A Business Case for the Implementation of a Nurse Practitioner Role in the Student’s Local Environment
Executive Summary
The decision was made to explore a school-based clinic within the [name of the city] school district at the high school level. The Advance Practice Nurse (APN) is in a pivotal leadership position from which to serve as the key individual to plan, develop and administrate the facility while using her health care delivery skills caring for student/patients.
A business case was developed which explores the roles and status of the APN in relation to school nursing, the need for school-based clinics run by Advance Practice Nurses along with budgetary considerations.
A plan was proposed that would enable the clinic to become self-sustaining using Medicare reimbursement for services provided by the APN as allowed by Medicare policy, Federal and State grants and other funds, such as for special needs children and through private donations from community and corporate sources. This will enable the APN and facility to be of benefit to the students and staff without drawing on funds necessary to support in-class educational opportunities and become a model for other school-based clinics as part of a pilot program within the state.
A series of evaluations is outlined, both pre-development and post-development to be used for audit purposes, to assess program efficacy and measure original goals and objectives against current measures of success.
Introduction
As a result of the growing prevalence of chronic conditions and the related cost burden, health promotion and illness prevention are increasingly becoming a top priority for schools. Spotlight is therefore given to school nurses who are first in line in watching over the health of school children.
Approximately 50,000 licensed professional school nurses provide health services to children and youth in the school setting ( 2004). School nursing is a specialized practice of professional nursing that facilitates the well-being, academic success, and lifelong achievement of students. School health services like school clinics have the goal of supporting educational success by enhancing the student’s health.
Research tells us the school nurse must possess skills in more than theory and clinical knowledge, that skills in political awareness and activism, public relations and management are essential for today’s school nurse (2001). Competencies in “program planning, research and evaluation skills, management by objective techniques and statistical data collection and compilation” are additional skills required and are only found in the educational preparation and requirements consistent with the Advance Practice Nurse (APN) (2001).
Let us first discuss what an Advance Practice Nurse is. The APN is generally the most independent functioning nurse ( 2004). APNs are usually nurses with a master’s degree in nursing (2005), advanced education in pharmacology and physical assessment ( 2004), and certification and expertise in a specialized area of practice ( 2004).
The term APN is actually an umbrella term describing several nurses with different functions. It refers to advanced clinical nurses that include nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and nurse midwives. The APN functions as a clinician, educator, case manager, consultant, and researcher within his or her area of practice, to plan or improve the quality of nursing care for a specific population (2004).
APNs are state regulated relative to the services they can legally provide. Based on the combination of state legislation and federal recognition of their skills, several funding sources are available both to provide for funding as well as offer additional rebates or reimbursement for school nursing endeavors.
Research also tells us that school-based clinics serve as a pivotal healthcare function for many students who would otherwise miss school due to health reasons while not seeking or being eligible for medical attention (2003). A bigger problem is the tightening budgets seen by school administrations that require shifting funds from healthcare programs to academics ( 2006; 2005). Primarily in the large urban setting, APNs are in a pivotal position to develop effective school nursing programs.
This business case presents a model of school-based healthcare developed with the APN in mind. Budgetary figures are provided, funding sources are explored and facility staffing, management and functionality are explored.
Background
Changes in lifestyle and an increase in disease states common to school children such as asthma ( 2004) or mental health issues (2004), as well as the additional program potential that a school nurse can provide, indicate an advance practice nurse can be an essential addition to school-based healthcare programs. APNs are also in a unique position to assess families for child abuse or neglect estimated in excess of 900,000 children annually and provide programs through school districts to advance training for recognition of risk factors (2005). Additionally, APNs, by virtue of their training, would be in a position to develop other community outreach programs that further the goals of health education for students.
APNs are empowered to both diagnose and treat many common acute and chronic disease and disorder states (2002). APNs are skilled in providing common diagnostic services such as taking a medical history, performing a physical assessment or ordering laboratory tests ( 2002). Additionally, APNs provide therapeutic management and health promotion activities with the authority to practice independently in 21 states as of 2002 ( 2002). In addition to patient care, APNs are highly skilled nursing professionals who have extensive training in developing and effectively administrating community health services and political activism, management and organizational strengths are required for developing a new model for effective school nursing (2001).
Various federal and state programs are currently available to increase funding to school districts for school nursing and student health programs ( June 2004; 2006; 2006;2005; 2003; 2005). Federal grant programs are also becoming commonplace for the development of school-based clinics ( 2005). Additional sources can be developed through effective community outreach activities that a highly skilled APN performs within the natural scope of professional practice. Finally, the option of utilizing the school health facility as a formalized outpatient clinic from which to charge Medicare and Medicaid for reimbursement for professional services rendered ( 2002) are optional sources of funding to offset the cost of the APN and the educational model proposed herein.
Organizational Aims and Objectives
Organizational goals are relatively simple: to ensure that every student, in the community has access to qualified medical care. In an era of declining enrollment, when school districts are apportioned funds on a per student basis, based on the student meeting attendance requirements, it is in the best interests of the school administration to ensure their students have access to quality health care.
The use of an APN to develop an effective school-based clinic model would provide the diversity and breadth of healthcare, administration and community health knowledge to effectively design, develop and administer such a program. APNs are skilled at community health issues, are skilled and knowledgeable in fund-raising and acting as a corporate liaison, are highly skilled at collaborating and establishing collaborative services with other health care facilities in the community, understanding budgetary planning and facilities management. Therefore, when matching the skills outlined with the requirements of the school-based clinic model and goals outlined above, the APN is in the unique position to deliver more than health care to the community; she is ready to design, develop and implement this model.
Description of Services Required
(2005) documents the model for a school-based health clinic that mirrors a small doctor’s office in size and scope yet offers students the privacy needed to seek services without drawing the attention of other students.(2005) states the school-based clinic must offer privacy “where the student can feel comfortable about counseling and sensitive medical treatments.” Too often school health centers are located in administrative areas that are high activity locations and counterproductive to providing confidentiality of student use (2005). The (2005) model called for a 1,200 square foot clinic sectioned off to provide a waiting room, conference room, two exam rooms and a holding area that can be curtained off to maintain student/patient privacy as well as room for administrative and support staffing.
A facility of this size is designed to handle a student population of approximately 1,000 students (2005). As a pilot-program for the community, it is suggested that this model be adopted for use, however, the design should provide for expansion should clinic use exceed expectations.
Current usage expectations are that 65% of the student population will utilize the clinic for any one of a variety of services offered by the APN or other staff members.
Description of Services Provided
A school nurse develops programs that foster children’s growth, positive life skills for successful coping, and acquisition of knowledge and skills for self-care, and that reinforce positive health attitudes ( 2004). The services performed by the APN and nursing or on-call adjunct staff will be outlined in the succeeding paragraphs. It will include the following that are listed, but should not to be limited to those only. A rationale for providing such services will also be given.
· Diagnosing and treating infections such as strep throat, ear, sinus or other illnesses (2005). Infections account for the majority of all childhood illnesses; respiratory infections are the most prevalent (2004). The common cold also remains the chief illness of childhood ( 2004). These are common illnesses that could affect school children and it is therefore a must for school clinics to have the right medical devices to diagnose and treat such common infections;
· Performing laboratory screenings as required (2005). This is not a usual procedure of school clinics and is usually done only in extreme conditions requiring results. School age children are also significantly affected by cancer, birth defects, and heart disease ( 2004) and should be screened for these also;
· Assisting in treating students with chronic health issues such as asthma or diabetes ( 2005);
· Provide dental health awareness programs emphasizing the importance of oral hygiene in the totality of good health;
· Performing sports and/or other routine physicals required for school participation (2005). It has become increasingly clear that children are becoming less active with the result being an increase in childhood obesity (2000). Schools can be an excellent facilitator of physical fitness and exercise (2002). Strategies such as offering sports and other physical activities incorporated early into a child’s daily routine could provide a foundation for lifetime commitment to good health and physical fitness (2004).
· Be the first line of treatment for sports related injuries that take place on school property (2005);
· Write prescriptions on a limited basis for the treatment of an illness, such as antibiotics for infection ( 2005);
· Perform assessments for risk behavior, such as substance use or abuse, sexual practices and nutrition/dietary habits ( 2005). Certain groups of children are more prone to disease and disability, often as a result to different barriers (2004);
· Administer immunizations to the student body and faculty1( 2005);
· Offer programs that promote healthy lifestyle habits, proper including nutrition. School age children should participate in educational programs that enable them to plan, select, and prepare healthy meals and snack;
· Maintain comprehensive documentation compliant with HIPPA requirements;
· File and follow-up on claims for Medicare reimbursement;
· File and follow-up on documentation relating to reimbursements or rebates available from other Federal Education programs, such as the Individualized Education Program that pays for some healthcare services rendered to special needs children (2005);
· Ensure that the school and its environment is one that could promote safety and good health in students;
· It is important to note that although APNs can be skilled in their jobs and provide the highest level of care to the school children, there are some factors that could affect the state of health of the school children outside the school. One priority that should be specifically mentioned here is problems related to mental health of the child. This could spur from many things, on top of it dysfunctional families. Dysfunctional families could push a school child to certain addictions, withdrawal, or worse a negative view of self. The APN could therefore offer counseling services to school children as well as to the parents if the need arises;
· Lastly, yet most importantly, APNs have the responsibility to provide health education to school children. The school-age period is a crucial period for the acquisition of behaviors and health practices for a healthy adult life (2004). Because cognition is advancing during the period, effective health education is therefore appropriate. Promotion of good health practices is a nursing responsibility (2004) and programs directed at health education should be frequently organized and conducted in the school.
Some of these services provided will be summarized in a table below with the top school children concerns and health promotion interventions of the nurse explained briefly.
SCHOOL AGE HEALTH CONCERNS
HEALTH PROMOTION INTERVENTIONS PROVIDED BY THE APN
Nutrition
Provide nutrition education that promotes healthy lifestyle: food guide pyramid; limiting fat and saturated fat intake as these could lead to hypertension (Guyton & Hall, 2000), and other serious health complications.
Provide assessment of nutritional status of school children.
Oral Hygiene
Review mechanics of dental hygiene: brushing and flossing.
Stress the importance of regular dental check-ups.
Infections
Provide immunization services, information, and follow-up.
Provide diagnosis and treatment.
Teach infection prevention practices such as hand washing and care of minor skin injuries.
Teach simple concepts of viral and bacterial illness.
Tobacco, alcohol, and drug use
Provide information regarding the hazards of use of tobacco, alcohol, and drugs.
Provide tobacco, alcohol and drug use assessment and prevention programs.
Human Sexuality
Provide information about sexual maturation and reproduction in age-appropriate manner.
Provide risk assessments for sexual abuse.
Safe Environment
Educate school children about safety measures to prevent accidents and injuries.
Encourage school children to take responsibility of their own safety.
Table 1. Health Promotion for School-Children
Potential Benefits
The benefits of the proposed school-based clinic are categorized as serving several target populations: the patient, the service level and the staff.
Benefits to the patient population based on the addition of the APN to both the development of the program and through her participation as an active staff member providing patient care are multiple.
The student population is expected to see the primary benefits of the proposed APN administrated school-based clinic. An increase in student health and well-being should correlate to an increase in student grades, student school attendance and a corresponding increase in health skills the students can carry with them into their college and adult years. An increase in student mental health awareness and availability of mental health services at the clinic is also expected to ameliorate potential issues related to abuse (2005) or depression and anxiety (2004) often missed in the student population. Research tells us that teens who fail to receive necessary health care are at a significantly increased risk for not only physical but mental health issues but that when these students visit their school-based health clinic for physical issues, mental health problems are frequently uncovered by the APN (2003; 2004).
School staff and administration are expected to receive a number of benefits as well. As the school-based clinic evolves, it is anticipated that faculty and staff will receive healthcare from the facility on an as needed basis; however, for the first rollout, this will not be the case. But still, faculty and staff will experience higher attendance in their classes (2005), healthier and more attentive students who are more likely to be participative in classes and less disruptive.
Clinic staff and collaborative associates, such as nearby hospital staff or on-call physicians for emergencies, will benefit from the experience of being led by the APN due to her wide range of administrative and practical abilities to work through the system. Immediate staff will benefit from her leadership and management skills at creating a functional yet comfortable environment and in her abilities to provide health care delivery options beyond that of the traditional school nurse.
Taking care and ensuring that the school environment can promote wellness and good health in school children is one essential aspect of good health yet one that is oftentimes overlooked. Many school nurses develop plans for health promotion in school children, yet most often they focus on diagnosis, assessments, screenings, immunizations among others; and tend to forget the environment.
It must always be remembered by the nurse that the environment is one of the primary determinants of health (2005). The environment, aside from being unclean, could be one that will present accidents and injuries to school children. Accidents and injuries are a major health problem affecting school-age children (2004).
It is not enough to think solely in terms of self when one thinks of health promotion. What affects the environment has a ripple effect and could affect everyone in the school. To start, the APN could come up with a plan that could ensure a clean and healthy environment within the school. This could be considered a prevention strategy which is of course better than finding cures when school children get diseases.
Also, the provision of guidance and counseling services is a task that should be appointed not only to school guidance services but also to the APN. After all, a healthy well-being includes a healthy mind. When the child goes through adjustments, the nurse assists in promoting health. This could be done by helping the parents and child to identify potential stressors and by designing interventions to minimize stress and the child’s stress response ( 2004).
The nurse needs to direct school children toward normal developmental behaviors, assist them in maximizing their abilities and use them to cope; all of which could function under the service of guidance and counseling provided in the clinic. By helping children achieve a necessary developmental balance, the nurse promotes health.
Key Outcome Criteria
The APN run school-based clinic is expected to meet the following outcome criteria:
Audit and Research Plan
Once initial funding is provided to start-up costs, a detailed audit will be conducted from which to assess final budgetary figures and confirm facility and staff planning as detailed in this business case. Separate questionnaires will be presented to teachers and school administrators, students and parents or guardians. Each survey will be tailored to the participant population; all will focus on items relating to the efficacy of a school-based clinic and planned utilization, perceived benefits, areas of concern and perceived limitations of the facility, staff or fee structure.
A one-year time frame is expected from the time initial grant funds are received from which to distribute and analyze survey responses, confirm or alter plans according to results and initiate the re-build, obtain necessary funding and arrange for the build-out and all hiring and administrative functions for the school-based clinic to become fully functional. Therefore, the clinic is expected to begin seeing students in September 2007.
A second round of surveys distributed to the same target populations will be conducted at the end of January 2008 and during the last week of school in June 2008. The January and June 2008 surveys will be correlated with results of clinic records for number of patients/students seen, number of return visits, number of students utilizing Medicare, rate of Medicare reimbursement along with types of services performed.
Position Description
The APN will be responsible for all primary activities related to the school-based health clinic, such as performing all administrative functions, grant writing activity, facilities management and project management, establishing collaborative relationships with local healthcare institutions and emergency transport providers, hiring and firing practices, serve as liaison to the school board, provide health promotion programs, and even function as a mental health nurse providing guidance and counseling services to disturbed school children as well as their parents.
Additionally, the APN will manage all Federal and State compliance issues relative to position compliance for self and staff as well as service compliance areas. The APN is responsible for assuring compliance with State and Federal healthcare regulations such as HIPPA and electronic medical record transmission.
The APN will also be responsible for providing healthcare services to the student population, developing awareness programs, leading seminars, interacting with faculty to bring healthcare awareness into the classroom. The APN will be responsible for medication management and medication administration policies and practices.
To summarize, the APN provides specific nursing interventions in the school setting including health education, parent programming and counseling, communicable disease control, physical and mental assessment, crisis intervention, environmental safety, nutrition planning, and emergency care. Without the school nurse, an overall process of education within the school is not complete.
Budget for the Position
According to research, the average salary for a school nurse is ,216 ( 2006). The average salary for an APN is ,203 (). Many districts, such as those in Alabama provide a state budgetary allowance that allocates a specific allowance for both salary and benefits for school nurses, in Alabama this amount is ,888 although actual salaries are determined at the local levels ( 2006). While many districts are struggling with insufficient funding to properly meet health care needs within the state and local districts, when funding that has been allocated is not used, unused funds must be returned to the state ( 2006).
The APN in this model is more than just a school nurse; the APN will design, develop and implement the school-based clinic model, teach and mentor other RNs and staff members and act as a community liaison. The APN in this case therefore completes the role of educator, consultant, manager, researcher, and practitioner. Making recommendations, developing a plan of care, and performing specific advanced procedures as are appropriate in the school setting are all tasks the APN may do.
As such, it is inappropriate for the APNs salary to be paid with resources allocated for the facility’s RN. Funding for the APN will be paid through the provisions of a Federal, state or corporate grant as part of the program development costs.
Planned staffing for the facility includes the APN as full time coordinator, a nurse, nurse practitioner and a part-time administrative assistant.
Healthcare related supplies are estimated at 0,000, although healthcare supply corporations will be solicited for tax-deductible donations through goods and materials to support the community effort.
In the current model, the proposed school location has a 1,275 square foot building, off site, adjacent to the football field currently being utilized for storage. Adequate storage facilities have been ascertained as available within the school building to enable the school-based clinic to remodel and bring the building up to code as a health care clinic. It is anticipated that costs associated with a build-out will significantly reduce costs that would otherwise be incurred for a new-build. Current estimates are 0,000 with a turn around time expected at 6 months.
Start-up costs associated with permits, filing fees and assistance in grant preparation, miscellaneous expenses related to seeking community support and the purchase of a laptop computer, printer and associated supplies, plus salary for the APN are estimated at ,000.
Initial sources of funding are expected from private corporate or community sponsorship funds and are not expected to come from the school budget. School clinics, though located on school campuses, are run primarily by community-based healthcare providers who all tap the same funding pool: federal and state grants; private donations and in-kind contributions from local hospitals (2005).
Also, the provision of proper nutrition to school children is often a component of major programs of the government. Governments that could afford such programs ensures proper nutrition of the young which is essential for the good health and physical growth of children at that critical stage, and hopefully producing healthier citizens as these school children grow older.
This facility is expected to provide services that can be reimbursed through Medicare at a rate of 85% (2002). According to school district records, 97% of the student body is enrolled in Medicare compliant managed care programs. Based on anticipated patient/student flow through combined with Medicare reimbursements, it is expected that the facility will be self-sustaining after a two-year period. This does not include the cost of potential upgrades and remodeling should the patient/student flow exceed delivery of care expectations.
Of course, in all these, the level of economic activity determines to a large extent how much resources and budget can be devoted by the country to help these types of activities.
Constraints
There are several issues that will hinder the APN from providing the services that were mentioned. Sometimes, clinics could not function well not due to the APN assigned but to other factors such as lack of funding. No matter how capable and APN is, if there are not enough resources to support him or her, then it is likely that the services provided will not be of good quality.
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