Children in eastern North Philadelphia face a host of health challenges. They suffer from chronic illnesses at a higher rate than their counterparts in the five counties of Southeastern Pennsylvania. They are more likely to be in fair or poor health. They are more likely to face issues of access to and affordability of care. Rates of coverage by Medicaid or the Children’s Health Insurance Program are higher. Residing in a medically underserved area, these children often go without preventative or primary care. They may also lack a medical home. The establishment of a School-Based Wellness Center at Pan American Academy Charter School seeks to connect the educational home that already exists for these children with a functioning medical home. The Wellness Center is the result of a partnership among five Philadelphia entities: Education-Plus, Inc., the National Nursing Centers Consortium, Congreso de Latinos Unidos, Inc., Pan American Academy Charter School and Temple University Department of Nursing, College of Health Professions and Social Work. The School-Based Wellness Center converts the traditional school nursing model into one centered on the role of the primary care nurse practitioner. Traditional school nursing focuses on managing illness and meeting state mandates on screenings and immunizations. The School-Based Wellness Center places a greater emphasis on overall wellness by providing health education, preventative and primary care.
The Problem: Poor Access to Health Care for School-Age Children
Pan American Academy is located in a medically underserved area. Medically underserved areas are areas or populations designated by the Health Resources and Services Administration (n.d.) as having too few primary care providers, high infant mortality, high poverty and/or a high elderly population.
Results from the Public Health Management Corporation Southeastern Pennsylvania Household Health Survey (2010) illustrate the disparities between the area surrounding Pan American Academy and the five counties of Southeastern Pennsylvania as a whole. Table 1 presents data for the 19133 zip code in which Pan American Academy is located, as well as for 19133 and six surrounding zip codes, to provide a slightly broader picture of the area surrounding the school and a more complete representation of the school’s student body catchment area. These first two sets of numbers are then contrasted with the third dataset, which represents the five counties of Southeastern Pennsylvania: Bucks, Chester, Delaware, Montgomery and Philadelphia.
Table 1. Disparities between the area surrounding Pan American Academy and the five counties of Southeastern Pennsylvania
|Pan American Zip Code (19133)||Pan American and Surrounding Zip Codes (19133, 19121, 19122, 19125, 19132, 19134, 19140)||Southeastern Pennsylvania
(Bucks, Chester, Montgomery, Philadelphia and Delaware Counties)
|Children with Asthma||33.4%||22.1%||18.5%|
|Children Overweight or Obese||67.7%||56.9%||34.8%|
|Children with Medicaid Coverage||60.7%||60.4%||21.6%|
|Children with CHIP Coverage||29.1%||9.4%||7.3%|
Source: Public Health Management Corporation (2010).
In every health category in Table 1—general health, asthma and overweight/obesity—children in the Pan American Academy zip code have the worst results. The zip code immediate to Pan American and the six surrounding zip codes rate similarly in terms of Medicaid coverage, but there is a sharp disparity when compared to rates of Medicaid coverage for Southeastern Pennsylvania. Coverage through the Children’s Health Insurance Program (CHIP), which is provided for uninsured children and teenagers who are not eligible for medical assistance, however, is much higher in the 19133 zip code than in both the surrounding zip codes and the whole Southeastern Pennsylvania region (Public Health Management Corporation 2010).
The Solution: School-Based Wellness Center
The Wellness Center at Pan American Academy is a partnership among Education-Plus, Inc., the National Nursing Centers Consortium, Congreso de Latinos Unidos, Inc., Pan American Academy Charter School and the Temple University Department of Nursing, College of Health Professions and Social Work. The School-Based Wellness Center at the school seeks to alleviate the access to care issues discussed above by co-locating the children’s school and source of primary care. Currently, the school serves students in kindergarten through sixth grade; by the 2012-2013 academic year, Pan American will serve students in kindergarten through eighth grade.
There are 1,909 school-based health centers across the country. Nearly 1,100 of these centers provide some type of primary care. Fifty-seven percent are located in urban areas and 27 percent are located in rural areas (National Assembly on School-Based Health Care 2008). Most school-based health centers have at least some of the following characteristics. They are (1) located in or on school grounds, (2) integrated into the school community, (3) composed of a multidisciplinary team of medical providers, (4) connected to a qualified health provider, such as a hospital, health department or medical practice, to provide clinical services, and (5) required to obtain parental consent for services provided at the health center (National Assembly on School-Based Health Care 2008).
A three-year study in Ohio (Guo et al. 2010) examined the efficacy of school-based health centers. The study compared the health outcomes of students in schools with a health center to students in schools without a health center. The study found a 3.4 point increase in the self-reported Health Related Quality of Life total (74.1 to 77.5) among users of the health center, but not among other students. Asthma treatment and prevention is also an area where school-based health centers improve outcomes. In schools with health centers, asthmatic students were 34 percent less likely to have emergency room visits compared to asthmatic students in schools without health centers. School-based health centers prevented productivity losses of $542,761 by parents who would have had to take children elsewhere for care. They also saved $42,956 in travel expenses. Approximately 80 percent of students in the Ohio schools studied returned to class after visiting the school-based health center. In short, “School Based Health Centers reduce the need for parental work leave, limit the amount of classroom time missed for health care appointments, promote health and the use of preventative strategies, improve follow-up and compliance with treatment plans, and provide care regardless of the ability to pay for it” (Hansen-Turton 2010, 24).
The health center at Pan American Academy is staffed by nurse practitioners from Temple University. The nurse practitioner leads an interdisciplinary team of nursing and other health professions students. The team offers preventive health care and health education services. All services are coordinated by Dr. Nancy Rothman, the Independence Foundation Professor of Urban Community Nursing and Director of Community-Based Practices at Temple University Department of Nursing. Preventative health services offered to children include screenings for common chronic conditions such as asthma and diabetes, immunizations, and home assessments to determine environmental and health risks. The Wellness Center at Pan American Academy just finished its first academic year (2010-2011). According to Dr. Elizabeth Polizzi of Education-Plus, Inc., one of the funders of the Wellness Center, “Healthier students are more likely to be in school, and healthier students are then better consumers of education while in school.”
Early Indicators of Wellness Center Success
According to Pan American Academy (June 2011), an average of 25 students per day visited the Wellness Center for illness or injury. This figure does not include visits for the regular administration of medicine. The Center completed all vision, hearing and growth screenings. Nine students received vision examinations through the Eagle Eye Mobile Van. Eleven students received dental examinations through the St. Christopher’s Dental Van. The Wellness Center also provided primary care services to a number of children by prescribing medication through its collaborative agreement. No parents have refused this service to date. These interventions have helped to reduce the number of student absences due to illness and missed classroom time for medical appointments. The Wellness Center also has been able to reach local families through a bilingual monthly newsletter that contains information on nutrition and other health-related themes.
Also important is the improvement in attendance rates. The average daily attendance rate for the 2010-2011 school year was 94 percent. In 2009-2010, it was 92 percent. The average monthly attendance rates from 2009-2010 to 2010-2011 increased for every month except January and June. The relationship between school-based wellness centers and attendance is receiving increased attention. A study conducted in two urban high schools in western New York State found that students not enrolled in a school-based health center lost three times as much seat time, defined as the time students are available in school to learn or access support services (Van Cura 2010), as students with access to such a clinic.
Pan American’s attendance rates indicate that the presence of a school-based health center may help to ensure that students across Philadelphia are where they belong: in school. Lydia Jerchau, Director of Special Education and Student Services at Pan American Academy, believes that in five years the Wellness Center can connect the areas of mental health, social health, behavioral issues and the overall wellness of students. That is, the Wellness Center, and Pan American Academy as an institution of learning, can implement a truly holistic approach to the child.
The Asthma Home Assessment program, an intervention conducted by the Wellness Center targeting the high rate of asthma in the area around the school, is also proving successful. As Table 1 showed, children in the Pan American Academy zip code have a higher incidence of asthma than children across Southeastern Pennsylvania, 33.4 percent versus 18.5 percent, respectively. In the program’s first year at Pan American Academy, Temple University students conducted 20 home assessments. According to the Asthma and Allergy Foundation of America, “As much as 40 percent of the risk of asthma in minority children is attributable to exposure to residential allergens that could be reduced, if not eliminated” (Asthma and Allergy Foundation 2005: 3).
The Asthma Home Assessment program incorporates components of Asthma Safe Kids, a best practices program based on the American Lung Association’s Attack Asthma curriculum, and the Environmental Protection Agency’s Home Environmental Assessment. The program trains Temple health professions students to conduct in-home asthma education for caregivers. The goal is to identify potential triggers and provide management techniques. For example, dust gathers more quickly in blinds than traditional curtains because it is more difficult to clean blinds than curtains. Noting the presence of blinds versus curtains can identify a common trigger for asthmatic children. In an effort to ensure practices are continued, cleaning supplies, bedding materials and pest management tools are provided to eliminate other potential triggers. The program allows for coordinated care between the home assessment workers, the nurse practitioner at the Wellness Center and the child’s primary care provider. Eliminating such triggers reduces asthma attacks and subsequent emergency department visits.
The Role of the Nurse Practitioner and Pan American’s Partnership with Temple
According to Dr. Rothman, the key to making the Wellness Center at Pan American Academy work is the combination of two roles: the traditional school nurse and the primary care nurse practitioner. Many schools have certified school nurses. However, several factors prevent the traditional school nursing model from fully supporting students and their families. For instance, some schools only have nurses for certain hours each day. In addition, some charter schools may contract with agencies for health services. This makes it difficult for the nurse to truly become a part of the school community and limits the nurse’s capacity to observe children for changes in their emotional, mental, social and/or physical behaviors.
At Pan American Academy, there is a nurse practitioner on-site all day, every school day, to ensure continuity of care. Whereas traditional school nurses focus primarily on managing illness and ensuring compliance with state-mandated screenings and immunizations, primary care nurse practitioners have two very important, and different, characteristics: advanced assessment skills and prescribing power. This means that they can write a prescription for a child who visits the wellness center with a primary care illness, such as allergies. When appropriate, children can remain in school and do not have to miss additional class time to visit their traditional primary care provider during school hours. While parental consent is required for this service, to date not a single parent at Pan American Academy has declined permission.
Four nurse practitioners from Temple University’s Department of Nursing rotate time at the Wellness Center. Five to six nursing students assist with screenings and education. These students spend one day per week at the Wellness Center throughout the four years of their program. There is also a growing interest in involving public health students.
The opportunity to support the Wellness Center came at a perfect time for Temple University Department of Nursing. Over the last two academic years, the department completely revised its undergraduate and graduate curricula to reflect the type of nurses the country will need in the future. It is now mandated that the Nursing School find clinical sites for students in community health settings, such as the Wellness Center at Pan American Academy. Temple Nursing increased its emphasis on primary health care in community-based settings.
According to Dr. Fran Ward, Chair of the Department of Nursing at Temple, “The Wellness Center can be used as a symbol of change, particularly in an urban environment, that reflects the intermeshing of systems.” In this case, the connection is between the healthcare and education systems. Dr. Ward believes the Wellness Center is a type of pilot program that can demonstrate both the benefit of converting a traditional school nursing program into a primary healthcare setting, and the utility of the role of the nurse practitioner as a primary care provider in urban settings.
Social Return on Investment: ER Visits vs. Preventive Programs
School-based wellness centers offer an opportunity to decrease medical costs by decreasing the overuse of the emergency room (ER). In 2007, 116.8 million individuals visited the ER. The potential to divert individuals from the ER to other avenues of care, often preventive ones, represents a great cost-savings opportunity for insurers and the medical system as a whole (Centers for Disease Control/National Center for Health Statistics 2007).
ER diversion has come under increasing national scrutiny as a potential means to lower system costs and enhance appropriate access to care. For instance, the Convenient Care Association (CCA), the national trade association of companies and healthcare systems that provide consumers with basic healthcare services in retail-based locations, has assessed the percentage of ER users who could safely be diverted to more appropriate sources of medical care. According to the CCA (2011), approximately 55 percent of those utilizing the ER could receive care elsewhere, or have previously received care elsewhere to prevent a similar visit. Of that 55 percent, 26 percent are considered emergency primary care treatable (the condition can wait 12 hours to be treated by a primary care provider), 23 percent are non-emergent visits, and 6 percent are emergency department needed but preventable/avoidable (the patient is suffering an acute episode of a chronic illness, such as asthma, and better management of the chronic disease might have prevented the acute episode).
Aetna Health (2011) estimates that the cost of a visit to the ER for asthma is $600; if the patient is hospitalized, the cost could rise to approximately $6,000. The estimated cost of one asthma home assessment conducted by the Wellness Center at Pan American Academy is $50. During its first year, the Wellness Center staff conducted 20 home assessments, for a total cost of $1,000. Assuming that each student who received a home visit has one visit to the emergency room without hospitalization, the estimated cost for that care is $12,000. If the Wellness Center’s interventions keep each of those children from visiting the ER once with an acute asthma attack, the Asthma Home Assessment will have saved $11,000 in overall healthcare costs. Note that this is a conservative figure because the calculation assumed a hospital visit without overnight stay. This is one concrete example of the social return on investment the Wellness Center can provide; there is ample additional opportunity for savings and social impact.
Figure 1: Example of the Wellness Center’s Social Return on Investment
Policy Implications and Replication
Across the country, many school-based health centers bill public insurance for health center visits. This includes Medicaid (81 percent), CHIP (68 percent) and Tri-Care, the health program serving the military, including active duty, National Guard, Reserve, and retirees, and their families and survivors (41 percent). Additional funding sources include state government (76 percent), private foundations (50 percent), sponsor organizations (49 percent) and a school or school district (46 percent). Approximately 39 percent of school-based health centers receive funding from the federal government (Ammerman 2010: 1). Medicaid is the largest source of non-grant funding for school-based health centers, yet many are challenged in accessing this funding stream. This is a significant barrier to the expansion of school-based health centers.
The primary challenge to the long-term sustainability of the Wellness Center at Pan American Academy, and other school-based wellness centers in Pennsylvania, is the lack of reimbursement for services. The National Assembly on School-Based Health Care currently advocates for policy changes to allow for Medicaid reimbursement of services at all school-based health centers. Ultimately, school-based health centers must be recognized as an eligible provider or primary care service type. One way to do this is to link the school-based health center to a sponsoring organization, such as a hospital, nonprofit or public health department (National Assembly on School-Based Health Care 2011).
An additional challenge is the non-credentialing of nurse practitioners (NPs) as primary care providers. The utility of NPs in non-traditional practice settings is increasingly being recognized. Writing about retail-based convenient care clinics, Hansen-Turton et al. (n.d.) observed:
NPs, possessing advanced clinical skills and a strong desire to expand access to care, are identified as the ideal provider to be in this setting and deliver these needed services. Easily accessible and affordable, this health care model provides an entry point into the health care arena where NPs have the potential to triage patients to the needed level of care, advocate for a medical home for all patients, and reduce unnecessary visits to Emergency Rooms and Urgent Care Centers, while diagnosing and treating common health problems.
Yet only 33 percent of HMOs have a policy for credentialing nurse practitioners as primary care providers, and only 40 percent of companies with Medicaid plans in place credential nurse practitioners as primary care providers. Even when nurse practitioners are recognized as primary care providers, only 52 percent are reimbursed at the same rate as primary care physicians (Hansen-Turton et al. 2006: 204).
The Wellness Center at Pan American Academy is innovative in its blending of health and education. It brings healthcare services to users (students) at a convenient and consistent point of access (school). By providing preventive care and chronic disease management for children in eastern North Philadelphia, the Wellness Center also meets a crucial need. If the reimbursement barriers mentioned above are lessened or eliminated, the Wellness Center at Pan American Academy has the potential to further improve health outcomes and decrease health disparities. The demand for replication already exists. In 2011-2012, the partnership is opening a Wellness Center at Belmont Academy Charter School in West Philadelphia.
About the author
Kaitlyn Woods is a candidate for the Master of Public Administration degree at the Fels Institute of Government at the University of Pennsylvania. She received a Bachelor of Arts in Political Science from Rosemont College. Kaitlyn previously worked in the nonprofit field and focused on community cultivation, fundraising and advocacy. She is currently the Executive Director of the Public Policy Challenge, an interdisciplinary competition for policy-minded students, hosted by the Fels Institute of Government.
Aetna Health. (2011). What Health Care Really Costs. Available at http://www.aetnabetterhealth.com/pakids/members/what-health-care-really-costs/ (accessed July 17, 2011).
The Allergy and Asthma Foundation of America and The National Pharmaceutical Council. (January 2005). Ethnic Disparities in the Burden and Treatment of Asthma. Available at http://www.npcnow.org/App_Themes/Public/pdf/Issues/pub_related_research/pub_diversity/Ethnic-Disparities-in-the-Burden-and-Treatment-of-Asthma.pdf (accessed July 17, 2011).
Ammerman, A. (2010, August). School Based Health Care: How It Is Funded. Southeast Education Network. Available at http://www.seenmagazine.us/articles/article-detail/articleid/864/school-based-health-care.aspx (accessed June 5, 2011).
Centers for Disease Control/National Center for Health Statistics. (2007). National Hospital Ambulatory Medical Care Survey. Available at http://www.cdc.gov/nchs/ahcd.htm (accessed July 19, 2011).
Convenient Care Association. (2011, February 10). Co-Pay Waiver Project draft PowerPoint presentation. Slide 6, Population of Interest: Distribution of NYU Probability Weights. Source: Desypher Analytical Services, Analysis of Emergency Room Use with NYU ED Algorithm.
Guo, J. J. et al. (2010). School-Based Health Centers: Cost-Benefit Analysis and Impact on Health Care Disparities. American Journal of Public Health, 100(9).
Hansen-Turton, T., D. Bailey, N. Torres, and A. Ritter. (September 2010). Nurse Managed Health Centers: Key to a Healthy Future. American Journal of Nursing, 110(9).
Hansen-Turton, T., A. Ritter, N. Rothman, and B. Valdez. (July/August 2006). Insurer Policies Create Barriers to Health Care Access and Consumer Choice. Nursing Economic$, 24(4). USED
Hansen-Turton, T., S. Ryan, K. Miller, M. Counts, and D. Nash. (n.d.). Convenient Care Clinics: The Future of Accessible Health Care. Unpublished manuscript.
Health Resources and Services Administration. (n.d.). U.S. Department of Health and Human Services. Find Shortage Areas: HPSA & MUA/P by Address. Available at http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesignationAdvisor.aspx (accessed July 1, 2011).
National Assembly on School-Based Health Care. (2008). School-Based Health Centers: National Census, 2007-2008. Page 1. Available at http://www.nasbhc.org/atf/cf/%7Bcd9949f2-2761-42fb-bc7a-cee165c701d9%7D/NASBHC%202007-08%20CENSUS%20REPORT%20FINAL.PDF (accessed July 11, 2011).
National Assembly on School-Based Health Centers. (2011). Position Statement: Medicaid and School-Based Health Centers. Available at http://www.nasbhc.org/atf/cf/%7Bcd9949f2-2761-42fb-bc7a-cee165c701d9%7D/SBHCS%20AND%20MEDICAID.PDF (accessed June 5, 2011).
Pan American Academy Charter School. (June 2011). Wellness Center Summary Report.
Public Health Management Corporation. (2010). Community Health Database. Southeastern Pennsylvania Household Health Survey. Available at http://www.chdbdata.org/ (accessed July 14, 2011).
Van Cura, M. (August 2010). The Relationship Between School-Based Health Centers, Rates of Early Dismissal from School, and Loss of Seat Time. Journal of School Health, 8(8).