principles for developing interdisciplinary school-based primary care centers

Principles for Developing Interdisciplinary School-based Primary Care Centers Stephen Barnett, Virginia Niebuhr, Constance Baldwin

ABSTRACT: A 50% increase h a s occurred in ihe number of school-basedprimary care centers (SBPCCs) in ihe Wniied Siaies since 1993-94. Public schools offer a well-established and respected comrnunity-based infrasiruciure within which healih centers may feasi- bly be developed. SBPCCs have documented improved access io care f o r underserved children and some iniiial success in addressing the complex morbidiiies and associaied behavioral risk factors of children and adolescents. This paper presenisjve working principles io help communiiies establish SBPCCs ihai link community healih and social services wiih iheir educational system. The principles encompass communiiy participation, early assessment of community needs, iniegraiion of healih and human services wiih educa- iional services ihrough an inierdisciplinary and interagency team approach, developmeni of a business plan, and program evaluaiion. These principles refeci ihe experiences of 22 Texas communiiies which operaie 76 SBPCCs. They should prove helpful to many other communiiies and siaies ihai propose io develop, jnance. and evaluate school-based. inierdisciplinary healih care and preveniion services. (J Sch Health 1998;68(3):99-105)

n the late 1960s, pediatric innovators in Dallas, Texas and I Cambridge, Massachusetts' established the nation's first school-based primary care centers (SBPCC). The model was soon afterwards adapted for children of migrant farm worker families in Colorado.z The rate of growth of SBPCCs in the United States has been impressive: 150 clinics in the late 1980s grew to over 600 in 1994, and over 900 in 1997.'" This expansion reflects a growing recogni- tion that school settings can be involved in addressing the health and psychosocial problems of children and youth, especially those who otherwise do not have access to services. SBPCCs have been shown to improve access to care.&'

One of the best arguments developing primary care centers in the public schools is that schools offer a preexist- ing infrastructure1 that already has economic and political support and includes elected community representatives who can participate in the creation, administration, and long-term evaluation of SBPCCs.'O Schools are therefore a natural setting for the co-location of integrated community health and social services. Providing care to children in the schools also circumvents logistical barriers to access such as lack of transportation and parents' inability to leave work. Furthermore, healthy lifestyles and use of health maintenance services can be promoted and reinforced through a comprehensive health education curriculum taught in the classroom.

A growing body of evidence confirms that SBPCCs are more effective and likely to survive if they are community- driven and use an interagency and interdisciplinary approach.'' Preliminary reports suggest that comprehensive interventions that are multidisciplinary, integrated, and school-based or school-linked are improving the health and psychosocial outcomes of children and youth today.

Siephen Barneii, MD, Medical Direcior, Primary Care Depi. Health and Human Services 15 Waller Si., RBJ Bldg. 5th floor, Austin, TX 78702; Virginia Niebuhr, PhD. Associaie Professor of Pediairics, Direcior of Behavioral Education: and Constance Baldwin, PhD, Associaie Professor of Pediairics. Direcior of Behavioral Education, Wniversiiy of Texas Medical Branch at Galveston University of Texas Medical Branch ai Galvesion, Primary Care Pavilion, 400 Harborside Drive, Galvesion. TX 77555-1 I 1 9. Funding for ihis work was provided in pari by ihe Roberi Wood Johnson Foundaiion. This article was submiiied July 31, 1997. and revised and accepted for publicaiion December I , 1997.

Communities using an integrated services approach to address child and adolescent health problems have reported reduced substance abuse,l2." school- age p regnan~y , '~ . ' ~ school fa i l~re , '~ and improved school readiness.18.'9

Widespread national and state support exists for using school-based primary care to address the health and social needs of underserved, high-risk populations of children and youth. The concept is being promoted by many groups, including the American Academy of Pediatrics,20 American Public Health Association,21 National PTA,2z Association of State School Boards of Education,23 National School Board A~sociation,~~ and National HealthEducation Consortium.25 The U.S. departments of Education and Health and Human Services collaboratively established an interagency committee and a national coordinating cornmittee.l6 A review summarized 25 nationally published reports which support school-based services and health promotion.27

Despite these early indications of the advantages of SBPCCs, and the numerous supporters of the concept, some concerns about SBPCCs have been expressed. Critics argue that solid evaluations with controlled comparisons have not been conducted, that evaluations were inade- quately planned or methodologically flawed, and most were limited by the lack of time to measure long-term outcomes. Nevertheless, a review of evaluations of school-based programs reveals some evidence of improved access to care and utilization of service^,^.^^ two measures which can be documented relatively easily in the short-term. Published evaluations have shown limited effects, however, on longer term outcomes like health behavior and health status measures. These outcomes take longer to document and are influenced by factors outside of the SBPCC. Clearly, better evaluations with adequate funding are needed to build a convincing case for the efficacy of SBPCCs.

Political and pragmatic concerns have also been raised. Some educators and parents have voiced the fear that SBPCCs may detract from, rather than enhance, the educational mission of schools, and that financing of these intervention efforts may divert dollars allocated for education. Others are concerned about potential duplication or frag- mentation of health services and increased competition for the scarce resources needed to help high-risk, school-aged populations. Problems with the implementation of SBPCCs need to be resolved creatively for this promising model of

Journal of School Health March 1998, Vol. 68, No. 3 99

health care to succeed. This paper presents working principles to help commu-

nities establish SBPCCs that link community health and social services with their educational system. These principles are based on the authors’ experience with development of SBPCCs in the high school and middle school of Galveston, Texas.?” These principles were further refined to reflect the experiences of 22 Texas communities which operate 76 SBPCCs funded by the Texas Department of Health’s Office of School Health.2y The principles were subsequently supported and expanded by a national consensus conference of 50 private or public associations convened by the American Academy of Pediatrics and others in 1994.””’ With the rapid expansion in the number of SBPCCs in America, the principles should prove helpful to many other communities and states that propose to develop, finance, and evaluate school-based, interdisciplinary health care and prevention services.

FIVE WORKING PRINCIPLES

1. Community Participation is Imperative To initiate a successful, integrated model of basic

community services into the public school system, it is essential to involve all community partners: the school district, medical association, health district, community hospital, social services, mental health authority, parent, teacher and student associations, and business community. Depending on which issues the community wants to address, other partners may also be included, such as the juvenile justice/probation system, recreation department, early childhood education community, or local housing authority.

The best community leaders of SBPCC initiatives are usually physicians or school personnel, or both. For example, in Galveston County, Texas, one SBPCC was developed through the driving efforts of two family physicians interested in reducing school-aged pregnancy rates. Others were developed by the school district to address high rates of absenteeism attributable to poor access to health care. Managed care organizations (MCO’s) also may also be involved.”-” Because of common interests in prevention, health maintenance, and reduction of unnecessary services, MCO’s in Minneapolis, Denver, Oregon, and Connecticut are engaging SBPCCs as primary care providers to share capitations or contracting with SBPCCs as co-managers of care.

Partner buy-in to a SBPCC will be enhanced if each partner is clear on what it will contribute and what value it will receive. For example, if a mental health authority repo- sitions a drug counselor into a SBPPC, the authority may aim to demonstrate a reduction in emergency department visits and hospitalizations related to substance abuse. Where the local department of human services has provided Medicaid eligibility workerdcase managers to a SBPCC, it expects to benefit from improved rates of Medicaid certifi- cation for eligible adolescents and improved rates of EPSDT compliance.

To carry out a collaborative venture to launch a SBPCC. the combined political will and resources of each partner are critical to success. A useful process to guide collaborative planning and implementation is community-oriented

primary care (COPC),” the methods of which have been applied to the development of SBPCCs.’” The COPC process facilitates community consensus building by articu- lating the steps by which community partners can collaboratively identify their needs, select effective interventions, and evaluate those interventions.

One commonly used vehicle for broad community participation is the school health advisory council. A number of models and published guidelines exist for development of such councils.’h-16 Guidelines adopted by the American School Health Association help explain to council members the scope and format of comprehensive school health programs.” Advisory councils should include parents and families, who are an essential ingredient for successful school-based programs. SBPCCs need to be creative in finding ways to gain strong parental participation, especially from disadvantaged, high-risk population^.^"^'

Another vehicle to facilitate broad participation in developing SBPCCs is the state-level interagency and inter-association council, which can provide leadership on how to achieve and finance integrated school services. In Texas, such an interagency council has helped to identify and clar- i f y how various agencies can mobilize funding and resources for collaborative SBPCC efforts. The council identified a potential scope of services for each agency or association and offered policy guidance. I t also encouraged participation by regional and local agencies i n their community’s school-based initiatives, and provided the impetus to establish an Office of School Health i n thc Texas Department of Health.

2. A Needs Assessment Should Precede the Development of Program Services

A local school health advisory council, or equivalent group, should document the need for specific health and human services in a community. Relevant data may be available from sources such as school nurses’ records, hospital information systems, city or county health departments, local or state medical and dental associations, or specialized community resources such as the mental health authority, the juvenile justice system, or the police department. Specific types of needs assessment data might include health resource utilization rates, such as frequency of visits to emergency rooms, rates of hospitalization for sexually transmitted diseases or asthma, percentages of eligible Medicaid participants certified, and local incidence or prevalence rates for specific conditions such as teenage pregnancy, lack of timely immunizations, or school drop-out.

Access to data from such secondary sources reduces the time and expense of primary data collection. However, collection of primary data through community-based or school-based surveys of students, families, and/or health providers can provide vital grass-roots information on needs and satisfaction. Previously used needs assessment instruments are available.”, ’’ In some states, health departments have provided guidelines for development of needs assessments, supplied data on county-wide indicators and state comparisons, and supported local assessments of conditions targeted for intervention.” Community needs assessments are useful not only to identify and prioritize problems for intervention, but also to facilitate program evaluation. If well designed, they can provide essential

100 Journal of School Health March 1998, Vol. 68, No. 3

baseline data against which post-intervention data can be compared.

3. interventions Should integrate Health and Human Services with Educational Services, Using an interdisciplinary and interagency Team Approach

Practitioners learned in the 1970s that merely placing a physician in a underserved rural community will not solve the health crisis in rural America. So today, merely placing a nurse practitioner in a school will not successfully address the morbidities of underserved children and youth. The prevention or resolution of these complex morbidities requires complex solutions.” Implementation of multi- faceted interventions requires effective collaboration between separate disciplines and agencies to provide integrated services. For SBPCCs, possible participants include the school nurse or health aide; a health educator andor curriculum specialist from the school district; a physician, nurse practitioner or physician assistant; a social or human services worker or case manager from the community’s social services agency; a mental health professional; an evaluation coordinator; and administrative support staff. In smaller communities, one individual or a single agency may need to fulfill several functions.

Community representatives and participating agencies must, from the outset, understand and support the need for development and maintenance of the interdisciplinary health team. Achieving smooth teamwork often proves difficult, however, because the participating agencies may have little experience with the collaborative process of creating and managing an integrated service delivery system. Interagency commitment of time, good will, and a willingness to share resources is also essential. Similarly, individual team members may lack experience functioning on a collaborative health team. Training modules and protocols for health team development are available.” Forming an interdisciplinary health care team is especially challenging when potential community partners have in the past competed for scarce resources and political control.

To bridge among partners, some communities found it helpful to create a 501/C(3) nonprofit association. In both Galveston and Houston, such a neutral organization was created and managed by the joint venture partners. This association provides objective accounting for funding and financial contributions, repositioned staff, and in-kind contributions. Such an umbrella organization can also define an overarching mission and goals and undertake a relatively unbiased evaluation of the project’s progress towards these goals.

4. A Business Plan that Defines Collaborative Financing from Each Participating Agency Should Precede initiation of Services

SBPCCs cannot survive if they a re created as yet another unfunded mandate for schools. Although school systems are increasingly aware that improvement in education cannot be achieved solely through curriculum and instruction, their budgets are already severely strained. School districts have some significant, traditional resources budgeted for health service; however, most financing for school-based primary care must come from other sources. In development of a financial plan for a SBPCC, 1 ) there

should be an expectation that each agency participating in the joint venture must bring along its own funding sources, 2) the needs for start-up and maintenance costs must be estimated in advance,“‘ and 3) a strategic plan for financing and marketing should be developed. Several comprehensive reviews of potential federal funding sources are avail-

Outlined in Figure 1 are potential funding sources from each of four core partners: health services, mental health services, socialhuman services, and education.

Health Services. From the health services, at least four funding sources are potentially available: state funding through legislative initiatives and/or Maternal and Child Health Service Block Grants; Medicaid (Title 19); Family Planning (Title 10 of the Public Health Service Act and in some states, Title 20 of the Social Security Act); and fees through third party reimbursements and/or direct payments.

Currently, the biggest contributions to SBPCC services come through legislative initiatives using state revenues. Since 1992, these contributions have tripled from $9 million to $27 million. The second largest source of contributions are Maternal and Child Health block grants to state health departments, which have increased from $8 million to $13 million.’ Medicaid reimbursement is available for Early Periodic Screening, Diagnosis, and Treatment (EPSDT), direct care, and School Health and Related Services (SHARS) for special needs children.‘b Medicaid reimbursements for service costs are also available to those SBPCCs working through Federally Qualified Health Centers (FQHCs) or community health centers.

SBPCC funding has also come from “disproportionate share” Medicaid reimbursements to community and university teaching hospitals that care for large indigent populations. These Medicaid sources may become more scarce as the Medicaid Program moves to a managed care model. SBPCCs, as “essential community providers,” can be integrated into Medicaid managed care plans, either as a “point of service” provider or through a capitated care plan.12 ’4

Although Medicaid negotiations and billings can be complicated and time consuming, the reimbursements are slowly beginning to pay a significant, though small propor- tion of the costs for SBPC.

For SBPCCs that provide reproductive services and reproductive health education, financing may be available through Title 10, and in some states Title 20, of the Social Security Act. Other sources which should be considered include billings for reimbursements from third party payers (ie, health insurance companies) and direct payments by users and their families.

Mental Health Services. Although more than 20% of patient encounters in a SBPCC relate to psychosocial issues,oy47 the likelihood of cost-based reimbursement for these services from Medicaid and/or mental health authori- ties is slim to nonexistent. Medicaid reimbursements through SHARS for evaluations and treatment are limited to special needs children and rarely cover provider costs. A more promising resource to meet mental health needs is repositioned staffing from state and federal programs already located in the community, such as Community Mental Health Centers (CMHC) or loca l programs supported by Substance Abuse Prevention and Treatment block grants (SAPT).

Socia//Human Services. A few states, most notably New Jersey and Kentucky, have SBPC programs that are

IHJJJ’


funded through their state departments of human or social services.” Although direct service reimbursement for SBPC is uncommon, repositioning of local staff such as eligibility workers, case managers, and outreach specialists can greatly assist a SBPCC by enrolling students, identifying

Figure 1 Funding Streams from Partners

for School-based Primary Care Centers (Principle 4)

Health Services 1 . State-level Funding

a. Legislative Initiatives b. MCHS Block Grant

a. EPSDT b. Direct Service c. FQHC (Community

Health Centers) d. Disproportionate Share e. SHARS

3. Family Planning Services a. Title 10 - PHS ACT b. Title 20 - SS ACT

4. Third Party Billings (Private) a. Fees/lnsurance b. Managed Care

2. Medicaid

Contracts

Mental Health Service 1 . Community Mental Health

2. Substance Abuse Block Grant

Prevention and Treatment Block Grant

3. State Legislation

SociallHuman Services 1. State-level Initiative

a. Title 20 - SS ACT b. Legislated Initiative

2. Regional / Local Initiatives

Education 1. Local School Districts

Support 2. State Legislative Initiative 3. Chapter I of ESEA 4. Drug-free School and

Communities a. Governor’s Office

Grants b. Local Educational

Authority

Start Up Maintenance

a

a

a

a

a

eligibility for Medicaid and other entitlements, and providing case management.

Educational Services. Some funds and resources available to school districts are earmarked for health. Local school budgets may provide for school nurses, school health aides, curriculum specialists, and health educators, as well as space and utilities. School districts may hire or contract for health services, such as school physician consultants. In Florida, the Department of Education has legislative funding to support “Full Service Schools” that provide social and health education and services.” Many school districts take advantage of federal Drug-Free Schools grants, which have just expanded the scope of allowed activities. These funds pass from the U.S. Department of Education through state governments (eg, 70% to the education agency and 30% to the governor’s office) and 90% of all of these funds are passed on to local school districts or community-based programs. Finally, schools and districts with a large number of students living in poverty or subject to other high risk conditions qualify for funding through Title I and Title XI of the Elementary and Secondary Education Act. Recent revisions of this act have expanded eligibility criteria and the scope of supported health and community integration activities.’’

Other Sources. In addition to the funding sources from federal, state, and local dollars that each core partner can bring to an SPPCC joint venture, other public and private sources also invest in the development and expansion of SBPCCs through grants. At least four national foundations are supporting the development of school-based or school- linked integrated service models for children. The Robert Wood Johnson Foundation’s Making the Grade program is investing $23 million over five years in 12 states to develop diffusion models for SBPC. Other foundations supporting SBPCCs include the Annie E. Casey Foundation, the Kellogg Foundation, and the Pew Charitable Trust, as well as state and local foundations.

Federal programs are also supporting services which could be integrated into SBPCCs. The Health Resources and Services Administration (HRSA), following the lead provided by the Bureau of Maternal and Child Health, has instituted a grant program with the Bureau of Primary Health Care Delivery, called Healthy Schools/Healthy Communities, to address homeless and other at-risk student populations. The Center for Substance Abuse and Mental Health Services Administration has a major grant funding program to address drug abuse prevention in high-risk minority youth using community-based (including school) interventions. Federal funding from a number of other special grant projects has been identified by Advocates for Youth (formerly Center for Population Options).”

Local health and social service agencies, managed care organizations and philanthropic organizations may contribute increasingly to SBPCC efforts in the future. The current challenge is finding the resources to fund the administrative effort needed to acquire and manage these contributions.

5. Careful Evaluation of SBPCCs is Essential to Their Long-term Survival

Relatively few of the hundreds of SBPCCs in the country have published evaluation data6~n~l~~lh.’s,lP,47~49-~2 and only a handful of multilevel si te evaluations have been


pub]ished~8.12.11.19.34 Most of these reports include discussions of the limitations of their data, confounding factors, and restrictions on evaluation design. Dryfoos has challenged skeptics of school-based services, suggesting that they may be expecting a higher standard of evaluation for this intervention than for a number of other well-funded health interventions for youth, particularly those related to substance abuse.“ Nonetheless, to achieve long-term security and stability, a SBPCC must provide evidence of accountability to partners, funders, and stake-holders, including solid data showing that the center’s mission is being accomplished.

Both process and outcomes should be evaluated. A mini- mum requirement for evaluation at the local level is the collection of data on everyday functioning of the center, such as the number and kinds of services, patient satisfaction, service requests, income, and costs. More comprehensive evaluations, such as comparisons of health outcomes between the SBPCC and other health care delivery systems, are most cost-effective when undertaken at multiple sites by a state, region, or group of SBPCCs. Use of shared intel- lectual resources and combined data is likely to enhance the power of the results and thus provide more convincing data regarding the SBPCC’s efficacy. The following recommen- dations may help centers plan for evaluation of their programs:

Develop an evaluation plan, including funding mechanisms, before clinical services are initiated. Sound evaluation planning must accompany the development of SBPCCs, to ensure that necessary data are collected routinely and prospectively in usable formats. Systematic collection of these essential data should be built into routine clinic operations, and expenses for evaluation included in the operating budget. Considerable money and time can be saved if evaluation experts are consulted early in the interventi~n.~~ Local and state agency partners will often facilitate access to technical assistance for evaluation, if it is planned from the beginning.

Choose carefully among the variety of evaluation designs. Evaluations come in many forms and serve many purposes. Outcome evaluations measure long-term changes in health status or risks, such as pregnancy rates or graduation rates. Process evaluations assess how well the SBPCC is functioning, such as cost analyses of clinic operations or surveys of how clients found out about clinic services. Quality assurance studies can focus on outcomes or process in monitoring the quantity and quality of services rendered. Satisfaction evaluations qualitatively assess the satisfaction of users, staff, or contributors. Comparative studies of services and/or outcomes may assess differences in the services provided by SBPCCs compared to conventional health care services. They may also compare local findings with published results from other centers, often using previously developed data collection in~truments.’~~~’,” A center should decide which type of evaluation is most needed and most feasible, and to plan appropriately.

Select outcome variables that are related to the center’s goals and are clearly defined, measurable, and sensitive. A clear statement of mission and goals makes it possible for the evaluation to assess whether a SBPCC is addressing its intended mission and prioritized goals, and whether needs have changed. Previously reported assessment^'^.'^^" have addressed better access to care, decreased risk-taking behaviors, and improved health

status. Any indicators selected must be precisely defined, observable or quantifiable, and accessible for data collection. Health status indicators and healthy behaviors are much easier to document than health attitudes. The outcome variables selected should be sensitive to change in the time period being evaluated. For example, significant changes in a school’s pregnancy rates will take much longer to document than changes in self-reported use of contraception.

Make efforts to link SBPCC data with educational performance da fa, while assuring strict confidentiality of sensitive information. Evaluation of associations between health interventions and school performance may help SBPCCs to establish their value to the school and the community. Educational variables which have been evaluated in relation to SBPCC utilization include absenteeism,I6 drop-out,’s.’6.48 graduation rates,I5.l6 and suspension rates.16.Ss Links between health and utilization data and specific acad- emic measures such as grades have not yet been reported, but these associations are of great interest.

In the past, evaluating such linkages has been techni- cally, politically, and ethically difficult because school health and educational data sets are controlled by separate organizational structures. Computers have reduced some of the technical difficulties, but political and ethical issues involved in data sharing require a collaborative and cooper- ative approach, especially when student confidentiality may be at risk.18 Evaluations must be undertaken with assur- ances to students, parents, and partner agencies that honor- ing confidentiality is a high priority. Young people will use SBPCCs only if their confidentiality is assured.

CONCLUSION Historically, the health needs of children have been

addressed through the public education system when other systems have proven inadequate. As long as the political will exists to address the problems of youth, communities and states will find a patchwork of strategies to fund school-based primary care. Reform in the financing of health could greatly facilitate this movement.

The promise of SBPCCs as an effective approach to primary care for underserved children and youth is suggested by the 50% increase in the number of these centers in the United States since 1993-94.5 In 43 states, programs have been established to promote development of SBPCCs.’ This record reflects a growing public demand to meet the severe and complex needs of underserved youth. Early evaluations of existing SBPCCs documented improved access to care for underserved children and some initial success in addressing the complex morbidities and associated behavioral risk factors of children and adolescents.

The need continues, however, for improved evaluation of SBPCCs. Documenting the outcomes of SBPCCs is difficult and expensive, but essential to the long-term success of this approach to accessible health care for children. The Robert Wood Johnson Foundation and others have helped to support some of these evaluation costs. Federal, state, and local agencies also need to recognize the need for adequate funding of carefully designed evaluations of the SBPCCs for which they provide service dollars. In an age of increasing fiscal accountability, measurement of the relative costs of school-based clinics and the effects of


these clinics on specific morbidities in targeted populations should help to justify continuing support of school-based primary care.

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A S H A P A R T N E R S

These institutions and corporations have expressed their commitment to and support of comprehensive school health programs by joining with the American School Health Association as an ASHA Partner. The contributions of ASHA Partners enable ASHA to continue to shape standards of practice for school nurses, physicians, and health educators, to maintain high-quality education programs, and to conduct and report research on the cutting-edge. Programs supported by ASHA Partner contributions include: sponsorship of the Outstanding School Nurse Achievement Award, School Health Educator of the Year and sponsorship of the John P. McGovern Annual Lectureship in School Health. We thank ASHA Partners for their support.

President's Diamond Endowment Partner + + Merck Vaccine Division, Box 4, Sumneytown Pike, MS - WP37. B315, West Point, PA 19486 Smithnine Beecham Pharmaceuticals, One Franklin Plaza, P.O. Box 7929, Philadelphia, PA 19 I0 1

Platinum Endowment Partner + McCovem Fund for the Behavioral Sciences, 6969 Brompton, Houston, TX 77025

Gold Endowment Partner + 4

Consumer Health Care Division of Pfizer, Inc., New York, NY 1001 7 Tambrands, Inc., One Marcus Ave., Lake Success, NY 11042

Silver Endowment Partner + + Dept. of Health Science Education, University of Florida, Gainesville, FL 3261 1 The Imagineering Group LLC, 96 Atlantic Ave., Lynbrook, NY 1 1563

Sustaining Partner + +

Dept. of Adult Counseling, Health and Vocational Education, Kent State University, Kent, OH 44242-000 1 School Health Corporation, 865 Muirfield Drive, Hanover Park, IL 60103

Century Partner + + + +

Grafeeties &Company International, Inc., 1730 Blake St., Suite 400, Denver, CO 80202-1275 Health Wave, Inc. 1084 St., Stamford, CT 06907 William V. MacCill & Co., 720 Annoreno Drive, Box 369, Addison, IL 60101 Meek Heit Publishing Co., P.O. Box 12 1, Blacklick, OH 43004

A M E R I C A N S C H O O L H E A L T H A S S O C I A T I O N 7263 State Route 43 * P.O. Box 708 * Kent, OH 44240 e 330/678-1601


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