From mission creep to mission critical: Bringing health care and education together

The idea that healthy kids perform better in schools seems obvious, but bringing health care and education together in tangible ways has proven to be tougher than one might expect in Indiana.

Offering health care in schools has often been called “mission creep” by Hoosier policymakers. This perspective is defended by the sheer existence of two different governmental systems.

Clearly, the Indiana Department of Health and the Indiana Department of Education both have their own missions, budgets, staffs, and federal policies, but this doesn’t mean they should be discouraged from working together. Both organizations are facing devastating shortages and one of the toughest climates in modern history.

While the notion that these agencies working together is “mission creep,” the reality is that solving the issues our state faces necessitates that we find innovative ways for our health and educational services to work together in tangible ways.

Existing Pathways

The Title IV, Part A (Title IV-A) Student Support and Academic Enrichment Program (SSAE) was authorized under the Elementary and Secondary Act of 1965, as amended by the Every Student Succeeds Act in 2015.

The Title IV-A program is intended to improve students’ academic achievement by increasing the capacity of states, local education agencies (LEAs), schools, and local communities to (1) provide all students with access to a well-rounded education, (2) improve school conditions for student learning, and (3) improve the use of technology to improve the academic achievement and digital literacy of all students. The second priority has been defined as “Activities to Support Safe and Healthy Students.”

Indiana has embraced the implementation of the school safety measures with vigor. The Indiana Department of Homeland Security supports schools via their Secured Safety Grant Program to pay for law enforcement and security needs in all Indiana schools. In August of 2023, Gov. Eric Holcomb announced a $30 million matching effort to the existing school safety efforts, with two-thirds of this going specifically to law enforcement and school resource officers — meaning the budgets for school safety efforts more than doubled.

This funding came on the heels of the Governor’s Public Health Commission’s report that called for more school nurses, yet no such funding came for schools seeking to provide health care services. While the commission’s report was clear that Indiana has a desperate need for more school nurses and school-based health services, these calls were left unanswered. Even more worrisome is that the Indiana legislature approved an unprecedented $275 million in health spending to address the needs in the commission’s report and neither school nurses nor school-based health centers are even mentioned.

Senate Enrolled Act No. 4, which is 37 pages long, was funded to the unprecedented tune of $275 million dollars via the Health First Indiana Initiative. While many school-based health and school nurse advocates were hopeful that these funds could be the shot in the arm needed to address the issues outlined in the commission’s report, the prevailing notion of “mission creep” won the day.

Neither school nurses nor school-based health services were named as priorities for funding. Schools were briefly mentioned as venues to provide vision, dental, immunizations, and hearing screenings, but this barely scratched the surface of minimal care and in no way offered support for innovative services that could address the current health or educational issues we face recovering from COVID-19. 

While the initiative recognized the role schools could play in providing access to children in the communities for health services, a prominent opportunity to serve those students with desperately needed physical and mental health services was lost.

From Access to Absenteeism

At 180 days per year, the average student spends 1440 hours at school. With summer school and extra-curricular options, some students reach as high as 2600 hours per year at school.

Now, compare this to the average amount of time children spend with pediatricians. According to a 2016 NIH study the average medical appointment lasts 20 minutes. And 23.3% of all children touch the health system “not more than once per year.” Another 9.9% of children in poverty utilize the health system less than once every two years.

Thousands of Hoosier kids missed between 10 and 18 days of school last year, per new data

A 2023 study by the Paramount Health Data Project found that students in Indianapolis saw a school nurse eight times more than a pediatrician, making school-based health care the primary source of medical care for children navigating poverty.

Research has consistently upheld the impact of school-based health services on absenteeism and academic achievement. To successfully decrease chronic absenteeism, it is essential that school nurses routinely be included as integral members of school attendance teams. Another study showed that the “presence of a school nurse is associated with reduced absenteeism and missed class time.”

The benefit of school based health care is also beneficial to our struggling health care system. The University of Colorado published a study in the National Library of Medicine in 2022 showing that access to a school nurse reduced emergency room visits by 34% and inpatient hospitalizations by 44%.

Indiana’s own Richard M. Fairbanks Foundation, who funded school-based health services from 2005-2017, found a direct economic impact when school’s offer health services. According to their 2022 “Lessons Learned” report, “These services have also been shown to have a positive economic impact.” For example, for every $1 spent on school nursing, the savings equal $2.20, fewer emergency room visits and less work missed by parents caring for sick children.

The CDC and the Association for Supervision and Curriculum (ASCD), two leading national voices in education and healthcare, came together to address the gaps between the two fields by creating the “Whole School, Whole Community, Whole Child“ (WSCC) model. This was in collaboration with key leaders from the fields of health, public health, education, and school health — to strengthen a unified and collaborative approach designed to improve learning and health in our nation’s schools.

They note, “The education, public health, and school health sectors have each called for greater alignment that includes, integration and collaboration between education leaders and health sectors to improve each child’s cognitive, physical, social, and emotional development. Public health and education serve the same children, often in the same settings.” According to the National Association of School Nurses, healthy communities provide the infrastructure and resources that create the conditions and opportunities to support healthy lifestyles.

Mission Critical

Schools across Indiana are listening to the needs of their students and communities and choosing to address academic loss and absenteeism by offering school-based health care on shoestring budgets during devastating shortages. We must squash the notion that funding or even allowing already budgeted tax dollars to go to school-based health services is “mission creep.” We need to embrace it in a similar fashion to law enforcement presence in schools.

Both health and safety services in our schools are mission critical to fully utilizing the opportunities Indiana schools play in healthy communities. Supporting these efforts are mission critical for both education and healthcare to meet the growing needs of our state.