Contracted services have been an issue of increasing interest to school and community health leaders. For years, school boards have experimented with contracts for the administration and management of education programs, food service, and student maintenance. However, there has been little or no published information on the effectiveness and outcomes of contracted services as compared with direct employment of personnel to provide health services.
A study conducted from 1993 to 1994 by the University of Colorado Office of School Health provides the only nationwide survey data of contracted school health services. The survey describes 472 school districts of all sizes across the US, and documents the existence of contracted services for nineteen job titles of school health personnel.
In 1995, a community health organization requested information about the advantages and disadvantages of contracting school health services from the University of Colorado Office of School Health, prompting a study of 10 large school districts with over 25,000 student enrollment. The study included two follow-up surveys to monitor changes in the type and level of general contracting activity from 1995 through 1997, and the districts’ interest and activity in specifically contracting student health services.
• Does your school district administer the entire school health program? Have you contracted with outside agencies to deliver school health services in the past year? If so, which programs are contracted with outside agencies?
• In the past year, have you encountered any difficulties in transferring health programs traditionally administered by the school district to outside contractors? If so, please check all that apply (e.g. school health staff opposition, teacher or principal opposition, new regulations, unions, parent/community opposition, contractual agency opposition).
• Has your school health program improved in the past year?
• Who is/are the lead agency/agencies for your school-based student health centers (if applicable)?
• Have you transferred any of your school health services to school-based student health center personnel (if applicable)?
• Is there a connection between general school health work and the lead agency for school-based student health centers in your school system (if applicable)?
In most of the 10 school districts surveyed, various components of the school health program were managed by different individuals in separate departments of the school district. The supervisor/coordinator responsible for each district's school health services however was the principal respondent for this survey, and was interviewed by telephone. Seventy-two percent of the school health service coordinator/supervisors were registered nurses, which is higher than the national percentage (42%) of nurse supervisors responsible for school health programs. The remaining 28% of supervisors interviewed for this survey represented health education, health promotion, and public administration fields.
The complete study results include a descriptive profile of each school district’s school health services programs, the types of services contracted, outside agencies involved, and problems encountered with contracting in recent years. Also included is information about the perceived value of contracting school health services, predictions about future use of contracted personnel for the delivery of school health services, issues of financing and administration, and school-based student health centers.
While the majority of school districts investigated em-ploy their own school health personnel to provide health services, they all outsource for staffing of school-based student health centers. This is consistent with the current thinking of health planners that primary care delivered in nontraditional settings needs to be linked closely with other primary care delivery systems in the community.
Although the study findings indicate that general school health services are largely provided by school board-employed personnel, this arrangement is more typical of larger districts (those with student enrollments of 50,000 to 70,000 or more) than smaller districts. Furthermore, most school districts appear to retain control of their health education and food service programs. This may be because of collective bargaining arrangements which discourage the use of outside contractors.
Contracting for school health services (e.g. occupational and physical therapy) for students with special needs was a common practice among the school districts surveyed. It was not determined whether environmental health and safety services were handled through outside contracts. The survey respondents assumed that contracts existed, possibly involving health departments, but were unaware of the details.
Survey respondents reported the barriers to contracting to be school health staff opposition, unions, contractual agency opposition, and new regulations requirements. However, none of the school districts reported opposition by other school personnel, parents or communities. Three school districts reported barriers unique to their state. Previously in one state, a state statute granted public school districts legal immunity but denied this exemption to outside contractors. This statute no longer applies according to the most recent survey of this district which has since outsourced many of its school health services. It should be pointed out that several respondents indicated without risk protection, outside contractors cannot offer school health services, and small agencies cannot price their school health services competitively given the high cost of liability insurance.
Several conclusions can be drawn from these descriptive data.
• All 10 school districts contracted some school health services at various times during the 18-month study period. The most frequently contracted service was primary care through school-based student health centers.
• Contractual services for general school health services increased in two school districts during the 18-month study period.
• The most common barriers to contracting were internal.
• No formal guidelines for school health services contracting could be identified.
• Cost data for general school health services (i.e. not primary care services provided by school-based student health centers) for students with special needs were unavailable in the majority of school districts.
School-based student health centers existed at all grade levels (elementary, middle, high school) in the 10 school districts that participated in the study.
The study participants offered these suggestions to school districts that may consider contracting of student health services to outside agencies.
• Negotiate contracts with care to decrease grounds for challenges. Given the informality of contracting processes identified in some school districts, unsuccessful bidders could well create barriers to contracting.
• Less is best. Begin by contracting a small portion of the district’s health services, especially if data about costs, need for services, and time requirements are limited.
• School districts and school health services managers must be familiar with the unit costs of providing student health services.
• One of the greatest frustrations expressed by the study respondents was the absence of organized comprehensive planning for overall school health programming. Two recent publications–one from the Institute of Medicine and the second from the Centers for Disease Control and Prevention, Division of Adolescence and School Health–provide information about planning for school health programming.
Contracting school health services is an issue that continues to confront school and community leaders. The findings of the longitudinal, descriptive study provide some guidance for school districts in search of new ways to deliver student health services.
The report is available for $25.00 from the University of Colorado Office of School Health, Campus Box F-541; PO Box 6508; Aurora, CO 80045. Phone: 303-724-0644; Fax: 303-724-0905. Email: Judy Igoe
References
1. Institute of Medicine, Division of Health Sciences Policy, Committee on Comprehensive School Health Programs in Grades K-12. (1997). Schools & health: Our nation’s investment. D. Allensworth, E. Lawson, L. Nicholson, & J. Wyche (Eds.). Washington, DC: National Academy Press.
2. Marx, E. and Wooley, S. (Eds.). (1998). Health is Academic. New York: Teachers College Press.
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