Learning First Alliance

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Providing Medical Care at School: A Conversation with Nurse Practitioner Jennifer Danielson

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A few weeks ago, we wrote about the promise of school-based health centers (SBHCs). We also heard from Linda Gann, an official in Colorado’s Montrose County School District RE-1J who helped spearhead efforts to open two of these centers in her district. She told us about how her district came to embrace SBHCs as part of a broad strategy to address the needs of its growing Hispanic community and her experience planning and implementing these centers. Today Nurse Practitioner Jennifer Danielson tells us more, giving us a look at the day to day work that happens at her clinic.

Public School Insights: Tell me about school-based health clinics.

Danielson: One of the biggest keys to understanding school-based health clinics is that they are all different. There are some similarities, but a district or a school can tailor a clinic to meet its needs.

For example, our clinic works differently from others in that a lot of clinics have an enrollment form that parents sign at the beginning of the year. If their children go to the school nurse at any point, they get funneled back to a nurse practitioner or a physician's assistant. Sometimes the clinic calls the parents and sometimes it does not. Kids are essentially pre-consented to get care throughout the school year.

At our clinic, we talk to the parent for every visit. So while we are physically on a school campus, we function in a lot of ways like any small medical clinic or doctor's office. Everything is by appointment, though we do accept some walk-ins if we are available. And a parent is either present or part of the visit over the phone every time we see the kids. Kids never come see me without their parents wanting them to be seen and aware of why they are being seen.

We do have a convenience in being at this elementary school. When my patients who go here need a follow-up or have something pretty minor I can call the parent and ask, “Do you want me to take a peek?” I can see them and send them back to class a bit quicker than if they had to be picked up and taken to a doctor's appointment. But the parent is a key player in the entire process, which I think works well and also helps to avoid some anxiety on the part of the parent.

Public School Insights: What services does the clinic provide? Would you do something like set a broken bone?

Danielson: We have a full-time mental health therapist who does individual, group and family counseling. We have a dental hygienist who comes once or twice a month to do cleaning, fluoride applications and sealant applications.

I do sick visits, well visits, sports physicals, ADD management, depression management, anxiety management, and things like that. I prescribe the medications that go along with those things and order whatever labs or tests I need to. I do some on-site labs, and I am waiting for a machine that will allow me to do more labs. And we gave flu shots this year. They are the only vaccines we have given so far. I want to continue those and, little by little as we can handle it, expand in vaccines.

Some of the things urgent care clinics do we do not do. I do not set bones or do casting. But I do splinting, wraps and things like that. I do not place stitches or staples, but I remove them. I do some wound care.

I do see teens. And when a parent brings a child in, from about age 12 on, I ask if I can speak to the child alone. If the parent says okay and leaves the room, then anything that child shares with me, apart from abuse or that they are going to hurt themselves or hurt someone else, is confidential by law. I talk to them about risk behaviors, sexual health, reproductive health—the whole spectrum. But I refer out anyone who has reproductive health needs. I do what I need to do to safely care for them medically—for example, if a teenager needs certain antibiotics, I may have to prove she is not pregnant to safely give her the antibiotics. But most reproductive needs are referred out.

I think a lot of school-based health clinics work differently. They are set up at high schools and focus more on adolescent health than anything else. But we are on an elementary school campus, so we are a little different. Still, I think that reproductive health is part of physical health, so if it was up to me I would not say, “We will take care of all your physical health except for this piece of it.” And I think just because someone is not 18 or 21 does not mean that they should not have information to make good decisions, because unfortunately they are making all sorts of decisions without information, and without understanding the consequences. Picking and choosing what information we give kids is not helping them to make better decisions.

But how we have set it up is what the district, and the community, is comfortable with now, so we will respect that. However, the needs are still there, unfortunately. It's tough.

Public School Insights: As a nurse practitioner in a school-based health center, how does your job compare to that of a nurse practitioner in doctors’ office or hospital?

Danielson: I would say it is broader than it would be in those settings. We are a small clinic and do not have a medical assistant, so I do what in a bigger facility the medical or nursing assistant would. I do all the vitals and labs. I take weights, give shots and that sort of thing. I do phone triage on managing things at home without a visit. And I have a lot of administrative tasks I would not do in another setting.

But when it comes to my scope of practice, and what I can do in a visit with a child who is sick, for example, that is the same. I use the same process to diagnose them, determine what treatment would work, manage follow-up, order tests and things like that. So I do not have a limited scope, but I have additional tasks and responsibilities.

Every day varies. I usually get here between 7:30 and 8:00am. Thursdays I come late and stay late to see patients after parents get off work. Most commonly I leave around 6pm, so my days end up pretty long. Some days are almost entirely booked with patients and I'm doing almost all clinical work. At the end of those days I catch up on billing, finish my charting and update the logs I keep to help with the reporting for our grants. On a different day, I might only have a couple patients. And any day, I spend at least a half hour to an hour on e-mail correspondence, setting up conference calls, scheduling or sitting in meetings, and other administrative things. Sometimes that takes the whole day.

As the only medical professional here, I do a lot of phone triage. I am one of two bilingual staff, and about 65 to 70% of patients are Spanish speakers. When the family outreach coordinator is busy or not here, I do scheduling, take phone calls, help patients with registration forms and things like that. And I oversee the budget, order supplies and other such tasks. So there is a lot of variability, but my day is usually at least 50% patient care. And even that varies by time of year, what is going on with illnesses locally and that sort of thing. So it is hard to really say what a totally typical day would be. But we are getting to the point where we will need to get either administrative support or a medical assistant, and I think that the administrative support would be more helpful at this point.

Public School Insights: What has been the biggest medical emergency that you have had to handle at the clinic?

Danielson: Probably the scariest was a 10-year-old kid this spring who was really having significant trouble breathing. He needed oxygen. He needed other medications and was really sick. At the time, we did not have all the emergency equipment I would have wanted. We did not have oxygen, and he needed it probably an hour before he even got to the clinic. That was scary, because even though he came to the right place, I felt we couldn’t get oxygen on him fast enough. He was in the hospital for several days. He was on oxygen for eight days. So he was a really sick kid.

That was a light bulb. We had all of the equipment and supplies needed to give breathing treatments, but we did not have oxygen. That experience helped me get it ordered and set up for the future. SO that was probably the scariest thing that I have experienced here. Thankfully, I have not had too many serious emergencies.

Public School Insights: How do people in the community know to come to the clinic?

Danielson: Getting the word out is an ongoing process. We advertise in the paper periodically. We had a scroll advertisement on TV. We go to a lot of community functions. We have a family outreach coordinator. We go to back-to-school nights at all the schools in the district and we try to go to registration days. The health department refers patients to us. The local pediatric practice has our information and if a patient does not have insurance or for whatever reason cannot be seen, they will refer patients to us. And we are starting to get more and more patients who say family or friends referred them.

While we are part of the school district, we see any kid in the county, including kids who go to private school or who are home schooled. But most of our referrals come from within the school system—a flyer in a child's packet of papers, a letter sent to district newcomers, things like that. And as much as we feel we're putting an emphasis on outreach, we constantly hear people say, “We had no idea that you were here. We did not know that you existed.” So we are not as well-known as we wish we were.

Public School Insights: How does the clinic handle issues regarding health insurance?

Danielson: 50 to 60% of our patients have Medicaid or CHP+ [Children’s Health Plan Plus, a Colorado public health insurance plan]. A handful has private insurance. The remainder is uninsured. If a child does not have insurance, we still treat him or her. We have a sliding fee scale based on family size and family income for kids who are uninsured, and even actually for kids who have private insurance. Right now we only bill Medicaid and CHP+. Hopefully that will change.

And we will see any child who needs to be seen regardless of whether the family can pay or not. While we do not jump out and advertise it, if a family cannot pay we write-off the visit. We have a partnership with a local pharmacy to try to help with the cost of medication for uninsured children. And our family outreach coordinator works a lot with kids who are uninsured but eligible for insurance. She helps them get applications filled out and get enrolled in Medicaid or CHP+.

Public School Insights: Could you talk a bit about the preventative care work that you do at the clinic?

Danielson: My interests include nutrition and obesity, especially how obesity affects kids—their health, their self-esteem and how they do in school. I started a camp last winter open to kids of a certain age, about fourth through sixth graders. As it turned out, only girls signed up. It was called Power Hour. Once a week we met for an hour and did different activities and exercise. I took baseline blood pressures and weights. We calculated baseline BMIs, and we did some fitness testing the first day.

The first 30 minutes of each hour were structured exercise. We built up to 20 minutes of sustained cardiovascular exercise, walking or running laps. And we did some core work—sit-ups, push-ups, squats and stretching. Then we spent the second half hour playing some sort of active game.

That first group of girls came from December to February. I reintroduced Power Hour in April with an additional Peewee group for kindergartners and first- and second-graders that did games, stretches, sit-ups and push-ups. And I opened it to parents.

So we had a 30-minute Peewee Power Hour right after school, followed by an hour-long Power Hour. We had a really good turnout, on average six to eight Peewees, with quite a few older kids as my helpers. They came right after school, participated with the Peewee Power Hour and stayed for the older kid one. We had anywhere from three to seven parents doing exercises along with the kids.

We are off this month because of scheduling conflicts, but will resume Thursday mornings in July and go back to the afternoon when school is underway. The goal is for this to be a year-long program that gives kids the tools to be more active in their free time. Being active for an hour once a week is not going to make a big difference, but hopefully kids will learn activities they can do at home. And it is exciting that parents have been involved, because then they can make changes as a group at home.

There is one kid I started working with in September, before Power Hour started, on diet and exercise who has had very positive results. His BMI has come down about five points and he has maintained a small weight loss while growing an inch and a half. A lot of that is diet-related, but he and his mom, dad and brother—his whole family—has been involved in Power Hour. It came at a good time for him, so that when he successfully changed, and maintained, his diet he could add in some exercise.

And the primary care doctor of a child I do not see for medical care but who does Power Hour told me that she is continuing to lose weight and that the family is making good diet changes. So I think there have been some effects on kids. And while I cannot say I have seen huge changes in blood pressure or BMI, I've seen some kids embrace exercise. They come and tell me all of the things they do at home to exercise. And all of the kids who have done it seem to really have fun and enjoy the social interaction and the games. So I think it has been a positive program.

Public School Insights: How do you measure the performance of the health center?

Danielson: It is an ongoing challenge, figuring out how to measure anything. We try to keep track of how many families we help enroll in insurance programs, but given that some people use the clinic more like urgent care, coming once when they are sick and then never again, there are a lot of kids we do not know about. We think they are probably covered, since we helped them with the paperwork and submitting the application, but we do not verify. But that is one thing we try to track.

We track the number of patients we see, which gives us good information on the utilization of the clinic. The first year and a half the clinic was open, from October of 2007 until July 31, 2008, we saw around 500 patients, probably a little less. I've seen 500 this year so far. And when I first started here, I would see maybe 30 patients in a month. Now there are weeks I see 30, and there are months when I see 120. So we are really starting to pick up numbers.

We do not have a good way to track the effect of the center on students yet. We know of a couple kids who were always going to the school nurse and missing school frequently. One particular child has worked with both the mental health therapist and me, and this past school year she had many fewer absences than in previous years. That may be in part because of her maturing, but I think a lot of it is from working with the mom and the child to say, “You do not need to go home from school for this.” Now when she is sick, we see her during the school day and we usually send her back to class. So there are a few cases like that. We have talked about identifying some kids we see as at risk for missing school unnecessarily and tracking their attendance as we see them at the clinic over the years. But we do not have solid data on those types of effects yet.

Public School Insights: Are there any other questions that I should have asked you but did not?

Danielson: I think that the first thing I said is helpful, that every school-based health center is different.

A lot of people are very anti-school-based clinics. And I think that in an ideal world you would not need them. I think school-based clinics should be a support or an addition to the current healthcare system. I refer a lot of kids to the local pediatric group or family practitioners. Any time there's a chance I encourage children to establish a relationship with a primary care provider, and then we are here if they cannot get in with that provider or something happens at school or if they choose to come here for convenience. I think that is how it should be. I do not think that we should replace pediatric practices or be seen as the same in a different setting—we provide different types of services.

But if there are going to be kids in public schools, or kids in general, who do not have health insurance and do not have an option of where to go, school-based clinics form a really important piece of the safety net. In cases where both parents work or where they have transportation problems, they can help. And for routine pediatric care we can really help get kids back in the classroom more quickly.

So there is a good place in the health care system for school-based clinics, but they are not perfect, either. There definitely are challenges. We are lucky and we have a good partnership with a pediatrician. That is not always the case—a lot of school-based clinics struggle to find medical support for assistance. We definitely have it good compared to some, and probably because of that we can demonstrate that we provide really high-quality care to children.