San Jose: School Nurses Put Health Care Back into the Schools

April 01, 2013

Today we’re featuring a case study from Health in Mind, a new report from HSC and Trust for America‚Äôs Health (TFAH), which details immediate solutions that can help close the achievement gap and create a healthy future for all children. Here, we learned about how San Jose Unified School District transformed the health of its school community through the work of school nurses.

Today we're featuring a case study from Health in Mind, a new report from HSC and Trust for America’s Health (TFAH), which details immediate solutions that can help close the achievement gap and create a healthy future for all children. Here, we learned about how San Jose Unified School District transformed the health of its school community through the work of school nurses.

By Kadesha Thomas

Melinda Landau vividly remembers the 12-year-old girl who had struggled with raging type 1 diabetes since age 2.   

Her A1C readings, which measure average blood sugar control, were beyond twice the recommended level, and she was not getting regular insulin shots. Her parents’ conflicts with gang affiliations and domestic violence were so volatile that the girl’s diabetes was a forgotten afterthought. Physicians were giving up, ready to dismiss the family as non- compliant for constantly missing appointments.

“She was headed towards being blind or losing limbs,” recalled Landau, RN, MS, manager of the San Jose Unified School District’s health and family support programs.

The girl had transferred from a school without a school nurse. Though she was only in San Jose Unified School District for one year before transferring again, she happened to be there during a school nurse demonstration project called Putting Health Care Back Into Schools. In late 2006, the Lucile Packard Foundation for Children’s Health and Lucile Packard Children’s Hospital at Stanford approached the district about partnering in a five-year demonstration project to evaluate rigorously what really happens to children’s health and academic outcomes when there is a full-time school nurse at the school. Landau and her team knew intuitively that full-time school nurses were the key to improving student health and academic performance, but there was limited hard data to prove it.

The district already had a team of nurses who were each responsible for two to three sites within the district’s 40 schools, but the project grant—$2.65 million over five years—provided funds for two elementary schools and two middle schools in low-income communities for each to have a full-time school nurse. The project also formally linked the full-time school nurses to a nurse practitioner. The nurse practitioner was hired for this project and stationed at a school health clinic, operated by School Health Clinics of Santa Clara County, which serves as a medical home to children. Funding was also allocated to design and implement a rigorous five-year evaluation, which included studying comparison schools without full-time nurses, conducted by doctoral researchers at the Stanford University School of Medicine.

“The hospital and the foundation wanted to work together on a project that could impact children’s health status and perhaps change the way that preventive and primary care is provided to children,” Landau said. Lucile Packard Children’s Hospital is the pediatric and obstetrics hospital at Stanford University Medical Center. The Lucile Packard Foundation for Children’s Health works with the hospital and the child health programs of Stanford University to prioritize children’s health and increase the quality and accessibility of children’s health care.

“We had a hypothesis that putting health care back into schools was critical,” said Candace Roney, executive director of community partnerships at the hospital. “We approached San Jose Unified and School Health Clinics because they had the infrastructure and leadership to help design a good demonstration project.”

It worked out extremely well for the girl with diabetes. Every day, a school nurse spent time teaching her how to take her own glucose readings and administer her own shots. The nurse also gave her ample training on nutrition and carbohydrate counting. The nurse also picked up on the girl’s undetected learning disability and helped her qualify for special education. “That would not have happened without a full-time school nurse,” Landau said.

Caring for Students’ Vision, Addressing Barriers to Follow-Up

The grant’s goals were to improve students’ chronic disease management, link students and families with medical homes, and, of course, push for more full-time school nurses. The state of California was averaging one school nurse for every 2,100 students, far below the recommended ratio of one to 750, according to data from the Lucile Packard Foundation’s resource bank, kidsdata.org.

Step one, Landau said, was to figure out how to do all of this. “We started with the low-hanging fruit. We were already doing vision screenings,” Landau said. But parents were not following up on referrals to get their children glasses or further tests. The full-time school nurses were able to follow up with these parents—several times, when necessary. They were able to uncover deeper issues that prevented parents from following through, like fear of being deported, lack of health insurance, not truly understanding the need for glasses, and simply being too busy, working two or three jobs, to make time for the eye doctor.

The school nurses forged partnerships with local organizations to get free eyeglasses and to get eligible families signed up for Medicaid or subsidized health coverage, regardless of citizenship status.

Follow-through on referrals jumped from 40 percent to 69 percent in the first year and continued to increase to 98 percent during this current school year. Because of the new partnerships and best practices gleaned from project schools, the rate has even increased to 55 percent in schools without a full-time nurse.

Supporting Learning By Managing Chronic Illness

The funders and the district also decided to focus on chronic disease management, particularly for students with asthma. When school nurses looked at county data, it was clear that the district had only identified about half of its asthmatic students. Additional data showed that asthma mismanagement was creating a gap in school performance: 30 percent of students without chronic diseases scored proficient or advanced on California standardized tests, compared to only 23 percent for students with asthma.

School nurses sent surveys to parents about asthma- related symptoms and followed up with phone calls to families with already-diagnosed children, as well as to parents who reported noticing asthma symptoms. It turned out that 55 percent had taken their child to the emergency room for asthma or related symptoms in the past year. The next step was to ensure that these children were linked with a medical home so they could be properly diagnosed and treated both in and out of school. The full-time nurses worked one-on- one with students and parents to teach proper inhaler use. Students who received care at the school health clinic had regular meetings with the clinic’s nurse practitioner. The nurses also established a partnership with Breathe California, the school health clinic and Stanford University School of Medicine to offer asthma education programs for staff, parents and students.

Recent data showed that the district’s numbers of children identified with asthma match county statistics, and during the 2010-2011 school year, academic performance was “almost on par,” between children with and without asthma, Landau said.

Since students’ health conditions have become more complex, the district also needed to establish a more direct flow of health information among school nurses, medical homes and the school health clinic. Landau said forging such a connection had been fraught with challenges, particularly because of patient privacy laws. For example, a school nurse would refer a student with no medical home to the school health clinic, but could not give any of the student’s identifying information. “So, the school nurse would have to call the clinic and say something like, ‘I’m sending you a kid with scabies.’ If that student didn’t follow up on the referral, the clinic’s nurse practitioner would call the nurse back and let her know the student didn’t come in. Then, the nurse would go back to the student and parent,” Landau said. Sometimes, there was no way of knowing if the student followed up on the referral.

 Without permission to share information, the district struggled to track referrals from the school nurse’s office to the school health clinic. Tracking referral  follow-up was also challenging for those students who had medical homes. Nurses discovered that language barriers were a significant reason why parents and students skipped follow-up appointments at their physicians’ offices. To ensure that students followed up on referral appointments from the school nurse, either to their own physicians or to the school health clinic, the district implemented a policy to have parents sign an exchange of information consent. This allowed the school nurses to collaborate with the school health clinic, knowing exactly who needed to be treated for what condition and when they were expected to come in for it. Families that did not have a strong relationship with their medical providers could also turn to the school health clinic as their medical home.

Connecting With Resources

The school nurses in San Jose Unified School District did more than just improve health outcomes for individual children and certain populations within the school. They were able to rally medical care and equipment for the district’s low-income families. In addition to free glasses and asthma education, the nurses also collaborated with community organizations to bring dental services, vaccinations and community health fairs to students throughout the district.

“They’ve redefined what a school nurse does. People say, ‘It’s so nice you get to work with kids.’ But school nurses are case managers in a population with really complex medical and social issues. So many of our underserved kids have chronic health problems and academic issues, and a school nurse is trained to navigate both,” Landau said.

The district has been able to shift funding from less needy schools to keep the full-time school nurses for an additional year after the grant ends in 2012. Landau’s goal is to find additional funding not only to keep the current school nurse capacity, but also to expand so that a full-time school nurse is stationed at each of the district’s 19 Title 1 eligible schools. Scattering a team of nurses among several schools is not going to have the same impact on health outcomes and school performance, she said.

“They strengthen the district’s ability to utilize community resources,” Landau added. “They sift through the needs of the population and decide what’s a priority and what’s a good fit so we can provide wrap-around services for our students. We can’t do that, if they aren’t here full-time as part of the community.”