Safety Net
Clinics move onto nation's campuses to address the health needs of students—and the lack of school nurses

By Janet Wells
October 16, 2003

Three months after Mary Hagedorn, Ph.D., PNP, RN, opened a clinic on the elementary and middle schools' campus in Fountain, Colo., a single mother with four asthmatic children walked through the door.

"The mom didn't have insurance and worked three jobs, so she didn't qualify for Medicaid. These four children were receiving care at the emergency room when they had asthma attacks," recalled Hagedorn, director of the Fountain School Based Health Program and vice president of the Colorado Association for School Based Health Care. "She was getting billed by the ER, but didn't have any money."

Each of the children was averaging two to three absences a month from school due to asthma, said Hagedorn, who assessed each child, switched their medications, tested them for allergies and did some education with the family.

"Now, it's four years later, and they have not had any more ER visits, and the asthma has been very well controlled. One child had perfect attendance last year, and the others were absent just once every one to two months. The mother said that without us, she would not have known what to do for health care," Hagedorn said. "Parents call us their 'angels of mercy' for providing services that weren't there before."

Comprehensive care

Hagedorn's clinic is part of a nationwide movement to address the needs of an estimated 11 million children in America with no health insurance, according to a recent article in Health Affairs, published by Project HOPE. Efforts to reach these children, who often live in poverty, have been only partially successful.

For teenagers, "access to health care is especially tricky," according to the article. "Teens face problems-substance abuse, reproductive health needs and depression-that are difficult to face and can land them in serious trouble. However, ignoring the problems of adolescents can lead to even bigger troubles: 1 million unintended pregnancies a year, 3 million sexually transmitted diseases, more than 4,000 suicides and flashes of school violence."

In response, communities are putting health care where the kids are-in schools, especially in low-income neighborhoods. About 1,500 health centers in schools in 45 states serve an estimated 2 million students-a more than tenfold growth since 1990, when 150 centers covered about 140,000 children.

These health centers are designed to deliver comprehensive primary, preventive and acute care. Most are staffed by nurse practitioners, as well as nurses, mental health care providers and licensed practical nurses. Some centers include physicians on a regular schedule; some are training sites for medical students. Many centers have lab facilities for routine blood tests.

Two nondescript portable buildings nestled between classrooms and the athletic fields in downtown Berkeley, Calif., house the Berkeley High School Health Center, part of a county coalition of 11 school-based health centers. The center-easily identifiable by the colorful artwork emblazoned with public health-related messages on the outside walls-has a small reception area, two exam rooms, a quiet room with cots, a lab, counseling rooms with a sound-screening machine outside the doors and offices.

Physicians assistants staff the clinic four days a week and medical residents from nearby Children's Hospital and Research Center at Oakland come in twice a week to do sports physicals and internal medicine. Social workers and mental health counselors also are on staff.

The week before school started in late August, the center's first-aid nurse, Amy Balding, RN, was busy checking the immunization history of 1,000 kids arriving from middle school. During the school year, she's even busier, treating Berkeley High's diverse student body of 3,500.

Balding, 45, does a lot of first aid-in fact, she makes sure to wear sensible shoes that she can run in when she responds to a medical emergency elsewhere on campus. She treats an array of sports injuries and dispenses over-the-counter drugs for menstrual cramps, headaches, colds, allergies, earaches and emergency contraception.

And sometimes she just listens.

"I have kids that are here because they broke up with their boyfriend or are having a hard time at school. They don't always want to talk to the mental health provider, so sometimes I'm Mom at school," said Balding, who, after 20 years in nursing, took a significant pay cut last year to work in school-based health care. "The kids are just great. They come up and hug me in the hallway, say, 'Yo, what up, nurse?' or 'That's my nurse. Don't be disrespectful to her.'

"We've resolved a vast array of problems on campus," Balding said. "I'll see someone who was here a week later and they'll have a smile on their face instead of tears."

School-based health care is an attractive option for many in the nursing field, said Linda Juszczak, DNS, MPH, PNP, RN, director of the Center Evaluation and Quality for the National Assembly on School-Based Health Care in New York.

"There are no barriers to providing care. The clinics provide services at little or no cost, and the systems that are set up to get the kids in have a minimal amount of paperwork. It's a very frontline experience," Juszczak said.

"Follow-up for issues is very satisfying. You don't have to depend on [patients] to return. They are captive," she added with a laugh. "You can go to class and see how an asthma patient is doing."

Hagedorn agrees. "A school-based clinic offers access to the children. We do health education classes, tobacco education. We help school nurses and health teachers. It offers a variety to the NP who likes to work with children and adolescents, an opportunity not only to see patients, but to teach and be involved with the community. It's a broader perspective than just going to a clinic and seeing a population of patients."

Because physical examinations and prescribing medications are part of school-based health care, most clinics rely on nurse practitioners to run the programs, with other health professionals offering support. Nationwide, school-based health clinics employ more than 900 nurse practitioners, 500 registered nurses and 200 licensed practical nurses, as well as mental health professionals.

Many school-based health clinics collaborate with school nurses, who typically provide basic first aid and annual health screenings, as well as track immunizations. However, because of the faltering economy, many schools have been forced to cut school nurse positions altogether or slash their hours back to a few hours per week or per month. If a school is lucky enough to have an on-site clinic, the staff there often picks up the slack. Berkeley High School, for example, has no school nurse, but Balding has taken over many of those responsibilities as part of her clinic job.

"Most of the time, school districts are really strapped and don't have a school nurse that can focus on one school," said Yvette Leung, MPH, program administrator for the Alameda County School-Based Health Center Coalition, which oversees 11 centers near San Francisco. "Triage alone is about 30 students a day, and that could really fill up your day-to-day activity. Between vision and hearing screenings, you can't place the attention on other types of services. School-based health centers can offer medical treatment and also mental health services that adolescents are seeking these days."

Controversial connection

The push for school-based health care started in the late '60s and '70s with pediatricians opening clinics at a few schools in cities such as Dallas, Minneapolis-St. Paul and Cambridge, Mass.

In the mid-1980s, the model picked up steam when a nationwide teen pregnancy crisis prompted health providers to promote family planning through school-based health programs. However, linking health care in the schools with reproductive services meant increased controversy. Parents, politicians and church officials sometimes created a firestorm of criticism at the idea of providing contraceptives, or even discussing the issue of teen sex in the schools. As a result, reproductive health services vary widely in school-based health programs, depending on community needs and tolerance.

Hagedorn's program in Colorado, because it is partially funded by a Catholic Health Initiatives grant, offers no reproductive services on site. That is appropriate, Hagedorn said, because the community is "fairly conservative" and "the biggest needs are primary health care and episodic acute care."

The Hope Healthy Start program, at Newport-Mesa Unified School District in Costa Mesa, Calif., gets around the issue by focusing on students aged 2 weeks to 12 years.

"Working with teenagers opens up a whole new area of sexual health that in some areas is difficult to get involved in," said Leslie Dootson, MSN, PNP, RN, who works as both a clinician and a school nurse at the clinic on the district's elementary school campus. "It's not appropriate for our community. Our focus is school readiness."

At the Berkeley High School Health Center, however, 75 percent of services used by students fall under family planning. "We're one of the few [school-based health clinics] that can give out contraceptives," said Kimi Sakashita, MPH , director of the center, which serves about 1,400 high school students annually at its clinic as well as providing outreach education for another 3,000 students.

Sakashita said that in a survey done several years ago, 88 percent of Berkeley high school students reported being sexually active and not using birth control. Since the clinic opened in 1991, the school's teen birth rate has dropped almost 60 percent. "We have the lowest teen birth rate of any jurisdiction in California," Sakashita said.

Although few school-based health centers are as progressive as Berkeley's, many programs provide some kind of reproductive health services. According to a recent survey completed by the National Assembly on School-Based Health Care, 76 percent of the clinics nationwide do not dispense contraceptives on site; however, 75 percent will do pregnancy testing and 60 percent will test on site for STDs like chlamydia.

The biggest threat to the health of school-based health programs is not politics or controversy, but funding. Although some federal money is available for the programs, most clinics must scramble to cobble together money from various public and private sources.

"All the school districts around us are pleading to have the same kind of program," Hagedorn said. "With the funding we have now, we can't get something started. Unless funding gets better, these kinds of programs are never going to expand."

Contact Janet Wells at janetawells@hotmail.com