School Nurses & Obamacare

While kids may be sad to hit the books again, the start of the 2014-15 school represents an positive period for school nurses.

Implementation of the Affordable Care Act started in 2010 and now 4.2 million people have selected a marketplace plan during the first five months of the open enrollment period, according to the most recent report by the Department of Health & Human Services on March 31.

As of that time, 15 states are running their own health insurance exchanges and an additional 36 states have marketplaces supported or fully run by the HHS.

“There’s an expectation that there’s an increase in the number of students with health insurance this year,” confirmed Carolyn Duff, MSN, RN, NCSN, president of the National Association of School Nurses.

“Basic dental and vision packages will be in place depending on the determination of essential health benefits. Medicaid has been expanded (in 21 states including DC, as of May) and, most importantly, the Children’s Health Insurance Program (CHIP) has resulted in more student coverage.”

Impact of CHIP

CHIP was created in 1997 and reauthorized with $33 billion in federal funds in 2009. It’s provided insurance for those with incomes above the eligibility for Medicaid to an additional 7.7 million children by the end of 2010. Funding continues through 2015 and the Affordable Care Act extended the program through 2019.

“School nurses will now be able to complete dental and vision referrals because of CHIP, whereas before that hasn’t been possible,” said Duff. “For students who are uninsured or underinsured, it’s traditionally been very difficult to get glasses.”

Additional screenings will also be available to children for behavioral issues, alcohol and drug use, autism and development, blood pressure, depression, HIV, lead, Hgt, Hct and tuberculosis. Even though school nurses may not personally be performing the screenings, they’ll be working with a better diagnosed patient population.

Because there’s finally a payment source, Duff said students will get the therapies they need to optimize their time in school.

“This will strengthen the ability of school nurses to partner with community health providers,” noted Duff. “It’s now possible to have individualized healthcare or education plans for all the students.

“We’ve had the Individuals with Disabilities Education Act (IDEA) ensuring that students with special needs receive the appropriate support. Within that is a category called ‘other health impaired’. With today’s medical home model, we can connect with providers to fully access both medical and educational resources.”

The need isn’t always medical. The category of “other health impaired” covers students with ADD/ADHD, for instance, so school nurses can provide feedback on how medication is working.

Preventing & Managing Chronic Conditions

Whether the child needs more medical, educational or therapeutic attention, there’s no doubt that school nurses will finally be included in the treatment team. Almost unequivocally, Duff said they’re thrilled at the chance to have a broader impact.

“Though the intention of the Affordable Care Act is that children will have greater coverage and access to specialists for chronic conditions, it doesn’t imply less reliance on the school nurse. The school nurse’s inclusion in the continuum of care will be important,” she said. “A pediatric allergist, for instance, may only see a child for a 30-minute period when there’s no wheezing. The school nurse, however, sees many symptoms as children engage in their school life, lunches and physical education.”

Because of the medical home model, Duff predicts tighter management of allergies, asthma, diabetes and seizures.

The increased emphasis on prevention trickles down to the school nurse as well. Evidence-based literature has validated early intervention for obesity for years and now students will see pediatricians from birth. The Affordable Care Act also mandates menu labeling for restaurants with 20 or more establishments. Although the rules have not been finalized, many chains have taken the initiative to post their own caloric information.

“I think this has had an effect on students,” said Laura Jannone, PhD, NJ-CSN, FNASN, associate director and coordinator of the school nurse program at Monmouth University. “Childhood obesity rates are dropping for the first time.”

Community Collaboration

In addition to working more closely with individual providers, school nurses are encouraged to team up with local organizations. In New Jersey, Jannone said schools and hospitals are working together to provide ECGs for students playing sports.

Sometimes, the partnerships fulfill simple needs. In one of the special interest groups Duff contributes to, a vision partnership that previously served uninsured children is altering its offerings. This year, they’ll provide transportation during the school day so parents don’t have to leave their jobs for eye doctor appointments as well as an extra pair of glasses for the kids.

“Just having insurance coverage doesn’t mean kids will get to the doctors,” said Duff. “Our partnerships are in a time of changing how to serve kids.”

Parents and clinicians alike speculate on whether this will mean a return to the days of a nurse stationed at every school. Right now, Duff said her guess is as good as anyone else’s but there’s reason for hope.

“All school nurses in every state can bill Medicaid for their services on some level,” she said. “With more students covered under Medicaid and CHIP, school nurses will be reimbursed more. It’s a source of funding for the school districts. It’s our hope that they use some of those funds to hire more school nurses.”

Robin Hocevar is on staff at ADVANCE. Contact

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