Building the Infrastructure for School-Based Care Coordination: A Start-Up Guide

Guide to School-Based Care Coordination

School Nursing Infrastructure, Staffing and Capacity
School nurses are natural leaders for school-based care coordination teams. However, school nursing infrastructure, staffing, and capacity can vary widely from school to school and nearly 25% of U.S. schools do not have a nurse at all.
• Connect with school and/or district health leaders to understand school nursing infrastructure, staffing, and capacity including financial resources and payment models.  
• Connect with your local NASN affiliate and AAP chapters to understand perspectives on the adequacy of current school-nursing resources as well as the related political landscape.
• If nursing resources are inadequate, identify other key school-based partners and begin by supporting efforts to ensure a minimum of one nurse in every school.  
AAP Policy: Role of the School Nurse in Providing School Health Services
National Association of School Nurses Position Statement: School Nurse Work-load: Staffing for Safe Care
Identifying Partners and Creating a Shared Vision
Identifying key partners, understanding interests and priorities and establishing a shared vision is critical for the success of a multi-sector effort.  
• Learn about the organizational structures for school health, student support and special education services in your school or district.
• Identify existing groups, such as school health councils, already working on similar efforts.
• Connect with your local organizations, including your AAP chapter, for support understanding the existing landscape, including any work that is already taking place.  
• Plug in to existing networks or convene potential partners to learn about needs, priorities and interest in care coordination efforts.
Principles from the AAP School Health resources Healthcare and School Partnerships and Management of Chronic Conditions in Schools, as well as the School Friendly Health Systems Initiative from the Child Health Advocacy Institute at Children’s National can assist in identifying and engaging partners and creating a shared vision for the collaborative work.  
The AAP Training, Education, Assistance, Mentorship, and Support to Enhance School Health Services (TEAMS) program provides an opportunity for structured partnerships between pediatricians, school systems, and the community to strengthen policies, practices, and infrastructure related to school-based health services and supports.   
Care Coordination Needs
Understanding the chronic health conditions and school-based care coordination needs of your population requires input from patients, families and all other members of the care team – particularly school nurses working on the ground. Data from pediatric practices, hospitals or health systems and the local school/school system can be augmented by interviews, focus groups or meetings with key partners. 
It may be helpful to begin by identifying 1 or 2 chronic health conditions most important in your population to focus on. This narrower focus may make goal setting more straightforward and progress easier to measure. Moreover, key components of the process will be relevant across all conditions.  
With input from patients, families, and other members of the care team:
• Identify key health conditions important to the local population as well as to the school/school system based on prevalence, severity, disparities and/or educational impact.
• Map the current process of care coordination and communication and identify opportunities for improvement.  
The AAP Health Services Assessment Tool for Schools (HATS) is a self-assessment tool that can support districts and states in assessing the quality and comprehensiveness of school health services, the level of infrastructure to support those services, and the strength and implementation of school health services policies and protocols.
 
Understanding the Impact of Privacy Laws
Health and educational privacy laws such as the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) intersect in the school health space. It is essential to understand the practical implications of these laws for communication around school-based care coordination. Communication is possible across sectors and thoughtful planning may be needed to insure privacy and legal compliance.  
• Identify federal, state and local statutes, regulations and policies relevant to information sharing between healthcare providers (HIPAA covered entities) and educational agencies (FERPA and HIPAA covered entities).  Utilize individual information release consents as appropriate, ideally leveraging bidirectional consents.  
• Develop care coordination approaches that plan for addressing information sharing at a system level wherever possible.
The AAP School Health HIPAA and FERPA Basics page is home to many helpful resources, as well as a Learning Burst Library on HIPAA and FERPA.
Evaluating Data Systems
Health and educational data are typically stored in complex information systems that often do not intersect. While direct verbal communication is a key component of successful care coordination efforts, many elements of communication can be made more efficient through electronic information-sharing.
• Identify existing data systems for student educational, special education, mental health and somatic health information.
• Assess whether existing systems have privacy compliant data sharing options.
• Identify information exchanges (eg, state health information exchange) that may be leveraged to facilitate communication with proper privacy protections.
• Anticipate potential limitations to electronic data sharing, such as differing electronic health records among healthcare providers and between healthcare providers and schools and identify solutions or alternative approaches. 
HealthIT.gov provides background on Health Information Exchanges.
Implementing the Vision and Measuring Progress
Using a quality improvement framework for school-based care-coordination can provide a common language for individuals working across sectors and can support outcome measurement and continuous improvement.  
• Come to consensus on the overarching goal of the collaborative effort.
• Create SMART objectives (specific, measurable, attainable, relevant, timely) to focus efforts and track progress.
• Include outcomes and metrics relevant to educational as well as health partners (eg, school absenteeism).
• Regularly review data with the team to identify areas for improvement. 
• Share results with all partners and influential decision-makers.
The Medical Home Care Coordination Resources page from the National Resource Center for Patient/Family Centered Medical Home has information about a wide array of care coordination metrics.   
The NASN Improving Care Coordination for Students with Chronic Conditions Toolkit includes specific school-based care coordination implementation resources.