BY: COLETTA BARRETT, RN, FACHE, and SUE CATCHINGS, MA, CHES
In the 1980s, federal health care officials knew that adolescents were the most underserved age group in the United States. Data since that time has shown some improvement, but this age group is still virtually ignored in our health care system. Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana, has been at the forefront of partnerships and program development to address the health care needs of our youth through school programs.
A request for proposal from the Robert Wood Johnson Foundation in the late 1980s caught the eye of a Louisiana pediatrician practicing at one of the state-run hospitals in Baton Rouge. The foundation wanted to know if local communities would apply for funds to place a "disruptive innovation" into local schools in the form of school-based health centers. More than 25 communities were funded across the country, with Baton Rouge and New Orleans, two of the state's largest cities, granted dollars for school health centers. From that day forward, schools and health care providers have been teaming up to provide services to underserved youth across the state.
In 1996, the Louisiana legislature made a $2.5 million initial investment in the model of care. Through the years the legislature has increased its commitment, and today it supports 65 school-based health centers with $7 million funded through the state's Adolescent School Health Initiative.
The health centers flourished in Baton Rouge by bringing needed primary care and mental health services directly to the adolescents in the one place that they consistently congregate — school. Through careful data collection, school officials knew health centers were able to keep the students in school by addressing both medical and mental health needs.
The East Baton Rouge public school system voted in 2004 to outsource the school nurse program to the organization Health Centers in Schools, a provider of on-site medical and mental health services. About 5,000 mostly middle- and high-school students in seven schools already had been accessing preventive care from HCS through an integrated, primary preventive health care model involving physical and mental health providers working as a team with support team members known as clinic coordinators and medical assistants. With the school board's decision to outsource the school nurse program, the organization assumed responsibility for another 38,000 students.
COORDINATED CARE NETWORKS
Why outsource? In the words of Superintendent Clayton Wilcox in East Baton Rouge parish, "I am an educator; I know about education. I do not know anything about health care, and yet I find the school system education and support staff caring for a large population of children and teens who are very medically fragile."
In 2012, Louisiana's Medicaid population moved into managed care through the creation of "coordinated care networks." With this changing health care environment, HCS began to search for a partner and found one in Our Lady of the Lake Regional Medical Center, the largest hospital in the region. HCS became a wholly-owned subsidiary of Our Lady of the Lake Children's Hospital — another part of its family of services. HCS retained the East Baton Rouge school district contract for the school nurse program and the state contracts for the school-based health center program — but more was to come.
Our Lady of the Lake Children's Hospital and HCS already were collaborating with the East Baton Rouge public school system on several large projects, notably an influenza immunization program throughout the school system, the first such program in the state. It was a win-win for all of the partners — the school system could demonstrate a decrease in absenteeism, the hospital could demonstrate a reduction in influenza cases for the oldest and youngest of the population, and HCS was fulfilling its mission to keep students healthy so they could stay in school and learn.
HCS also offered Our Lady of the Lake pediatric residents a unique opportunity to practice pediatric care at a population level. Residents are rotated through the school health centers to learn risk assessment and how to integrate primary care and mental health services to better serve a pediatric population.
Our Lady of the Lake Children's Hospital began a pediatric residency program in 2012. It was only natural that the children's hospital leaders brainstorm with HCS about ways to integrate school health with advocacy and research projects that residents designed and implemented, all the while increasing access for children and teens in the school system and learning how to work with the community. The goal — and the result — was to create more population health programs, and they are still being implemented.
POPULATION HEALTH PROGRAMS
Here are examples of programs from the fruitful collaboration:
• Community Asthma Management. A trained respiratory therapist who is a certified asthma educator meets every child and teen who enters Our Lady of the Lake Children's Hospital with a diagnosis of asthma. She works diligently to educate the parent and the child or teen, showing them how to use inhalers, the difference between a rescue and a controlled medication, uncovering what the asthmatic's triggers are, and notifying HCS team members if the child attends a school where they provide care. The team members have been trained in Open Airways, an American Lung Association program.
The HCS medical director (a board-certified adolescent medicine specialist and an employee of Our Lady of the Lake Physician Group) has created a school asthma management program that delineates between whether a child's or teen's asthma is well-controlled or not well-controlled. If a student's asthma is not well controlled, his or her parents and primary care physician are notified. Because of this program, the Lake Physician Group has created a standard asthma action plan as part of its electronic health record.
• Pulmonologists have created a quality improvement controller medication program that is being tested on a small number of asthmatics. Early indications, through pulmonary function tests performed at school, indicate participating students are well-controlled and have better lung function because the controller medication is being given at school, twice each day.
• HCS leadership team members have worked with neurologists to develop and train school RNs on a new protocol for seizure-disordered children that is carried out at school.
• Working with allergists and the HCS medical director, EpiPens (epinephrine injectors for emergency treatment of severe allergic reactions) have been deployed on all campuses with physician orders for trained unlicensed school employees to administer EpiPens if needed. School nurse team members monitor the program and report any cases where an EpiPen has been administered on a school campus.
• HCS has brought in a vision screener called Plusoptix. This machine takes about five seconds to perform a vision screening on students, and the child or teen doesn't have to come close to the device or read letters or numbers. As a result, many fewer students are deemed "untestable." In the first year of implementing Plusoptix screening, the number of untestable students dropped from about 450 to fewer than 60. Cross-training and discussions with pediatric faculty have allowed their practices to begin using the same machine on all children and teens in their practices.
• Because HCS works with so many children whose families lack adequate transportation, nurses are piloting the use of telehealth equipment, through participation with the Franciscan Missionaries of Our Lady. Telehealth is a way for children and teens to "see" a provider without having to travel across the city. Our Lady of the Lake health system currently is considering deploying telehealth equipment to medical subspecialists to: 1) increase patient compliance without transportation; 2) allow parents to interface with the provider without having to travel to the provider's office; and, more importantly, 3) secure better patient care and parent compliance. The parent usually can walk to his or her child's school and participate in the "visit" to their primary care provider or sub-specialist.
• HCS is in the process of hiring three care coordinators who will work primarily with the RN team members and physicians to help bridge the gap of misunderstanding and confusion from parents whose children have a chronic health concern. Education and navigation of the health system — including the coordinated care network resources — will be a huge part of the program. Team members will work collaboratively with the care coordinators and the physicians to help patients and families understand the disease process, clear up any confusion caused by dealing with different care networks, and be a resource in each neighborhood for families who need additional assistance in utilizing the health system appropriately.
• HCS partners with local dentists to provide students access to oral health care and sealants through the American Dental Association's "Give Kids A Smile" program. HCS team members coordinate the collaboration between dentists and the school transportation system.
• Eight elementary schools participate in the Greater Baton Rouge Food Bank's Back Pack Program. Nutritious food goes home with the children each Friday so that they and their family have a source of food for the weekend.
• Hospital and community leaders interface with the HCS Student Alliance Council, an advisory group of high school students trained in advocacy skills, communication techniques and leadership as they work with HCS team members in every public high school in the parish. Members of the Student Alliance Council work closely with their health providers on each campus and interact with leadership from many different agencies and companies as they learn from adult mentors — and the mentors learn from them.
Weaving together programs born of such innovative thinking ties community providers and school health programs together. Physicians see school health personnel as extensions of their offices, and school health team members can focus on preventive health, behavioral health and screening services to an age group that traditionally has been underserved.
COLETTA BARRETT is a registered nurse and vice president of mission at Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana.
SUE CATCHINGS is administrator of Health Centers in Schools, Baton Rouge, Louisiana.