The job of a school nurse is changing. More students suffer from complicated medical problems related to asthma, diabetes and obesity. And more health symptoms are showing up that may be rooted in emotional stressors, including a troubled home life, a drug problem or a behavior disorder. So, with an eye to preventive care, school administrators are looking for new ways to serve adolescents who are most vulnerable to health risks.
Yet they're also under pressure to cut costs. Many districts have cut school nurses' hours, eliminated nurses altogether or replaced them with registered nurses who have more general training.
In more districts around Illinois and the nation, though, administrators have increasingly turned to a different approach. Under a model first tried in the mid-1980s, local school boards invite operating health clinics into schools to complement the care provided by their school nurses.
Doctors who often specialize in pediatrics or family practice oversee these school-based health centers that are staffed with nurses, physician assistants, counselors, and sometimes dentists and psychologists. They can become resources for faculty, staff, students and their families. Students simply walk down the hall to be treated for anything from bellyaches to suicidal thoughts. They can make appointments for sports physicals, immunizations, nutrition counseling, dental checkups or, in some cases, prenatal care, provided they have parental permission.
Chicago Public Schools Chief Arne Duncan says the 23 existing school-based health centers in his district provide a model for addressing students' social and emotional needs, as well as some of the family members' needs.
"We talk about schools truly becoming community centers. That's actually part of the vision," Duncan says. "You want this wide variety of high-quality programming beyond the normal school day. And if we could expand the number of school-based health centers, we would do it tomorrow."
Duncan says the centers focus on a holistic and preventive approach that improves student attendance, which increases federal funding. They also heighten the chances of better academic performance, another statistic rewarded by the federal No Child Left Behind Act.
Financially, however, Duncan says the district can't expand school-based health centers without state help. "Like everything else we're trying to do right now, due to the lack of state support, extending that now is unrealistic. With additional state support, that goes right back onto the table."
More schools want to connect preventive health care with school achievement. Both are linked to capturing federal dollars, but neither the states nor the feds have been a source of sustainable funding for school-based health centers. So clinics often turn to private companies, nonprofit foundations and in-kind donations to keep the doors open. As more clinics try to start, however, momentum is building for local, state and federal governments to foot more of the bill.
About 50 communities within Illinois already have school-based health centers. They're located around Chicago and scattered throughout rural and urban areas downstate where clusters of children enrolled in Medicaid go to school.
About 50 other communities have expressed interest in starting new clinics, according to Victoria Jackson, school health program coordinator for the Illinois Department of Human Services. The interest "never stops growing."
Principals or local health care providers often spark the interest and bring it up to the school board. If the board decides to pursue a clinic, then a local advisory committee usually searches for startup money, building accommodations and community acceptance. The board also decides the extent of services to be offered, allowing the community to deem it appropriate or not for students to have access to birth control or to be referred to another community clinic that can provide it.
Along with local control, however, comes the responsibility to find sustainable funding for the clinics.
"It's almost, literally, like bake sales," says Dr. Elizabeth Feldman, a family physician and medical director of the Advocate Illinois Masonic Medical Centers, which operates school-based health clinics in Chicago. "We're trying everything we can do."
She's been involved in school health centers in two Chicago public schools on the North Side since they opened their doors in the mid-1990s. Last year, according to the annual school report cards, more than half of the students at Amundsen High School were Hispanic and about 90 percent were considered low-income. The second clinic is in Lake View High School, which was then more than half Hispanic and nearly 82 percent low-income.
Feldman says though the students and their families have access to medical services in their communities, the school health centers can better reach students in a way that's tailored for them. "Even in an urban setting where there's plenty of [emergency rooms] within a 5-mile radius, kids often don't access care unless it's proven to be adolescent-friendly, confidential, respectful, nonjudgmental."
The need to connect those students to health services heightens because Hispanics are the most likely population to be uninsured, according to a 2006 report by the U.S. Department of Health and Human Services, the U.S. Centers for Disease Control and Prevention and the National Center for Health Statistics. In 2004, 41 percent of people born in Mexico and living in the United States lacked health insurance for at least part of the year before the interview.
At the same time, the number of 12- to 19-year-olds who were overweight gradually increased from 10 percent in 1994 to more than 17 percent by 2004, the report says. The numbers are even higher for children younger than 11.
It's a double whammy if the adolescents are Latino and from low-income families. Both groups are more likely to be overweight than children who are white or black and from middle-income families.
At the southern tip of the state, the number of low-income students in Murphysboro led locals to want a school-based health center. They've worked for a year and a half to secure funding and support services, according to Connie Favreau, assistant director and operating officer at Shawnee Health Service. The provider already operates one in Carbondale Community High School and one in Marion Community Unit School District 2.
Murphysboro will start a clinic if it can find a way to pay $140,000 for remodeling and come up with operating costs, Favreau says. "That's not small change to school districts that are typically struggling nowadays, and we certainly don't have the funds."
When startup money is secured, she says it'll take up to three years to earn enough income from the billing of Medicaid or of private insurance companies so the clinic can sustain services.
The school nurses in Murphysboro are especially interested in bringing a health center to the school, she says. They're often the first ones to see a child when the child complains about not feeling well, she says, but they can't always immediately connect the student to a doctor. It also takes time to reach parents so they can get off work and take a child to the doctor. Favreau says a school-based health center could help provide more prompt care and help parents avoid conflicts with work.
By establishing a health clinic within the school, medical providers also hope to catch some of the physical and behavioral problems before they start or alleviate them if they've already developed.
"Adolescents generally aren't good health care consumers," says John Schlitt, executive director of the National Assembly for School-Based Health Care based in Washington, D.C. "They just don't go for preventive health care visits, and regardless of socioeconomic status, that's fairly well established."
He says the school-based health centers complement different types of health insurance, whether public or private. "Insurance simply means you've removed some of the financial access barriers. It doesn't necessarily mean you've broken down the geographic barriers, or the cultural barriers, or the physical access barriers, or the barrier of just no motivation to seek care," Schlitt says. "There's a lot of barriers that teenagers particularly have that have nothing to do with their lack of insurance."
He says because the leading cause of mortality and morbidity in adolescents is behavioral health issues — not physical problems — the clinics are becoming a new way to treat adolescent mental health. Because the medical providers are right in the school, they can recognize students who visit the clinic for vague symptoms on a regular basis, Favreau says.
"The bellyaches that you see children coming in with, vague complaints, headaches, sometimes really aren't a physical problem but are more of a mental health issue," she says. "It could be family relationships. It could be relationships with other friends. That does affect how they perform academically."
To encourage holistic health, the clinics work with the physical education classes, develop on-site weight loss programs, identify kids going through the grieving process and start support groups within the school.
"The more services that you provide on-site, the more comfortable it is for the children to participate," Favreau says. "They don't feel quite so threatened in the participation process."
Feeling comfortable is critical for adolescents to reach out for help, particularly if their parents aren't around. At the Lake View and Amundsen clinics in Chicago, about 20 percent to 30 percent of students' monthly visits are for mental health diagnoses, according to Feldman. She says parents are sometimes the catalyst for misbehavior. "Most of the time, what we're helping these kids deal with are the result of things that are beyond their control and are behaviors that adults around them are engaging in," Feldman says. "We have a number of kids who really are parenting themselves. One parent in jail, another who has passed away, so they're officially being raised by a grandparent who's disabled or who has a mental illness."
While parental involvement remains a standard priority among school health clinics, state law protects some aspects of adolescents' privacy. Parents of 12- to 19-year-olds can't access the students' medical records for reproductive health, substance abuse or mental health unless the student allows it.
But parents do have a say in the extent of services their students can access. Parents in Carbondale, Cahokia and Marion, for instance, didn't want the clinics within their high schools to dispense contraceptives, says Williamenia Allen, a nurse and program manager for school health centers in Cahokia High School and East St. Louis High School. "We don't do any condoms, and we don't do any birth control methods from inside."
The registered nurses can write prescriptions for birth control devices.
But Allen says dealing with birth control issues is a minor part of the clinics' challenges. The biggest part is finding sustainable funding for all types of services, some of which can't be billed to any type of insurance or which have low federal reimbursement rates.
State funding is available, but limited. Illinois gradually increased funding for school-based clinics from about $3.8 million in fiscal year 2003 to $4.1 million in fiscal year '07. That amount is divied among some 40 health centers.
Compared to other states, Illinois funds more clinics than some but far fewer than others, says Jackson of the Illinois Department of Human Services. "Some states still fund almost three times as many health centers as we do."
The clinics that do get state funding typically only get between 26 percent and 44 percent of their operating costs, according to a cost-benefit analysis by the Illinois Coalition for School Health Centers, a project of the Chicago-based Illinois Maternal & Child Health Coalition. The clinics' operating budgets can range from $170,000 to $460,000.
Most school-based health clinics rely on a mix of local, state and federal grants, as well as private and in-kind donations from foundations, medical providers and local businesses. But when the grant money runs out, the search for a sustainable mix of funding ensues.
Four of five school-based health centers sponsored by Cook County closed in April because of across-the-board budget cuts. The surviving center, J. Sterling Morton East High School in Cicero, is in a predominantly poor area. The school's 2006 report card shows that nearly 95 percent of the 3,362 students were Hispanic. About 65 percent of them were considered low-income.
State Sen. Martin Sandoval, a Chicago Democrat who helped fight for the Cicero health clinic, says administrators realized that out of all school-based health centers in the county, Morton East needed to be saved from the budget ax because of its high dropout rates and high pregnancy rates.
"Statistics that we are not proud of is what led to the saving of the health clinic," he says.
Government reimbursements also had something to do with it. Don Rashid, director of public affairs for the John H. Stroger Jr. Hospital of Cook County, one of the clinic sponsors, says, "The Cicero center has remained open largely in part to 71 percent of its clients being Medicaid patients. That represents a lot of money for the [Cook County Bureau of Health Services]."
Pressure is on for the feds to commit more money for the existing 1,700 school-based health centers around the nation. Numerous advocates gathered in Washington, D.C., this summer. They're supporting a measure that would create the Health Schools Act of 2007, which is designed to ensure government reimbursements reach student health centers that serve children covered by Medicaid and the State Children's Health Insurance Program. It also would set minimum services that the schools would have to offer for such primary care as mental health, dental health and health education.
A second effort seeks to authorize federal grants for school-based health centers.
At the state level, advocates want more funding to the tune of $30 million over five years to start 20 new centers. The legislation, which was sent to Gov. Rod Blagojevich in June, states that the clinics save the state about $2.5 million a year by reducing emergency room visits, $2.7 million a year by providing immunizations and up to $342,000 a year by reducing asthma-related hospitalizations.
With a delayed state budget and ongoing negotiations stretching into August, school-based health centers didn't know whether they would receive more state money in the next couple of years.
"We have excellent support for [the measure], but it's just a question of how far the state budget will go," Favreau says. "So I guess our legislators will have to prioritize. We all hope that we're the priority, but in reality, somebody's not going to be a priority. We don't know where we'll end up."
Illinois Issues, September 2007
