Columbus Public Health
School-Based Supplemental Health Services Consent Form
Columbus Public Health (CPH) protects the health and improves the lives of nearly 1 million Columbus and Worthington, Ohio residents through more than 40 programs. We protect our community through diverse services such as restaurant inspections, STI testing and treatment, women's health and wellness services, newborn home visiting, immunizations and much more. Together with our community partners, we also are working to reduce infant deaths, address the opiate epidemic, prepare for and respond to emergencies, prevent the spread of disease, lower disparities to achieve health equity, reduce chronic diseases, and increase access to affordable health care. Through these services and collaborations, CPH is a nationally accredited leader that identifies health priorities, mobilizes resources, and ensures the conditions in which all residents can be healthy.
One important community partnership CPH has is with Columbus City Schools (CCS). Barriers to students receiving needed school-based health services are numerous. Prior to this newly implemented practice, for each health service that was offered in CCS, a separate consent form is sent home by the school via the student at various times throughout the school year. Parents had to complete the individual health service program forms for each of the desired services, and much of the information was duplicated among the health services' forms. Having parents redundantly complete this information is time-consuming and may be confusing. School staff may not have had time or forgot to distribute consent forms to students in the necessary time frame for upcoming services. Students may have forgotten or elected not to give the blank forms to their parents and/or completed forms back to their teachers. Unreturned forms prevented the student from accessing needed health services.
CPH led a partnership with Nationwide Children's Hospital, OhioHealth Wellness on Wheels and PrimaryOne Health to create a unified consent form for school-based health services for the students of CCS. Along with collaboration from CCS and the City of Columbus Department of Education, the partners aim to maximize the available health resources to promote student wellness and academic success. This combined form strives to ease the process for parents to register their children for school-based health services, therefore increasing accessibility to healthcare providers.
The form was vetted through multiple processes: by the committee; by each partner's institutional leadership and attorneys; as well as with parents through four focus groups. Most participants found the form self-explanatory and easy to use. The majority stated that they would use the form for their own children and that the inclusion of sexual and reproductive health services was not a deterrent. Key concerns raised surrounded the amount of verbiage, privacy/confidentiality, and clarity regarding the financial responsibility for the available services.
Due to form change requests from the CCS Board of Education, there was a delay in having the consent form ready for district-wide use at the beginning of the 2015-2016 school year as intended. This delay led to a soft roll-out of the form with utilization by one service provider (Nationwide Children's Hospital) in the winter of the 2015-2016 school year. In the summer of 2016, the School-Based Supplemental Health Services Consent Form 2016-2017, was approved by the CCS Board of Education for district-wide use. Copies of the consent form were made over the summer and distributed to all of the districts' 109 schools for distribution by school office staff with the beginning of the school year packets for all students, grades PreKindergarten-12th. The timing of consent form distribution was identified as an important factor by the planning group since parents typically are looking for and expect to complete important paperwork at the beginning of each school year.
Consent forms completed by each student's legal guardian are returned to the school nurse at the respective building. The school nurse is the designated contact person at each school responsible for the maintenance, confidentiality and distribution of the consent form to the identified service providers. Each school within the district has the option to promote the consent form and the included services in different and unique ways. Some school principals utilized the robocall option to encourage form completion and return for specific services, while others included information in school newsletters or email blasts. Additionally, each provider included in the form also may promote participation in a service.
The key public health practice implications for the success of the unified consent form process are improved access to care for students and increased utilization of school-based health services, specifically immunizations.
The website for the School-Based Supplemental Health Services Consent Form is: https://www.columbus.gov/publichealth/programs/school-health/School-Based-Health-Services/
One specific public health issue that the use of the School-Based Supplemental Health Services Consent Form promotes is improving childhood immunization rates. Ohio's immunization coverage rates are suboptimal. The inclusion of vaccine services, through targeted grade level requirements, such as Tdap and meningococcal vaccine for those entering grades 7 and 12, or age-appropriate vaccines for all students, seek to address and improve immunization compliance and coverage in Columbus school children. According to the 2015-2016 School Year Vaccination Coverage Dashboard published by Centers for Disease Control and Prevention (CDC), Ohio kindergarten immunization coverage was 92.1%. In order achieve the Healthy People 2020 objectives related to Immunization and Infectious Diseases: maintain vaccination coverage levels for children in kindergarten; increase routine vaccination coverage levels for adolescents; and increase the percentage of children and adults who are vaccinated annually against seasonal influenza, vaccine coverage rates must improve. These efforts are vital to decrease rates of vaccine-preventable disease and associated morbidity and mortality.
To address the barriers of Columbus City School students which impact their receipt of school-based health services, the committee members, along with input from their respective legal counsel, created a 12 month academic year unified consent form, School-Based Supplemental Health Services Consent Form. Research was conducted into other consent forms for school-based health services in the initial development of this consent form. Through an internet search examining consent forms in use by other healthcare providers across the United States, many examples of forms for multiple services were discovered. One key point, however is that other existing tools were typically for one service provider versus the basis for the School-Based Supplemental Health Services Consent Form, which was developed for multi-agency utilization.
Columbus City Schools is the largest school district in Ohio. This central Ohio urban district consists of more than 50,000 students in 109 schools. According to the school district's Digital Dashboard for November 6-12, 2017, 8,100 students (16.1%) of the district population have limited English proficiency. Additionally, 7,837 (15.6%) students received special education services. This ethnically diverse district is comprised of 54% black students, 23% white, 12% Hispanic, 7% multiracial, 4% Asian and less than 1% each Pacific Islander and American Indian. Beginning in the 2015-2016 school year, every student in Columbus City Schools is able to receive both a free breakfast and lunch at school. The districts' participation in the U.S. Department of Agriculture's Community Eligibility Option was prompted by nearly 64% of the students being enrolled in such as Supplemental Nutrition Assistance program or Temporary Assistance for Needy Families. In addition to families struggling with poverty, the district also faces the challenge of transient students who don't spend the majority of the school year in the district. According to the 2016-2017 Ohio Department of Education Report Card for Columbus City School District, the overall mobility rate for all students was 17.4%. Additionally, the chronic absenteeism rate for the 2016-2017 school year was 37.8%. During the same time frame, the overall attendance rate for all students was 89.3%
The goal of the unified consent form is to help improve the health and well-being of students so that they can be present and successful in school. This is achievable through increased utilization of school-based health services through the consent form, which decreases the redundancy of school staff and parents in completing health-related consent forms of various agencies and their programs throughout the school year. The health services offered in the unified consent form provide quality healthcare in a friendly and familiar school setting at a time that works well for the student and family. All services are optional and families are encouraged to continue with their established healthcare providers if they have them. The consent form is designed so that parents can provide the necessary information for all current supplemental in-school youth health services in a one-time process. The form is sent home with all students along with other required forms such as the emergency medical card at the beginning of the school year, at which time parents are already accustomed to completing annual forms. Additionally, the consent form is available at the Enrollment Center for parents enrolling a student after the start of the school year, on the Internet, and in each school office for those who want to change their service preferences or update their child's health information.
A supporting document to the consent form, School-Based Supplemental Health Services Information for Parents & Students, was created to give a more thorough introduction of each the service offerings and healthcare providers. This document is given with each consent form distributed. The Supplemental Health Services Information form is not intended to be returned to the school; it is designed to be kept by parents for their future reference.
The history of the school-based flu vaccine offerings by Columbus Public Health began after the 2009 H1N1 influenza outbreak. The flu vaccines are offered at no cost to the student's family. Insurance is billed when applicable and utilization of the Vaccines for Children (VFC) Program covers the vaccine cost for children that are Medicaid-eligible, uninsured, underinsured, or American Indian or Alaska native. Completion of a flu vaccine specific consent form was used prior to the utilization of the School-Based Supplemental Health Services Consent Form. No physical incentives have been used for completion of the consent form in the past specifically related to the flu vaccine.
The 2016-2017 school year was the first year that Columbus Public Health used the new School-Based Supplemental Health Services Consent Form for the school-based flu vaccine clinics in Columbus City Schools. Flu clinics were held at 91 of the district's schools, with 3766 first dose flu vaccines administered. Additionally, 243 second dose flu vaccines were administered to students who qualified based upon age = 9 years and prior vaccine history. In total, 4009 flu vaccines were administered to Columbus City School students compared to 2817 during the prior year. This equals a 42% increase in the students vaccinated through the CPH school-based flu vaccine clinics.
The utilization of the School-Based Supplemental Health Services Consent Form, with district buy-in from the Columbus City Schools Board of Education and district-wide distribution at the beginning of each school year has improved the flu immunization rate through the school-based offering by Columbus Public Health. Overall, this increase in immunization coverage should be reflected in a decreased incidence of flu among Columbus students. This in turn will have a positive impact on school attendance and subsequent academic success.
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Many students of the Columbus City School district face increased rates of health disparities that impact their wellness and ability to be successful students. Some families have access to and utilize adequate health services, while others do not. It can be difficult to obtain parental consent for child involvement in programming, specifically among higher-risk youth who may already be disenfranchised due to poor parental involvement. There are several Columbus health organizations that provide school-linked services to the students of Columbus City Schools, however their services have often been under-utilized by those who would benefit from them. In order to address the non-academic barriers to student success and improve access to quality health services, Columbus Public Health initiated conversations with nursing leadership from Columbus City Schools as well as representatives from Nationwide Children's Hospital and the City of Columbus Department of Education in early 2015 regarding the feasibility of a unified consent form for school-based health services. As the project continued, additional partners were brought in from OhioHealth Wellness on Wheels and PrimaryOne Health (formerly known as Columbus Neighborhood Health Center, Inc.)
The goal of the creation and implementation of a unified consent form is to help improve the health and well-being of students so that they cam be successful in school. The health services offered provide quality healthcare in a friendly and familiar school setting at a time that is convenient to the student and family. The key objective of this goal is to increase the utilization of health services offered to students within Columbus City Schools.
Representatives, including legal council, from the respective health organizations, Columbus City Schools Director of Health, Family and Community Services and the City of Columbus Department of Education Director met many times in early 2015. Once the committee agreed upon a final draft of the consent form, the decision was made to utilize parent focus groups to assess the form for ease, feasibility, and parent concerns regarding the inclusion of reproductive health services. The committee opted for four focus groups to be held in each of the four quadrants of the city in order to capture various parent demographics. Columbus Public Health was the lead agency for organizing and hosting the focus groups. A consultant, Tuesday Ryan-Hart (Confluence Unlimited, Inc.), was contracted to facilitate planning and implementation of the focus groups' parent conversations. The one-time expense of this contracted service was $1800.00 and was paid for by Columbus Public Health.
Since the focus group sessions were held in early summer 2015, venues other than schools were identified to engage parents where they were already likely to be involved in the community. All of the locations were directly on or very close to metropolitan bus routes in order to provide a convenient option for parents that may not have personal transportation. Incentives for parent participation were donated from the Center of Science and Industry (a COSI family day-admission pass) and Molina Healthcare (a $10 Kroger gift card). The flyer for parent participant recruitment was distributed widely to the community through:
Columbus Public Health's health information listserv
PrimaryOne Health Center locations
Nationwide Children's Hospital Primary Care locations
Columbus Public Health clinics and Maternal-Child Health home visiting programs
Columbus Health Advisory Council chairpersons
Columbus Neighborhood Pride team leaders
Franklin County WIC offices
Columbus Metropolitan Library branches
Columbus Recreation and Parks Department
Columbus Public Health's Facebook page
Columbus City School's summer school sites
Children's Defense Fund Freedom SchoolsÂ® Program- Community Development for All People at Lincoln Park
Children's Defense Fund Freedom SchoolsÂ® Program- Summit on 16th United Methodist Church (UMC)
University Area/Weinland Park
Additionally, in-person recruitment was held at several of the flyer distribution sites during the two weeks prior to the sessions.
Participants were asked to RSVP by phone for the session that they wanted to attend. Initial information gathered included parent name, phone number for a reminder call, home zip code, and grade(s) and school(s) of attendance for the 2015-2016 school year. Parents were asked to confirm that they were the parent or legal guardian of a Columbus City School student. The target number of participants for each focus group was 15. Greater than 15 RSVPs were accepted to account for no-shows and cancellations.
A limitation of the focus groups was the exclusion of parents who do not speak and read English. The short time frame of the project did not permit the translation of the draft consent form and accompanying service descriptor document into other languages. Although the distribution of the participant recruitment flyer was widespread throughout the community, it could not be shared with every Columbus City School parent due to the timing of the sessions being held during the summer months. All of the sessions were either held in mid-late afternoon or early evening weekday hours. These times would have been restrictive for parents that wished to participate who work a second-shift job.
To vet the consent form, four parent focus groups were conducted to gain parental feedback regarding the ease and feasibility of the form, as well as gain insight surrounding the inclusion of school-based reproductive and sexual health services. Overall, the majority of the focus groups participants were in favor of the unified consent form for school-based health services to be offered by local health providers. The majority of the participants identified the form as user-friendly, self-explanatory, and easy to read and understand. The most common concern related to the ease of the form was the amount of words on the form. When asked how likely they would be to complete this consent form for their own children, 76.9% responded affirmatively. Suggestions for increasing the likelihood of form completion were related to form availability, the use of incentives, as well as clarification of fiscal responsibility, privacy and confidentiality concerns. These statements on the draft consent form and health services information sheet were amended after consideration of participant feedback from the focus groups. Most participants were very supportive of the consent form and school-based health services as a means to access convenient care for their child(ren). This included the inclusion of reproductive and sexual health services.
Throughout the 2015-2016 school year, and subsequent years, the committee members from the various healthcare organizations, Columbus City Schools and the City of Columbus Department of Education continued to meet and share feedback, challenges and successes of the unified consent form project. Additionally, Columbus Public Health held internal meetings with staff from the respective CPH programs included on the consent form. To date, this has included the following programs: Alcohol and Drug Abuse Prevention; Dental Sealants; Immunizations, including Project L.O.V.E. and the Strategic Nursing Team; Maternal Child Health; and Youth Sexual Wellness. Feedback from the programs was elicited regarding the form itself as well as the processes of school-based health services in Columbus City Schools. Feedback from internal partners at the involved health organizations has been used to make improvements to the consent form since its' inception.
The past and present committee members from CPH and the partner organizations are: Columbus Public Health: Nancie Bechtel, MPH, BSN, RN, Chief Nursing Officer/Assistant Health Commissioner
Jane Dickson, MS, RN, Director, Strategic Nursing Team
Sherry Mayes, MSN, RN, Nursing Education & Emergency Response Program Manager
Shannon Yang, BSN, RN, Public Health Administrator, Family Health Division
Jennifer Young, MSN, RN, Licensed School Nurse, School Health Liaison
Columbus City Schools: Kate King, MS, BSN, RN, LSN, Director, Health, Family and Community Services
City of Columbus: Rhonda Johnson, MA, BS, Director, Department of Education
Nationwide Children's Hospital: Jessie Cannon, Director, Community Wellness Initiatives
Mary Kay Irwin, EdD, School Health Services Manager
OhioHealth Wellness on Wheels: Sonia Booker, MSN, RN, Manager, Community Outreach
Orelle Jackson, System Director, Community Health and Wellness PrimaryOne Health: Buhari Mohammed, MD, MBA, CHCEF, Senior Director of Quality Improvement and Clinical
Beth Whitted, MBA, DrPH, Director of Regional Operations
The goal of the creation and implementation of a unified consent form is to help improve the health and well-being of students so that they can be successful in school. The health services offered provide quality healthcare in a friendly and familiar school setting at a time that is convenient to the student and family. The key objective of this goal is to increase the utilization of health services offered to students within Columbus City Schools.
During the 2016-2017 school year, Columbus Public Health nurses administered 4009 flu vaccines to Columbus City School students compared to 2817 during the previous year, prior to the implementation of the School-Based Supplemental Health Services Consent Form. This data was collected by nurses of the CPH Strategic Nursing Team at the completion of each school clinic and compiled in a Microsoft Excel spreadsheet.
Additionally, in February 2017 the CPH Project L.O.V.E. program reported a 15% increase in utilization of their immunization services at Columbus Global Academy. This school program location serves students that are English language learners, many of whom are new immigrants to the United States who are unimmunized or under-immunized. The service increase at Columbus Global Academy has actually surpassed what CPH is able to provide, so Project L.O.V.E. staff prioritize students to be vaccinated through the school-based partnership based upon the student's current status with/without a primary care provider.
In addition to the improved utilization of school-based immunization services, several other CPH programs have seen an increase in program participation at some schools within the Columbus City district with the roll-out of the School-Based Supplemental Health Services Consent Form. The Dental Sealant program, which serves children in grades 2 and 6, reported an increase in returned consent forms for eight schools as of February 2017.
The CPH Youth Sexual Wellness Program was a new offering within Columbus City Schools in the 2016-2017 school year with a mid-year start in November of 2016. Since this was a new service, there is no comparison data. This program is able to offer school-based sexually transmitted infection (STI) testing, education and referral for treatment, if applicable, for students in six Columbus City high schools. Adolescents are at high risk for STIs and this important program is working to raise awareness, education and access to care for a typically underserved population. Twenty-three screening appointments were completed with 21 students, which included one positive screening with follow-up treatment at the CPH Teen Health Clinic. Two qualitative outcome evaluation examples are:
Last school year, a school nurse helped set up a screening appointment for a student who was nervous to get screened. The student engaged in high risk behaviors and ended up with a positive STI result. The student, however, was open and receptive to our hour-long risk reduction conversation and follow-up conversation; they were able to identify meaningful ways to protect themselves from future STIs/HIV. The student was linked with the Teen Health Clinic for same-day STI treatment.
A young woman found out about Teen Health Clinic through her Columbus City high school nurse. The student decided to come to the Teen Health Clinic with her mom to have a LARC placed. After her appointment, the student told staff that this was my best doctor's experience everâ€ and that even when I thought I would be uncomfortable, the nurse made me laugh so that I didn't feel uncomfortableâ€”I love it here!â€ The student's mom also had a positive experience; while at the Teen Health Clinic, the mom was able to meet with a social worker who assisted her in enrolling in a healthcare plan.
The School-Based Supplemental Health Services Consent Form is sustainable and valued as an important factor in increasing access to school-based health services for Columbus City school students. After the initial year of full-scale use of the unified consent form by all of the included health partners, the committee agreed to continue the form, with some edits, for the 2017-2018 school year. The hope of the group is that parents of Columbus City students will have increasing familiarity and ease of use with the consent form with each additional school year so that more students are able to access care through the school-based offerings.
Prior to the 2017-2018 school year, the Columbus City Schools Board of Education, for the second consecutive year, endorsed the use of the unified consent form for district-wide use and distribution. This acknowledgement of the utilization of school-based health services as an important factor in addressing the non-academic barriers to student success is notable to the promotion of the consent form across the school district.
Partner collaboration from the involved health organizations included on the consent form is also another important factor in the success of the consent form. The health organizations included in the consent form are committed to supporting the health of Columbus youth through school-based health offerings. One important factor throughout the process was the adherence to the common goal from all partners: inclusion on the consent form should make it easier for families to access school-based health services for their child(ren).
It will be important to continue the multi-agency, as well as internal agency, collaboration to gauge the impact of the consent form on service offerings and utilization. This may include the deletion and/or addition of health services from the consent form from year to year to meet program and student needs.
Future expenses toward this project are mostly the personnel contributions of time and work related to further collaboration and execution of the unified consent form. Additionally, Columbus City Schools Health Services has covered the copying expenses for the consent form and accompanying Supplemental Health Services Information form for distribution to the districts' >50,000 students.
In early 2018, Columbus Public Health will hold an internal check-in with all of the programs included on the consent form to gather feedback, review participation data and discuss positives as well as areas of improvement with the consent form. Soon after this, a multi-agency meeting with the committee members from the various partners included on the current form will be held to discuss planning for the School-Based Supplemental Health Services Consent Form 2018-2019.