Net Exchange Response


Title: How to improve school teamwork and climate?

Date Posted: 12/8/2003

Question: "We are wrestling with how to best balance respect for student/family privacy and confidentiality and protection of the alliances and trust established between clinicians and students/families in the schools, while still meeting the basic requirements for clinical record keeping at our sponsoring hospital. More specifically, the hospital requires that patient records be opened on all students receiving services in the schools. So the first issue is how best to define services? We provide both consultation to teachers and parents as well as 1:1 treatment with children. For the purpose of medical record keeping at the hospital, we would like to define services as 1:1 contact. Have you or programs you have consulted to faced a similar issue? In addition, in order to open medical records, the hospital requires insurance information. We believe that this requirement will be very difficult for our families for several reasons. Families were offered these school-based services with the understanding that the services were free of charge. Asking for insurance information at this point may undermine their sense of trust in their providers and be a barrier to access. Further, many of our families live in poverty and are uninsured. In asking families to disclose this, they may feel uncomfortable and/or embarrassed. Others may feel uneasy about having personal information on file at a large urban hospital where they have never been seen. We are trying to identify already established models for negotiating these competing needs in order to persuade the hospital to modify some of their requirements for the school program. Any thoughts, contacts or references would be much appreciated!"

Response:

You raise a familiar set of concerns. As you note, the need is to balance respect for student/family privacy and confidentiality and protection of the alliances and trust established between clinicians and students/families in the schools, while still meeting the basic requirements for clinical record keeping.

Describing it as a "balance" is a good way to approach the contrasting cultures and practices of school-community partnerships. With regard to the specific concern you raise, here are some thoughts and resources.

  1. About the hospital requirement to open records on all students receiving services and about "How do we define services?"
  2. You indicate that you propose that "service" be defined as one to one contact with a student. (You might want to use the term "client contact" or "direct service" so that you highlight what is the defining characteristic that calls for a case to be opened.)

    Some folks would argue that consulting with school staff or parents about a student who is being seen in a one to one situation is a "service." They would raise the question about: What are the costs and benefits of not opening a case when you are consulting rather than providing a direct service? In this respect, they would also suggest having a record of this type of activity for your evaluation of impact at the school. The right type of consultation can often be the most effective intervention in assisting the parents and school staff in their interactions with adolescents and youth. (What is the right type of consultation is a separate and involved discussion.) For school staff, the right type of consultation is an important capacity building activity.

  3. Coordination/Care Management -- Records also are critical in this respect since others will be working with the same student and the records/recommendations are an essential aspect of working in a coordinated way. So, if you don't open a medical/clinical record, it is still important to set up some format for logging the information.

  4. With regard to asking parents for insurance information -- Clearly, your concern about undermining the sense of trust with families is well taken. It permeates, of course, all facets of the processes that provide access to the services and resources you provide. Asking about insurance can be a particularly sensitive matter for some folks. So, if the insurance won't be billed, the hospital must provide an explanation to share with the families about why this information needs to be collected. Given a good reason, we would preface the request for information with a clear indication that the insurer will not be billed and the explanation about why the information is needed. Sometimes simply formatting the question in a way that acknowledges that some children are not insured handles this in a matter-of-fact way (e.g., using a multiple choice format -- a) private insurance, b)State Children's Health Insurance, c) no insurance). Obviously, it would be best to be able to indicate that this info is optional, rather than mandatory.

  5. With regard to "already established models for negotiating these competing needs in order to persuade the hospital to modify some of their requirements," you can start with the following resources:

Go to our website (http://smhp.psych.ucla.edu) and click on Quick Find (left col.); it takes you to Center Responses. Use the arrow on the right to scroll through alphabetized topics' menu. When you come to "Confidentiality" click on Go. This takes you to Center materials on this topic, such as the Quick Training Aid on Confidentiality and the Introductory Packet on Confidentiality and Informed Consent. Both have guidelines, resources, and contacts for further information. In addition you will see links to online documents from other sources, including: (1) Confidentiality for Teens and (2) Confidentiality in Adolescent Health Care

If you scroll farther down the list of Quick Find topics you will come to "Memoranda of Agreements" which has links to a number of online documents outlining school-community partnerships.

The above resources will provide you with examples to shape your position.

Hope you find some of this helpful. If you would like to develop a brief statement for the hospital that outlines your proposal regarding these matters, we would be happy to provide feedback on it before you go forward.


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UCLA Center for Mental Health in Schools
Dept. of Psychology, P.O.Box 951563, Los Angeles, CA 90095.
tel: (310)825-3634
email: smhp@ucla.edu ~ web: http://smhp.psych.ucla.edu