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5.0 Program Procedures and Linkages with the Community
"The program has provided information about community
agencies
that can help on any problem;
it helped in providing information about
necessary exams and preventive care.."
—Head Start Parent
5.1 Overview
In order to carry out the requirements of the Program Performance Standards, each Head Start program must develop and implement a plan to meet component objectives. Aspects of these procedures are often unique to specific programs, because each program must operate within the restrictions or framework set by their internal organization (e.g., if the grantee is a school system versus a Community Action Agency), the physical size of the program (e.g., the number of enrolled children, the geographic size of the designated service area), and the availability of community resources (e.g., the number of providers, provider acceptance of Medicaid).
Program procedures ensure that enrolled children receive the required health screenings and examinations and that all parents become actively involved in the health care of their children. Procedures also include activities designed to address preventive health issues with children and families.(6) Finally, the health section of the Program Performance Standards (§1304.3) requires that programs implement procedures, including the establishment of a Health Services Advisory Committee (HSAC), which enable staff to be responsive to community health needs that affect the children that they serve. Programs are expected to use available community resources to benefit Head Start children and families by establishing working relationships with appropriate organizations or institutions in the communities they serve. The establishment and expansion of community linkages was one of the major policy recommendations of the Advisory Committee on Head Start Quality and Expansion (1993).
The Program Performance Standards require that programs identify and address the health problems of their local service areas (§1304.3-3; §1304.3-9). Certain health screens for children may be required based on these periodic assessments of community health conditions (e.g., increases in the prevalence of lead poisoning or intestinal parasites). Additionally, as part of Head Start's efforts to help families obtain the health services indicated by screening efforts, programs are required to explore and use all available community resources to the maximum extent possible (Program Performance Standards, §1304.3-4) (see Chapter 2: Historical Context of the Health Component). Programs also are required to inform parents about available health resources and assist parents in gaining access to care.
The effective transfer of health care information from the Health Coordinator or a member of the Health Component staff to the family member responsible for connecting the child with the health care system is an essential aspect of program procedures. Health Coordinators serve as brokers for Head Start parents with community-based providers. By assisting with identifying providers, furnishing information and assistance, and securing necessary funding, Head Start staff provide support for parents in negotiating the health care system themselves. This means enabling parents to make and keep appointments with appropriate service providers in the local community and to obtain follow-up treatment for conditions identified through screenings and examinations. Head Start's objective is that parents be in a position to assume sole responsibility for these tasks upon completing the program.
It is critical that each Health Coordinator, each member of the health staff, and the HSAC be aware of both the financial and the non-financial barriers to health care facing the families they serve (see Chapter 2: Historical Context of the Health Component). The health staff must navigate the local health care system and facilitate access to care for these families. The HSAC can ease the brokering process by initiating communication with individual providers, hospitals, clinics, and other community resources to provide parents with appropriate bridges to health care in their communities. The HSAC is intended to lend organizational weight to the Health Coordinator in breaking down barriers to access. However, the success of the Head Start system in facilitating access to health care is dependent on the ability of the Head Start staff, the community, and the parents to overcome the challenges they face in obtaining proper health care.
5.2 Findings
The findings in this chapter are based on staff reports about program procedures and community collaborations. Parents' reports of information provided by Head Start are included, as are Head Start staff reports on barriers to care and the activities that their programs use to help families overcome these barriers. Finally, staff perceptions of community health risk factors that may impact on Head Start children are discussed.
5.2.1 Community Resources
Medicaid and the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program. Since many children enrolled in Head Start are eligible for Medicaid and can receive EPSDT services (see Chapter 2: The Historical Context of the Health Component), Head Start staff and parents were questioned about Medicaid eligibility, enrollment, and utilization.
When parents were asked how they paid for health care services when their children became ill, 68.1% reported Medicaid as a source of payment (see Exhibit 5-1). It should be noted that parents could report multiple payment sources and that, over the course of a year, parents could have made use of several, perhaps all, of the payment sources listed.
|
Payment Source for Health Services |
Percent |
|---|---|
|
Medicaid |
68.1 |
|
Private Insurance |
20.9 |
|
Direct Payment (out-of-pocket) |
16.1 |
|
Free Care |
4.2 |
|
Other |
2.9 |
|
N |
1,189 |
| Note: Parents could report multiple payment sources. | |
Of the 729 children for whom the date of Medicaid enrollment was available, almost two thirds (64.0%) were enrolled at or near the time of their birth (during the years 1988-90), and an additional one fifth (21.0%) were enrolled in Medicaid at about the time they enrolled in Head Start (during the years 1993-94). The enrollment of the latter group may have been influenced by the children's enrollment in Head Start. However, since parents were not specifically asked whether their child's enrollment in Medicaid was directly linked to their enrollment in Head Start, there is no direct evidence to support this conclusion. Parents of children not enrolled in Medicaid reported that they either had other insurance coverage (48.2%) or were ineligible for Medicaid at the time of the interview (41.9%). Few parents reported a lack of knowledge about Medicaid, how it works, or how to enroll as reasons for non-enrollment.
Health Coordinators at each program site were questioned about procedures employed by the program related to Medicaid enrollment. Almost nine out of ten (85.7%) reported that their programs had a formal process for identifying Medicaid-eligible children enrolled in their programs. This process generally included screening for eligible children at intake, verifying proof of income, and referring eligible children to the appropriate social services agency for assistance in enrollment.
When asked what procedures were used to enroll eligible children in Medicaid, Health Coordinators generally reported that staff explained the Medicaid program to parents and encouraged them to enroll. Staff may then either make appointments and/or take the parent to the Medicaid agency; or they may simply refer parents to the local Medicaid agency.
Thus, the findings suggest a concerted effort by staff, especially at intake, to identify Medicaid-eligible children, and that staff may go as far as taking parents to the Medicaid agency to assure enrollment.
5.2.2Staff Activities with Community Providers
As noted in Exhibit 5-2, many Health and Mental Health Coordinators and, to a lesser degree, Center Directors, reported having responsibility for selecting and reviewing community providers, developing interagency collaborations, and negotiating payments for services. Most of the Nutrition and Parent Involvement Coordinators also indicated that they had some responsibility for establishing interagency collaborations, but they were not asked about their involvement in more direct service provision. Mental health and nutrition consultants associated with the Health Component had little formal responsibility for establishing relationships between Head Start and community providers.
|
Percent |
|||||
|---|---|---|---|---|---|
|
Responsibilities |
Health |
Mental |
Nutrition |
Parent |
Center |
|
Review Health Providers |
78.6 |
73.0 |
-- |
-- |
27.1 |
|
Select Providers |
78.6 |
73.0 |
-- |
-- |
5.9 |
|
Negotiate Payments |
68.3 |
48.6 |
-- |
-- |
5.1 |
|
Establish Interagency Collaborations |
92.9 |
91.9 |
89.7 |
83.3 |
55.9 |
|
N |
42 |
37 |
39 |
42 |
59 |
Community Linkages. In providing services to Head Start families, programs must develop relationships with a variety of health providers, consultants, health-related agencies, and service-providing institutions. The Health Coordinators responded to the open-ended questions regarding the types of individuals and organizations with whom they had formal or informal arrangements and the types of services or resources which they provided. The responses were summarized through content analysis procedures. The percentages presented reflect the number of Health Coordinators with a response coded under each category. Because the information provided was not always sufficient for coding (e.g., when a respondent only gave the name of an organization without clearly indicating the type of service provided), not all organizations cited could be linked with the specific services or resources.
Public health agencies (50.0%) and private group providers (28.6%) were the most often reported organizational categories, followed by mental health organizations (23.8%) and public interest/service organizations (23.8%). Because of the great diversity across the communities visited, the Health Coordinators reported a broad range of services and resources as being available to their programs. The most commonly reported services provided by these organizations include medical services (40.5%) and screenings (35.7%), vision screenings and eye care (23.8%), immunizations (23.8%), dental services (21.9%), and nutrition and meal planning services (16.7%). In reviewing the reports on collaboration with community providers, it appears that programs are more likely to link with and receive services from organizations or agencies than from individual providers. However, it was not clear from the responses whether specific agencies, institutions, or individual consultants were used for referrals only or maintained more formal and comprehensive links with Head Start. Aside from screening activities, many services were not available from individual providers or consultants, and were provided primarily by agencies or institutions with greater resources.
The Health Coordinators also furnished information on the affiliations of the individuals who provided specific screening and examination services for enrolled children. A broad range of community organizations and individuals provided physical examinations, most often private practitioners (71.4%), community health centers or clinics (64.3%), and State or local health departments (61.9%). Additional tests, such as vision and hearing screenings and dental screenings, were often provided through Head Start programs. The Program Performance Standards do allow for non-trained staff to conduct some screenings, including height and weight, vision, and hearing. However, information on the actual responsibilities of staff in completing these examinations or screenings were not compiled. This information would be particularly useful in clarifying the role of Head Start staff in conducting physical examinations, hematocrit and hemoglobin testing, and dental screenings.
Community Resource Information. The Program Performance Standards require that programs provide parents with information about available health resources and services in their community (§1304.3-6). Many programs provide resource information to families at the time of enrollment in Head Start in the form of booklets or pamphlets. In this study, although the question was open-ended, almost two thirds of the parents recalled receiving such information from program staff at the time of enrollment. It also is noted in Chapter 6: Health Education, that 75% of the parents reported receiving information from Head Start on "helping agencies" in the community.
5.2.3 Child Health Files
Child health files are created during the intake/health screening/examination process and require regular updating and maintenance thereafter. These files typically include medical information noted during screenings and examinations, health history information provided by a parent or caregiver, the status of current treatments, and information on immunizations and Medicaid status. Usually, the files also include information on dental, mental health, and nutrition status. The Health Coordinators were most often reported as having primary responsibility for health record maintenance (37.3%), followed by the Center Director/Head Teacher (23.7%), and the Family Service Worker (20.3%). Only one third of the Mental Health Coordinators (33.3%) reported that they alone had primary responsibility for documenting follow-up mental health evaluations in children's health records. The pattern that emerges here is that the responsibility for the maintenance of both health and mental health records may vary among several different staff members, depending upon the circumstances of the situation.
5.2.4 Health Screening and Examination Procedures
Health and Mental Health Coordinators and Center Directors were asked about the procedures that are used if a teacher suspects that a child has a serious health or mental health problem. Virtually all of the respondents, over 97%, indicated that their programs had standard procedures in place. In general, teachers discuss the situation with the Center Director, who, in turn, contacts the appropriate Health or Mental Health Coordinator, who contacts the parent to further discuss the situation and, if warranted, makes a referral to in-house staff (e.g., a nurse) or to an outside health care provider. The responsible Health or Mental Health Coordinator documents the problem, and provides follow-up as required. In cases of very large programs, some of these tasks are completed by other members of the health staff who are responsible for children and families at specific centers.
Almost all of the Health Coordinators (92.9%) indicated that their programs had a mechanism or process for the early identification and screening of children who appeared to have health problems. The processes described generally included physical examinations at entry into Head Start, on-site screenings and classroom observations, and evaluations or screenings by health consultants.
5.2.5 Treatment Procedures
The services most often provided by programs include informing parents about their children's health service needs and the treatment services that are available. Staff also reported that they identified specific health care providers for parents and helped them coordinate services with providers, as well as followed up with both parents and providers to ensure that the necessary services were actually provided. The picture that emerges is that of the Health Component staff acting as brokers of health services, linking Head Start families with community health care providers.
Health Coordinators also identified the types of treatment available on-site at the Head Start center, and their responses are presented in Exhibit 5-3. What can be inferred from the strong division point in this Exhibit is that most treatment, unless directly linked to classroom activities (communication, behavior, meals, etc.), is not provided at the center.
In general, staff reported that they followed up on treatment by contacting the parents and providers directly, documenting the treatment in the child's health record, and periodically reviewing the record for completeness. Some staff also reported that they used a computer tracking system to monitor treatment progression.
|
Treatment Type |
Percent |
|---|---|
|
Nutritional Counseling |
95.1 |
|
Speech Therapy |
90.2 |
|
Mental Health Counseling |
70.7 |
|
Physical Therapy |
31.7 |
|
Supplemental Fluoride Tablet Program |
29.3 |
|
Immunizations |
26.8 |
|
Other |
22.0 |
|
Dental Treatment |
14.6 |
|
N |
42 |
5.2.6 Barriers to Care
Reports on barriers to health care for families fell into several different categories. Internal barriers are those that existed within programs, while external barriers include both community and personal barriers as discussed in Chapter 2. In this section, all three types of barriers, as reported by Head Start staff, are presented.
Internal Barriers. Internal barriers to care reflect staff perceptions of program-related impediments to the level of services provided to enrolled families. The responses of staff to open-ended questions were categorized using content analysis procedures. Staff from more than 20% of the programs responded that each of four types of internal barriers significantly affected their ability to work with families. These responses suggested that 1) limited communication across program components, 2) limited component budgets, 3) limited staff education and training, and 4) staff shortages were the most common barriers. Because these responses were to open-ended questions, the frequencies for these categories are likely to be lower than if staff were prompted by limited-choice questions.
External Barriers. Of particular interest in this study were staff perceptions of the barriers to care directly faced by the families they serve and how Head Start responds to these barriers. Exhibit 5-4 presents staff reports of community-based barriers that affect parents. Parent Involvement Coordinators' reports of barriers were generally quite high, regardless of the type of barrier. Health Coordinators focused on scheduling and provider-related issues, as did the Mental Health Coordinators. Almost 50% of the latter also cited problems resulting from the lack of specialist providers. This is consistent with the 1994 GAO report, which cited the lack of health professionals willing to accept Medicaid reimbursements to treat Head Start children as a major barrier to care and service provision. Staff reported a number of barriers that impede families in obtaining needed health services for children. These barriers, taken from a list presented during the interviews, are shown in Exhibit 5-5. Across staff positions, the most often reported parent-related problems were lack of time and the failure to understand a child's need for treatment, with almost 60% of the Health and Mental Health Coordinators citing the lack of parental understanding. The Mental Health Coordinators were approximately three times more likely than other staff to report parental resistance as a frequent barrier. The staff differences presented in Exhibit 5-5 clearly reflect the different responsibilities and domains represented by the staff, particularly when focusing on the often misunderstood field of mental health.
|
| [D] |
Parents also were given the opportunity to report on barriers to care through an open-ended question about their experiences with accessing health services while enrolled in Head Start. Unfortunately, parental reports of barriers to care were almost nonexistent, allowing no comparison with the staff reports. This may have been due to the open-ended nature of the question. However, some program staff suggested that parents become so caught up in their day-to-day activities that the barriers they face are not always apparent to them. These staff members predicted a low frequency of parental reports.
 |
| [D] |
Program Responses to Barriers. In order to meet the overall program goals of assuring needed health services for children and increasing parents' ability to overcome barriers, local staff must respond to these barriers. Although they differed in their perceptions of the barriers facing parents, Head Start staff were remarkably consistent in their views of the services that their programs provide to families in an effort to overcome barriers to care. Services that Head Start staff identified as being helpful to families primarily fell into five categories: providing parent education, helping families with provider scheduling, providing Head Start staff education on recognizing and overcoming barriers, providing transportation, and conducting outreach activities with community providers.
5.2.7 Perceived Community Health Risk Factors
The Health, Mental Health, and Parent Involvement Coordinators and the Center Directors were asked their perceptions of the three most critical community risk factors affecting the health or mental health status of Head Start children. As seen in Exhibit 5-6, there was a high degree of variability, based on the staff position of the respondent. For example, while substance abuse was rated as being critical by respondents in each staff position, 56% of the Mental Health Coordinators listed concerns in this area. This was about 15% more than the other staff positions. Child physical and sexual abuse was also a key risk factor cited by more than twice as many Mental Health Coordinators as by any other staff position. However, some of the risk factors addressed by staff in other positions-inadequate housing or clothing, low immunization rates, poor hygiene, and infection with human immunodeficiency virus (HIV) or other sexually transmitted diseases (STDs)-were not mentioned by the Mental Health Coordinators. The lack of parent education and parenting skills were consistently mentioned as risk factors by approximately 20% of the staff in each position. Surprisingly, the lack of immunizations was rated much higher by the Parent Involvement Coordinators than by other staff. This ranking may reflect the roles that these Coordinators assume in assisting parents obtain health services, particularly parents preparing their children to leave Head Start and enter kindergarten. For example, Parent Involvement Coordinators take an active role in working with parents to prepare families for kindergarten, a transition that involves updating immunizations.
|
Percent |
||||
|---|---|---|---|---|
|
Risk Factors |
Health |
Mental |
Parent |
Center |
|
Substance Abuse |
36.0 |
56.0 |
28.0 |
41.0 |
|
Lack of Parenting Skills |
21.4 |
16.7 |
16.7 |
16.9 |
|
Lack of Access to Support Services |
19.0 |
13.5 |
22.0 |
15.5 |
|
Poor Nutrition |
18.9 |
3.0 |
21.7 |
7.0 |
|
Poverty |
16.5 |
25.0 |
9.5 |
2.5 |
|
Lead |
16.5 |
0.0 |
14.5 |
5.0 |
|
Inadequate Housing or Clothing |
0.0 |
7.1 |
11.9 |
|
|
Physical/Sexual Abuse/Neglect |
9.5 |
38.7 |
14.5 |
5.0 |
|
Community Violence |
7.1 |
19.4 |
0.0 |
11.9 |
|
Poor Hygiene |
7.1 |
0.0 |
4.8 |
8.5 |
|
Lack of Immunizations |
7.1 |
0.0 |
44.9 |
5.1 |
|
Adolescent Pregnancy |
2.4 |
11.1 |
4.8 |
3.4 |
|
HIV/AIDS/STDs |
2.4 |
0.0 |
14.3 |
11.9 |
|
N |
42 |
37 |
39 |
59 |
Program Responses to Health Risk Factors. Head Start staff were very consistent in describing how programs address local risk factors. Parenting workshops were listed by 50-70% of the staff as a frequently used method of helping families overcome risk factors, although each of the methods, including interagency collaborations, job counseling and referral, advocacy training for parents, and individual and family counseling, was frequently used by at least 40% of the programs. This is validated by the staff reports that a majority of programs address health risk factors through their parent education activities. Specific parent education topics, such as providing information on immunizations (see Chapter 6: Health Education), address some of the risk factors reported by individual staff.
6. Preventive health issues and procedures are discussed in Chapter 6: Health Education and Chapter 7: Immunizations. (back)
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