Making the Case: Supporting, Expanding and Promoting Access to Student Health Services through Innovative Health Financing Models

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1 Making the Case: Supporting, Expanding and Promoting Access to Student Health Services through Innovative Health Financing Models Overview Challenging economic times invite opportunities for innovation. School nurses are in a unique position to promote prevention and wellness, keeping our children healthy, safe and ready to learn. Research shows that early access to care is vital. School nurses serve vulnerable populations by addressing their health risks and promoting healthy lifestyles and disease prevention for students during their early and most impressionable years and lasting through high school. This is increasingly important as our nation begins to move our health care system from one that is high-cost and high-volume to one that is high-value and focused on prevention. School nurses are on the forefront of a new way forward, utilizing electronic health records to expand access by coordinating students care with a primary care provider or working with students families to enroll in public health insurance for which they are eligible. School nurses can be a valuable member of care coordination teams by helping to reduce unnecessary health care utilization, such as emergency room visits, and improving children s overall health outcomes. The following case studies should inform the development and implementation of school health financing models that help to improve health and academic outcomes for our nation s children, paving the path for a more secure future. These diverse examples illustrate how engaging school nurses in a population-centered, coordinated and integrated care delivery mechanism can help achieve better care, lower costs and better health. Case Study 1: Louisiana In Louisiana, there are approximately 1,400 public schools and 700,000 students. Students health care needs are multifaceted as the number of children with medically complex health conditions and chronic illnesses has increased in recent years. About 60 percent of public school students in Louisiana are enrolled in Medicaid, but many face barriers accessing care. Only 350 school nurses are available to serve all of the students in these schools. School districts often depend on state health services, many of which are in the process of reconfiguration and difficult to access. Most school districts have a few nurses who are itinerant and provide services at more than one school. Typically, these school nurses provide episodic care, develop and implement health plans for children with disabilities and children in special education and respond to emergent needs. The majority of Louisiana schools do not have a systematic link to health care partners such as primary care providers. In addition, the infrastructure does not exist to allow data sharing through an electronic medical record system to capture reimbursable costs. In order for these schools to continue to provide access to student health services, they must align with the larger health care community.

2 Innovative Ideas Leading the Way The Picard Center for Child Development and Lifelong Learning, a research center at the University of Louisiana in Lafayette, recognizes that school districts can be an efficient platform for health care. Students are in a central location, which provides an opportunity to manage their care in a population health model. The Picard Center has proposed to expand Medicaid reimbursement payments for the full range of services school nurses are already providing such as writing health plans, administering medication and managing chronic diseases at no cost to the State for their portion of the Medicaid match. By expanding the availability of school nurses and providing care coordination, the Picard Center estimates reduced hospital utilization rates, the development of stronger partnerships between health care networks, school districts and communities, the creation of approximately 1,000 new well-paying nursing jobs and about $3.6 million yearly in tax revenue for Louisiana. A Glimpse at the Proposed Structure The Picard Center is working to implement these proposed changes in several school districts in Louisiana. The school districts vary in size from 6,700 to 30,000 students; 14 to 43 schools. On average, about 65 percent of the students are enrolled in Medicaid. Each district is at different stages in the process of designing and implementing this cost-effective, high-quality health care delivery mechanism in their schools; it is anticipated to take 3-5 years for this model to reach full implementation. The proposed model includes the following elements: Capacity To ensure adequate access to health services for all of its students, the model suggests one registered nurse (RN) and one licensed clinical social worker (LCSW) for every 450 children, and one nurse practitioner (NP) for every four RNs. Care Coordination The Louisiana Department of Health and Hospitals has submitted a proposal to the U.S. Centers for Medicare and Medicaid Services (CMS) amending the State Medicaid Plan to include a requirement to provide care coordination in the State Plan Amendment. The provision of care coordination includes three components: 1) electronic student health records, 2) quality assurance and 3) chronic disease management. Sustainability The Picard Center has proposed multiple funding streams to finance the delivery of health services to students. The NPs and LCSWs can generate revenue in partnership with Federally Qualified Health Centers (FQHCs) to offset costs. FQHCs can provide off-site services in schools through Medicaid reimbursements, which cover their full costs. FQHCs will bill for all of the services, with the exception of billing a parent for a related service on an Individualized Educational Program (IEP). The FQHC and the Local Education Agency (LEA) ultimately would share in the benefits from these new resources. RNs could receive payments from Medicaid that will cover 35 to 40 percent of their costs with approval of the amended Louisiana State Medicaid Plan. A district employing 20 RNs could be paid approximately $420,000 for their services as estimated by the state Medicaid actuary. Districts are also exploring a second payment methodology referred to as Upper Payment Limits (UPL). This is a Medicaid funding strategy, common in many states, provided through a Low Income and Needy Collaboration Agreement. Districts may identify state or local funds they are willing to transfer to the State Medicaid Agency, which could be matched by federal funds and sent to a private hospital or hospital consortium. The hospital entity would act on behalf of the district and contract with those funds for health care services that will benefit the school district. For example, if a district sent $35,000 to the State Medicaid Agency, the state could write a check for $100,000 to the hospital consortium to use to contract for services for the school district provided the school district and the consortium had a legal agreement such as a memorandum of understanding. Revenue generated through UPL can be used for a wide variety of health care services including care coordination, health care personnel and durable medical equipment. The school district can use various payment strategies simultaneously to develop a comprehensive and sustainable school health care system. Health Networks and Partnerships The school health care system can engage a variety of partners to ensure sustainability through a supporting care coordination infrastructure. The Picard Center is developing and strengthening relationships with a variety of stakeholders, including LEAs, FQHCs, the Louisiana State Medicaid Director, Office of Public Health, Coordinated Care Networks and managed care companies, community hospitals, health insurance companies, foundations and other health providers.

3 Case Study 2: Portland, Oregon A critical goal of the Affordable Care Act is to move our health care system from one that is high-cost and highvolume to one that is high-value. The federal government is not the only entity that is implementing reforms. States, as well as private businesses and insurers, are testing different payment models to fundamentally change how health care is paid for and delivered. The state of Oregon, led by Governor John Kitzhaber, is at the forefront of these efforts. The state has adopted changes to its Medicaid program that will transform how health care is delivered throughout the state. The Oregon approach encourages local control and flexibility as well as accountability for overall health. All agencies that provide services to Medicaid-eligible patients are now required to form Community Care Organizations (CCO). These CCOs are reflective of the community culture and resources. The largest CCO in the state, Health Share, covers the Portland metro area including Multnomah, Washington, Clackamas counties. This CCO involves health care systems in the Tri-County region, including hospitals, health departments, mental health agencies, dental providers, etc. CCOs have the flexibility to support new models of care that are patient-centered and team-focused, and reduce health disparities. CCOs will be able to better coordinate services and focus on prevention, chronic illness management and personcentered care. The goal for all CCOs is to reach the triple aim: better care, lower cost and better health for the population they serve. Innovative Ideas Leading the Way School nurse leaders representing the three counties have met with decision makers in the Tri-County CCOs to discuss the way in which school nurses serve a critical component in delivering coordinated care to children enrolled in Medicaid. Fifty percent of children in Portland are enrolled in Medicaid. A select group of school nurse leaders has collaborated with the two CCOs established in the Portland area, Health Share Oregon and Family Care, to discuss and plan for the school nurse role with the CCO function and process. School nurses practice in an educational setting and are typically the only health care professionals in the school community. School administrators, educators, students and families depend on school nurses to provide health services that promote the health of the school community. This includes management of chronic health issues as well as prevention activities of health promotion, education and management. If school nurses are well-positioned in the education and health care arenas, it is possible to change the funding stream for school nurses from education, to a blend of funds from the education and health care sectors, which is a more sustainable way of doing business. A Glimpse at the Proposed Structure The Multnomah Education Service District (MESD) has developed an agreement with a local pediatric clinic, which is part of a larger hospital system, to set up a coordinated care pilot project. The pilot will include two phases: 1) Increase access/communication between potentially 120 school nurses serving the Portland area and the pediatricians serving at the clinic. 2) Incorporate the use of the EHR vendor, Epic, to help school nurses gain access to this data and start using the software. The overarching goal of the pilot is to provide the outcomes data needed to persuade the CCO to include the school nurses in its delivery and financing model. Ultimately, school nurses offer a value-added component to the current attributes of the CCOs including: managing coordinated care; promoting team-based care that crosses appropriate disciplines; planning for prevention and wellness, including addressing disparities; adopting and using electronic health records; measuring performance; paying for outcomes and health instead of volume; and creating incentives for prevention and improved care of chronic illness.

4 Case Study 3: Austin, Texas In 1996, the Austin Independent School District (AISD) established a formal relationship with the Seton Healthcare Family to provide school health services on a contracted basis in response to a need identified by the school district. This program, Dell Children s/aisd Student Health Services, is committed to optimizing the health and well-being of children and families. The distinctive collaboration with AISD and the Seton Family of Hospitals provides more than 70 full- and parttime RNs and more than 50 full-time school health assistants to care for more than 84,000 students in 113 schools. This model program is the first public/non-profit school health collaboration of its kind in the United States and has been nationally recognized by the Robert Wood Johnson Foundation. Innovative Ideas Leading the Way The Seton Healthcare Family contracts with AISD for the provision of student health services. Student health services staff, including RNs and school health assistants, clinical managers, the director and medical director, are employees of Seton Healthcare Family/Dell Children s Medical Center. There is also a quality improvement consultant contracted with Seton Healthcare Family. This comprehensive and robust model ensures quality care coordination. The school nurses and school health assistants have immediate access to support from centrally-based nurse managers, a nurse director of student health services, a physician medical director, and if needed, to the additional resources of a tertiary care pediatric medical center and the many clinical specialists who work at Dell Children s Medical Center. The health team also connects children and their families, with limited or no health insurance, to needed services available in the community. One example of a community partnership that supports students is the collaboration with St. David s Community Health Foundation and the City of Austin. This collaboration provides needed preventive and acute dental care to many AISD students at their schools. RNs in the AISD/Student Health Services program pursue national accreditation in nursing through the National Board for Certification of School Nurses. Within the program, 16 nurses are Nationally Certified School Nurses. A Glimpse at the Structure The Student Health Services program uses a tiered model approach in which an RN and school health assistant work together to provide health services to students during school hours. Each school campus has an RN who functions as the leader and coordinator of the student health services team. The District contact is the AISD Supervisor of Health Services. The RN in each school works closely with families and health care providers of children with special health care needs, such as diabetes, asthma, cystic fibrosis, seizure disorders, cancer and cardiac issues, to provide the health care necessary to keep students safe while at school. The school health programs and services focus primarily on wellness, health promotion and prevention. This enhances students ability to learn by eliminating non-educational barriers, allowing them to enter the classroom in optimal physical and emotional health and be ready to learn. Student Health Services monitors its annual goals by measuring outcomes in the following categories: 1) Prevention including immunizations, childhood obesity and cardiovascular health 2) Safety including reportable communicable disease surveillance, incidents and accidents and student behavioral health 3) Ill and Injured Child Care 4) Special Populations/Reduction of Health Disparities/Removing Barriers to School Success including case management for special health conditions such as asthma, diabetes and adolescent pregnancy 5) Quality and Customer Satisfaction including surveying school administrators, school staff and students

5 Moving Forward Health happens where we live, learn, work and play. Changing the way we do business will require reframing the conversation: School nurses are in the business of promoting wellness, serving healthy students, coordinating with multisector partners and working precisely where children learn, work and play in school. Working with a broad array of stakeholders on innovative approaches to offer better care, lower costs and better health, school nurses serve an integral role in improving the health and well-being of students, families and communities to create a sustainable, healthy and successful future for all. For More Information Picard Center for Child Development and Lifelong Learning: John Lacour, Health Sciences Director: john.lacour@louisiana.edu Health Share Oregon: Oregon Health Policy Board: Dell Children s/aisd Student Health Services: