Using the SHCIP evaluation system as a model, the SBHC Program anticipates the following minimum technical and staff requirements in order for SBHC sites to meet reporting requirements and to participate in the program evaluation. (Note: The staff requirements may be fulfilled by a single person.)

Recently, CDPHE invested over $1 million in SBHC Program grantees for business infrastructure, including EHRs and on-boarding to Apex evaluation. One of the primary reasons Apex was selected as the SBHC Program evaluation vender is their proven ability to work with a variety of SBHCs with existing business structures without imposing exorbitant cost. CDPHE’s consideration of additional funding will be based on the minimal and most reasonable accommodation to participate in the evaluation. CDPHE will support sites to the fullest extent possible. Requests for such funding will be considered on a case-by-case basis with the understanding that resources are very limited and must be shared across 50+ SBHC-funded sites. SBHC funding is never guaranteed and is subject an annual appropriation by the Colorado Legislature.

Funding and Third-Party Payer Sources

• Federal funds
• Other state funds
• Local government funds
• Private funder/foundation support
• Public insurance reimbursement (Medicaid and Child Health Plan Plus)
• Private insurance reimbursement
• Donations
• In-kind support

Enrollment Information

• Number of students enrolled in host school
• Number of students from host school enrolled in SBHC
• Number of children/youth (ages 0-21) not from host school enrolled in the SBHC
• Number of children/youth assisted with enrollment in Medicaid and Child Health Plan Plus

User Information

• Student ID
• First and last name
• Date of birth
• Gender
• Race/Ethnicity

Visit Data

• Insurance enrollment by visit
• Date of service
• Provider of service
• Diagnoses codes
• Procedure codes

Totals Provided Within Contract Year

• Immunizations
• Depression Screenings
• BMI Screenings
• Group Information

Apex’s business associate agreement outlines the assurances and safeguards we take to secure PHI as required by HIPAA. Data are secured through encrypted, password-protected transmission and within the Apex Data Hub, which meets all security requirements. Our staff members are HIPAA-certified, and we conduct all recommended audits and maintain all recommended written policies and procedures for administrative, technical, and physical safeguards.

No. A business associates agreement between Apex and each SBHC’s medical sponsor and mental health partner is established, which allows for the release of PHI under HIPAA. Specifically, there are several permitted uses for which a covered entity may disclose PHI without consent. First, for treatment, payment, and health care operations. Several criteria are met under health care operations, including use of data for quality assessment and improvement activities, medical record review, and planning and development. Second, public health activites are also a permitted use that does not requre active consent. Administration of the School-Based Health Center Program is a public health activity under the CDPHE.

The data includes demographic information, insurance status, provider type, and CPT and ICD-9 codes for every visit (see chart below).

The visit data provides the following site-specific information:

• Number of visits by gender, age, race/ethnicity, and insurance status
• Types of visits (acute visit, preventative visit, psychotherapy, care coordination, etc.) by service provider (primary care provider, behavioral health provider, dietician, etc.)
• Diagnoses associated with the visit (UTI, asthma, depression, well-child care, STI screening, etc.)
• Procedures performed (throat culture, immunization administration, blood draw)

Patient and visit level data allow for analysis between and among these data elements.

The data warehouse would simplify and potentially eliminate the service data and work plan reports because much of the information would be collected through the visit data export. The plan is to eventually satisfy all reporting requirements through the use of the data warehouse.

Yes! We have proven so with the New Mexico SBHC program and under SHCIP. The entire data set is included in the CCR, which actually includes many more data elements. The CCR is a national electronic document exchange standard for sharing patient summary information.

Protected health information (PHI) data provides the most granular level of detail, including assuring unduplicated patient counts, which permits a more powerful data analysis. PHI is needed for data integrity. Confidence in the data set is built by gathering and using data in a granular form. It allows staff to construct, deconstruct, and compare data across patients and SBHCs in ways that are not possible with aggregate data. The evaluation is designed to be agile, robust, and responsive. Broad evaluation questions lead to more specific evaluation questions – ones that cannot be initially anticipated. Using a simple foundation of a minimum data set creates a data collection baseline for all sites and from which analysis can be expanded, if needed, and agreed upon. Aggregate data does not allow for a deep analysis within an SBHC or across different SBHCs, thereby limiting the program view across the state.

Additionally, for any SBHC using Just Health, PHI is needed to link to Just Health and provide site-specific internal reports to compare student self-reports to actual services received.

Note: PHI will not be disclosed beyond the covered entity that submitted it, and evaluation reporting will not breach PHI. CDPHE does not have access to, nor a need for, PHI.

If an SBHC has already linked the data and the SBHC is not using Apex Data (Just Health, PHQ-9, SCARED, etc.) to collect patient information in the clinic, then an SBHC can use the Limited Data Set option, which suppresses names and identifications. It is still PHI, but with a lower level of exposure.

Both visit data and Medicaid claims data were analyzed by the evaluators as part of SHCIP. The SHCIP team concluded that the visit data is superior to claims data in terms of quality improvement and evaluation for a number of reasons:

• Claims data is from a billing perspective, not a patient visit perspective. The visit data is more comprehensive. Unlike claims data, the visit data includes visits billed but not visits paid, visits not submitted for reimbursement (such as confidential visits), and visits of uninsured patients and private pay patients (that may or may not be submitted for reimbursement). Additionally, Medicaid claims data is limited to only claims paid by one public payer source.
• For some of the SBHCs, the visit data also includes visits to the behavioral health provider, which are not captured through the claims data.
• The visit data is more readily available for evaluation and quality improvement purposes. There is a lag time and potential cost to getting Medicaid claims data.
• The visit data has the potential of capturing unbilled services not otherwise captured in claims data, such as activities with recognized CPT codes (and corresponding diagnosis codes), including follow-up telephone calls, case management, care coordination, and group health education.
• The collection and analysis of visit data is an important aspect of tracking services and improving the quality of service delivery. It is also necessary for program evaluation and accounting for state dollars spent for SBHC servies. Visit data analysis can assist SBHCs in meeting the requirements of Meaningful Use Adoption of electronic health records.

The visit data is transferred by school-based health center staff (or lead agency staff) from their electronic health record (EHR) into an Excel spreadsheet. SBHCs, with IT support from their lead agencies, have created a query to generate the transfer to the Excel template. The spreadsheet is then password-protected, which encrypts the file for secure transmission to Apex, who in turn imports it into Apex’s web-based data warehouse for the SBHC evaluation. Apex will provide each SBHC site with an Excel spreadsheet template to facilitate the export process. Once the process is established, generating the export is routine and automated and is a low burden on SBHC/lead agency staff. The data is due monthly to Apex by the third Tuesday of the following month to allow time to reconcile the visits and codes.

Apex works directly with each SBHC to address challenges and improve the process to increase efficiency and accuracy. As health information exchange becomes more common and sites adopt EHRs, the export process is becoming easier. As data sharing continues to evolve, the export-import process will likely be replaced as EHRs interface directly.

The sites that have been unable to automate a query from their EHRs to populate the Excel visit data spreadsheet have instead worked with their EHR vendor and Apex to create a customized report. The report enables the data fields to be easily extracted from their EHR. CDPHE funding can be budgeted by SBHCs for this purpose.

The SBHC story is only as good as the data provided by SBHCs. For many SBHCs, the use of electronic health records is new. Becoming familiar with the features of the EHR and assuring that all the critical data fields are accurately captured takes time to learn. Under SHCIP, significant improvements in the visit data were achieved since the beginning of the project given our ongoing technical assistance and quality improvement support.

Attendance and grades are secondary sources that may be incorporated at the school level, not the individual student/patient level.

The HIE is regularly monitored with an eye toward efficiency, if not consolidation. The data sets are comparable, at least with regard to the CCR. All the required SBHC data elements are in the CCR. Inter-operability standards will support a more automated transmission process. However, CORHIO and QHN are not currently ready to accept SBHC data. Part of the issue is a matter of priority, and another issue that requires resolution is privacy concerns for the adolescent population. The New Mexico HIE is grappling with how to accept SBHC data, integrate it with other PHI, and support different levels of access – all while protecting privacy. Meanwhile, the SBHC evaluation is set to go now, so waiting for CORHIO/QHN or dependence on their system is not prudent.

Currently, eSolutions provide a .pdf report using Box.com that can be uploaded into the EHR as a file/image (.jpg). The actual data elements from eSolutions do not currently go to the EHR, although that is a possibility for the future once EHRs are ready to receive the data.

You bet. Apex provides a high level of personalized tech support for all of our clients. We will work closely with each SBHC.

The oral health performance measure is defined as the percentage of unduplicated SBHC users, aged 3 to <21 years, seen during the measurement year with documentation of an oral health screen, in the past 12 months, by the SBHC primary care provider OR by the SBHC dental professional. The oral health screen performance measure is calculated two ways: using D0190 and other dental codes found in the visit data and using oral health screening numbers reported in the Hub.
• Using D0190 and Other Dental Codes – Apex calculates the percentage of SBHC users who had an oral health screen by the SBHC primary care provider and/or SBHC dental professional is using D0190 code and other D codes to identify this service.
• Using Numbers Reported in Hub – Many SBHCs are unable to export dental visits because dental visits are either not entered into the medical electronic health record and/or dental visits are not associated with D codes in the electronic health record. For those SBHCs, oral health screens provided to SBHC users by dental providers can be reported in the Hub 4th quarter report. Apex will use the information reported in the Hub as the second way to calculate the oral health screening performance measure.
• Both methods will be used to calculate the percentage of oral health screens for each site.

Yes. We want dental services data that is not captured in the data exported to Apex and that meet the following criteria:
• Recipients of the service are enrolled or not enrolled in the SBHC.
• Service provided by a dental professional, i.e., dental hygienist or dentist.
• Service provided in the SBHC site OR within a school or on a school campus provided directly or indirectly by the SBHC.
• Service provided as a direct result of the SBHC site, meaning SBHC staff provided the service, and/or SBHC staff coordinated the provision of the service.

For each dental service question, we are interested to know total number of unduplicated students served. It is correct to report the same user in multiple questions if the user received those services. For example, if a student received both a dental sealant and fluoride varnish(es) over the course of the year, that student would be counted as both having received a dental sealant and a fluoride varnish, but counted only once as a unique SBHC user.

Please report the number under the site that is providing the service.

Please only report the number of unduplicated users who received at least one fluoride application and not the number of fluoride applications performed.

No, report only fluoride varnishes provided by dental professionals in the Hub. Apex captures fluoride varnishes provided by medical providers in the visit data by looking for the D1206 code.

That number would be reported under the referral number as opposed to the restorative care number since we are looking for dental services provided by a dental professional in the SBHC, school, or school campus.