and thank you to Eunice for inviting me Eunice and I actually first met at Cornell University where I first became interested in school-based health care in school nurse and I’m not the school nurse myself never have been but a good friend of mine back in the early 90s was beginning a school-based health center and so since I was casting around for a dissertation to do I decided to do an evaluation at comparison of school-based health care comparing school nursing services traditional school nursing to the availability of a school-based health center and I did this utilizing a participatory approach so I involved administrators and teachers and parents because it was my hypothesis that the more we involved individuals who do not understand school nursing and what school-based health centers are the more they would want them and that actually worked in the community where I did this we started out with two school based health now they have six in that community so I don’t know that my justification research was his sole responsibility for that birds I like to think it had apart so I had the opportunity following that to do some examination of school-based health care in Australia and Canada I already had a good idea at that point what we were doing in the US and I thought well they must be doing it better and I have some colleagues that I worked with in Canada and Australia and we interviewed 73 what we would call commune Foreman services and teachers and administrators community leaders regarding how school-based health care is going what they are doing and the barriers to increase in the availability of school-based health care we use the grounded theory approach and course some qualitative analysis software and we do back and forth the email as you can imagine because I could have spent a lot of time in Australia and Canada an encounter funding for that we looked at current health aides of children or chala you have talked about certainly we all know in this audience in particular what the health needs of children in school are and whether or not they’re being addressed we also looked at them specific health needs in Australia for example they have high incidence of skin cancers so they spend a lot of time focusing on prevention and you can see that their big hats are one way that they’re approaching that it’s fascinating to see the children out on the playground because you just see a sea of blue hats and if the children don’t remember their hats they have to go under and one of those big son say ups that they have on every playground so the children remember them because they don’t like getting stuck under those we have a lot of medication administration going on in schools which some of you have already talked about and we know that we don’t have enough school nurses one of the things that surprised me a lot I when I went to Australia and Ken I thought they did they were doing it better than us because they do have health insurance but they’re not depending on what state you’re looking at pending on which province depending on school district some of them have schools many of them don’t and actually in Canada and Australia I think they have less school nurses than we got here in the states again it depends on the state I just moved to Idaho where it’s particularly found I think some of you said Colorado and California it’s bad I think I’d was probably worse I’ve been there by year I came from New York whereas school nursing is regarded pretty well and we have pretty good ratios there so I was really surprised and we have exactly one school-based health center on site it’s actually linked to the school’s not in the school in Idaho and we have one mobile school-based health center so I have a lot of work to do I’ve moved to a great state to do that we looked at a health care provision and the models in the various countries and we have a variety of vowels as all of you know some schools will include school nurses full-time most don’t most have some kind part-time status in Canada and Australia it was more common to see community

health nurses going into the school so they weren’t placed there regularly they just came in and out as consultants doing some education although I interviewed one principal of a school for children with special needs who said she had been there for five years and had never seen a community health nurse and as you can imagine they had many many children with health care needs the children with special needs issue came up in the research because many children in Canada and Australia as well as the US were not able to get the care they needed in school and often they were being sent home or not allowed to come to the school because they could not provide the care that they need it there was a great debate amongst the people that we interviewed as to whether or not there should be mainstreaming of children with special needs because in the regular schools it was felt they could not get the care they needed so in Australia in particular they send the children to special schools for children with special needs and many of the parents like them the teachers like that because they feel are able to get the care they need whereas in a more public school they would not be able to get the way they’re structured right now so is a very interesting comparison their ratio of school nurses to students in Australia and Canada is in general much higher than it is here in the states again that varies over my state 1 2 750 as a general recommendation of the national association of school nurses but then of course that depends on the acuity level and the number of children with special needs and what’s going on in that particular school so it’s a very general recommendation but we didn’t begin to even see that in most of the schools that we were looking at so i can talk about that for now that i won’t barriers to providing school-based health care or very similar across the three countries we know that we have limited resources and we often have a physician opposition to nurses practice particularly school-based health centers we’re not seeing that so much anymore in the United States but we’ve seen that a lot still in Australia and Canada nurse practitioners have increased or been allowed to practice to their scope of practice much more in the United States than they have and in Australia and Canada it’s still fairly new there so they’re going through many of the same battles that we had already had here teachers have expressed a lot of anxiety and stress with regard to the increasing expectations that they have for providing health care to children in schools so particularly in Australia and Canada will it have no school nurse on site they’re being asked to give medications they’re being asked to do g tube feedings they’re being asked to do all of those things that school nurses would be involved in if they were there and the teachers are starting to say you know I really don’t have time to do this I’m supposed to be teaching and some teachers particularly unionized teachers are objecting and refusing to do that teachers that I spoke with in Ontario for example we’re refusing to provide the health care many of the teachers in Australia said well if we don’t do it who will these children will not be able to come to school if we don’t do it we have a duty of care so it’s a really interesting dilemma and something that all of us know to work on we saw differences in rural versus urban the attitudes towards school nurses and school-based health centers continued to differ significantly between districts whether they were Americans sometimes because a very conservative points of view with regard to what school nurses do we also saw the attitudes toward school nurses often were well they only put on band-aids they thickest be band-aids all day so we really don’t need them and this was a lot of people like principles one principal said to me well I was school nurse here I’ll have kids lined up around the block to see her why would I want to be doing that and I thought because you have students that need to see her other structurally and culturally embedded issues included

racism and classism one Prince principal when being interviewed said well the aboriginal population like sitting in the ER they get to be in air conditioning and watch TV so why should we provide care for them here and this was a principal so you can see we’ve got a lot of issues that we need to work on my only regret is that like this happens here day they’re singing to the choir all of us believe very much in this cause what we need to do is get it out amongst a larger population and so my participatory evaluation worked with involving parents and teachers so that they could then understanding differences and hopefully become advocates for us as well thank you nursing services the study was published last year in JAMA Pediatrics first I would like to use this opportunity to acknowledge all my processors for very important the contributions actually well my promise or areas here today I was Charlie salita the background of this study Oh as many of you know the demand of those nursing services has increased significantly in the past few decades however the funding for school nursing services has not in fact in the past few years due to budget a budget cut many districts across the nation has been eliminating school nurses reducing their hours or replacing them with entrained asusta several studies have evaluated the effects of spoilers and services on students and teachers outside of school nursing services were found to be effective in improving student pendants reducing religious leaders and the reducing teachers time spent addressing sleep and health issues hi world economic studies of those universal services were very limited you know cost conscious Arabs know being a public program is effective is no longer sufficient to just fine standing given the growing pressure on education graduate school nursing services need to be shown not only in fact but cost effective so the objective of this study was to conduct a case study of documented school nursing services practices to demonstrate the cost benefit of school nursing services delivered by full-time registered nurses because data availability we chose to use we chose the Massachusetts essential school health services program for this study almost every school in the program has at least one photon registered schooners providing a wide range of school nursery services such as direct care house education case management policy program our side all school nurses are required to submit in monthly activity report to the State Health Department and the State House did have money will generate an annual data report which shows all the school nursing activities that took place during 10 months a year according to the 2009-2010 data report about some tea anger district’s reported a total of four point nine million student housing counters 1.2 mating medication and administration and one may new medical procedures performed by school nurses during a 10-month school period the early dismissal read after hurting us owners was six point two percent because program selection decisions or resource allocation decisions are typically made the interest of society as a whole so we conduct this study from a societal perspective and the standard cost-benefit analysis approach was used to compare the central school health services program with a no nursing services scenario the known nurses who knows who nursing service

is a hypothetical scenario in which we basically projected what will happen to student health services news when there is materials for nursing services provided the main media source for this study is the 2009-2010 Massachusetts report we also used published estimates for certain parameter estimates such as early dismissal rate with other stoners and the teachers time spent with and without school nurse we also used the physician fee and coding guide Apache CVC code code book and the Massachusetts maniacally is scheduled to generate some medical care costs as means for the 22 medical procedures performed or reported by school nurses with each scenario we asked to be the three type of costs first health care costs related to the medical procedures performed by school nurses we basically assumed when there is no school nurse present I school all those medical procedures will be performed we provided at medical facility by physicians or nurses we also asked me the parents probably lost costs related to student or ladies museums and the medication administration in Massachusetts according to the state regulation even there is no nurse in the school system parents have to go to school to vitamins medications for their children the search type on Conley I submitted is that teachers perfectly perfecting the lost cauze which is associate with teachers time span addressing student housing issues because lack of available data we did not include costs awarded potential classroom or virtually related to reduce the neverland house reduce the yellow races and reduce hospitalizations the program benefits will memorize a cause of work it compared with the nose nursing services scenario the cause of school nursing services incurred in the 70s interest rates during the 2009-2010 school year or estimate americanized program costs which includes nurse salary and fringe benefits as well as the causal Michael supply and equipment cosmetic American who night benefit benefit cost ratio the all costs and benefits were measured in two thousand nine dollars the results are other based his assumptions at the program cause of sending nine million dollars the estimate total cost aborted by the program was 20 meeting dollars in medical care costs today eight million dollar receive parents were protecting lungs and 129 million dollars you teachers product loss as a result you generated a night benefit of 98 million dollars for every dollar invested in a program 202 dollars were saved in assisting the analysis 10,000 assimilate simulation trials were performed and the ninety-five percent of those trials the total costs are working range from 36 million dollars to to 302 million dollars and the benefit cost ratio range from 0.72 308 eighty-nine percent of the 10,000 trials resulting knife singing all night benefit the results of these studies suggest that the basic rule says essentials for Health Services program was a cosmetic facial investment of public money and environment careful considerations by policymakers decision makers when they have to make resource allocation decisions of school nursing positions because lack of availability there are many other benefits of school nursing services will not count in this study such as reduced Nagamani house yahoo easier hospitalizations reduced how screams by physicians increased attendance reducer job always et cetera

so the extra benefits of the program could be much higher and some others who nursing services my revisions to house care provider to insurance providers the house education and house promotion how lay there is no way to estimated economic impact of those services so the findings of this study suggests that school nurses the benefit of school nursing services could be the cause of those services school nursing services can be a benefit to many parties including students families health care system as well as community at large however to achieve all those energies school math schools must have a photog registered school nurse in schools where education budgets are constrained Oh school nursing services are low priority education agencies may be able to work with health care system planners to use for other funding sources and the health care system might value their contribution to this partnership as part of Community Benefit investment my time’s up okay there are as many economic studies this study has many limited as if you research limitations however when you have because of all this in English and we have been cultures and have carefully conducted on various is maybe analysis to address those planet for future research that and the medical approach divided up in this study can be used for programs in any other state or district school nurses should regularly with for their service activities and work with other school staff to collect data on school attendance our ladies meadows teachers can spend as well as 911 calls etc so when all those data become available more research studies can be protected to reply no impact of school nursing services okay I will stop here thank you so much for having me even though I am a UC Berkeley alum no there’s for that in there um so I heard a lot of jeans today around resources for school health services and how we make these programs sustainable unfortunately I’m not the silver bullet I wish I could but I did want to present a couple of opportunities that we’re watching at the state level that we think are really exciting for the state of California so before I jump into that I really wanted to quickly introduce our organization if you’re not familiar with us and we’re a statewide organization that is really promoting and advocating for school health services and historically that has been oriented around school-based health centers but we are definitely expanding our mission and supporting the work of school health services generally recognizing that center is not going to be the right fit for every for every of the 10,000 schools in California so right now we’re working on a lot of our mission is our policy mission has really been oriented around integrating school-based health services into the healthcare delivery system so we recognize that our state’s healthcare system is evolving and making changes to how it’s delivering care and we think that there are some really exciting opportunities to lift up the school health model recognizing that school health services are about providing primary care and access but also it school represent this really unique opportunity to provide preventative care to do why to do school wide screens to do assessment to do prevention work in a way that is really unique to a school based model so we’re definitely so my talk is really going to be around this health care system and I did want to recognize there are a lot of policy changes happening on the education side of this world we sit in a real interesting nexus between this crazy education system on this crazy healthcare system so there are changes happening on the education side like little control funding formula like changes for billing for school-based health services and that

I’m happy to talk to you about how can I focus on this situation and so I didn’t want to talk about for policy changes so I’m going to talk about the Affordable Care Act and the Triple Aim and what that means I’m going to talk about accountable communities for health it’s a really exciting model of health care that stays looking at I’m talk about this preventive services rule and then I’m also going to talk about school health services and managed care health plans so the first ones i’m going to talk about in the Triple Aim and the Triple Aim if you’re not familiar with this is that the core of our health care reform efforts across the country it’s this idea that we want to improve three three aspects about the health care system we want to improve about a health care so better access to health care better patient experiences of health care we want to improve population health so making sure that we are health oriented system and not a disease oriented system and we want to lower costs should probably be a bigger triangle in California but that’s the model we see and I think that there’s also an argument to be made that if we achieve all of those things we are going to reduce health disparities so this is at the core of health care reform this is this idea this concept and part of this work is how our school health services relating to those three red pieces of the time um we know health services work we’ve talked about that a lot today and they have an impact school health services and school-based health centers have a positive impact on the health of students and the community they have decreased emergency department visits and they increase access to health care so that extent that nurses are referring and making sure that their students are going to the pediatrician and going to their well child visit that’s a part of access to care and better referrals they can screen for diabetes risk factors and they reduce asthma related hospitalizations they increase health care utilization which I mentioned they can provide effective health education so how do you access to school classes and students to provide them information about what it means to be healthy what it means to prevent diseases and to monitor chronic diseases that they happen to have them they addressed some of the public health needs so immunizations screenings case management so this is part of what we’re seeing in school health services and how it relates the Triple Aim and I wanted to present this because these are things that the health care system is interested in this is what as the Steve’s making changes these are the pieces of the health care system that are really resonating and are guiding a lot of the transformations that are calcutt states of California engaging in as well as across the nation so one of the exciting models of health care of population health as this idea of accountable communities for house and our state applied to the federal government for funding to implement what we are calling our california state innovation model our kalsa it’s a model it’s an innovative model of how we want to transform our health care system that is in the feds didn’t give us dollars to implement this we apply in the fall we didn’t get it but I think a lot of what was laid out in the Towson is a baseline for California’s vision of health care and what we want to see your healthcare system change and and it is its underlying a lot of some of the reform idea that the state is moving and continues to move with so one of the aspects of the calcium was this accountable communities for health and there are states that are playing with this with this model and it’s a population health model it’s um the goal is to regionally geographically defined pilots linking health care systems with community-based prevention strategies so it’s this idea that you want to take a defined geographic region which can be a county which can be a city which could be a school district so those are just some examples to focus on one health condition and some of the conditions that the state was considering we’re diabetes cardio disease which resonate with this crowd but asthma is it was it was one of the conditions I’m also mental health is a mental health issue in a community-wide an issue for community and it partners and it purrs the health care system so it takes the health plans hospitals primary care providers to help County Health

Department and merges with them with it community partnering organizations like schools so I to merge the the needs of the health care system with those that can be connected with the community and school so I think that this is an exciting model because it brings the health care system with the community to provide to increase preventative care to increase some of the screenings to increase some of this wide education that we’re seeing happening and and merging it together so I think that this is an exciting community and even though the state isn’t moving forward the best idea there are communities that are that are proceeding with these concepts I know Fresno is one and I think this is an idea that resonates with a lot of foundations and so there is an interest in different regions and pockets of California to to see some of these pilots actually happen so the third one I wanted to talk about and I’ll try to go through this really quickly I’m running out of time is a preventive services rule so this was a rule from the federal government that allows reimbursement of preventive services provided by professionals that may fall outside the state’s clinical licensure system so long as the services have been recommended by a physician or a licensed practitioner so this is a rule that states can choose to adopt and we see this as an opportunity to support some and reimburse for some of the preventive services that may be happening at schools like screams light health education and a lot of what we’ve heard in our school-based health centers is working with health educators croatoans it could be school nurses to that are doing some of this / kind of work that are doing some of this health education so an opportunity that we see is moving beyond the preventative health education in a clinical setting between a doctor and hit her patient to some other models as their home visiting that we can promote is there a group health education that we can wrote we know that you are doing this so is there a way to provide reimbursement mechanisms for these services our school-wide screenings a part of this are you doing our school of source of providing school-wide behavioral health screenings so is that a part of this preventive care that we can see reimbursed through other types of providers at a school sign so I’m going to try to go through this really quickly the fourth one I want to talk about is managed care health plans so our state has been delegating a lot of the health care delivery through managed care health plans and so part of our work is is showing and lifting up examples of where health plans are working and reaching out into their community to provide support one opportunity is through the children’s health and disability prevention program managed health care health plans are actually required to execute mo use with schools in their area that they serve to support the promote the provision of CHD p services so this can be direct reimbursement this can be providing the health plans providing staff to the school and providing referral mechanisms for the school to make sure that students are getting there I’m getting access to the children’s health and disability prevention program and there’s another model that I want to talk about but I’m not going to jump into it we can talk about a little bit during the question the answer program but um we’re we’re lifting up models of where health plans are actually partnering with school districts to reimburse school nurses for school-based health centers for preventative services and one example is kern county they the health plan there is working with the school district on as programs where the school nurses are providing a four-part program and that’s what’s included in the activities and the health plan is actually reimbursing for their covered for per per component of that program per student that to help the school nurses serve that are enrolled in the health plan so that’s really brief I can certainly talk more about that but those are examples of this health care system that was engaged and wants to lower their costs and reduce emergency room visits and improve population health and how we want to see schools become an integral component of the soft so I apologize that was really fast but I’m happy to answer any

questions in those sources professor and a lot of what I’m going to tell you today is based on the experience and the work of the nurse demonstration project and many of the speakers that spoke before me he spoke very well the issues that we’re interested in Oh connect so I’m going to move very quickly on this couple of slides just because we’ve been talking about this a lot and they’re mainly just a background information and justification for the project itself and what we are interested we are interested in what it’s good that presentation micros engine problems of Lisa’s presentation because we have stay focused so while it’s interesting for us to look at what’s happening in other countries and the Australian experience Canadians periences very interesting and we want to know what California do and what other states are doing that might be relevant for the California experience so to recap this morning basically we had the problem so many of the challenges is first of all the uninsured and the underinsured in California so we recovered this before custom bar was explaining that we have a decreasing number but it’s still significant numbers that are about seven percent of the children are uninsured so we want to know what we can do in regards with the uninsured and the other insured reminding ourselves that the is social disparities that are important and the Latino population and after descendants are affected in different ways insurance and emotions we also saw we also saw this gentleman we talked about the needs the increasing needs chronic conditions complex needs of children what that means in what the reality is in the state we talked about asthma and the increased number of cases were asthma implicates on not only the health but education attend next so from that background where where do we go there are many ways to provide health services in schools we also talked about health service health care centers in schools and we have in the state of California has made progress with regard with health care centers in schools and the number of health care centers in schools in California has also at least however as you can see in this map it doesn’t solve some of the problems of disparities regional disparities and the concentration in urban areas and I was saying with wealthier urban areas so we’d like to revisit the situation on the conditions of their provided by health care centers in schools but we are focusing on another way to provide health care services in schools and that is to have full-time nurses and I’m sure you are familiar with this indicator this ranking of the called the ruler that deals with a ratio of nurses first two terms and California has consistently ranked among the worst in the country with the ratio that varies but it’s basically depending on region remember this is also averages of those regional disparities that I was telling you about are also significant in terms of this of the ratios okay so focusing on full-time nurses and the impact of full-time nurseries to white have those states that consistently ranked above you know the average in the nurse per student ratio then what is the differential that those states are

providing and again we also looked at the states on the bottom the states that are ranked West to see what their experiences and if there is anything that they are doing that we could study to see the relevance or maybe the viability of implementing some of those actions in California this before before we talk about what other states are doing I just want to revisit some of the main challenges in California so we can see the experience of other states is relevant for us so some of the challenges that will talk about this morning include first of all the budgetary restraints and for many reasons you normally we heard from very early on the consequences of proposition 13 and what that has meant in terms of diagnosis and all the non intentional consequences after that that have affected the school nurses ratio and the budgeting for school health services in general we also taught anything Lizabeth again with Lisa the need for nursing data sets so currently we don’t have a uniform method of collecting data in for the state so basically right now it’s predominantly on self-reporting districts of reporting data and that gets some districts report that are better collectors of days come on the district’s not the data is different so for any analysis we need that data not only to be collected but also to be uniform and and also this data has to be available not only for those policies but the white public we talked about regional disparities and then we also talked this morning about what we call a lack of cross-cultural communications and awareness and this is when we have the principal so when we have the case that the early there were so many leases I I think might have been one of them and we’re talking about the Lisa the principles that do not recognize the need of health care services in schools and principals that do not recognize the need for nurses full time less in stores so that’s what we’re calling the lack of cultural and communications weddings so what the other states have done and this is before I move on to this I want to say this is not a solution we’re not necessarily recommending this and I’ll tell you why lesson that so one of the things that things have done when they realize that they rank among the worst in the country is to create a task force a task force that constitutes that brings together different kinds of expertise and are different actors to discuss the situation and really draw some recommendations that could be implemented for a specific girl and we put together this table that shows some of the states that used to bring or still ranked among the worst and you see Idaho’s there yes Lisa I was there and what have they done so they put in they they created a task force and that task force has generated policy and my have contributed to the improvement so you can see that there is some improvement they in terms of the wrapping a new mexico is there and they have created this task force however New Mexico has consistently been above the the average or the recommended ratio other practices that are also present in other states that could be relevant to California our legislation so for example in terms of budgeting school health can have a designated budgeting this is the case for example in Vermont it’s not necessarily the solution as task force

is not necessarily solution we would have to see what of the recommendations from the task force were in fact implemented to see they have results but legislation is in the same case again school nursing datasets oh yes information needs to be available and it is to be transparent about what’s happening in the schools we need to know what’s happening in schools and then we also talked about partnerships briefly and this is something that other states have been doing partnerships with universities with hospitals and with other institutions even though technology development and industry so this is another area is for explanation and some of the things that we are investigating and looking into to see the viability for work at Point okay thank you so at this time I’d like to invite up and what I suggest because it’s leading to that lunch power and sure pretty hungry we have scheduled 20 minutes but what I’ll do is in if there’s any really challenging or lengthy questions and if you’re all over me here during the lunch hour perhaps we could face of death during lunch how are you all immutable to that okay so then let’s try to see we can committee to 10 15 minutes I don’t know what’s the answer this but you know in California you have a some pretty dynamic and powerful University unions and I think in order to the legislation along or funding along often times it takes so much who are battling that page how active our school nurses in groups like California Nurses Association voice and these are outreach to these to participate out bago agenda is that within the Union organizations for nursery nurses pick school nurses can become active and organizations like this or not because I think without somebody else advocating powerfully behind school nurse and Spike organizations like that it’s going to be a very difficult avenue for getting any kind of additional support so does anyone know the relationship between the nurseries and schools don’t talk to me yeah yeah of course hi I did speak to that so California has 22 powerful large nursing organizations one is California Nurses Association which functions as a professional Union and the other is the health or Nia branch and the American Nurses Association which is not unionized and as a profession SI organization school nurses have a very strong and substantial partnership with a na currently there is no conversation going on with the CNA Gretchen yeah and I just I just want to add a piece which is not particular I don’t know if this working is it on this is the cry but life is on oh there you go um I i can’t speak particular to school nurses organisation but i do know that all state organizations are challenged with a lot of the infrastructure and the funding infrastructure in california so one of the things i did not mention was california has also realigned all of their and the school based funding to local control it’s our new local control funding formula so right now instead of the state telling school districts what they need to spend their dollars on a lot of that is being is at the control of the local school district so the school board’s have been given an allocation from the state and they have to go through a very community driven process in theory to allocate those dollars and so that is just part of the world in which a lot of state organizations are operating under is yes we can advocate our very we can activate our very active members and advocate to the state for more dollars but under

local control funding formula likelihood that we’re going to see state dollars go directly to school nurses or a school-based program in particular is unlikely because a lot of that of the governor and the legislature will say we’ve given the school districts their dollars if they want to hire more school nurses if they want to hire more teachers if they want to implement if they want to build a school based health inner that’s up to the prerogative of the local decision-making I just wanted most certificated school nurses jubilant teachers union I’m not sure how much do for us they are Jews just like the teachers but I a lot of advocacy kunin teachers union and I think that it really almost starts so like at home meaning that each our districts first of our districts have to look at us as a priority they need to look at us as really important and I’m not sure that that’s yeah i think it’s sharing that data is there that supports our students will have better outcome but i think i just want to possibly nurses are what are they the locals report or what our local government city or what it would be the school I mean it’s a it’s the school board this school district superintendent I mean it depends a lot on the district so bigger district would probably also allocate to their local principles as well some of those funding decisions and if you are interested we have a whole page on our website about the local control funding formula we have a toolkit that describes what are the components of this local control funding formula part of what school districts have to address as absenteeism so I think that that is a part of making the case for school-based health services and so I you know we certainly advocated on a state level but I think the onus is a lot on local school nurses local parents use to to go to their school board to go to their principles to understand how their funding formula is being allocated and make the case for what they want I would like to add one thing to this before coming to idaho i was in maryland and the Alliance for school-based health centers in Maryland actually hired a lobbyist to go to the state and lobby for school-based health care and school-based health centers any other questions it’s a hand no okay yeah why is it that Connecticut which is up at the top ranking how is it that they decided that school nursing is a great priority compared to California which is way down Bob do you know how that came about which one of you showed that ranking so yes I’m Connecticut Rhode Island Vermont day it’s not it wasn’t a decision after the rank it was a decision that had been developed along the years right so they have a lot of actions that lead to that one of them in the case Connecticut is legislation specific legislation for school health so it’s not like the budget goes to the education and then gets relocated it is a specific the sig- funds are also there’s practice and what’s allowed to be delegated did you all hear back I’m sure what I were going to think that it was not as we looked and we talked to the grace people parties and the nurse Practice that’s which a lot of the Easter egg in the best juices parts to they can’t hella gate and so they can or cannot they cannot delegate many of those things and so there has to be scores to give it room in the school or in other states that allows for much more interpretation and so that makes a big difference and then once they’ve had a school nurse they know what a school nurse can do and it goes back to it they think bandidas all you know there’s nothing that has shown that otherwise why do they need it work because so it’s a multitude of

different dr. Meade you have become in now our head district nurse from issaquah Union High School District couldn’t make it today but she actually was a nurse in Connecticut schools and what she had relate to me is that Connecticut it also had big advocacy on Clinton’s and I don’t know if this has been documented in God she said that that was a huge push in Connecticut to have that support so I think the legislative approach is definitely one way to approach it grassroots is one thing but the top down thank you have that question in the back wait a minute I don’t like talking about the physicians here but I’m actually poised on the verge of adopting the city Fremont in flight school district which is a district that has 14 school nurses and no position back with whatsoever so just in response to this general sort of what can we do to advocate these things I mean are legendary obviously I dude do the disabled advocacy but at the same time I can speak for many of my colleagues in general pediatrics and in some sub specialties you know these people are working with sort of hours that don’t really make it possible for them to sort of step up the community to do so that things and i’m doing i’m only doing it because i’m not doing a whole lot of love bouquet right now so i provoked my time to do it but to me there’s an untapped resources amongst our retired nutritious right burnout rate in pediatrics is actually getting higher and higher and there are patricians who are working hard time now and who are retiring at who if approached would step up to do these kind of things especially in the area we were talking about advocating for global under control issues i’ve already you know i stepped up on the issue of gun violence and crisis preparedness and deal with disaster and this is how that was my opening into the district but immediately became aware that the obvious to me that there was so many mother issues for free month and yep p123 students in our schools that are homeless so we have issues there to deal with nursing medication issues are a huge it you’d give up with asthma deal with diabetes insulin needles at me pens in particular they’ve been asking me about what to do about that depends disbanding of having a universal at the tenth or three or four bill on your school and who’s going to touch it who’s who’s going to touch it quickly enough and not be afraid of the fallout if you mark alexis physician even as nice as nurses there there’s a lot of quantity there so i’ll impress the case for and i believe personal listserv across the country at 1,200 pediatricians anytime we need one in the stator or our place we just have our listserv would say it was available out there I’d like to press for it especially in the area the san francisco bay area for getting on you know sort of going like drug reps door-to-door these pediatricians and find out how much you can trigger out of them there’s a there’s a certain voluntary sort of system that’s building up with a pediatricians now where they used to be very concentrated other clinics but now they’re opening up to getting involved with local air is a local controls and it feels to me like that is a lot a source of security for nurses who are dealing with these issues when they’ve got and these license or signature or recommendation behind what they’re doing and they won’t be so hesitant to act for some of these issues that feel that they’re a little bit out of their baby bit sometimes such as I think that was well said we’re actually fortunately bed in san mateo we have a high school district we have wellness creators in all eight school districts within de southern San Mateo County that’s quite healthcare district supports in other one is a pediatrician she’s alone according to the high school mr. dr Karen Lee who has done some work around that legacy and getting a heavy kind of legislation and so that’s a good start and she works with the school nurses and I hope you two will talk later right now I think unless there’s anything pressing think we should go grab some lunch and a further discussion