The Richmond Register

May 28, 2013

Board to vote on school nurse options tonight

By Crystal Wylie
Register News Writer

MADISON COUNTY — School nursing services are “more than just putting a Band-Aid on — it’s taking care of the whole child; the whole family. It’s providing the child resources to care for every need,” according to Madison County Schools nurse coordinator Becky Carr.

During last week’s special-called work session, the county school board looked at ways to reduce its 2013-14 budget, including cuts to the school nursing program.

Carr, along with several school nurses and teachers, were present at the meeting to give some perspective on options being considered.

The board will vote on one of the three options during the regularly scheduled budget meeting 6 p.m. today at Madison Central High School.

For 22 years, both Madison County Schools and Berea Independent Schools had partnered with the Madison County Health Department to provide school-nurse services, so finding a provider is “a new venture for the school district,” Carr said.

In February, the health department announced it would not renew school-nurse service contracts with the districts without a substantial increase in payments.

Including the current school year, the health department will have incurred estimated losses of $830,000 as a result of dramatic reductions in Medicaid reimbursements for school-nurse services, according to Public Health Director Nancy Crewe.  

Since February, the district has been looking for a provider large enough to work with 18 schools, said Superintendent Tommy Floyd.

However, other health providers are having their own problems with Medicaid reimbursements and are hesitant to bring in their own nurses, said board member Beth Brock, who has a bachelor’s degree in nursing and also works as a clinical analyst.

Instead, the board will consider three options to hire nurses currently employed by the health department who have been working in the schools and are acquainted with the district’s students.

In the current year, the total cost of the school nurse program was $453,000, but was supplemented by a $150,000 reimbursement from the Chemical Stockpile Emergency Preparedness Program.

Those CSEPP funds are no longer available for next year, said Debbie Frazier, the district’s chief finance officer. However, one nurse position will be funded with $60,000 from the Federal Emergency Management Agency. The FEMA nurse is included in either option the board chooses.

The three options on the table

 "The current plan (with the health department) is impossible," Carr said, but she would feel "comfortable" with a plan that had a total of nine nurses.

For the first option, it would cost $454,300 to keep eleven nurses, the same number of nursing staff as 2012-13.

This option would include nine nurses contracted for 190-days, the district health coordinator (Carr) and a FEMA nurse, both contracted for 205 days.

The second option would include a total of 9 nurses and cost $394,300. Carr called this option “doable.”

Nurses would be in high schools around three days a week, two days in elementary schools and one to two days in middle schools.

Each nurse would be responsible for three schools a piece,  she said, instead of four or five schools, which each nurse would be required to cover if the board were to choose the third option.  

In the past, the health department had always acted as the program's “medical director,” which provides standing orders for nurses and authorizes them to assess children with parental consent, Carr said.

“Without that, we can’t touch a child except for emergency situations,” Carr said. “We have to be under the umbrella of a doctor to assess children.”

Carr said with this ability, nurses can treat children and “more than likely keep them in school.”

Without nurse assessments, teachers and office staff have no option but to send students home, she said.

“The district’s at 95 percent attendance,” Floyd said. “Our school nurses are a valuable tool for keeping kids in school; 95 percent attendance doesn’t happen by accident.”

However, the third option does not include a medical director and therefore no general consent under which the nurses may operate. It would cost $334,000.

Under this plan, the district would employ just five school nurses, the district health coordinator, and again, the FEMA nurse, whose pay is not included in the total.

This “bare-bones” option would put nurses in each school only one day a week at best, Carr told the board.

With this minimal staff, nurses would only be able to provide training, general “case management,” and emergency aid, she said. “We would not need a medical director because we wouldn’t have enough nurses to assess kids.”

School staff would be required to refer all sick students to their primary medical doctor, instead of having a chance to let a nurse assess them, treat them and send them back to class, Carr said.

Under the third option, nurses would be essentially “administrators of a health-care training program,” said board chair Mona Isaacs.

If the board were to choose the first option of nine nurses, the district could seek the help of Paragon Family Practice, a health care provider that could serve as medical director at no cost to the district, Carr said.

Paragon currently operates the two “Learn Well Be Well Clinics” at Madison Central and Madison Southern high schools. The clinics serve as a provider for children who do not have a primary medical doctor, Carr said. They also provide episodic care to those who choose to utilize their services with parental permission.

Private insurances are billed for the service and all of the equipment inside those clinics are provided by Paragon. The district covers the cost of utilities to run the clinic.

Although these clinics are an option for students, Paragon cannot address the needs in all the schools, Brock said.

“We never know from year to year how many special health care needs we will have,” Carr said. But, 400-plus staff must be trained each year on medical procedures such as nasogastric tube feeding, tracheal suctioning, tracheostomy tube changes, catheterization and changing colostomy/ileostomy collection bags.

Board member John Lackey asked why private insurance couldn’t be billed for every school nurse visit.

One school nurse stood up during the work session and talked about how she treated a student who already had a primary doctor who diagnosed the student with having migraines. The nurse called the child’s mom, gave him Ibuprofen and let him rest in the clinic for 30 minutes.

If that same child was seen by a clinic, the parent’s insurance would be billed, she said.

“And if every student that comes to see a nurse has their insurance billed, you’re going to have an uproar in the county,” she said. “If my child has a headache and they go to see a nurse for a Tylenol, I’m going to be furious about having to pay a $20 co-pay for that Tylenol.”

“Why?” Lackey asked.

“What’s 20 bucks? Pay it,” he said. “Do you want to pass that cost along to the tax-payers or do you want to cut another program? We’ve got to get those savings in line somewhere. It seems to me that if you’re getting a service that cost $20, it may inconvenience to take the child to the White House (Clinic).... That is shared sacrifice, why can’t you do that?”

The health department’s school health program director Michelle Malicote said last year, school nurses had 28,000 student visits. Around 82 percent of that number were unduplicated students.

“But that was with nine nurses (not including the FEMA nurse and district coordinator),” she added.

“There’s nothing wrong with having 10 nurses, 14 nurses, I’d love to have them all,” Lackey said. “But, we’ve got to make some cuts. Nobody wants to cut the PASS program. Nobody wants to cut Middle College. Nobody wants to cut para-educators and full-time substitutes, but somewhere, there’s got to be some shared sacrifice. Nobody wants their taxes increased either.”

Carr said some parents had mentioned paying a health fee for the school-nurse program.

“A lot of parents would send in a $25 fee to use the school nurses,” board member Becky Coyle said.

Lower income families could have the fee waived, but the district could generate enough to cover at least one nurse salary, she said.  

Floyd said that was an option the board could look into and Coyle suggested creating a parent poll to gauge interest.  

Crystal Wylie can be reached at cwylie@richmondregister.com or 623-1669, Ext. 6696.