A nationwide survey of financing health-related services for special education students

The Division of Labor Among Systems of Therapeutic Care for Children with Disabilities

This article demonstrates that there is a division of labor in therapeutic care for children with disabilities (i.e., physical, occupational, and speech/language therapy) between educational and medical systems, with educational systems providing the bulk of that care. Analyses of the 1994—1995 National Health Interview Survey Disability Follow-back show that the majority of children with disabilities who received therapeutic care (75%) received those therapies only through school, whereas the remaining children received therapies only through health insurance (14%) or through other or multiple systems (11%). The majority of children who received therapies through school received speech/ language therapy, whereas most who received therapies through health insurance received physical therapy. Children served through the schools were younger and were more likely to have communication and learning limitations, compared with those who received therapies through insurance. Policy implications regarding payment for pediatric therapies and coordination of care across multiple service systems are discussed.

Supporting children with disabilities at school: implications for the advocate role in professional practice and education

PURPOSE

School settings are a common practice context for rehabilitation professionals; health advocacy is a common and challenging practice role for professionals in this context. This study explored how pediatric practitioners advocate for children with disabilities at school. Specifically, we examined everyday advocacy in the context of school-based support for children with disabilities.

METHOD

Our theoretical framework and methodological approach were informed by institutional ethnography, which maps and makes visible hidden social coordinators of work processes with a view to improving processes and outcomes. We included families, educators, and health/rehabilitation practitioners from Ontario. Of the 37 consented informants, 27 were interviewed and 15 observed. Documents and texts were collected from the micro-level (e.g. clinician reports) and the macro-level (e.g. policies).

RESULTS

Pediatric practitioners' advocacy work included two main work processes: spotlighting invisible disabilities and orienteering the special education terrain. Practitioners advocated indirectly, by proxy, with common proxies being documents and parents. Unintended consequences of advocacy by proxy included conflict and inefficiency, which were often unknown to the practitioner.

CONCLUSIONS

The findings of this study provide practice-based knowledge about advocacy for children with disabilities, which may be used to inform further development of competency frameworks and continuing education for pediatric practitioners. The findings also show how everyday practices are influenced by policies and social discourses and how rehabilitation professionals may enact change. Implications for Rehabilitation Rehabilitation professionals frequently perform advocacy work. They may find it beneficial to perform advocacy work that is informed by overarching professional and ethical guidelines, and a nuanced understanding of local processes and structures. Competency frameworks and education for pediatric rehabilitation professionals may be improved by: encouraging professionals to consider how their practices, including their written documents, may affect parental burden, (mis)interpretation by document recipients, and potential unintended consequences. Policies and texts, e.g. privacy legislation and the Diagnostic and Statistical Manual (DSM), influence rehabilitation professionals' actions and interactions when supporting children with disabilities at school. An awareness of the influence of policies and texts may enable practitioners to work more effectively within current systems when supporting individuals with disabilities.

County-level variation in the prevalence of medicaid-enrolled children with autism spectrum disorders

This study examined how county-level resources are associated with the identification of children with autism spectrum disorders (ASD) in Medicaid. Medicaid claims from 2004 were combined with county-level data. There were 61,891 children diagnosed with ASD in the Medicaid system in 2004. Counties with lower per-student education expenditures, more students, a greater proportion of students in special education, higher per capita number of pediatricians and pediatric specialists, and a greater proportion of Medicaid enrollees and white residents had higher Medicaid prevalence. Within states, counties differ in how they implement Medicaid policies. The results suggest the substitution of education and Medicaid-reimbursed services. Our findings highlight the need for geographically targeted outreach to minority groups and clinicians to improve recognition of ASD.

Medicaid's role in financing health care for children with behavioral health care needs in the special education system: implications of the Deficit Reduction Act

BACKGROUND

Recent changes to Medicaid policy may have unintended consequences in the education system. This study estimated the potential financial impact of the Deficit Reduction Act (DRA) on school districts by calculating Medicaid-reimbursed behavioral health care expenditures for school-aged children in general and children in special education in particular.

METHODS

Medicaid claims and special education records of youth ages 6 to 18 years in Philadelphia, PA, were merged for calendar year 2002. Behavioral health care volume, type, and expenditures were compared between Medicaid-enrolled children receiving and not receiving special education.

RESULTS

Significant overlap existed among the 126,533 children who were either Medicaid enrolled (114,257) or received special education (27,620). Medicaid-reimbursed behavioral health care was used by 21% of children receiving special education (37% of those Medicaid enrolled) and 15% of other Medicaid-enrolled children. Total expenditures were $197.8 million, 40% of which was spent on the 5728 children in special education and 60% of which was spent on 15,092 other children.

CONCLUSIONS

Medicaid-reimbursed behavioral health services disproportionately support special education students, with expenditures equivalent to 4% of Philadelphia's $2 billion education budget. The results suggest that special education programs depend on Medicaid-reimbursed services, the financing of which the DRA may jeopardize.

Health-care use and expenditures for children in special education with special health-care needs: is dual classification a marker for high use?

OBJECTIVES

Children with special health-care needs are an important group for policy and research planning. Special education engages a group of children with increased utilization of services related to education. While increased service utilization in education or health-care settings is often used to classify children as having special needs, considerable heterogeneity exists within each group. The extent to which being identified in two functionally defined systems--special education and health care--relates to health-care utilization is unknown. We sought to determine health-care and mental health utilization and expenditures for children dually classified as receiving special education and having special health-care needs (SHCN) compared with those who only have SHCN, only are in special education, or don't fall into either category.

METHODS

A nationally representative sample of children aged 5-17 years from the Medical Expenditure Panel Survey was used to compare mean health-care and mental health utilization and expenditures for the four groups.

RESULTS

Dually classified children had significantly higher mean utilization of health-care services than the other three groups (p < 0.05). Mean 12-month total health-care expenditures were highest for dually classified children ($3,891/year) (p < 0.05) and higher for children classified only as having SHCN ($1,426/year) than for children with neither classification ($644/year, p < 0.05).

CONCLUSIONS

Children dually classified as receiving special education and having SHCN represent a subgroup of children with SHCN with high levels of health-care utilization and expenditures. This information can assist policy makers in identifying characteristics that place children at risk for very high expenditures, and in allocating health-care resources.

Decision making for physical therapy service delivery in schools: a nationwide analysis by geographic region

PURPOSE

This study investigated the relationship between geographic practice location and recommendations for the contexts and frequencies of physical therapy service delivery in schools.

METHODS

Participants were 626 school-based physical therapists from all 50 states. Four case descriptions were presented in the survey: a four-year-old girl with motor delays and typical cognitive functioning, a four-year-old girl with motor and cognitive delays, a six-year-old boy with spastic diplegic cerebral palsy, and the same boy at 12 years of age.

RESULTS

Proportionally fewer respondents in the Northeast recommended providing services in exclusively natural settings, as compared with other regions. Respondents in the Northeast recommended mean monthly frequencies of at least one more session for each case (3.7-7.6) than those in the other regions: West (2.5-5.5), South (1.6-4.7), and Midwest (1.6-4.5).

CONCLUSIONS

These findings suggest an association between geographic region of practice among school-based physical therapists and the contexts and frequencies of service delivery.

Disability and risk of school related injury

OBJECTIVE

Approximately six million children with disabilities attend school in the United States. Cognitive and physical limitations may compromise their ability to handle environmental hazards and hence increase their risk for injury. The objective of this study was to describe the epidemiology of school related injury among children enrolled in 17 special education schools in one large, urban school district.

DESIGN

Altogether 6769 schoolchildren with disabilities were followed up from 1994-98. Injury and population data were collected from pupil accident reports and existing school records. Associations were estimated through generalized estimating equations.

RESULTS

A total of 697 injuries were reported for a rate of 4.7/100 students per year. Children with multiple disabilities had a 70% increased odds of injury compared with the developmentally disabled (odds ratio (OR) 1.7, 95% confidence interval (CI) 1.3 to 2.3). The physically disabled (OR 1.4, 95% CI 1.0 to 1.9) had a modest increased odds of injury. Cuts, bruises, and abrasions composed almost three fourths of all injuries; almost half of these injuries were to the face. Falls (34%) and insults by other students (31%) were the most common external causes. More than a fourth of injuries were sports related, and 21% occurred on the playground/athletic field. Injury patterns differed across disabilities.

CONCLUSIONS

Although limited to one school district, the population studied is the largest cohort thus far of schoolchildren with disabilities. With this large study base, potentially high risk groups were identified and circumstances of injury described. This information is imperative for developing and improving school based injury prevention measures.

The relationship between school characteristics and the availability of mental health and related health services in middle and high schools in the United States

Problems related to mental illness are increasingly becoming the focal point of public concern over the safety and performance of schools, yet little is known about the availability and quality of school-based mental health services in the United States. In this article it is estimated that approximately 50% of US middle and high schools have any mental health counseling services available onsite and approximately 11% have mental health counseling, physical examinations, and substance abuse counseling available on-site. There are substantial differences in mental health counseling availability by region, urbanicity, and school size, with rural schools, schools in the Midwest and South regions, and small schools being least likely to offer mental health counseling. Multivariate estimates suggest that disparities between schools in the availability of mental health counseling and related health services may be partly explained by differences in access to Medicaid for financing of health services provided at school.

Variations in state-level definitions: children with special health care needs

Multiple agencies at the federal and state level provide for children with special health care needs (CSHCN), with variation in eligibility criteria. Epidemiological studies show that 3.8%-32% of children could be classified as children with special health care needs, depending on the definition and method of determination used.

OBJECTIVES

To determine the extent of variation between definitions used and funding by Supplemental Security Income (SSI), Title V, and Medicaid for CSHCN.

METHODS

Statistics on children receiving SSI and the amount of funding were obtained from the SSI website. This was compared to information on Title V children from the Maternal and Child Health Bureau (MCHB) website and eligibility definitions published by the Institute of Child Health Policy in Gainesville, Florida. Medicaid definitions were obtained through interviews with state Medicaid agencies and confirmed with state regulations.

RESULTS

The population enrolled in SSI has varied with alterations in eligibility criteria. The number of children enrolled in SSI and the amount of funding per child in each state correlate with the state poverty rate (r=0.56, p<0.0001; r=0.44, p<0.001). Enrollment in Title V does not correlate with state poverty rates (r=0.16, p=0.25). Title V definitions vary widely among states, but there was no correlation between the number of children served or amount of funding per child and the type of definition used (Z=-0.12, p=0.91; Z=-0.59, p=0.55). State Medicaid agencies rarely define CSHCN.

CONCLUSIONS

There is significant variation in definitions used by agencies serving CSHCN. Agencies need to be more explicit with eligibility criteria so the definitions are logical to those making referrals for services.

Variations in state-level definitions: children with special health care needs

Multiple agencies at the federal and state level provide for children with special health care needs (CSHCN), with variation in eligibility criteria. Epidemiological studies show that 3.8%-32% of children could be classified as children with special health care needs, depending on the definition and method of determination used.

OBJECTIVES

To determine the extent of variation between definitions used and funding by Supplemental Security Income (SSI), Title V, and Medicaid for CSHCN.

METHODS

Statistics on children receiving SSI and the amount of funding were obtained from the SSI website. This was compared to information on Title V children from the Maternal and Child Health Bureau (MCHB) website and eligibility definitions published by the Institute of Child Health Policy in Gainesville, Florida. Medicaid definitions were obtained through interviews with state Medicaid agencies and confirmed with state regulations.

RESULTS

The population enrolled in SSI has varied with alterations in eligibility criteria. The number of children enrolled in SSI and the amount of funding per child in each state correlate with the state poverty rate (r=0.56, p<0.0001; r=0.44, p<0.001). Enrollment in Title V does not correlate with state poverty rates (r=0.16, p=0.25). Title V definitions vary widely among states, but there was no correlation between the number of children served or amount of funding per child and the type of definition used (Z=-0.12, p=0.91; Z=-0.59, p=0.55). State Medicaid agencies rarely define CSHCN.

CONCLUSIONS

There is significant variation in definitions used by agencies serving CSHCN. Agencies need to be more explicit with eligibility criteria so the definitions are logical to those making referrals for services.

Measuring outcomes of school nursing services

Considerable information exists about the impact of school health services on student health and academic achievement. Much less information exists about the specific impact of school nursing services. This article reports on a Washington State project that studied documentation of outcomes of school nurse interventions, the scope of the school nurse role, and the infrastructure necessary to report outcomes of school nursing. A literature review about outcomes of school nursing was conducted. Twenty-two leaders in school nurse issues were interviewed. The literature review yielded 15 articles documenting positive outcomes of school nursing. Interview analysis revealed leader ideas about important outcomes of school nurse services and the infrastructure needed to document the impact of school nursing. The existing literature on positive outcomes addresses a limited portion of the school nurse role. Components of infrastructure necessary to document outcomes are delineated. Resources for infrastructure development are discussed.