For several decades, recognition of the link between health and education has steadily increased, with greater understanding that a child must be healthy to learn and a child must learn to be healthy. There is also greater recognition that school health service programs are in a unique position to improve child health status, resilience and well-being, provide care essential to the student's school attendance, and identify and refer students with certain health risks and conditions. These activities ultimately support the student's ability to learn and contribute to both the school and community state of health.
During the past twenty years, school health service programs (school-nurse-managed model) in the Commonwealth's 351 cities and towns, serving 968,661 public school students and 127,168 private schools students (FY07 data), have faced many challenges, resulting in the demand for more onsite services. These challenges stem from such factors as changing family structure and support systems, social morbidities, changing priorities for public funds, classroom inclusion of large numbers of children with special health care needs, and many students who lack comprehensive health insurance coverage and/or primary care providers. As the health care delivery system undergoes a dramatic restructuring and hospital stays are reduced, management of many medical conditions, health related problems, disease prevention and health promotion have shifted to the school setting, where children spend their "working days." Yet, until recently, school health services in Massachusetts remained a largely unrecognized component of the health care delivery system serving children and youth.
Essential School Health
The Essential School Health Service (ESHS) Programs originated in 1993 and expanded in 1999-2000. The ESHS Program requirements have aimed to support high quality school health services in as many school districts and schools as possible throughout the Commonwealth. The original model included the following enhancement components: (a) strengthening the administrative infrastructure of the school health service program (nursing leadership, staffing requirements, health assessments, policies, emergency care, etc.), (b) implementing tobacco control and cessation programs, as well as supporting efforts to prevent substance abuse, (c) linking the school health service program with local health agencies, health care providers, community-based activities, and public health insurance programs,  and (d) developing management information systems. In 1997, a consultation model was added to the basic program: experienced school districts agreed to provide consultation to certain other "recipient" districts. In 1999-2000 grantees were also required to provide specific health services to community private schools aimed at strengthening the school health services available to private school students.
As the programs developed and expanded, the MDPH modified the model in response to (a) an ongoing review of the program, (b) changing health care needs with increasing transfer of disease management to the schools, e.g., diabetes and asthma, (c) increase in the mental and behavioral health needs (including substance abuse) and the increased prescribing of medication to young people to treat behavioral health needs, (d) emerging public health issues such as obesity and emergency preparedness, and (e) increasing opportunities for coordination between school health programs and the formal health care delivery system serving children.
Through its 14 year history of providing Essential School Health Service grants to school districts, including provider feedback, the MDPH has identified at least two critical elements for achieving the highest return on its school health service investment:
- Administrative support (district-wide): Administrators include the superintendent (director of the board of health, as appropriate) and all other administrators who work within the school district, including but not limited to principals, special education directors, pupil personnel directors, business managers, technology directors, and athletic directors. Support means they are facilitating the school nurse leader and school nurses to implement a high quality school health services program, its data systems and all other aspects of grant requirements.
The January 2008 Request for Response built on the Department's past experience and is intended to continue to expand the number of Massachusetts school districts who benefit from Essential School Health Service Programs. It is a refinement of the original ESHS model and differs from the 1999-2000 procurement in several ways:
- Inclusion of a requirement for each ESHS program to provide consultation to a minimum of two school districts (mentored schools), as well as networking for school nurses in other schools within their own community. Please note: the MDPH will assign the mentored school districts to the school districts awarded the ESHS grant after grant awardees are announced. To the degree possible, they will be in close geographic proximity.
- Increased scoring during the competitive review process if the ESHS school district (or Board of Health, if school nursing services are provided by this agency) assumes graduated funding for the school nurse leader role. As the school district gradually assumes responsibility for the SNL position, ESHS funds may be freed for use in other aspects of the school district's school health program to meet the grant requirements. These include adding other staff, e.g., support staff, as defined by the SNL, programming to meet the needs of the student population, e.g., mental/behavioral health, etc. See application questions.
- A requirement for the provision by the private school of a minimum of 5 hours per week of nursing services (RN) within the first 6 months of the grant. The private school will be required to increase this to 10 hours per week the second year and a minimum of 15 hours per week the third year and every year thereafter to participate in the program. Nursing hours provided by volunteer parent nurses (RN) can count towards this minimum requirement. Preferably the nursing services will be spread over as many days per week as possible.
- A strengthening of the requirements for evaluation and performance improvement (continuous quality improvement).
The general goal of the ESHS grants is to create and/or expand the Essential School Health Service structure and standards throughout the Commonwealth, under the oversight of the MDPH School Health Unit. The programs are designed to begin and/or continue to establish the infrastructure to provide all school-age children access to a school health service program that is:
- based on a student needs assessment (See Chapter 2 of the revised Massachusetts Comprehensive School Health Manual, 2007.),
- based on accepted nursing standards and evidence based practice as outlined in the second edition of the revised Massachusetts Comprehensive School Health Manual (2007),
- community-based and culturally and linguistically relevant, addressing racial and ethnic disparities as appropriate, (Community based is defined as including all children attending public and private schools within the geographic area generally defined as a city/town in Massachusetts.),
- advised by a School Health Advisory Council, including parents, students, board of health representative, providers and others, (Please note: I f the school has a separate Wellness Committee, its activities should be incorporated into or coordinated with the ongoing School Health Advisory Council. Please see Chapter 2, revised Massachusetts Comprehensive School Health Manual (2007), for further guidance.)
- integrated within and supportive of the goals of the educational system, i.e., student achievement,
- managed by a qualified school nurse leader,
- implemented by sufficient numbers of Massachusetts Department of Education (MDOE) licensed school nurses (registered nurses) during the entire school day, 
- designed to optimize available public and private funds, e.g., Municipal Medicaid, grants, third party insurance reimbursement, business partnerships, Foundation Budget, Community Benefits Program, federal Title grant funding, etc.,
- linked with community primary care, mental health, behavioral health and dental health providers, local youth and family serving agencies, and state-supported public insurance outreach programs,
- designed to offer a range of prevention, assessment, referral and/or treatment services, including, healthy weight, substance abuse, tobacco use prevention/cessation, mental health and oral health,
- linked to other aspects of the coordinated school health program ,
- responsible for providing informational resources for families on a range of issues, including Massachusetts Health Care Reform, communicable diseases, emergency planning, etc., and
- evaluated periodically to determine the effectiveness and efficiency of the program.
School districts applying for the ESHS program were expected to identify private schools within their community and demonstrate how they plan to begin or continue to provide basic ESHS services as outlined in the procurement. School districts had to identify other types of schools within the community, e.g., educational collaboratives, charter schools and vocational technical schools, and provide opportunities for ongoing networking and communication.
All school districts that received funding from the MDPH are expected to provide consultation to a minimum of two non-funded school districts. The assignment of non-funded school districts is made by the School Health Unit.
Regional Advisor School Districts:
Upon receipt of the award for the current ESHS program, school districts previously funded for the ESHS grants and meeting specific criteria, were eligible to apply for additional funding to be designated as regional advisor districts to provide consultation to ESHS grants within a generally defined region.
The general goal of the RA-ESHS grants was to maximize the existing school nursing expertise, leadership and infrastructure to provide additional consultation to ESHS programs (including their mentored school districts and community public schools as appropriate) within a general region. Please note: The RA-ESHS Programs are expected to meet the requirements of the basic ESHS program, as well as provide ongoing consultation assistance to the ESHS programs (including their mentored school districts and community public schools as appropriate).
 School nurses are uniquely connected to families and providers; therefore they also offer a critical link in implementing the Commonwealth's efforts at health care reform.
 In some districts the nurse leader is titled school nurse manager or director. The role entails managing the entire school health service program, including the ESHS grant.
 The SNL should not be used as a substitute nurse.
 Based on the needs of the students in building and consistent with the recommendations of the 1998 Report to the Legislature: Options for Developing School Health Services in Massachusetts: 1.0 fulltime equivalent (FTE) licensed nurse for buildings with 250-500 students; 0.1 FTE for each additional 50 students above 500; and 0.1 FTE for each 25 students for buildings with fewer than 250 students.
 Coordinated school health programs, as defined by the United States Centers for Disease Control and Prevention, (and expanded in Massachusetts) include the following components: health education, health services, social and physical environment, physical education, guidance and support services, food service, school and work-site health promotion, integrated school consumer science and community health promotion.