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Spokane, Washington  Est. May 19, 1883
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Spokane hopes to establish a school-based health clinic

Students who are well learn better and nurses are stretched thin

No workday is the same for Spokane Public Schools nurse Marianne Fischer. But there is one given – she’ll spend it running.

By 11 a.m. Wednesday, Fischer had handed out asthma plans for several students at Woodridge Elementary School, looked at a student’s rash, educated a teacher on another student’s medication, headed to Salk Middle School to help a support nurse deal with a diabetic student and rushed to help a student who was having trouble breathing. After that, she was off to Logan Elementary.

“A lot of days, there is no set plan,” said Fischer, who oversees six schools.

School nurses are stretched thin in the Inland Northwest, with many working at multiple locations, taking care of the increasing health care needs of student populations.

Health care plays a vital role in educational achievement and may even improve a district’s dropout rate, according to several recent studies. School officials would like to provide more school nurses, but there’s no money available, officials say.

Districts in Western Washington and nationwide are having success with an alternative, however – school-based health clinics, which provide a wider range of care to schoolchildren, some of whom may not otherwise have regular access to medical care. Communities in Schools, a nonprofit with a dropout-prevention mission, has landed a $50,000 grant to work on establishing a school-based health clinic in Spokane County.

“There are 1,700 school-based health clinics across the country, and we are one of the largest metro areas that does not have one,” said Ben Stuckart, director of the nonprofit’s Spokane chapter. “When we do needs assessments in the schools we’ve been in, health care is constantly in the top three needs. A school-based health clinic is something we’ve been looking at for the last two years.”

Such clinics offer a range of services, depending on their staffing.

Some are staffed with a part-time medical doctor and a registered nurse and focus on preventive care; others might have a full-time doctor, registered nurse and a mental health professional; the most comprehensive might also include visits by specialists, such as dentists and ophthalmologists. A majority of the clinics stay open a couple of hours after the school day ends and primarily serve students, but some also care for the students’ family members. Often insurance companies are billed, but some clinics offer services for free.

“We don’t want to turn kids away, so some will be billed (via their insurance) and some will be free,” Stuckart said.

Kathe Reed-McKay, director of health services for Spokane Public Schools, said a school-based health clinic would “improve what it is that school nurses aspire to do: mainstream health care for children.”

Stretched thin nationwide

The growing number of students with severe health conditions and the reduced number of school nurses started to snowball in the 1970s, officials say.

Funding failed to provide one school nurse per school in Washington at the same time many disabled children began moving from specialized facilities to mainstream schools.

Those students for the most part, no matter how severe the health condition, are entitled to do what their peers do, officials say.

For example, “we had a student that required a complex tube feeding who went on a field trip to the fair. By law, they are allowed to do that. We had to send a nurse there to do the feeding,” Reed-McKay said.

To handle the issue, “nurses are spending a great deal of time supervising staff to help with students, or training them and attending to students with high risks,” she added.

The number of school nurses is low nationwide, according to a study by the Robert Wood Johnson Foundation.

An estimated 66,000 nurses work in the nation’s 133,000 schools, according to the study.

Only Delaware requires a nurse in every public K-12 school. Half the states require school districts to have nurses, and only 13 states meet the federally recommended ratio of one nurse per 750 students.

Spokane Public Schools has one nurse for every 1,450 students. In Central Valley School District, it’s about one per 1,156. Mead School District has one per 1,647, and Coeur d’Alene School District has about one nurse per 1,200 students.

“A growing body of research indicates that school nurses – when present every day – advance the twin goals of improving health and educational outcomes,” the study states.

The services offered by school nurses usually include management of chronic conditions, handling life-threatening allergies and asthma events, responding to epidemics, connecting students with treatment and health care providers, developing health plans for students, administering medications and providing first aid.

That mix is missing more prevention measures such as immunizations, medical professionals say, as well as health education on topics such as sexually transmitted diseases.

“If we can establish a system of school-based health clinics, I think we can decrease teen pregnancy and prevent sexually transmitted diseases,” said Stacy Wenzl, Spokane Regional Health District’s program manager for community health assessment and communicable disease prevention. “Current data shows that children under 17 in Spokane County are contracting chlamydia at a rate higher than others in the state.”

A majority of school-based health clinics are prohibited from distributing birth control, but they do offer contraceptive counseling, as in the Seattle School District.

Wenzl is a member of the steering committee working to establish a school-based health clinic.

“I generally have a passion for adolescent health, and I think there are health problems going on in which we could do more to help,” she said. “And there is a direct link between health and academic achievement.”

Many need specialized care

Washington law does not require each school to have a licensed medical professional, and often teachers as well as support staff are trained to give out medication or use an EpiPen in an emergency.

“We train the staff to call 911” if they are unsure what to do, Fischer said.

“Asthma, severe allergies and diabetes have all gone up steeply for children, which requires more supervision during the school day,” Reed-McKay said.

Steven Powell has Type 1 diabetes. The eighth-grader is a regular visitor to Kim Douglas’ office at Salk Middle School. Douglas is a registered nurse and one of several who work part time. Powell reports to her on his blood sugar levels and insulin intake, or he’ll go to the office “if he feels funny,” Fischer said.

If Douglas, who splits her time between two schools during her six-hour shift, can’t be there, then he can call her on his cell phone to check in. “I try to see him once a day,” she said.

The teen is just one of hundreds of kids in the Spokane district with a health care plan because of a chronic or life-threatening condition, Reed-McKay said.

“Spokane is located in a medical hub area, which means an increase in the number of students with complex medical conditions,” she added.

Douglas said in situations such as Steven’s, a school-based health clinic would help immensely because if she were unavailable to help him, he could go there.

Studies by the University of Washington of school-based clinics in Western Washington have shown that students who use them do better academically, have more regular attendance and are less likely to drop out.

TJ Cosgrove, director of the Seattle and King County Community and School-Based Partnerships, said school-based health clinics there are “a great opportunity to help kids be healthy and learn better.”

The Seattle School District has 14 – 10 in high schools and four in middle schools.

Stuckart, who is heading up Spokane’s clinic effort, is looking at several models including the Seattle School District.

There, the first school-based health clinic opened at Rainier Beach High School in 1988.

“The pilot program proved successful, and gained interest and support from the city of Seattle, which led to the first Families in Education levy, a tax to support it, which passed in 1991,” Cosgrove said. “Part of that tax was to expand school-based health centers,” but it also helps fund school nurses.

Seven more clinics were opened, all in high schools. That’s a good location for the facilities because adolescents face health risks from sex, drugs and mental health issues, he said. Plus, teens are “much better positioned to access health care as opposed to a primary setting where a parent is needed to help explain,” he said.

The clinics are funded with about $3 million annually from the city tax, and four partners contribute additional resources – Group Health, NeighborCare Health, Swedish Medical Center and Seattle Children’s Hospital.

“The big picture: We are creating an access to health care for kids who would not otherwise have received it or even sought it,” Cosgrove said. “These are the same kids who populate the achievement gap – low-income families who are poorly (insured) or uninsured.”

With Spokane Public Schools’ poverty rate of more than 56 percent, the district is an ideal location for such a clinic, Stuckart said.

The grant money awarded to Communities in Schools is to plan for a school-based clinic here.

“We also need to look at sustainability funding. We don’t want to open one, run it for three or four years, then shut it down,” Stuckart added.

The goal is to have a clinic established in Spokane County by fall 2011, Stuckart said.

While plans are preliminary in Spokane and the role of school nurses hasn’t been solidified, their role is vital to the clinic’s success, said Cosgrove, in Seattle.

“School nurses are the bridge between the students and the clinic,” Cosgrove said. “This makes the school nurse’s job easier; they take care of the basic issues and the clinics take care of the more complex health problems. It saves time for everybody.”

Reed-McKay added, “The clinics increase access to health care to assist with the well-being of the students and families.”

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