Could access to a school nurse five days a week increase school attendance?

Shelby County Schools, Le Bonheur Children's Hospital and Urban Child Institute have partnered on a two-year pilot program in five Memphis schools to answer that question.

The pilot schools are A.B. Hill Elementary, Riverview K-8, Hamilton K-8 and Hamilton High School in South Memphis, as well as Magnolia Elementary in the Glenview area at the eastern edge of South Memphis. 

SCS chose the schools because of their high absentee rates and feeder connections. Students can advance to middle or high school and maintain access to a nurse. Consistent contact benefits students but also provides data to study the program's long-term impact.

Though it's less than three months old, the pilot program is already showing early success.

“As of September, we have actually been able to return 93% of students that we’ve seen in the clinic back to class," said LeBonheur's Charnece Brown, who supervises the program.

Why invest in nurses to curbing absenteeism?

In short, adequate healthcare is critical to school attendance and school attendance is critical to lifelong health and prosperity. In Memphis, pervasive poverty creates serious barriers to adequate healthcare and consistent attendance.

School nurses can help remove those barriers.

“I have a lot of asthmatic children that have their inhalers here, have a couple students with seizures that we have to monitor and have a student with sickle cell disease who we make sure stays hydrated," said Patricia McCraw, A.B. Hill's school nurse. "[By being here daily], we can monitor them so they can come to school."

Dr. Patricia Bafford, senior manager of SCS's Department of Exceptional Children and Health Services, said the pilot program is a chance to "set some additional sets of eyes" on students, especially those without insurance. Intervention could then reduce absenteeism.

"[The nurses] might be able to plug them into some sort of program that they would not be able to plug into if they were in a school that did not have a nurse every day,” said Bafford.

In addition to administering medication and basic treatments, the nurses assist with hearing, vision and blood pressure screenings and measure height and weight. They track state-mandated health screenings, such as immunizations and physical exams, and offer referrals to outside services. A social worker visits each school weekly for additional support and referrals. 

The program will soon include a nurse practitioner who can provide physical exams and treat sick students, including prescribing medications.

"The goal of the program is to keep the children healthy and ready to learn," said Brown.

School nurse Patricia McCraw prepares the exam table for the next student she'll see at A.B. Hill's nurse's clinic. The brightly painted walls put students at ease as McCraw treats what ails them. (Cat Evans)

Who's Absent?

Chronic absenteeism is defined as absenteeism greater than 10% or 18 days in a 180-day school year.

In neighborhoods with high rates of poverty, chronic absenteeism is three to four times higher than in affluent neighborhoods. The Tennessee Department of Education's most recent data shows 18.4% of SCS students are chronically absent but that figure jumps to 36% for low-income students.

South Memphis' overall poverty rate including adults and children is as high as 61%.

Most chronic absenteeism is a reflection of larger social conditions, like racial and class inequities. Low-income students, students of color, students with disabilities and students with juvenile records are the most likely to be chronically absent. Unsafe home and school conditions, bullying and household abuse or instability also impact school attendance.

Looking across SCS's high schools, the chronic absentee rates for black, Latinx and white high school students are 30.8%, 26.8% and 17.8%, respectively.

Low-income children are less likely to have access to healthy foods, safe environments and routine medical care. The result is higher rates of chronic illness including obesity, diabetes and asthma.

Asthma, for example, is strongly correlated to environment. It's the most common chronic childhood health condition, and low-income students are more likely to have both asthma and severe asthma.

Chronic conditions are a leading source of chronic absenteeism, especially among young kids. Chalkbeat noted in 2016 that some 44,000 SCS students reported a chronic health condition.

"Typically, without the nurse being there they would send a call out to a parent and that parent picks them up," said Brown. "Most of the time when the nurses see a student, they don’t go home."
 

LIFELONG Costs

Young children who are chronically absent in kindergarten and first grade are significantly less likely to read at grade level by third grade. Third graders who lag behind are four times more likely to drop out of high school.

When chronically absent students reach adulthood, they're more likely to live in poverty, engage in criminal activity and have inadequate access to healthcare and poor health outcomes.

Beyond the child, parents miss work to care for sick kids. Parents may also face legal ramifications for their child's chronic truancy.

The pilot project's partners said they're developing an early intervention program to identify children in need of specialized care, those experiencing chronic illness and those at risk. Bafford said the program will help parents recognizing symptoms of chronic illness, understand their needs and connect to additional resources.

"If it’s something like filling out information to get insurance or getting access to a computer to go online and register, the nurse can certainly help,” said Bafford.

A.B. Hill Elementary is one of five South Memphis schools selected for a new school nurse pilot program that puts a nurse on campus five days a week. (Cat Evans)

A GROWING Need for Nurses

The number of uninsured children in Tennessee rose 33% in 2017 and 17% in 2018. This staggering increase adds to the importance of alternative healthcare options, early intervention and preventative care for kids. 

School nurses could fill many gaps in healthcare and help protect kids from a lifetime of challenges, but public funding for school nurses is scarce.

Chronic absenteeism is also part of public school districts' state accountability metrics, which impact federal and state funding. The metrics include both unexcused and excused absences, meaning schools have to work to curb even legitimate medical absences.

The National Association of School Nurses recommends one nurse per 750 students. Unfortunately, Tennessee only provides state funding for one nurse per 3,000 students.

The pilots program's nonprofit partners are helping SCS bridge that resource gap for the five target schools.

State officials have said the increase in uninsured children is due to household incomes increasing, which in turn made many families ineligible for the state's low-income insurance programs, TennCare and CoverKids. 

However, an open records request by the Tennessee Justice Center found that between 2016 and 2018, TennCare terminated coverage for 220,000-plus low-income children due to paperwork errors. A 2014 federal mandate required TennCare update its antiquated, paper-based registration system, but its new digital portal didn't launched until March 2019. 

Tennessee is also the first state in the country to apply for a federal block grant for Medicaid funds, which proponents say will boost healthcare funding for low-income families. Critics say it will lead to additional cuts in coverage. The state government acknowledges it does not know the potential impact to payment rates, covered services, the larger economy or employment. 

Bafford said school nurses can't solve the problem of inadequate childhood healthcare on their own, but they can make a difference.

“[For example], with asthma you are talking about regular medication, regular doctors visits, regular asthma testing," said Bafford. "I don’t know if it’s going to alleviate the burdens of not having insurance ... but I think that it will help."


Support for this story was provided in part by the Urban Child Institute. It is one article in a series highlighting the impact and importance of early childhood education. The Urban Child Institute focuses on funding, advocacy and community support for kindergarten readiness and third-grade literacy in an effort to improve the education, health and well-being of children and families in Shelby County.