Vine School Health Center Expansion
Proposal from the University of Tennessee, Knoxville
SCHOOL-BASED HEALTH CENTER CAPITAL (SBHCC) PROGRAM (HRSA – 10-276)
U.S. Department of Health and Human Services Health Resources and Services Administration
Bureau of Primary Health Care
Introduction
The School-Based Health Center Capital funds will expand the current services provided by the Vine School Health Center (VSHC) and increase access to health care with telehealth technology. For the past fifteen years, VSHC has provided primary healthcare services to children ages 3 to 21 years in Knox County Schools who were in need of health services and unable to access care. The VSHC is staffed by University of Tennessee (UT) faculty nurse practitioners, graduate and undergraduate students from the university, and by a Knox County school nurse every school day. During the 2009/2010 school, year there were 1,139 healthcare visits to the clinic (677 physical examinations and 471 acute care visits). Of these visits, 17% of the students were from the Vine Middle Magnet School where the VSHC is located. The other 83% were
children who attended schools other than Vine. Many of the acute care visits could have been handled by telehealth without requiring the children to leave their school of origin and without the necessity of transportation to the VSHC.
Funding Priority
This application is requesting funding priority. The VSHC serves all students in the school district ages 3 to 21 that are unable to access health care regardless of their ability to pay. Last year, 52% of the children seen were insured through Tennessee’s Medicaid program (TennCare), and 36% of the children seen were uninsured.
Need
BackgroundThe Knox County Schools website (http://knoxschools.org/) reports that 42.8% of the student population is considered economically disadvantaged. The total number of schools in Knox County Schools is 87, and the district serves 56,616 students. Of those 87 schools, 25 have student populations of more than 50% who qualify for free lunch or reduced lunch: 1 alternative school, 2 high schools, 4 middle schools, 16 elementary schools, and 2 preschools.
The VSHC was established in 1995 to address health issues in school children through the collaborative efforts of Knox County Schools, Knox County Health
Department, and the University of Tennessee College of Nursing. The three primary objectives of this joint effort at that time were to:
1. Deliver pediatric primary care services to an underserved urban population; 2. Demonstrate the effectiveness of a nurse managed clinic as a primary health
care delivery site; and
3. Provide clinical experiences in primary care and community health for
The Vine Middle School location was selected because it is in census tract 6 of Knox County, an area that was designated as a Health Professions Shortage Area (HPSA) by the Federal Register and from the population data of the three zip codes served by the school: 37914, 37915, and 37917. The urban area at that time was 87.7% Black with the average household income below the federal poverty line. Below are the demographics of the zip codes from the last census.
Table 1. The demographics of the targeted zip codes as reported in the 2000 census.
Zip Code 37915 37914 37917 37921
Current Population: 5,810 20,513 23,377 28,296* 2000 Population: 5,564 20,120 24,480 26,240 Households per Zip Code: 3,242 9,304 12,884 11,605 Average House Value: $58,300 $73,000 $62,000 $77,400 Avg. Income Per Household: $9,721 $30,453 $23,807 $31,253 Persons Per Household: 2.02 2.39 2.06 2.47
White Population: 679 (12.2%) 11,386 (57%) 20,492 (83.7%) 20,088 (76.5%) Black Population: 4,750 (85%) 8,286 (41%) 3,130 (12.8%) 5,249 (20%) Hispanic Population: 48 178 406 (2%) 374 (1.4%) Asian Population: 3 56 133 172 Indian Population: 13 41 98 67 Hawaiian Population: 1 4 4 13 Other Population: 23 91 208 192
*The 37921 has changed most significantly in size since the last census, and it is speculated that this increase in number has been in the Hispanic population because Lonsdale Elementary (school population of 249) reports a school population of 25% Hispanic, 48% Black, and 27% White. For comparison, the City of Knoxville’s population in the 2000 census was 173,890 with 79.9% White, 16.2% Black, 1.6% Hispanic, 1.5% Asian, and 1% Other.
The expansion of the VSHC project will increase access to primary health care services for children ages 3 to 21 years of age through the school attended by the child. The schools were selected for the telehealth equipment because they are located in disadvantaged zip codes, have a high percentage of students eligible for free/reduced lunch, and/or were the largest source of referrals to the VSHC last year.
The VSHC will house the central terminal from which transmission of telehealth data will be sent to the nurse practitioners. It will be the health center where the
electronic health records will be utilized. Transmission of health data in the electronic health record via the telehealth system will be assessed but not required for
implementation of either system. The VSHC and the schools selected for expansion are listed below.
Vine School Health Center (in the Vine Middle Magnet School) 220 Langland Street; Knoxville, TN 37915
865-594-5078 Census Tract 6
http://vine-school-health-center.knoxschools.org/ Free/reduced lunch program = 74% of the 443 students Austin East High School
2800 Martin Luther King Jr. Blvd.; Knoxville, TN 37914 865-594-3792 Census Tract 20
Free/reduced lunch program = 67% of the 851students
The school had the largest number of referrals (72) to the VSHC last year. Lonsdale Elementary
1317 Louisiana Avenue; Knoxville, TN 37921 865-594-1330 Census Tract 28
http://lonsdalees.knoxschools.org/
Free/reduced lunch program = 100% of the 335 students
Lonsdale is a Provision 3 school where more than 90% of the student population qualifies for the free/reduced lunch program, so every student is considered to qualify without applying; therefore, 100% of the students are on the free lunch program. The school referred 27 students to the VSHC last year and was one of the top three elementary schools in the number of referrals to the VSHC.
Christenberry Elementary
927 Oglewood Avenue; Knoxville, TN 37917 865-594-8500 Census Tract 15
http://christenberryes.knoxschools.org/
Free/reduced lunch program = 73% of the 641 students
The school referred 28 students to the VSHC last year and was one of the top three elementary schools in the number of referrals to the VSHC.
Pond Gap Elementary
1401 Hollywood Drive; Knoxville, TN 37909 (865) 909-9040 Census Tract 38
http://pondgapes.knoxschools.org/
Free/reduced lunch program = 75% of the 401 students
This school was chosen because of its distance to the VSHC and their strong request for services. This school just received a $350,000 grant for the 2010-2011 academic school year to develop after-school activities and tutoring with dinner. Health services have been requested to complete the offerings.
Census tract data from the 2006-2008 American Community Survey Three-Year Estimates reveals that these census tracts continued to be disadvantaged communities. During these years, 16.4% of families in these census tracts were living below the poverty line and 23.2% of individuals in these census tracts were living below the poverty line. The comparative United States data was 14.4% of families and 20.8% of individuals living below the poverty line, which further substantiates the disadvantaged nature of the selected schools in these census tracts.
Uninsured Children
Of the students seen at the VSHC last year, 36% were uninsured and the services were provided without reimbursement. Research indicates School-based Health Center’s struggle to maintain services due to lack of funding and reimbursement, and telehealth access to services can fill this gap and provide successful health
services (Young and Ireson, 2003). Information and an application form regarding Tennessee’s Medicaid (TennCare) program is provided to all uninsured patients and is documented in those patients’ encounters.
TennCare
Participants in the state-managed TennCare program are assigned a healthcare provider. There are limited providers who will accept TennCare. Many of the TennCare recipients that the VSHC serves are asked when they were last seen by the designated provider on their card, and most have never seen that provider but relate that they only go to the emergency room. Additionally, many TennCare providers are overloaded with patients and frequently cannot see children because of the lack of appointment times. Consequently, many children are referred to area emergency rooms for conditions needing treatment although not emergent. The East Tennessee Children’s Hospital provides care for minor acute illness in their fast-track emergency room program for all non-emergent problems referred to the hospital for afterhours concerns and the inability to access primary care. Oftentimes, too, the child’s family will not see a provider until the child’s condition worsens. Therefore, insurance for some of these children provides access to emergency services, but primary care preventative services are not sought. Practices with high percentages of TennCare patients have been approached about decreasing the emergency room visits of the patients assigned to them, but their volumes are high and outreach for primary care expensive. The children’s hospital just built a new and larger emergency room with the fast-track program next to it. Studies indicate that telehealth access is associated with 22.2% less emergency room visits and 23.5% increase in clinic visits with telehealth capability (McConnochie, Wood,
Herendeen, Ng, Nowes, Hongyue, & Roghmann, 2009).
Transportation
Finding transportation to a provider’s office is also problematic for children in low income families. Public transportation is limited but available in the urban areas of Knoxville. The convenience of having children seen at the school that they attend is that it is convenient for the parent who does not have transportation or who is at work. The children we serve now and in the future often have parents who work in the
minimum-wage service industry and are unable to leave work without losing pay; therefore, the health history and education is by phone and/or written information sent home with the child. Research indicates parent satisfaction with telehealth. A study conducted in a clinic with telehealth reported 91.2% of 229 parents were happy with telehealth because it allowed them to stay at work. The participants also indicated they would choose a clinic with telehealth capability (McConnochi, Wood, Kitzman,
Herendeen, Roy, & Roghmann, 2005).
Clinical Experience in Community Primary Care for APNs
Some of the most important components of teaching and practice include discussions with students regarding evidence-based practice, what the research
literature says, and what additional testing is necessary and when. As the VSHC is also an academic practice, teaching patients, parents, and students at the same time occurs frequently, and the best evidenced practices are adhered to unless contraindicated. Information is frequently accessed via the internet on computers obtained through the university’s computer upgrade program. Computers replaced at the university are donated for use at the clinic. These computers will continue to be made available to students, and the requested funds will provide another computer for the office manager
to enter patient data and schedule appointments. The requested funds to purchase hardware for electronic health records will provide students the opportunity to use electronic health records, and the software offers checklists for the evaluation of particular concerns based on best practices. Although HRSA states that “preventive services (immunizations, screening tests, prophylaxis, and counseling) are a vital but too often neglected aspect of primary care” (2006), they are standards of care in the teaching facility for nurses and advanced practice nurses. The electronic health record will assist in supporting high quality care.
A Collaborative Effort
The VSHC is a collaborative effort between Knox County Schools and The University of Tennessee College of Nursing, and both are committed to the ongoing maintenance and growth of the clinic. Because of budget restrictions, the Knox County Health Department decided in 2001 that they were no longer able to assist with nurse practitioner staffing and physician coverage. In order to fill the staffing gap for the 2001-02 school year, Dr. Gaylord recruited additional volunteer nurse practitioner faculty members at the University of Tennessee. Physician coverage was contracted with Larry Rodgers, MD, who is a faculty pediatrician at the University of Tennessee Medical Center. From 2002 through 2006, the on-site nurse practitioner coverage was provided at 1.5 days per week by the University of Tennessee College of Nursing faculty who were also available by phone to assist the school district nurse who was on-site every day. In December 2006, a three-year grant was obtained from the Ronald McDonald House Charities (RMHC) to provide one fulltime pediatric nurse practitioner’s salary and benefits. The grant was renewed again for three more years in the December of 2010. Below is a table outlining the growth and sustainability of the VSHC.
Table 2. VSHC Statistics from 2005 until 2010 2005-2006 Academic Year 2006-2007 Academic Year 2007-2008 Academic Year 2008-2009 Academic Year 2009-2010 Academic Year Use of RMHC Monies ½ Yr ½ Yr Full Year Full Year Full Year Nurse Practitioners FTEs Days/Week 0.3 1.5 0.3 1.5 1.3 6.5 1.3 6.5 1.3 6.5 1.3 6.5 Nurse Practitioner Visits 331 536 887 961 1139 Rating of Health Services
Excellent Satisfactory Unsatisfactory 68% 31% 0% 65% 35% 0% 72% 27% 0% 77% 23% 0% 70% 30% 0% Number of Permission Forms
Vine School Other Schools Total 640 N/A 640 375 394 769 443 493 936 426 582 1008 188/443 687 875 Health Insurance Yes (Private) Yes (TN Medicaid) No 129 376 135 (21%) 341 270 158(21%) 187 504 245 (26%) 208 534 266 (26%) 111 453 311(36%) Student has primary care provider
Yes No 400 240 (38%) 581 355 (38%) 526 468 (49%) 412 463 (53%) ER visits within the last year 96 85 168 198 200 (23%)
The VSHC has charged for services through the billing services available through Dr. Larry Rodgers’ pediatric office and his office staff. Reimbursement received for the care delivered at the VSHC is through a check from Dr. Rodger’s office made payable to the College of Nursing with the billing fees and physician fee deducted. Table 3 (below) presents a record of the services provided, the charges, the payments received, and the amount of unreimbursed care.
Table 3. Budgetary Totals 2005/2006 Academic Year 2006/2007 Academic Year 2007/2008 Academic Year 2008/2009 Academic Year 2009/2010 Academic Year Total Billed $37,540 $39,807 $101,071 $162,311 NA Unreimbursed Care $19,985 $52,949 $69,550 $92,983 NA Payments Received $11,362 $15,476 $40,144 $70,347.40 NA Payments CON Received $ 6,987 $10,833 $28,101 $51,298 NA Billing Costs $2,434 $2,321 $6,021 $9,524 NA Physician Services $2,434 $2,321 $6,021 $9,524 NA Medication Expenses and Supplies $980 $4,583 $13,525.33 Meds = $1,385 Supplies= $2,541 Meds= Supplies-= Nurse Practitioner Visits PE 261 Acute 70 RN 28 TOTAL: 331 PE 347 Acute189 TOTAL: 536 576 PEs 311 Acute TOTAL: 887 570 PEs 391 Acute TOTAL: 961 677 PEs 471 Acute TOTAL: 1139 The charges for the last months of the 2009/2010 academic year have not yet been received; therefore, the last column will not be complete until August.
In 2007, the volunteer office manager was able to obtain insurance cards on many more patients, which increased the income of the clinic significantly. When she stated she needed a position with income and benefits, we elected to pay her salary with the incoming patient fees. Dr. Gaylord, in conjunction with the College of Nursing’s financial office, is evaluating the present billing costs (20%) and looking for alternative billing opportunities to increase the income to the clinic. Dr. Gaylord is in the process of credentialing each nurse practitioner provider with all local and national insurers through the University Physicians’ Association (UPA). Once credentialed, direct billing to
insurers is possible and the office charges are negotiated by the UPA. Once all nurse practitioners are credentialed, it is anticipated that the electronic health record may assist in off-setting the present 20% billing charges.
A new Memorandum of Agreement has been negotiated with Dr. Rodgers separate from his private practice and is found in the Attachment 6. The Memorandum of Understanding between Knox County Schools and the University of Tennessee College of Nursing can also be found in Attachment 6. There has not been a
VSHC has been in existence since 1995. However, it was suggested by the university audit office as we consider direct billing for our services and was initiated several
months ago. The attached document has been written and reviewed by both the County Law Director’s office and the University of Tennessee’s General Counsel. Although not signed as yet by the appropriate agency officials, no difficulty is anticipated. Both Knox County Schools and the University of Tennessee College of Nursing are committed to the success and long-term sustainability of the VSHC.
Response
Expansion of the VSHC services to four additional schools will increase the number of disadvantaged students who are provided health care by the VSHC. The access to services via telehealth equipment will be possible without adding nurse practitioner staff in another location. The equipment requested to institute electronic health records will provide the VSHC a method of data collection, tracking needed for patient follow up, and delivery of best practices for pediatric primary care. Electronic health records will also provide the opportunity for the VSHC to bill for services electronically.
Increasing Services and Improving Access to Primary Care
As soon as funding is guaranteed, the equipment will be procured. Funds will be used to purchase computers, web cameras, electronic stethoscopes, and electronic otoscopes/throat illuminators for each school and a terminal at the VSHC. The school nurses and nurse practitioners will be oriented on how to use the new equipment. As soon the providers in the clinics are oriented and procedures for telehealth have been established, a presentation to each school’s teaching faculty will be given about telehealth and school-based health care. A description of the services, how telehealth works and access to the services will be provided to families. A new flyer and
permission form for service will be sent home with each school child explaining the new service available. The present flyer and website will be updated to reflect the VSHC’s new capabilities. It is anticipated that 250 telehealth visits will occur during the first year of operation with the telehealth equipment. This number reflects an estimate of 1.5 telehealth contacts per day, which will occur in addition to the acute care visits to the VSHC. There were 471 acute care visits to the VSHC in the 2009/2010 academic year.
Electronic Health Record
Migrating from a paper chart to an electronic health record (EHR) will support the school-based health clinic with the management of both the teaching and practice arenas. The EHR will assist in maintaining the quality of care while teaching evidence- based care to APNs. Research on several her systems is in process. The support for Sage’s Intergy 5.5 system is provided locally through the present billing office and is congruent with the billing services also provided. It is anticipated that EHRs will assist with direct electronic billing for reimbursement of services. The EHR will also allow for access to patient records from Vine and all satellite clinics, as the Intergy system is a web-based system that meets all of the security requirements for EHRs. Other her systems in the process of evaluation now are eClinical and Office Practicum, although
working with Source may uncover other software products to be considered. Q-Source is a Tennessee company that is funded to offer expertise to improve patient outcomes and cost savings with electronic health records for practices serving the underserved. Q-source has been contacted, and further support for the company is expected if it is determined that they able to assist school-based health clinics. That determination is pending. The utilization of the EHR will assist with data collection, patient monitoring and necessary follow-up, and direct electronic billing for
reimbursement.
Impact
This project will increase access to primary care services for medically underserved and disadvantaged communities. With the delivery of telehealth services, it is anticipated that the numbers of acute care/minor acute illness visits will increase. The total number of students potentially impacted at the four other schools is 2,228. It is anticipated that 250 telehealth visits will occur during the first year of operation with the telehealth equipment. This number reflects an estimate of 1.5 telehealth contacts/day (7 to 8 per week), which will occur in addition to the acute care visits to the VSHC. There were 471 acute care visits to the VSHC in the 2009/2010 academic year. The total number of acute care visits for the 2010/2011 school year is anticipated to be at least 771. Comments and evaluations of the parents and users of telehealth will
measure program impact qualitatively. The VSHC and the expansion satellites will be a resource and possible solution for additional health needs as identified throughout the project once equipment is obtained. The telehealth equipment will be purchased immediately upon the receipt of funds.
The total number of patients served last year was 1,139. The number of physical examinations provided is anticipated to increase to 750 in the 2010/2011 academic year from 677 in the 2009/2010 academic year. At this point, a complete physical
examination for school or sports will require an appointment at the VSHC. With this increase in physical examinations and the predicted increase in the number of acute care visits to 771, with the assistance of the telehealth equipment, a total of 1,531 patient visits for the 2010/2011 year is anticipated. The ratio of uninsured patients, which has been between 35 and 40%, has remained constant during the past four years. It is anticipated that this percentage will remain the same for the next academic year. Reimbursement for services, however, will be collected from the other additional patients and will contribute to the school-based health clinic’s long-term sustainability.
The introduction of the EHR will be after the telehealth acquisitions and institution of that technology. The introduction of the EHR will impact all of the patients evaluated during the 2010/2011 academic year. The EHR will support the school-based health clinic with the management of both the practice and teaching arenas. Quality
assessment of the primary care services provided has been demonstrated previously, as all audited charts have met billing criteria by TennCare. Quality assessment will continue with peer review of care and clinical case discussions. The EHR will assist in maintaining the quality of care while teaching evidence-based care to APNs. A web-based EHR will also allow for access to patient records from Vine and all satellite clinics. The utilization of the EHR will assist with patient data collection, patient monitoring and necessary follow-up, and direct electronic billing for reimbursement.
Resources/Capabilities
The VSHC is an outgrowth of the university’s encouragement and the UT College of Nursing’s commitment to advanced practice nursing roles in the community. The Dean of the College of Nursing is a supporter and facilitator of the school-based health center. Her letter of support can be found in Attachment 5. Other letters of support in Attachment 5 include Dr. Larry Rodgers (pediatrician) and Ms. Lisa Wagoner (Director of Health Services of Knox County Schools). A letter of support from Mr. Keith Goodwin (President/CEO of East Tennessee Children’s Hospital) is available upon request.
The University of Tennessee College of Nursing (http://nightingale.con.utk.edu/) in Knoxville is a diversified academic community of faculty and students where
undergraduate, master’s, and doctoral students work together to become expert nursing professionals for various levels of nursing practice. The University of Tennessee
College of Nursing, established in 1971, has provided outstanding service to our state through academic excellence, a commitment to service, and the highest ethical
standards. The college is recognized for its excellent educational programs, unique research emphases, innovative practice arrangements, and services to the community. The mission of the College of Nursing is to promote the health of society at the local, regional, national, and international levels through nursing education, research, and professional practice. The college is committed to the delivery of high-quality academic programs at both the undergraduate and graduate levels, to the discovery and
dissemination of knowledge through research and other scholarly activities, and to the provision of service to the community.
The University of Tennessee is engaged in the community through a wide variety of outreach programs (http://www.utk.edu/outreach/) and encourages faculty to seek such relationships in the community. The Academic Outreach Award given by the Chancellor is an excellent example of the rewards and commendations for such
activities as a faculty member (http://chancellor.utk.edu/honorsbanquet/outreach.shtml). Dr. Nan Gaylord was a recipient of the award in 2006.
Dr. Nan Gaylord will be the key staff person responsible for the oversight of the project. She will coordinate the Project Team. The team will consist of Tami Bland, M.S.N., C.P.N.P, and Lisa Wagoner, B.S.N. Ms. Bland was a computer programmer prior to her return to nursing school and has assisted with the research and budget regarding this proposal. Ms. Wagoner is very supportive of the project and will assist with its implementation in the other schools, coordinating the program with the school nurses. Additional technology support is available both through the university and in the school district. The Project Team will work closely with both agencies to actualize the telehealth technology. The EHR hardware equipment will be ordered through the university’s contract with Dell computers unless other compatible tablet laptops are identified. The telehealth hardware will be purchased after consulting with the
university’s Innovative Technology office about the technology utilized in the university’s live on-line courses (including the College of Nursing) and with the companies offering the health evaluation equipment. The requested funds will be deposited in the VSHC account in the College of Nursing and the funds will be dispersed or transferred upon the request of Dr. Nan Gaylord. Spending oversight is provided by the business office in the College of Nursing, the UT business office, and the UT audit department.
Support Requested
The VSHC telehealth expansion and electronic health records project is requesting $46,600. The requested amount is for the equipment needed to fulfill the original missions of the VSHC at its inception in 1995. The request for the telehealth equipment will increase the delivery of pediatric primary care services to an
underserved urban population. The expansion of the VSHC’s services to four other disadvantaged schools will increase access with minimal additional costs after the equipment is purchased. The EHR will assist in demonstrating the VSHC effectiveness, improve the quality of health care, and provide the experience of EHRs to both graduate and undergraduate students. The completed SF-424C and budget justification are attached.
References
HRSA (2006) Health Resources and Services Administration: Health Disparities Collaboratives. (3/21/2006). Prevention Change Concepts. Retrieved July 7, 2010, from http://www.healthdisparities.net/
hdc/html/collaboratives.topics.prevention.aspxMC
McConnochie, K. M., Wood, N. E., Herendeen, N. E., Ng, P. K., Nowes, K. Hongyue, W., & Roghmann, K. J. (2009). Acute illness care patterns change with use of telemedicine. Pediatrics, 123, 989-995. Doi: 10.1542/peds.2008-2698.
McConnochi K. M., Wood, N. E., Kitzman, H. J., Herendeen, N. E., Roy, J., &
Roghmann, K. J. (2005). Telemedicine reduces absence resulting from illness in urban childcare: Evaluation of an innovation. Pediatrics, 115(5). Doi:
10.1542/peds.2004-0335.
Turner, J., Larsen, M., Tarassenko, L., Neil, A., & Farmer, A. (2009). Implementation of telehealth support for patients with type 2 diabetes using insulin treatment: An exploratory study. Informatics in Primary Care, 17: 47-53.
Young, T. L. & Ireson, C. (2003). Effectiveness of school-based telehealth care in urban and rural elementary schools. Pediatrics, 112(5). Doi: 10.1542/peds.112.5.1088. United States Census Bureau. (2000). Retrieved April 22, 2009, from
