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Partnering with the Community to Ensure Student Health: Montrose County School District RE-1J’s School-Based Health Clinics

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[Editor's note: This is the second in a series of three posts on school-based health centers. Yesterday we briefly reviewed evidence supporting the use of these clinics. Today, Linda Gann talks about how her district founded two such centers. Soon Jennifer Danielson will take us through a day in the life of a nurse practitioner and tell us how her school-based health center has impacted kids.]

School-based health clinics have shown a great deal of promise in improving health outcomes for students, decreasing Medicaid costs at a time when every penny counts and even in potentially raising academic outcomes for low-income students. But yet there are only about 2,000 school-based health clinics (SBHCs) in the United States. Why don’t more districts take this approach? Does it seem too expensive? Too risky? Too separate from the district’s academic mission?

We recently spoke to Linda Gann, Communications and Special Project Coordinator in Colorado’s Montrose County School District RE-1J, to learn more about how her district came to embrace SBHCs. She also told us about her experience planning and implementing the district’s first school-based health clinic three years ago and its second a few months ago. Some keys to their success? The clinics get all their funding outside the general fund. They keep the community engaged in and informed about these efforts. And they consider not only the physical but also the mental health needs of students.

SBHCs alone will not close the achievement gap. But in Montrose, they are part of a broad strategy to address the needs of its growing Hispanic community. And that strategy appears to be working—for example, the district has a 20% higher graduation rate for Hispanic students than the state does.

Here's the story as Gann told it to us in a recent phone conversation.

About Montrose County School District RE-1J

I think from a researcher’s standpoint our district is almost a perfect universe, as far as data analysis goes. We are located in west central Colorado. We are five hours away from Denver. We are about 1,100 square miles, with two distinct communities. Montrose is about 30,000 people. Olathe is probably about 8,000 people. So we are not very large. And we are separated from our neighboring districts by open space, so it is really easy to tell where our school district stops and another one starts.

In our district, we have 6,500 students. District-wide, 54% receive a free or reduced price lunch. But on the south end of our district, which is close to the ski resort of Telluride, the houses are larger, and there are more families considered upper middle class.  The free and reduced price lunch population at the elementary school in that area is about 11%. On the north end of our district, the free and reduced price lunch population is 80%.

When you look at our district and our standardized tests scores, we are right at the top of the bell curve. We have students who score very high, and we have students who are just coming into the country and score low. About 30% of our students identify themselves as Hispanic, with the highest percentage of those students attending schools that also have the highest percentage of free and reduced price lunch. The school where we put our first school-based health center, Northside Elementary, has one of the district’s highest percentages of free and reduced price lunch students and also one of the highest percentages of English Language Learners, whose parents primarily speak Spanish in their homes.

What I think is interesting about us is that within the district we have the same superintendent, the same budget and the same curriculum, so within the organization you can see how diversity and access to certain other factors affect outcomes. I think that is one of the reasons we are an interesting program to look at—it should be pretty clear to see what changes affect student learning.

Discovering School-Based Health Clinics

As a district, we implement research-based strategies. And one of the books that we started reading back in 2005 or 2006 was Richard Rothstein's Class and Schools. It was published in 2004, but we as a district took it on a little later as one of our book club books. In the book, Rothstein suggests that unless students have access to adequate healthcare, it is pretty hard to close the achievement gap. That is why we started looking at the idea of school-based health clinics, because as a district our challenge is to close the gap. For us, an achievement gap exists between our Hispanic and non-Hispanic populations, and between those on free and reduced price meals and those who are not. We also saw gaps in access to healthcare in that same demographic.

So we just started thinking about what we could do to get healthcare closer to our students who need it. For example, at Northside Elementary, many families work up in Telluride. The parents might get on the road at 5:30 in the morning and they might not get home until 7:00pm, because it is about an hour and a half away. And if their children do not feel well or become ill while at school, they often do not stay home from work, and the ill child attends school, which impacts all the other children in the school.

And if the children need something as simple as a throat culture or to have their ears checked, there are a really limited number of primary care physicians in our area who take new patients, particularly patients on Medicaid. And we only have one hospital. So there was a real problem, and we just thought we would check this model out.

The superintendent, who came to our district from Yuma, Arizona, and had seen a school-based health center asked me, “What do you know about school-based health care?” I said, “I do not know anything about school-based health care—I have never even heard of it.” But I started doing some research, and I found out that there really were some places where this strategy made a big difference. And just about that time, the Colorado Department of Public Health and Environment sent out an RFP [Request for Proposal] to plan for a school-based health center. I thought, “Well, this is perfect.” So we applied for the grant and got it.

Getting Started

We spent a little over a year planning the first clinic—we, the school district, being the lead. Typically what we had found was that a public health official or some person in the public health field who had a passion for this sort of work would take the lead. And they would run into barriers with the school system saying, “We are asked to do too much, and we cannot do that.” So what was different about our model was that we were the ones trying to figure out if this would work in our school system.

And while some members of our community were thinking, “This is a great idea, and we would love to do it,” we were surprised by some who were reluctant, particularly some local physicians. I was astounded. Montrose is a small enough town that I could say, “What is your hesitation?” It would be something they wouldn't want to talk about in a public meeting, but out in the parking lot they would say, “Linda, I am worried that you are going to take business away.” But personally, while I certainly do not know the medical care business, I suspected that our target audience was kids who did not have a medical home and who used the emergency room because they did not have any place else to go, which is inappropriate and expensive, and that these are people those doctors would not see anyway.

So there was a little bit of reluctance, but we went ahead. We completed the planning process. In doing so, we decided that we were going to locate the first clinic at Northside Elementary for a variety of reasons. It had the high free and reduced lunch population and high ethnicity. It was located in the middle of our town, so the clinic would be accessible by foot at least for some of our families. And the kids at the school, of course, could just come right in.

The Mental Health Challenge
We chose the school, and then we surveyed. We asked the parents at the school, in English and in Spanish, about the idea. We heard back from 63%. 41% of the parents who responded said that they had no medical home. 49% indicated they had no medical insurance. And 87% said that they would use a school-based health center if it was at Northside. Those were pretty compelling numbers.

We also surveyed our teachers and our staff at Northside. We asked them if they regularly, in the classroom, saw students who could benefit from a primary care facility. And 100% did.

I learned a lot through this whole process, but I was astounded at the results of our staff survey. When we started, we did not know the kind of services we were going to offer. We just did not know. What was the need?

The case for providing a mental health therapist was overwhelming, and that was so surprising to me. Staff talked about things like anger management, substance abuse, incarcerated parents…You need to know that Montrose is a charming little town, but we did not even realize what was going on—at least I did not, though I assume that social workers in town did—with the significant mental health issues that our kids deal with every day. That need was one of the big things that came out of the survey, along with the need for primary care—that first-line, safety net, physical medical care.

Finding the Money
Based on the results from our parents and staff, we moved forward. We started looking at grants. We are not a wealthy district. We are very conservative, very Republican. And the district did not have any extra money. In other words, we had to fund this thing completely outside of the general fund. So we had to find grants and/or community partners.

That is when we got interested in Jamie Vollmer’s work. He is a businessman who has written some books and has been on the speaker’s tour. He talks about how the community always looks to the schools to solve the problem, whatever it is—whatever happens to be the problem—rather than really wanting to work collaboratively. We got really interested in, how do we collaboratively solve this problem? We understand the need to look at the school system, because that is where the kids are and that is sort of the hub of the community. But rather than just having the community say, “It is the school's problem, fix it,” we would turn it around and say, “This is what we want to do. How can you help?” And really challenge the community, the people who were excited about it. We would ask, “What can you bring?”

When we moved from planning to implementation, we realized that the school district could basically provide the space. The land. We did not have any extra classrooms, though we had originally thought we could remodel a classroom into a clinic. But we are a growing district and we did not have any extra. So we had part of a vacant lot next to the school where we could provide the place. Other than that we had to have the community or grants provide everything else.

We had strong support from the Center for Mental Health, our regional mental health provider. They agreed to pay for half of a full-time mental health therapist. So we had that as in-kind. Then we just started looking for grants. We were very fortunate, because this was kind of a new idea, but thankfully there were some private foundations interested in this sort of thing. We were successful in getting grants for operations. We applied to some private foundations in Colorado—the Colorado Health Foundation, El Pomar Foundation, Boettcher foundation and The Colorado Trust. And we wrapped back into an implementation grant from the Colorado Department of Public Health and Environment.

We also needed a medical modular building. So we did some research on companies that built medical modulars. We ended up with a 1400 square foot, brand-new medical modular that they brought onsite over the summer. We opened up in October three years ago.

Staffing the Clinic

The staff includes a mid-level provider who happens to be a pediatric nurse practitioner. We have a full-time mental health therapist. While we have grant funding for both of these medical care positions, we have developed Memorandums of Understanding with their employers. In other words, the school district is not their employer. That was at the advice of our attorneys. They suggested that we not get in the healthcare business, which we did not really want to be in. So we have our MOUs with the Center for Mental Health and with Pediatric Associates, who hire the staff members who are onsite. Both the NP and the mental health therapistreally  are committed to this model of care and have made the clinic the success it has become. They are both highly qualified. The NP is bilingual, and the mental health therapist has been taking Spanish lessons for three years and often can now work with clients without the need for an interpreter.

We also have a promotora, a family outreach person. She is a school district employee, but grant funded. She is just remarkable. So much of our success has been finding the right people. We have a fabulous staff there. Patty is our promotora, and she is bilingual and bicultural. She is a Mexican naturalized citizen, and her dad happens to be a physician in Mexico. She has been able to really bring in trust—our families trust her. She knows the systems in Mexico, and she also has lived in the States long enough—about seven years before she took the position—to understand what it is like here. She can really help our families navigate the programs they qualify for—Medicaid or CHIP [Children’s Health Insurance Program]—and also just how medical care works in the States. You do not just go to the emergency room. In Mexico, that is kind of what they do—it is sort of socialized. But she helped explain how we do it here. She has done so many wonderful things.

So we have the pediatric nurse practitioner, the mental health therapist and the promotora. We also have the school’s health tech. Each of our district’s schools has a health tech who has first aid training, but does not have LPN credentials. They are the ones who take temperatures, call a parent if a child is not feeling well, or put ice on knees if children fall on the playground. Things like that. She was in the school next to the principal's office, but when we brought the school-based health center to campus she moved out there. She is kind of the receptionist who also does her regular health tech stuff. So there are those four people at the Northside health center.

What We Offer

Along with providing mental health and primary care, we also schedule dental care. While it is not available every day, students can schedule with a dental hygienist who comes in periodically. We also participate in a grant from the Telluride Foundation so that the kids can get their teeth sealed. It is just amazing. They will never have cavities. We have a week in the spring and a week in the fall where that is all the clinic does—dental screenings and sealants. And we also hand out toothbrushes.

We have also had other relationships. For example, Colorado State University came in and taught nutritional classes and parenting classes at night.

And the nurse practitioner is just unbelievable. She's fabulous. She discovered, as you might imagine, that we have some obesity issues. In particular, we have some young girls who are already showing some pretty hefty BMI numbers. So she developed this class called “Power Hour” for third, fourth and fifth grade girls—anybody could come but it ended up being girls. They would take their BMI and chart it. Then she would walk them around the playground, and then the next day they would jog a little bit. Then they would extend it. They tracked their BMI, and she talked to them about healthy food choices. We're trying to really integrate health and wellness into this whole plan.

What Comes Next

This has totally been a work in process. We continually look at our procedures, our operational practices and our MOUs, and every time we have a chance to revise based on what's working and what isn't working, we do so. I think that has really helped. We have definitely gone into this thing with our eyes wide open—we want to keep our options open to continually improve operations and quality of care.

We are finishing our third year at Northside and could not be happier with how it’s going. And about a year ago, we started a similar process to open another school-based health clinic in Olathe, which is a community 10 miles north of Montrose, with even a little bit higher level of poverty. It opened December 15. And what we are working on this summer is trying to get that well-positioned to qualify for Federally Qualified Health Care Clinic status, which will provide some fiscal sustainability. Our goal is to make sure that these health centers are strong, organizationally sound and sustainable, and then to get out of the way. In other words, to make sure that we are not providing medical care, that we are working with our partners to do so. So while we are the owners of the clinic, our goal will always be to look to the community to be the service provider.

The Olathe clinic is school-based—it is located at Olathe Elementary School—but it is open to the entire community. The Northside clinic serves children age 0 to 18. When it opened, it served just three-year-olds through fifth graders. That was one of the adjustments that we made for the nervous physicians who were worried that we were going to take their business. We just expanded last year from birth to 18, which is the credential of our nurse practitioner. And we could do that in part because now the physicians are totally on board. They love what we are doing and see the benefit, and are helping us. It has just been wonderful to have them fully on board.

The county commissioners, who are very, very conservative and did not think that this was the right thing to do, are now totally supportive because they see how it helps Medicaid costs, which they are charged with.

So it has ended up doing what we hoped it would do, be a safety net. And it does not end up costing the district financially, because it is the community solving a community problem. And that is the piece we really like the most about it.

As far as expanding, I am retiring in September—in just a few months. But I am very confident that these clinics are sustainable from the community support level, as well as the patient support level. And I could see expanding these into our middle schools—right now they are just at elementary schools. I might continue to work on this project, rather than with the district, with our community partners.

Seeing Results

These clinics are part of a broader strategy in how we view our families. It is going to take some time to look at the impact of this on academic achievement. But at least in part thanks to this broader approach, our district has a 20% higher graduation rate for Hispanic students than the state does.

We have so many programs, and so many relationships, in addition to these health clinics. For example, Mesa State College in Grand Junction, about 60 miles away, has a relationship with the district. We identify Hispanic students who are first generation college students, meaning their parents never attended college, who are doing well in school. Mesa will give them a scholarship to attend. We now have three teachers who have gone through that program, and they're back teaching in our district. That is another piece of the strategy. And once again, we work with community providers to do that.

Overall, I think it is showing students that we care about them, and getting their families involved in their education. And when you do that, students are just going to do better. These particular programs have been focused on our Hispanic population because it has increased so much from even 10 years ago—it has gone up about 50%, from 20% to 30% of students. I hope that this strategy is also making a difference with the community understanding the value of our new immigrants and what they bring to our community. And I'm hoping that the students feel valued.

The Biggest Lessons

To me, the big takeaways are that the mental health piece is so important, and that we needed to structure the protocols and the operational agreements so that the school district is the owner but that the community has to stay involved. For sustainability, the community partners need to remain engaged. And we need to really communicate what this strategy is doing, how it is benefiting the community, how it is helping taxpayers. Children are feeling better and they're going to learn better, so this is of course the right thing to do, but you also need to remember that there are many other political pieces and that you continually need to communicate how this is helping other areas of the community.

And something else. I remember thinking that, “Well, we've got these grants, I better move onto something else.” No, not exactly. It still takes a high level of involvement. And Jennifer Danielson, our nurse practitioner, is so great, and there is a fine line…She’s such a great care provider that we want her to be doing that, but she also so believes in this work that she is now taking on a bigger role as far as the next round of grants, public speaking and things like that. And that is so great because she's got authenticity, because she is a bilingual nurse practitioner.

As far as standardized test scores and other academic outcomes like dropout rates, time will tell. Obviously, we will track that. And in a few years, we will have extensive data, so we can really see how this has benefitted our students and community.

(Hat tip to the American School Board Journal, the National School Boards Association, and Sodexo School Services for letting us know about the innovative work going on in Montrose through their 2010 Magna Awards)


Since student health is

Since student health is obviously a priority and this district seems to understand the connection between health and learning, I am wondering why the district does not employ Registered Nurses as School Nurses in each of the school buildings, rather than health technicians with one supervising RN. School nurses provide essential services such as medication administration, emergency care and chronic disease management among other things to ALL children and staff at a rate far greater than 30 individuals per week, the number seen in the School Based Health Center. Most individual school nurses see 30+ students a day. School nurses also address mental health concerns, organize immunization clinics and provide levels of health assessment that health technicians are neither trained to nor legally able to provide. There certainly is a place for School Based Health Centers but School Nurses can manage many of the same services at a fraction of the cost and they do screen and refer students to the SBHS. Seems like this district is missing an essential link in student health services.