| Services offered |
The school-based clinic was designed to address several health
problems in the community by improving the physical health status
of school-age children in Tellico Plains and surrounding
communities and by identifying and treating health problems and
ensuring followup care. The clinic also provided a counselor and a
case manager to promote healthy psychological development
through group and individual counseling. The primary goal of the
clinic was to offer physical and mental health services in the school
setting. The project’s original service area included five schools in
the Tellico Plains area, with a combined enrollment of about
1,600 students, with plans to expand services into other schools in
the county.
Several organizations were involved in the project consortium.
The Monroe County Department of Education provided in-kind
contributions, space, and the clinic’s utility expenses. The
Department of Education provided maintenance, technology,
janitorial, and financial management services. Family Practice
Associates contracted with the clinic to provide two nurse
practitioners to work in the clinic 5 half-days per week. The
Peninsula Outpatient Center provided a case manager, training,
supervision, and a representative on the clinic’s management team.
The East Tennessee Community Services Agency provided partial
funding for the administrator’s position and a representative on the
clinic’s management team. The University of Tennessee at
Knoxville assisted in evaluating the project’s services. Finally, the
Monroe County Health Department provided materials and immunizations and a sliding fee scale model to help finance clinic
services.
Clinic services included early periodic screening, diagnosis,
and treatment; a school bus driver; and new-employee physical
exams. The nurse practitioner saw patients with acute illnesses,
such as strep throat, sinusitis, and ear infections. Tuberculosis skin
testing and tetanus shots were available to school faculty and staff
members. The clinic nurse also managed daily medications for
some students. Another service offered by the clinic was
participation in Tennessee’s Vaccines for Children Program. All of
these services were available to students, faculty, and staff
members of the Monroe County Department of Education.
Behavioral services also were available, at the parent’s request, to
students in kindergarten through eighth grade.
In rural areas, innovative methods of service delivery are
essential. To make the clinic as accessible as possible to the largest
number of students, it was established in a school building with
another school across the parking lot. The students at these two
schools had access to a full-time school nurse and a part-time nurse
practitioner who was onsite 3 half-days per week. The outreach
nurse traveled 4 days a week to the other three schools in the area
and to students’ homes as necessary. Nurse practitioner services
were offered a half-day at two other schools.
Parents could give
their written consent for nurses to provide over-the-counter
medications to students. If parents chose to use the nurse
practitioner service for their children, they filled out a complete
medical history for the first visit. Future office visits did not require
the presence of a parent; however, parents could call the clinic to
schedule an appointment, and the clinic would call the child out of
class.
Counseling services were provided in very much the same
manner. Parents came to the office for the initial intake, which
normally was performed by a case manager with a master’s degree
in counseling, after which the child was able to see a counselor. The
case manager also conducted home visits to collect intake
information and traveled to two other schools in the area to provide
counseling services.
The project’s first year was stressful for the staff members
because they had not anticipated the high demand for services. The
clinic simply did not have the staff resources to accommodate the
demand. In addition, many people in the community did not
understand the purpose of the clinic, so project staff members used
Parent Teacher Organization meetings as an opportunity to educate
parents about the clinic’s services. Perhaps the biggest challenge
was dealing with third-party reimbursements. It took more than
2 years to obtain a provider number with State Medicaid managed
care organizations; even then, many managed care organizations
did not recognize the value of school-based health care services. |
| Results |
More than 82 percent of the county’s student body was
successfully enrolled to receive clinic services. The clinic logged
more than 19,000 encounters with the school nurse and nearly
2,400 nurse practitioner visits. More than 600 students received
case management services, and more than 2,300 students and
families participated in group and family sessions. Although the
vast majority of clients were children and adolescents, the project
also served 200 adults. Every student with health needs became
enrolled in a health plan, and nursing staff provided followup care
to children and adolescents with special health care needs.
Project case managers averaged 21 home visits per month. In
addition, the licensed clinical social worker and the licensed
professional counselor averaged approximately 50 individual
sessions each month. |
| Replication |
This model could work well in other rural areas. It may be
necessary to contract for services that are not readily available
within the network. It also is necessary to have a dedicated, fulltime
administrator and to negotiate with State managed care
organizations to obtain a provider number.
The fact that the school system was a cooperative partner in this
effort played a major role in the project’s success. However, other
communities should be cautious because many school systems are
not as open to change as the school system in Monroe County.
Many agencies may be reluctant to contract with school systems to
provide services. In addition, other communities should not underestimate the amount of time, effort, and patience necessary to
obtain a provider number for third-party reimbursements.
Since the project saved $120,000 of its funds during the grant
cycle, the project will be able to extend its services for an additional
year. The clinic now has the necessary infrastructure to bill thirdparty
payers for provided services. Meanwhile, the project
continues to seek new funding sources to extend clinic services into
the years to come. |
