Abstract
Students entering North Carolina public schools must have documentation of a health assessment and immunizations by the 30th day of class, or they are excluded from attending school until they submit documentation. A community collaborative was essential in decreasing the number of students excluded from school for noncompliant documentation in the Winston-Salem Forsyth County school district.
In North Carolina, every child entering the public school system is required to have proof of a health assessment (HA) and proof of vaccination [1]. The HA ensures that the school is aware of medical and developmental concerns that can impact a child's well-being and their ability to learn and thrive in a school setting. Documentation of the HA must be on the state-approved form, and it must be received within 30 days of school entry, otherwise the student is not allowed to return to school until the form is remitted [1]. Until school year 2016-2017, the need for a completed HA form only applied to students entering kindergarten; however, in that year, the regulation was expanded to include all students that are new to the North Carolina public school system regardless of grade level [1].
Vaccine requirements, including mechanisms of enforcement, are determined by state laws; no federal United States laws mandate vaccination [2]. Thus, state and local requirements for school entry are important tools for maintaining high rates of vaccination coverage, which leads to lower rates of vaccine preventable diseases [3, 4]. In North Carolina, vaccination records are checked “when a child is enrolled in a child care facility or school. Children are not allowed to attend school (whether public, private or religious)…unless they have received all immunizations appropriate for their age” [5]. K–12 students are required to provide documentation of vaccination in kindergarten and 7th grade, and upon initial enrollment at any grade [6, 7]. North Carolina state law requires students who are not vaccinated to be excluded from school until the student meets the vaccination requirements, except in the case of a medical or religious exemption [8-10], and every year students are excluded from school due to noncompliance with vaccination and HA regulations.
Given that school absenteeism is linked with poor student performance, even in the early grades, minimizing the number of days a student is absent from school is paramount [11, 12]. In school year (SY) 2013-2014 our local school district, Winston-Salem/Forsyth County Schools (WS/FCS), had a total of 432 children not in compliance with vaccination and HA regulations at 30 days following school entry; 333 children were kept out of school due to noncompliance with obtaining Kindergarten Health Assessments (KHA), and 99 students were kept out of school due to noncompliance with middle school vaccine requirements (see Figure 1).
Number of Children Not in Compliance with Required Documentation on Day 30 of School by SY and Deficiency Type
The objective of this article is to outline the barriers to compliance with these requirements and review how our community collaborative has addressed these barriers and decreased student exclusion from school resulting from noncompliance with documentation of health forms.
Setting
For SY 2016-2017, WS/FCS had 54,528 enrolled students in a total of 81 schools: 43 elementary schools, 14 middle schools, 15 high schools, and 9 special schools. Of those, there were 4,162 kindergarteners and 1,725 students in grades 1–12 that were new to the district. General demographics for the students are 40.2% white, 28.5% African American, 24.5% Hispanic, and 7.8% other. WS/FCS serves children from urban and rural communities. In 2015 Forsyth county data from the United States Census Bureau estimated that, over the prior 12 months, 30% of children were living in homes with an income below the poverty level [13]. In our community, the Forsyth County Department of Public Health (FCDPH) employs most of the school nurses that serve WS/FCS. Data on student compliance with HA/immunizations are maintained by FCDPH (in conjunction with our school district).
Our Collaborative
For SY 2014-2015, WS/FCS approached the School Health Alliance for Forsyth County (SHA) for assistance in decreasing the number of students excluded due to noncompliance with HA and immunization documentation requirements. SHA manages the school-based health centers for our school district and facilitates our School Health Advisory Council (SHAC). For SY 2014-2015, partners included the SHA, WS/FCS, FCDPH, and the Downtown Health Plaza (DHP), a local pediatric office. In SY 2015-2016, Northwest Community Care Network (NCCN) joined the initiative. Of note, all partners in this collaborative have member representation on our local SHAC; therefore, members have a history of partnering to address health and safety issues for children and youth in our community.
Challenges
Since its inception, our community collaborative has identified several major barriers to students having the required HA and vaccination documentation. First, there is a lack of community awareness and understanding of the required health-related documentation that is needed for students to attend school. Parents, schools, and medical providers are often unaware of the implications for students if documentation is not obtained prior to the state mandated deadline. Second, effective management of students at risk for being kept out of school was challenged by the variations in school protocols for processing HA forms. For instance, the school staff position (eg, data manager, registrar, guidance clerk, etc) that is responsible for collecting forms and tracking compliance/noncompliance with health form documentation was not consistent between schools. Third, the data collection and management system to keep a record of students who were in danger of exclusion was not standardized between schools/school nurses. Furthermore, because noncompliance for students within each school in the district is tracked collaboratively with FCDPH, systems must be in place to facilitate collecting the forms and getting the information to the school nurses and school system staff that are responsible for tracking in a manner that respects both the Federal Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPPA) laws. Additionally, protocols for notification of parents whose children were not in compliance was not standardized between schools/school nurses. Fourth, data must be collected concurrently when schools are busy finalizing enrollment and nurses are consumed by compiling medical care plans. Fifth, many families face multiple barriers to come into compliance (eg, poverty, insurance status, health/mental health problems of the caregiver, transportation, inability to take off from work, inability to obtain a timely medical appointment, language barriers). Sixth, the number of students that needed documentation was dramatically increased for SY 2016-2017, the first year of implementation of the HA requirement for students above kindergarten. Many schools had not previously been required to collect these forms and had not established systems to handle the required forms. Seventh, the HA form changed for SY 2016-2017 further complicating the issue of form completion. When the requirements were expanded to include all new students entering the school system, the KHA form was replaced by a general HA form. This resulted in both types of forms being submitted by students.
Interventions
Over the 3 years of our collaboration (school years beginning 2014, 2015, and 2016), there has been an intentional focus on the identified barriers as interventions have been developed and executed. Each year, interventions from prior years that were successful have been continued.
SY 2014-2015
In the first year of the collaboration, SY 2014-2015, the SHA provided summer medical mobile unit clinics that were open to any student enrolled in the district. These were located at schools with the highest rates of children excluded due to noncompliance for the previous school year. The SHA also opened the Mineral Springs Comprehensive School-Based Health Center to all students in the district in order to provide ease of access to a medical provider. These services were available throughout the summer until 2 weeks following the 30th day of school and then upon request by school personnel across the district. Clinics were advertised through schools (robotic phone calls, flyers, website banner), distribution of clinic flyers with dates to local businesses and service providers (YMCA, mental health agencies, etc) near the schools served, and other local media outlets. The SHA services provided an alternative option for care where access to care or other barriers may have otherwise prevented obtaining a timely appointment. The SHA shared information on services provided to students with each student's primary care physician on record in an effort to coordinate care and avoid duplication of services.
SY 2014-2015 Results. Through these efforts the number of children excluded from school decreased from 432 to 389, with the majority (289) of those being kindergarteners (see Figure 1).
SY 2015-2016
The second year of the collaboration brought new challenges to light. While the mobile clinics were helpful in providing access to care, it was noted that simply increasing access to care was not the final solution. Many completed HA forms—not only those completed by the mobile clinic—had not been returned to the school as they were misplaced by families after receiving the completed forms from their medical provider. To address this problem, WS/FCS established a centralized fax line for receiving health transmittal forms from area medical providers and distributed these forms to their respective schools. Further, to improve caregiver awareness of the requirements, NCCN conducted 2 phone calls to all caregivers of Medicaid children in Forsyth County based on eligible age range to inform them of the requirements; one preemptive phone call was made in April and a second was made in August. NCCN also provided a letter to local medical providers reminding them of current requirements, along with a copy of the current assessment form. This letter made providers aware that students could remain out of school for extended periods of time without the completion of the HA and immunization form. The letter also gave guidance to providers and their practices to ask that they prioritize these patients when scheduling appointments. In addition, FCDPH increased nurse management of students that were not in compliance, administering needed vaccinations at the health department, making phone calls, sending messages home, and making home visits in some instances. SHA and FCDPH were featured separately on local TV stations to highlight the need for completed HAs and immunizations and to offer opportunities for completing these requirements.
SY 2015-2016 Results. In SY 2015-2016, collaborative efforts helped to decrease the number of children kept out of school to 146 students, a 66% decline from SY 2013-2014. Kindergarteners accounted for 129 of those students (85 were missing HAs) and the other 17 were 7th graders without vaccine documentation (see Figure 1).
SY 2016-2017
School year 2016-2017 brought new challenges with the implementation of the requirement that all students newly entering North Carolina schools must submit a completed HA. These new requirements dramatically increased the number of students that needed documentation for SY 2016-2017. In order to address these new challenges, in April 2016 FCDPH presented the new HA form and the expanded requirement to local physicians at a continuing medical education training to increase awareness. WS/FCS notified all students at the time of enrollment in school about the need for the HA form and documentation of vaccination. Of note and unique to our community is that outside of this initiative multiple community partners established a system that ensured that all refugee children had HA and immunization documentation. SHA and NCCN were present at a kindergarten enrollment educational event to inform parents of the need for forms and to give them contact information for their pediatric office or the SHA summer clinics if needed.
Since we were anticipating an increased number of students not in compliance, a ten-day estimate of the number of children at risk for exclusion was conducted for the first time in SY 2016-2017. At that time school nurses estimated 2,065 students were at risk for school exclusion. The collaborative met urgently to assess barriers and develop solutions to both lower the number of students kept out of school and to decrease the length of the absence for those students that were excluded from school. School nurses developed a postcard sized checklist that they sent home with students to take to their primary care provider, which showed what they needed to stay in school. The media teams at the major hospital systems created a joint press release that was published in our local newspaper in order to increase awareness and disseminate contact information. WS/FCS reminded teachers about the new requirements and sent out a system wide phone message reminding parents of the requirements. The collaborative drafted an informative, concise Situation, Background, Assessment, and Recommendation (SBAR) memo to send to all major local pediatric healthcare providers, including major healthcare systems. Through these steps, the medical community in Forsyth County rapidly created pathways to prioritize scheduling of HA visits and open additional clinics, including night and weekend clinics, and each of the major health systems provided a single centralized triage number that FCDPH distributed to nursing staff in order to improve ease of obtaining appointments.
The collaborative continued to meet and track students after the 30th day of the school year to ensure that the children that had been excluded were able to return to school as quickly as possible. Open communication continued with area health care providers during this time, and additional clinic visits at the Downtown Health Plaza as well as the SHA school-based clinics were available as needed to help accommodate these students.
SY 2016-2017 Results. With the new law in effect for the 2016-2017 school year, in total 5,887 students were required to submit HA documentation (4,162 kindergarteners and 1,725 students in grades 1–12 who were new to the district). The total number of students excluded from school due to noncompliance with the state requirements increased to 244 from the previous year's low of 146. Sixty-three of those were secondary to HA forms in children entering grades 1–12 which were not measured in prior years as it was not a requirement, which is a rate of 96.3% compliance. Ninety students did not turn in a KHA on time which is a 97.8% compliance rate. The other 91 students were missing vaccination documentation only. Unfortunately, vaccine rates were not separated between kindergarteners and other grades for SY 2016-2017 so that specific data is not known, and therefore, it is impossible to directly compare to numbers from previous years. It is notable that the number of children non-compliant with KHAs remained relatively stable between SY 2015-2016 and 2016-2017, from 85 to 90, suggesting the continued success of prior and continuing interventions.
One week after the 2016-2017 deadline, 160 children remained noncompliant with documentation requirements. Through continued intensive targeting of those students and opening of additional clinic slots, only 3 remained excluded 3 weeks after the deadline, and all had been provided appropriate resources but failed to follow through. Our results for SY 2016-2017 of 97.8% compliance rate with KHAs and 96.3% compliance rate with HA in grades 1–12 on the 30th day of school were above average as compared to statewide data in the same year, which was 94.5% and 73% respectively.
Moving Forward
A concerted, community effort and collaboration with multiple agencies participating collectively helped to substantially reduce the number of exclusions from school for students within our school district related to noncompliance with HAs and immunizations. We have already implemented changes for this year whereby we developed a standardized system of form intake, data collection, and management in order to efficiently and accurately identify children with gaps in compliance early enough to provide targeted intervention before the deadline; created an expanded community wide marketing campaign; and established a transportation fund. We plan to continue this collaboration's focus on addressing barriers through a multi-disciplinary approach with the ultimate goal of having no child excluded from school due to lack of proper health documentation.
Acknowledgments
Potential conflicts of interest. All authors have no relevant potential conflicts of interest.
- ©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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