43 2.75 Middle School SBHCs 2.67 2.75 3.50 3.25 High School SBHCs 3.33 3.17 0 3.17 All SBHCs 2.75 3.41 3.12 3.00 Mean Scores for Shared Sentinel Conditions

  27. Elementary SBHCs Middle School SBHCs High School SBHCs RA &PE 2.57 1.67 1.83 Asthma 2.71 Tobacco 2.50 Alcohol 3.00 Immuniz 1.86 Pg 2.25 Violence 3.33 Injury 1.00 Parent Conflict 2.33 STI 2.33 ADHD 2.43 2.50 0 Abuse 2.00 Depression 2.50 1.67 School 2.25 2.50 2.50 Mean Values - Ease of Use 1 ( Very Easy )…………5 ( Very Difficult )

  28. Elementary SBHCs Middle School SBHCs High School SBHCs RA &PE 2.43 2.33 2.33 Asthma 3.29 Tobacco 2.75 Alcohol 3.33 Immuniz 2.43 Pg 2.75 Violence 3.50 Injury 1.00 Parent Conflict 3.00 STI 2.50 ADHD 2.43 2.75 0 Abuse 2.33 Depression 3.00 2.33 School 2.50 2.75 2.83 Mean Values – Time Spent1( Minimal)……………5 (Excessive)

  29. Elementary SBHCs Middle School SBHCs High School SBHCs RA &PE 4.00 4.00 3.50 Asthma 3.14 Tobacco 3.50 Alcohol 3.33 Immuniz 3.14 Pg 3.50 Violence 3.33 Injury 1.00 Parent Conflict 2.75 STI 3.50 ADHD 2.71 2.75 0 Abuse 3.33 Depression 2.75 3.83 School 3.75 2.75 3.83 Mean Values- Usefulness1(Not at All)……..5 (Very Useful)

  30. Conclusions • Beta Test • Beta test chart audits done on site visits to 4 SBHCs corroborated the data entered on the web. • The tool works well in the field. Its’ use is “understandable” and it is a good organizer of quality measurements. • The beta test revealed points of confusion and inaccuracy, e.g. what constitutes a complete physical exam.

  31. Conclusions • Quality • The tool measures quality SBHC practice. Sites reported that the sentinel conditions reflected important health issues for their schools, and, that the tool gave an accurate measure of how they were doing. • The tool can be used for CQI. It lends itself to a “continuous” measure of quality, i.e. it encourages tracking of kids at risk, thereby improving their health over time. Some sites are already thinking of how to improve the care they provide (and thus improve their marker score).

  32. Conclusions • Ease of Use • The tool favors established programs with annual risk assessment forms (e.g., GAPS) and data collection systems (e.g. Clinical Fusion). Such programs spent 1-2 hours selecting charts and entering data per condition. • Prevention vs. Acute Care • The tool favors quality of preventive care over acute care.

  33. Conclusions • National Standards • The use of the tool has sparked debate about what might be national standards for screening tools regarding alcohol abuse, violence, depression, etc. • Evolution • It will take new programs some time to develop the resources and skills for thorough risk assessment, data collection and analysis, and provision of preventive services. The tool can be helpful in planning to provide these services.

  34. Recommendations From the Site Visits • Clinicians need to collect the data • MIS system may need to be set up with dummy codes for some of the sentinel conditions • Programs should set up a mechanism of doing reliability checks internally (another staff member) or externally (outsider)

  35. Recommendations From the Site Visits • If at all possible,use networked access to the web since faster connections make the process easier and less time consuming. • State offices that sponsor SBHCs could be trained in the use of the tool. Since site visits were so helpful in determining proper use of the tool, adding use of the tool on existing structures such as state site visits, could accelerate dissemination of the tool.

  36. Changes • Define what is a complete physical - the context the PE is done in such as an acute visit may or may not qualify • Define how to code incomplete immunizations in the process of being completed

  37. Next Steps • Recommendations for NASBHC from the Advisory Panel • Define what is the eligible population for a given measure • Give examples of how to construct the denominator for a sentinel condition if using an MIS • Identified what is need to continue development of the tool : trainers, site visitors, technical support, administrative support etc. • Feedback to the sites • Expand in a stepwise fashion

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