The Journal of School Nursing2022, Vol. 38(2) 210–219© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520986951journals.sagepub.com/home/jsn
Chronic school absenteeism directly affects educational outcomes while reducing school funding and reimbursement. Asthma is a prevalent disease associated with chronic absenteeism. This quality improvement project demonstrated classroom seat time preserved through use of school-based health centers (SBHC). The project also highlights the educational benefits, reduced emergency department utilization, potential cost savings to hospitals, and lower overall health care costs. Visit summary data were collected and analyzed to show quality asthma care and cost savings. Of 44 acute asthma visits that returned to class, an average classroom time of 3:42 hours were saved per student during the 2017–2018 academic year, resulting in a combined total of 166:07 hours saved. A minimum potential cost savings was estimated to be $67,770 for all 44 visits. Data analysis of structural, process, and outcome measures through quality improvement tools can demonstrate cost savings of SBHC care, which advocates funding for this pediatric care model.
quality improvement, school-based health, absenteeism, cost-saving, educational seat time, asthma
Asthma is one of the most prevalent chronic pediatric diseases, particularly among low-income communities. More than 6.8 million children nationwide have asthma (Bloom et al., 2013). Many children lack access to medical services for their asthma and often make unnecessary visits to the emergency department (ED), with African American and Latino children visiting the ED for asthma more than white children (Centers for Disease Control and Prevention, 2012). Asthma is also the most common cause of school absence in school-aged children with more than 13 million days of missed school annually (Akinbami, 2006). School absences and missed classroom instruction time directly affect students’ education and learning while also reducing school funding and reimbursement from chronic absenteeism. Frequent utilization of the ED also leads to an increase in overall health care costs for patients and creates further financial burden on the state.
School-based health centers (SBHC) are integrated medical and mental health care outpatient-licensed health clinics that are located in- or on-school premises through a collaborative relationship with the school and community. Recognized for supporting health, well-being, and academic support, SBHCs are often established in predominantly low-income communities and serve those who experience health equity disparities based on race, ethnicity, and socioeconomic status (Knopf et al., 2016; Love et al., 2018; Love et al., 2019). Despite these demonstrated outcomes, SBHCs are often subject to ongoing federal and state budget cuts, especially in times of government financial uncertainty and hardship. SBHCs are uniquely positioned to provide and assist with health services on school premises, with minimal classroom time missed for the patient (School-Based Health Alliance [SBHA], 2018; SBHA, 2020a). Furthermore, when children have chronic illness such as asthma, the amount of time caregivers takeoff of work to transport and attend a daytime primary care provider (PCP) office visits are significant (Goddard et al., 2019; SBHA, 2018; SBHA, 2020a). SBHCs allow less work missed for the caregiver as well.
Previous research on SBHC utilization has shown decreased hospitalization with estimated cost savings at approximately $970 per asthmatic child per school year (Guo et al., 2005; Keeton et al., 2012; Knopf et al., 2016). Furthermore, not only are SBHC-enrolled students less likely to miss school related to asthma, they are also less likely to go to the ED or be hospitalized for their asthma (Guo et al., 2005).
Quality improvement (QI) is used to show measurable improvement of processes and system level–based work to improve quality, safety, and value of health care and is usually based around efficiency, effectiveness, performance, accountability, and patient outcomes (Agency for Healthcare Research and Quality, 2016; Institute of Medicine [IOM], 2001; Riley et al., 2010). Health care quality defined by the Institute of Medicine (2001) states care delivered should be proven to work and get results (effective and efficient) as well as show responsiveness to patient needs and preferences (patient-centered, timely, and equitable). QI efforts must first explore the organizational system and program components and make data-driven decisions for patient-centered care. Utilizing the Institute of Healthcare Improvement framework (2020), this project utilized QI driven principles to demonstrate the effective, efficient, timey services of SBHC care while meeting ongoing patientcentered, asthma-related quality care. In QI, specific steps in a process, known as process measures, that lead to either a positive or negative relationship with particular outcome metrics (such as asthma care and disposition of services) are able to pinpoint concrete opportunities for health care process improvement and demonstrate value in systematic efforts. For this QI project, the micro and macro system level of care was examined with an element of data collection mindfulness to demonstrate the use of increased seat time and decreased ED transfers as they relate to the collaborative efforts of school nursing staff and SBHC referrals.
The SBHA (2020a) is a national nonprofit organization that provides support and promotion across the nation to include advocacy for continued funding that supports sustainability of SBHCs. Through a cooperative agreement with the SBHA, selected SBHCs were invited to participate in a 12-month Collaborative Improvement and Innovation Network (CoIIN) focused on making measurable improvements in the health of students. These standardized metrics, further defined as National Quality Indicators (NQI), included demonstration of classroom seat time–saved documentation. Seat time is considered a process measure in QI when examining SBHC services in terms of academic and healthrelated outcome measures. These standardized metrics allow federal and statewide comparison of SBHCs, which further defines the sustainability of the SBHC model (SBHA, 2020b).
As participants of the NQI CoIIN, this QI initiative provided the opportunity to demonstrate IOM quality domains of effective, efficient, patient-centered, timely, and value of health care services through SBHC utilization (IOM, 2001; SBHA, 2020b). The objective of this project study was to show the amount of seat time preserved when students in acute asthma exacerbation present to the SBHC (SBHA, 2018). This objective was chosen to highlight (1) the student’s education benefit of being able to return to class; (2) the school funding and reimbursement savings from reduced chronic absenteeism; (3) and a reduction in overall health care costs (from decreased ED visits).
In light of continued federal and state budget constraints, the role of SBHCs in protecting the welfare and safety of children and families needs to be highlighted now more than ever. SBHCs provide a valuable service in managing acute asthma exacerbations and decreasing school absences, missed classroom time, and health care costs (Bloom et al., 2013; Guo et al., 2005). National recommendations from the National Lung, Heart, and Blood Institute (NLHBI, 2007) include providing asthma education to all patients diagnosed with asthma regardless of severity, decreasing asthma-related ED use, and primary care connection and follow-up after ED visits for asthma (Academy Health, 2015). SBHCs have been recognized for following and achieving these national recommendations for both preventative asthma care and acute care asthma exacerbations (Goddard et al., 2019; Guo et al., 2005; Knopf et al., 2006; Lurie et al., 2001; Mansour et al., 2008).
Approximately 62,400 (9.7%) of children and 290,300 (10.3%) adults are reported to have asthma in Connecticut with more than $102 million asthma acute care charges: $56 million were for hospitalizations and $46 million were for ED visits (Connecticut State Department of Public Health [CTDPH], 2020). Of those $135 million charges, $102 million (76%) were charged to public funds (Medicaid or Medicare; CTDPH, 2020).
Asthma directly contributes to chronic absenteeism as it is the top reason for medical cited absences from school (Guo et al., 2005). Chronic absenteeism is defined as missing 10% or more of school (for any reason, excused or not) which calculates to 18 days a year or 2 days per month (Connecticut State Department of Education [CSDE], 2017a). Chronic absence is different from both truancy (unexcused absences with emphasis on compliance) as well as the average daily attendance (a school-level measure of students in attendance at school each day; CSDE, 2017b). Whereas, the monitoring of chronic absence gives a better overview of all absences (excused, unexcused, suspensions, expulsions) to focus on the overall consequences of lost instructional time to student and school performance outcomes. Chronic absences from school predict poor academic performance and is a leading indicator for school dropout (Attendance Works, 2020). Long-term consequences include less educated adults, who are underemployed, less financially stable, and have poorer health overall (Attendance Works, 2020). The National Collaborative on Education and Health (2015) called for addressing chronic absenteeism through a multipronged approach that specifically calls for SBHCs as a key strategy for ensuring student access to health care directly in the school in order to decrease missed school days.
Research has shown students with SBHC access have directly increased both classroom instruction time or “seat time,†which refers to the actual time students are in class during a school day (Knopf et al., 2016; Love et al., 2019). Students with access to an SBHC were significantly less likely to be sent home during the school day than those who did not have access (Van Cura, 2010). Research examining SBHC asthma care have also documented significant improvements in health outcomes such as less likely to miss school from asthma, less money spent on ED visits per asthmatic child per year, less likely to have asthma related restricted activity days, and less likely to go to the ED or be hospitalized with asthma from using the SBHC (Guo et al., 2005; Lurie et al., 2001; Mansour et al., 2008; Webber et al., 2003).
The CSDA (2020c) state data on chronic absenteeism indicate that statewide 12.2% of students are chronically absent from school. Most state-funded SBHCs are located in areas of health disparities and prevalence of poverty with higher state-average chronic absentee rates. In the districts in which this project was conducted, the school absenteeism rates reported are some of the highest in the state. The chronic absenteeism for the New London School District is 15.1% district-wide. At the time of this project, absenteeism rates were 15.5% in elementary, 24.1% in middle grades, and 26.87% in high schools, significantly higher than the state average (Edmondson et al., 2013). Absenteeism rates are currently 15.1% across the district with individual grade school chronic absenteeism rates unreported for this district (CDSE, 2020a; CSDE, 2020b).
For one full academic fiscal year (July 1, 2017–June 30, 2018), “seat time†data, or the actual time students are in class during a school day, were collected in order to measure the amount of seat time saved due to utilization of SBHC services. Seat time data highlight the value of the SBHC model to the patient, educator, and government funders. The project aim was to increase the percentage of documented seat time preserved among students seen at the SBHC for acute asthma exacerbation from 0% to 100% in the 2017–2018 fiscal year. Secondary aims included examining school funding and reimbursements in terms of chronic absenteeism with documented seat time data and analysis of disposition of care after each visit. The SBHCs are annually charged with demonstrating Agency and Department of Public Health key performance indicators that (1) >90% of students referred for asthma exacerbation have an asthma action plan (AAP) on file and (2) less than 10% of students being sent to the ED due to asthma.
This SBHC program includes 14 SBHCs across five school districts in three different communities in southeastern Connecticut. Each SBHC includes a full-time or part-time boardcertified advanced practice registered nurse (APRN) and a full-time behavioral health clinician. Only students registered for SBHC services are permitted to use the SBHC (known as “registered usersâ€). All students who attend a school with an SBHC were eligible to receive services once registration and parental/guardian permission was obtained. Three of the 14 SBHCs were chosen to participate in this CoIIN based on participation as early adoptees of the NQI from the SBHA.
The SBHC program is located in New London County, in Southeastern Connecticut. The district profile for the New London school district reports 47.4% (1,602) females and 52.6% (1,779) males with 72.7% (2,459) of students eligible for free or reduced-price meals (state average 38.0%). Hispanic or Latino (n = 1,705, 50.4%) are of majority with ethnic representation of 20.4% (n = 689) Black, 18.5% (n = 627) White, and 8.0% (n = 270) reporting more than one race. Chronic absenteeism rates are disproportionately higher in the New London School District among Hispanic or Latino students (19.5%), students with disabilities (29.4%), and students who are eligible for free or reducedprice meals (20.4%; CSDE, 2017a).
A baseline assessment of the acute asthma visits across all 14 SBHCs of the agency was gathered from data from the prior academic fiscal year (2016–2017). In 2016–2017, 14,450 medical visits were conducted with 182 (1.26%) of those baseline visits being for students with acute asthma exacerbation. Of the 182 baseline asthma visits to the SBHC, all 182 of the encounters did not require transportation to the ED. At the three targeted SBHCs, of 380 students who were enrolled in the SBHC with an asthma diagnosis, 61 (16.0%) students had a visit for asthma. Of those, 58 (88.0%) were sent back to class, 3 (5.0%) were sent home, and 0 (0%) were sent to the ER (see Table 1).
In the three SBHCs that participated in this project, 221 (27.0%) of the registered users (students who are registered and use SBHC services; n = 808) had an asthma diagnosis at the high-school, 133 (23.0%) of the registered users (n = 561) had an asthma diagnosis at one of the middle-schools, and 26 (13.0%) of the registered users (n = 197) had an asthma diagnosis at the other middle school. In the academic year of this project (2017–2018), 201 medical visits by students who had an asthma diagnosis were provided by these three SBHC sites, and 44 (22.0%) of those medical visits were for acute asthma exacerbation.
The SBHC Director contacted the Connecticut Hospital Association (CHA) for assistance in accessing specific ChimeData related to pediatric acute asthma care in the Connecticut hospital systems. The ChimeData database, the most comprehensive hospital database in the state, is a data collection and reporting service for all acute care hospitals and assists hospitals in meeting regular reporting requirements to support the CHA’s advocacy efforts (CHA, 2014). The ChimeData database includes over 31 million patient encounters from 1980 to present, UB-04 claimsbased data from inpatient admissions, hospital-based outpatient surgery, and ED nonadmissions. The average ED visit charge for children in Connecticut was $1,631 per visit, with $2,145 per visit for adults. The average hospitalization charge for children in Connecticut was $15,316 per hospitalization, with $24,175 per hospitalization for adults (CHA, 2014). In comparison, the average cost of an SBHC asthma visit is $125/visit, more than 13 times less expensive than a visit to the ED.
A QI team charter was formed based on the early adaptor SBHC sites from the National Quality Initiative CoIIN through the SBHA. The QI team included the Director of Medical Services as the QI Champion and project team lead, three APRNs located at three different SBHCs (two middle schools, one high school), and additional administrative and information technology (IT) support as needed.
The Institute for Healthcare Improvement (IHI) framework for selecting, testing, and implementing change was used to guide this QI project. Using a prioritization matrix referred to as the “5 P’s†(purpose, people/patients, professionals, patterns, and processes) for clinical microsystem, assessment was conducted (IHI, 2020). Significant enablers were identified based on these five dimensions including: agency mission alignment (to make life better for children), to improve asthma documentation in structured data entry in the electronic health record (EHR), to include APRN staff in QI processes and instruction, to highlight patterns of SBHC use (uninterrupted school time for students, decreased ED referrals, decreased absences), and to highlight the importance of SBHC efforts and mission (impact of the work and need for continued funding to SBHC grants).
A root cause analysis was performed using a common QI tool called the fishbone (or cause and effect) diagram (see Figure 1). Significant barriers were identified that the QI team evaluated prior to the advent of the project. One such barrier is recognized in SBHC data analysis at large is that only the students who are registered for SBHC services (registered students) can receive care at the SBHC; therefore, data would only reflect those students at each school who were enrolled and used SBHC services (registered users). Additionally, the SBHC sites are located in underresourced communities in which families face barriers to adherence to asthma care regimens related to social determinants of health (e.g., inconsistent technology/phone or internet access, high mobility rates, and unstable housing), adverse childhood experiences, and conditions that make attending school difficult (National Association of School Nurses [NASN], 2020).
School nurses’ position in the school directly supports activities to address chronic absenteeism and acute asthma care (NASN, 2020). However, in the southeastern Connecticut region, where the SBHC sites of this project are located, the school nurses are employees of the school system and not the SBHC program. Therefore, the collaborative partnership is paramount to completing any asthma care, data collection, or QI at the schools. Students who are symptomatic are always seen by the school nurse first (a requirement of the SBHC referral system), who is authorized to triage and assess the patient, and perform interventions according to provider medication authorizations or established policies as well as parent/guardian permission. Therefore, acute asthma patients either completed treatment by the school nurse or can be referred for further evaluation by the SBHC APRN. In these collaborative roles, school nurses have key metrics for reporting set forth by their own health care administrative body and the department of education, which are different than the SBHC reporting metrics. Additional data metrics specific to the SBHC Agency QI and QI projects must be collected by the APRN SBHC staff as to not create additional burden on the school nurse partners. Within the supportive, collaborative relationship with the school nurses, the QI team recognized that extraneous data collection could lead to decreased productivity for the APRN.
However, the relationship fostered continued collaboration with the school nurse, specifically referral for asthma interventions after they have assessed and triaged the patient, and was recognized as an integral part of the process for QI.
The region(s) school administrators, business offices, and school personnel, including school nurses and supervisors, agreed for the QI project to take place at the designated sites. The Director of Medical Services and the Senior Director for the SBHC program sent both a letter and email that expressed the background of the project including the significance and desire to present this data to SBHC stakeholders. These communications included a clear, concise overview of the project, and contact information for the site staff, SBHC Director, and QI team lead for any questions or concerns. Emphasis on minimum burden to the school nurse staff was made with the sole request of continued support in helping the APRN obtain an AAP on file for the student (in the form of a photocopy if already on file with the school nurse). The SBHC registration forms allow communication between the SBHC APRN and the school nurse to include the AAP on file or other needed information regarding coordination of care for treatment.
The SBHC program utilizes eClinicalWorks as the EHR in these sites. Per recommendations of the SBHA (2018), certain measures were identified in order to document seat time, including date of visit, time-in and timeout, reason for visit, and disposition of care. The date of visit specifically helped organize data collection points. The time-in and timeout defined the visit length and totaled the student’s time in the SBHC, including the wait, treatment, and observation time. The reason for visit was also collected for all SBHC medical and mental health encounters (such as upper respiratory infections, chronic illness, behavioral health, wellness examination, etc.). Data elements to be collected were identified and reviewed with the agency IT team. With IT assistance, these data elements were built into the EHR. An APRN constructed visit templates to allow for accurate data extraction of these project variables. For the purpose of this project, visit codes that were marked “acute asthma exacerbations†were analyzed. Finally, disposition of care was collected in order to determine what happened to the student after the visit to include (1) sent back to class, (2) sent home, or (3) sent to the ED. A paper log was additionally created as a backup method for the computer documentation of these variables.
The QI team created an asthma seat time log to collect data on time-in and timeout of the SBHC, treatment provided, and disposition of the visit. An EHR template was created to track all of the acute asthma exacerbations visits to obtain data on length of visit, treatment, and disposition. A workflow chart was created for the APRNs at each of the three SBHC sites to clearly delineate the action steps, tasks (patient treatment, AAP on file, schedule follow-up), decision-making (asthma treatment, disposition of care), and data entry required (check-in, checkout, EHR tag and template use, seat time based on end of visit, and time of the school day presented to SBHC).
The three APRNs at the targeted SBHC sites (New London High School, Bennie Dover Jackson Middle School, and Pawcatuck Middle School) then collected seat time data related to SBHC asthma exacerbation visits for the full 2017–2018 academic year. This seat time data included (1) time-in of clinic appointment; (2) timeout of clinic appointment; (3) treatment provided related to asthma disposition post visit; (4) disposition of care (sent back to class, sent home, or sent to the ED). The QI team also met periodically with the IT staff to ensure data were being tracked and able to be extracted for data analysis at the end of the project.
The statistical analysis used to examine the data for this project was descriptive and not inferential (i.e., hypothesis driven). Calculation of seat time was conducted by the SBHA research and evaluation biostatistician and data analytics department. For the acute asthma visits seen at the three SBHCs participating in the QI project, the visit times were calculated using the time-in and timeout through the EHR. The average time of visits were then calculated to show the minimal amount of time students utilized the SBHC services and then returned to class. Based on what time of day the student was seen, hours of classroom instruction or “seat time saved†was also calculated for each visit. These were specific to each school site, as the different schools have varying hours of operation. Seat time hours saved were totaled for the 45 visits seen and returned to class. Classroom instruction time saved was also calculated by utilizing the time of day the student was seen at the SBHC, and what happened to them after the visit—also referred to as instruction time hours saved. These hours of classroom instruction time saved by utilizing the SBHC was additionally calculated to emphasize SBHC value to schooladministrator stakeholders.
For example, for each visit that was marked “sent back to class,†calculation of the number of hours between time the student left the SBHC (“time outâ€) and the time school was dismissed provides the “hours saved.†If a school day at one of these sites ends at 2:30 p.m. (14:30), the calculations are as follows: Visit 1 = Time out 9:30 a.m. = 5 hours saved (14:30–9:30); Visit 2 = Time out 1:30 p.m. = 1 hour saved (14:30–13:30); and so on. These hours are then added together (5 hours + 1 hour + ...) to total the hours saved, which is then divided by the total hours of the number of visits to equal the average hours saved per visit.
This project aimed to increase knowledge on organizational systems’ improvement of data collection and patient disposition of care for a health visit in order to benefit administrators and financial stakeholders in the school health field. This project gathered information about organizational practices. Institutional review board approval was obtained, with the project categorized as exempt.
In the 2017–2018 CoIIN project, the three SBHCs that collected asthma seat time visit data had 45 visits for acute asthma exacerbations during the school day and averaged 29 minutes at their visit. Overall, students (n = 45) that were seen at the targeted SBHC sites (n = 3) during the academic fiscal year (July 1–June 30) were most often to be sent back to class (n = 44, 98.0%) or home (n = 1, 2.0%) than to the ED (n = 0, 0%) after receiving acute asthma exacerbation care from the APRN at the SBHC. Of the 44 visits that resulted in being sent back to class, an average classroom instruction time (“seat timeâ€) of 3:42 hours were saved per student with 166:07 hours of total classroom instruction time saved by all 44 students.
Based on the CHA (2014) ChimeData of $1,631, less the average SBHC visit cost of $125, a minimum potential cost savings of $67,770 for using the SBHC (n = 45) versus those patients being sent to the ED (n = 0) for treatment was found (see Table 2). Utilizing the seat time metrics for these data, the analysis can therefore be extended and cost savings as a factor of seat time examined. With $67,770 dollars saved and 9967 minutes of seat time preserved during the period, the monetary savings per seat minute preserved (67,770 dollars/9967 minutes) amounts to ~$6.80 cost savings/seat minute preserved or ~$408 cost savings for each student seat hour preserved.
The data demonstrated that SBHC acute asthma visits take less time to receive the needed asthma exacerbation service and return to class as soon as possible, much less time than the amount of time if the patient were sent to the ED. This project paves the way for utilizing data for results-based accountability (RBA) performance analysis that is required for funding of services at SBHC sites. Extrapolation of this information to the other 14 SBHCs that are run by this agency, through funding from the Connecticut Department of Public Health, shows enormous cost savings through highlighting the acute asthma exacerbation encounter data alone. The potential cost savings was calculated across all 14 SBHCs in this program in the 2017–2018 fiscal year which totaled 13,859 visits, with 182 of those visits for students with acute asthma exacerbation (not to be confused with the baseline numbers noted above). Of these 182 asthma visits for the 2017–2018 academic year, 157 (86.3%) were sent back to class, 23 (12.6%) were sent home, and 2 (1.1%) were sent to the ED. Using the CHA ChimeData, at $1,631 average per ED pediatric asthma visit, for students seen with asthma across all 14 SBHCs yielded $271,080 (n = 180) minimum cost savings from SBHC care, accounting for the visit cost to the SBHC (see Table 3).
Additionally, patients who present to the ED are treated for their asthma exacerbation emergency and sent home. Whereas, at the SBHC, an acute asthma visit includes medical assessment, nebulizer treatment, intensive education, review or creation of an AAP, and a follow-up visit within a week of the exacerbation. The SBHC APRNs conduct asthma education to include trigger recognition, review of proper inhaler use, self-monitoring for asthma control and recognition of worsening asthma, and both create and help parent and guardians understand the AAP; all of which are NLHBI quality metrics (2007) for asthma care. All 45 (100%) students who presented to the 3 SBHCs during this project had an AAP on file, received asthma education, trigger recognition review, and a follow-up visit.
The QI team found ongoing knowledge deficits related to inhaler and nebulizer use among students with asthma frequently seen at the SBHC. Overall, there was a lack of both a written AAP on file at the school as well as a misunderstanding of function and use of the AAP. The SBHC APRNs were able to provide teachable moments by providing asthma prevention education, including reviewing medications, asthma triggers, and strategies promoting adherence to the AAP. The APRN assessed inhaler technique, and taught correct technique with spacer or face mask use if warranted. A copy of the acute visit note and AAP were sent to the PCP on file with the SBHC, who may be unaware of frequent school exacerbations or noncompliance to AAP and medications.
While the SBHC sites in these districts are the usual source of care for many students, the SBHCs are not the PCPs or the designated medical home. Therefore, the SBHC APRNs had limited access to primary care records, including the AAP, the asthma diagnosis severity, and any recent asthma maintenance visits at the PCP. Current school data systems have limited capacity to accurately determine all school absences and most reasons for school absences are by parent report. Absence attribution is therefore a limitation of this metric on the impact of chronic disease management on instructional time.
It should be noted that Connecticut is one of two states and territories that do not use the ADA reimbursement rate for schools. Instead, the CT Education Department core performance outcome measure for schools is chronic absenteeism. As chronic absenteeism is factored into school district reimbursement revenue rates as part of a more complex, multifaceted algorithm, the QI team was not able to calculate cost savings in terms of ADA or chronic absenteeism in revenue/dollars.
Many students enrolled in the SBHCs already have both an AAP on file and a medication authorization for the school nurse to administer either the student’s inhaler, give a nebulizer treatment, or both. Additionally, many of these asthma maintenance measures were also already provided by the SBHC medical services and the student’s PCPs. Therefore, some patients who went to the school nurse health office in acute asthma exacerbation did not need referral to the SBHC services as the onsite school nurses have the preparation, skills, and authority to treat the exacerbation in the school health office to include medical authorization for nebulizer treatment. Additional cost savings were not able to be calculated in these incidences in which SBHC services preemptively prevented acute asthma exacerbations through collaboration and partnership with the school nursing services. Ideally, a future endeavor would utilize this collaborative partnership to collect all the seat time missed with students presenting to the health office including time spent with the school nurse and sent back to class.
Anecdotally, some parents have reported not feeling comfortable signing medication authorizations for the health office personnel to administer asthma medications without a real-time assessment by the child’s PCP first. Therefore, some students are not enrolled in SBHC care, nor are they permitted for the school nurse to administer treatment, requiring the school nurse to either call the parent/guardian to come pick up their child from school and take them to their PCP or go straight to the ED, depending on exacerbation severity. Students who were sent to the school health office, then seen by the school nurse, given a nebulizer treatment in office, and who then returned back to class were also not included in this project, as a referral to the SBHC was not warranted. These patient encounters are not able to be captured in this QI project, as described previously, and are often a limitation of QI studies.
This QI project only highlights the minimum savings of $293,580 from baseline data collected on acute asthma visits where a visit to the ED was circumvented (n = 182) which were 1.3% of the total visits performed during the entire academic year (n = 13,859). SBHC visits also include physical examinations, immunizations, other chronic illness management and collaboration, injuries, annual health risk screenings, behavioral health appointments and therapy sessions, acute crisis interventions, and more. These other visit types also save money to the health care system in terms of both decreased ED utilization, decreased classroom instruction time (or preserved “seat timeâ€), and decreased loss of work time for parents and guardians. While a limitation of this project was that other visit types were not included for comparison in the data, this further demonstrates the variety of delivery service types that SBHC programs have to offer to stakeholders in terms of cost savings.
Accurate seat time data cannot be collected indefinitely without adequate on-site administrative support, ongoing EHR data collection and data mining, as well as ongoing data analysis of classroom instruction time missed. Therefore, while seat time data entry was conducted for the full academic year of this QI project, and the findings in terms of cost savings per seat time were striking, long-term extraneous data collection limit future comparison from this academic year.
Finally, for the sake of comparative analysis of cost savings utilizing the SBHC versus ED, the methodology assumes that all 180 acute asthma exacerbations would require ED services in calculating cost savings. Enrolled SBHC students are referred to the SBHC from the school nurse when they do not have a quick-relief medication at school, do not have medication authorization for nebulizer treatment by the school nurse, or who received treatment from the school nurse but are still experiencing asthma symptoms. In these circumstances, without SBHC availability, the school nurse determines whether the student’s condition warrants observation and not immediate ED services. While most students are sent either by emergency mobile services or transported by a parent or guardian to the ED in these circumstances, there is no way to assess definitively if all students in acute asthma crisis would have been sent to the ED. The authors recognize this limit in generalizability of the work.
By providing much needed health services on the school campus, SBHCs address both short- and long-term consequences to chronic absenteeism by directly minimizing school absences. Without an SBHC, after seeing a school nurse, and recognizes the need for further management of care, a student would be sent to see their provider or be sent to the ED. Asthma treated in the ED is costly for families and the health care system. This QI project and cost analysis shows that pro-active, preventative pediatric asthma care continues to be the most cost-effective and quality-based care modality in school-aged children.
This project demonstrates the value of SBHCs in managing asthma, promoting education, and decreasing health care costs while preserving time in the classroom. SBHCs bridge access to care gaps at low or no cost to the families who utilize them and, therefore, save health care and taxpayer dollars across the continuum. SBHC location on school property not only allows for easier patient follow-ups but contributes to building a trusted, well-known relationship between the student, school nurse, and provider. SBHCs allow students to access health care at school, parents to remain at work, school nurses to continue assessing and providing interventions for more patients, and teachers to focus on the students’ educational needs.
The need to protect the welfare and safety of the children and their families includes advocating for the SBHC program benefits and strengths as well as showing the clinical impact and worth to funding legislative bodies. As federal health care dollars continue to dwindle and state budgetary constraints require local government to scrutinize department of public health funding, school nurse and SBHC organizations are experiencing more pressure than ever to demonstrate fiscal implications of maintaining funding. This QI project demonstrates how collection and analysis of the identified structural, process, and outcome measures through QI can be used for legislative advocacy.
SBHCs are an ideal, accessible, timely, cost-effective “safety net†in pediatric health care delivery. School absences impact the student’s academic achievement and overall school funding. When children with asthma have an SBHC, less money is spent on ED visits and subsequent inpatient hospitalizations. Management of asthma exacerbations in the school are one of dozens of health care services provided by SBHCs. SBHCs save money for the school, the taxpayer, and the Department of Public Health and keep kids in their seats.
Per the criteria defined by the International Committee for Medical Journal Editors (ICJME), all authors have met criteria for authorship.
The authors would like to recognize Jesse Frese-White, MA, LPC, past Executive Director of CASBHC, Lea Ayers LaFave, PhD, RN, and Amy Cullum, MPH, RN of JSI Research Institute Consultants; Samira Soleimanpour, PhD, MPH, School-Based Health Alliance; Aymi Bennhoff, Rose Shima, and Jason Morrill of Child and Family Agency of Southeastern Connecticut.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by funding from the Connecticut Health Foundation and the Connecticut Association of School-Based Health Centers (CASBHC).
Anna Goddard, PhD, APRN, CPNP-PC https://orcid.org/0000-0003-0699-8126
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Anna Goddard, PhD, APRN, CPNP-PC, is an Assistant Professor at Dr. Susan L. Davis, RN & Richard J. Henley College of Nursing, Sacred Heart University; SBHC Consultant, Early Childhood Education Nurse Consultant, and Pediatric Nurse Practitioner at Child and Family Agency of Southeastern Connecticut.
Andrew Konesky, MSN, APRN, PPCNP-BC, is a Pediatric Nurse Practitioner at Child and Family Agency of Southeastern Connecticut.
Vera Borkowski, MSN, APRN, FNP-C, is a Family Nurse Practitioner at Child and Family Agency of Southeastern Connecticut.
LuAnn Etcher, PhD, GNP-BC, CPG, is a JAHF & Atlantic Philanthropies Claire M. Fagin Fellow, Robert Wood Johnson Foundation Nurse Faculty Scholar Alumnus, Clinical Associate Professor, Online DNP Program, Dr. Susan L. Davis, RN & Richard J. Henley College of Nursing, Sacred Heart University.
1 Dr. Susan L. Davis, RN & Richard J. Henley College of Nursing, Sacred Heart University, Fairfield, CT, USA
2 Child and Family Agency of South Eastern Connecticut, New London, CT, USA
3 JAHF & Atlantic Philanthropies Claire M. Fagin Fellow, Robert Wood Johnson Foundation Nurse Faculty Scholar Alumnus, Clinical Associate Professor, Online DNP Program, Dr. Susan L. Davis, RN & Richard J. Henley College of Nursing, Sacred Heart University, Fairfield, CT, USA
Corresponding Author:Anna Goddard, PhD, APRN, CPNP-PC, Dr. Susan L. Davis, RN & Richard J. Henley College of Nursing, Sacred Heart University, 5151 Park Avenue, Fairfield, CT 06825, USA.Emails: goddarda@sacredheart.edu; goddarda@childandfamilyagency.org
