Model Proposals - Evanston Township High School Health Center

Watching a small free clinic that was built on good will and volunteerism grow in sophistication and capacity is a satisfying experience for funders, and we were pleased to recommend and approve this proposal submitted by HealthReach Inc. for funding at the August 4, 2005 VNA Board of Directors meeting.

The Evanston Township High School Health Center submitted this proposal for consideration at the VNA Foundation's May 2005 Board Meeting. It describes a feeder concept that identifies and provides essential services to school children who will one day attend Evanston Township High School and also serves as early intervention to address health concerns before they escalate. Up to 1,000 children will benefit for the extremely modest investment of $25,000, making this grant a true value-for-the-dollar investment. We found the strength of the feeder school concept to be persuasive in its own right, and look forward to seeing this program develop and expand.

---

PROPOSAL NARRATIVE

Background:

1. Organization's mission, history, overall goals and/or objectives.

The Evanston Township High School Health Center is operated in partnership with Evanston Township High School (ETHS), Evanston Northwestern Healthcare (ENH) and the city of Evanston Health Department (EHD) with partial funding from the Illinois Department of Human Services. The Health Center opened in February 1996 in response to a growing awareness that Evanston youth, particularly those with low income and of racial minority, experienced barriers to health care. The staff provides primary health care for all students with written parent or guardian permission to receive services. An advisory board composed of parents/guardians, representatives of ETHS administration and faculty, the student body, ENH, EHD, and community organizations meet biannually to oversee fund-raising, quality of care, and promotion of services. Our mission is to provide health services in a caring environment, promote healthy lifestyle practices, and reduce barriers to health care.

2. Description of current programs and activities. Please emphasize major achievements of the past two years.

The Health Center maintains an enrollment of about two thirds of the entire high school student population of 3,100 students. During the 2003-2004 school year, 2898 clinical encounters were logged for 883 students. These visits included evaluation and treatment of acute illness, follow-up and management of chronic illness conditions (primarily asthma), and health maintenance visits including routine and sports physicals, immunizations, contraceptive counseling and prescriptions, and sexually transmitted infection (STI) screening and treatment. Through its social work services, the Health Center provides case management, referrals to community resources, individual and group counseling, classroom presentations, crisis intervention, and assistance with Kidcare enrollment. Nursing staff work with classroom teachers to provide health education in a variety of academic departments such as special education, biology, and physical education. Annually, the staff provide classroom education to all ninth grade students regarding pregnancy and STI prevention. Recent achievements include:

1. the development and implementation of an individualized healthy lifestyle and weight management program, called Wellkits. The program is for students whose body mass index (BMI) is at or above the 85th percentile and who express interest in the program. Health Center staff presented an overview of Wellkits in New Orleans at the annual meeting of the National Assembly on School-Based Health Care (NASBHC) in June 2004.
2. the offering of Not on Tobacco (NOT), a group smoking cessation program developed by the American Lung Association for teenagers.
3. selection and participation in the Preventive Services Improvement Initiative (PSII), a program funded by a CDC grant to NASBHC. As part of this initiative, Health Center staff met quarterly with the staffs of other school-based health centers (SBHC's) in a Chicago cluster to develop joint objectives in the area of prevention. The process served as an important networking opportunity for SBHC medical providers to share experiences with regard to prevention strategies useful in working with adolescents.
4. the development and publication of Pawprints, the Health Center 's new biannual newsletter, now in its second year. The newsletter provides information about a variety of health topics of interest to adolescents and their parents.
3. Description of formal and informal relationships with other organizations.

All Health Center personnel are employees of Evanston Northwestern Healthcare (ENH), a major hospital corporation located in Evanston . Medical specialty services are available at ENH to students upon referral by the health care providers in the Health Center . The Health Center contracts additional social work hours from the ENH Bridges Program to obtain mental health services for uninsured students above and beyond what the Health Center 's social worker can provide. Dr. Susan Warner is an obstetrician/gynecologist on staff at ENH who volunteers hours on an as-needed basis to see uninsured students who need referral for more complex gynecologic care. The ENH Lab provides analysis of specimens sent from the Health Center for greatly discounted fees.

The Evanston Health Department (EHD) provides the Health Center with contraceptive medications. The two staffs cooperate on a number of public health initiatives. The Health Center maintains a representative on the EHD Community Health Advisory Board. Pediatric medical residents from Children's Memorial Hospital and nurse practitioner students from Rush University and University of Illinois at Chicago are precepted by health care providers in the Health Center continuously throughout the year. The Chicago Partnership for Health Promotion, a program of the University of Illinois Division of Community Health, provides a registered dietician to the Health Center weekly for individual nutrition counseling and periodic classroom presentations. In addition, the Health Center has working relationships with a wide range of community organizations including the Family Institute at Northwestern University , Family Focus, PEER Services, and the Evanston Substance Abuse Council.

---

Purpose of Funding Request

The target population for the proposed program is the medically underserved students in District 65, the elementary and middle schools serving Evanston and a small portion of Skokie . The school district has a current enrollment of 6,738 students housed in 16 school buildings. The ethnic distribution of students for the 2004-2005 school year is 41% Black, 41% White, 13% Hispanic, and 4% Asian, with the balance designated as American Indian or multi-racial. The numbers reflect a continuing rise in the number of Hispanic children in the district, with an increase of 5% since the 2001-2002 school-year, the first year for which this demographic data was recorded. The number of District 65 students designated as low-income rose from 32% to 41% during the last five years.

Evanston's rate of uninsured residents is rising along with state and national trends. Among families who registered students with the Health Center , the number of those without health insurance rose from 24% to 42% over the five-year period from 1999 to 2004. According to Families USA (2003) about 1,681,700 Illinoisans lack health insurance. That is about 15% of the state's population. Racial and ethnic minorities are more likely to be uninsured than whites. Among Hispanics, 29.2% are uninsured. Immigration status can be a barrier to qualifying for health insurance, because Medicaid and Kidcare do not cover many legal immigrant children.

Mary Larson, the Coordinator of Health Services for District 65 and a certified school nurse, identifies a number of problems that the program could help address. These include:

1. Many families experience difficulties accessing health care services for their children because they have no health insurance and/or are lacking regular healthcare providers. While no data regarding health insurance status specific to District 65 exists, the data for registrants at the Health Center would likely reflect the insurance status of the younger children living in the same community.
2. There are delays in students starting school due to not having had required school physicals and immunizations. In the fall of 2004, 372 District 65 students had not yet received the required physical exam or immunizations at the time of school registration two weeks before the start of school. Additionally, students moving into District 65 throughout the school year often experience lengthy delays in starting school due to the lack of physical exams and immunizations.
3. During the last school year, 94 District 65 students failed their hearing screenings. Approximately 50% of these students experienced a several month delays in receiving the medical follow-up necessary to determine etiology of the problems. In many instances, these children simply need impacted ear wax removed or chronic ear infections treated.
4. Asthma continues to be the leading cause of chronic illness among District 65 students and is a major cause of absenteeism. Many students are lacking appropriate medications and medical management. According to the Childhood Asthma Association, up to 20% of children in the United States have experienced asthma symptoms. Asthma is the number one cause of childhood emergency room visits and school absenteeism. For the current school year, there are 565 students with an asthma diagnosis attending District 65 schools.
5. A lack of health information for students about specific issues has been identified by District 65 staff. These include issues relating to puberty, hygiene, obesity, substance use, and sexual health, including pregnancy and STI's. The rising incidence of childhood obesity in the United States is recognized as a significant public health issue. It is estimated that 16% of all children and adolescents aged 6-19 are overweight (Hedley et al., 2004). The Illinois Campaign for Responsible Sex Education (Fall, 2004) reports 31,700 teen pregnancies in Illinois in 2002, with 18,500 (60%) ending in live births. Forty percent of Illinois ' new chlamydia and gonorrhea cases are among youth ages 10 to19, and 50% of new HIV infections occur in people under the age of 25. According to Substance Abuse and Mental Health Services Administration (2005), 11.9% of all Illinois inpatient admissions in 2002 for substance abuse treatment were children aged 11-17.

The proposed program will provide a nurse practitioner, working in collaboration with ENH pediatrician, Julie Holland, M.D., to bring specific primary care and health education services to high risk District 65 students. Appointments will be scheduled at times and locations convenient to students and their families. Specifically, this program expansion will address each of the needs identified above by the following mechanisms:

1. High priority will be placed on assisting eligible families with obtaining health insurance and on connecting families with health care homes where they can receive on-going care. The establishment of a health care home (also called a medical home) is advocated by the American Academy of Pediatrics (2004) and the National Association of Pediatric Nurse Practitioners (2002) as essential for all children. The Health Center is an approved Kidcare application agent and can assist families with the application process for this state insurance plan. The nurse practitioner is extremely knowledgeable about community resources and, after dealing with any immediate needs, will connect all referred families with the most appropriate source for on-going medical care.
2. Complete physical exams and immunizations will be provided at the Health Center located in ETHS for children not in compliance with District 65 admission requirements. Priority will be placed on getting the child into school as quickly as possible. It is anticipated that, due to the flexible nature of the nurse practitioner's schedule, all referred children will be accommodated within a week of referral. The nurse practitioner is prepared to schedule appointments during evenings and weekends if necessary.
3. Ear exams will be available to children after failed hearing screenings. The family may bring the child to the Health Center for these exams or the nurse practitioner may go to the child's home school to do the exam. Impacted ear wax will be removed, ear infections treated, and assistance with any necessary referrals given.
4. Asthma management and education will be provided to referred students experiencing frequent asthma absences or uncontrolled symptoms. Utilizing standardized asthma management protocols, the nurse practitioner will assess the child, family and environment and institute appropriate medical, behavioral, and environmental interventions. The family may bring the child to the Health Center for this care or the nurse practitioner may go to the child's home school. In some situations, it may be necessary for the nurse practitioner to go to the patient's home. In all instances, priority will be placed on involving the family in the care.
5. Individualized health education will be provided by the nurse practitioner to all referred students either in the Health Center located at ETHS or at the student's home school.

The goal of this program expansion is to provide earlier health interventions for Evanston 's most at-risk families. Program objectives include: 1) increased number of families establishing care with health care homes, 2) decreased delays in students starting school due to not meeting physical exam and immunization requirements, 3) increased numbers of students having medical follow-up after failed hearing screening, 4) improved asthma management for select students experiencing poor asthma control, and 5) availability of targeted health education for at-risk students.

Planning meetings between Distict 65 and Health Center personnel have already begun and will be intensified in July, 2005 when the program begins. Orientation to District 65 staff regarding the program and the referral process will be ongoing throughout August and September. Physical exams and immunizations will be scheduled starting in August, as soon as referrals from the health services staff are generated. All health services will be available throughout the year for the duration of the funding cycle ( July 1, 2005 - June 30, 2006 ).

The Health Center staff and Ms. Larson will develop publicity materials to educate parents, health staff, school administrators and teachers regarding the program. Teachers and support staff will be instructed to bring unmet health needs to the attention of the health clerk or school nurse assigned to their school building (14 schools are staffed by health clerks, and 2 schools are staffed by certified school nurses). If the health need meets program criteria, a referral will be initiated and sent to Ms.Larson. She will screen the request to ensure that the student meets high risk eligibility criteria (i.e. low income, immigrant status, lack of health insurance, lack of regular health care provider, or experiencing some other barrier to accessing care). Ms Larson will then contact the Health Center nurse practitioner who will arrange care on a case by case basis. An appointment will be scheduled at the student's school or at the ETHS Health Center , whichever location is most appropriate to address the health need. Written parent/guardian consent for providing medical care to a minor will be obtained before the rendering of any medical care. Parent/guardian presence will be requested (but not required) at all visits.

All direct services will be provided by a bilingual (English-Spanish) nurse practitioner employed by the Health Center . The nurse practitioner will devote 8 hours per week to the program. A secretary will devote 3 hours per week to the program. Ms. Larson and the school health staff of District 65 (health clerks and nurses) will play an instrumental role in referring students to the program. The administrations of District 65 and District 202 (ETHS) have approved the use of their respective sites for administration of the program.

---

Project Evaluation

1. Explain how you will measure the effectiveness of your activities.

The Health Center conducts program evaluation activities both quarterly and bi-annually, and will use the current system for evaluating this program expansion. All encounters are tracked using software (Clinical Fusion) created specifically for use by SBHC's. Statistics are generated and examined for utilization numbers and trends. Biannually, quality monitoring involving medical record reviews is required by both the Illinois Department of Human Services and ENH. The medical records created by this new program will be included in this rigorous quality improvement process. A tracking form specific to this new program will be created and utilized.

2. Describe your criteria for success.

The success of the program will be measured using the following objective outcomes:

1. Families of all students who are referred to the program will receive assistance with making connections to health care homes, and with applications for Medicaid, Kidcare, or other health insurance.
2. There will be a 25% decrease in the number of students out of compliance with required physical exams and immunizations at school registration in August, 2006.
3. All new students moving into the district during the school year and referred to the Health Center for required physicals and immunizations will be seen within one week of referral.
4. All students who are advised of the need for medical examinations following failed hearing screenings will be examined by the nurse practitioner within one month of notification.
5. All students who are referred to the program for asthma management will be seen by the nurse practitioner within 2 weeks of the referral.
6. All students who are referred for health education related to specific health concerns such as obesity, sexual health, or substance use, will meet at least once with the nurse practitioner within 2 weeks of the referral.
3. Describe the results you expect to have achieved by the end of the funding period.

It is expected that a number of at-risk children and youth in the Evanston/Skokie school district who currently experience barriers to accessing primary health care services will receive interventions that improve their health status. By bringing the model of school-based health care, which has a proven success record in ETHS, into its feeder elementary and middle schools, this program will demonstrate the benefits of early intervention in the lives of individual at-risk students. The hope is that improvements in health status of students referred to the program will be reflected in long term increased school attendance and sustained lifestyle modifications.

---

Program Budget

VNA Facts

VNA awards grants quarterly.

Enter your email address in the field below:

20 N. Wacker Dr., Suite 3118
Chicago, IL 60606
Phone: 312/214-1521
Fax: 312/214-1529