The Other 60 Percent

Districts push prevention with employee health clinics

Thousands of Poudre School District employees and their dependents will soon have access to a free walk-in health clinic not far from the Whole Foods Market in central Fort Collins. The clinic, along with a raft of related wellness efforts, is set to launch on September 3.

The site of the new walk-in clinic for Poudre School District employees, set to launch September 3.
The site of the new walk-in clinic for Poudre School District employees, set to launch September 3.

The clinic is part of a new effort by the school district and three community partners to change the way employees get and pay for health care, with the twin goals of promoting wellness and containing health care costs over the long term.

Poudre is not the first Colorado district to launch a free clinic for employees. Mesa County School District 51 launched its clinic in partnership with a local hospital in March 2012. Steamboat Springs School District joined the club in September 2012, creating a free on-site clinic in its administration building.

Still, as the state’s 10th largest district in its fourth-largest city, Poudre may well be the biggest player in the game right now and a key district to watch as its health care initiative unfolds.

“It’s a very exciting venture for all of us,” said Dan Robinson, CEO of Colorado Health Medical Group, a division of University of Colorado Health, one of the partners in the effort.

“I would think every school district would be looking at what Poudre School District is doing and would want to provide those same services to their employees.”

Focusing on prevention

Poudre’s new clinic, which will be called the University of Colorado Health Walk-In Clinic, has been in the works for around two years and envisioned for around eight, said Chuck DeWayne, the district’s executive director of human resources.

Currently, it is a public clinic and urgent care inside the central location of Miramont Lifestyle Fitness, another partner in the effort. In September, although its name will change and it will add Sunday hours, it will continue to be open to the public as it is now. For Poudre school district employees, the biggest change will be that they will no longer pay co-pays or portions of their deductibles to visit.

Instead, the visits will be free for all employees on district’s health plans as well as their dependents, nearly 8,000 people all told. Charges will apply for things like lab work or radiology, but those can be applied to the health insurance plan.

The clinic is not necessarily meant to serve as a medical home for district employees, rather a place they can go for same-day care for minor illnesses and injuries. It will be staffed by doctors and nurse practitioners from Associates in Family Medicine, the fourth partner in the effort.

“The goal is not to be a primary care clinic,” said Robinson.

The clinic is just one component of the district’s four-part health and wellness plan, dubbed the “Integrated Health Management System.” In addition to the clinic, the district plans to launch a program through Miramont providing one-on-one health and lifestyle coaching for employees who have or are at risk of chronic diseases. It already provides confidential mental health counseling for employees who are having trouble coping with work or personal problems.

Finally, the district will begin offering a series of free wellness classes at Miramont next month, covering topics such as weight loss, mindful relaxation and stress relief. The classes, like the mental health counseling, are open to all employees, not just the ones enrolled in district health plans.

Ashley Schwader, the district’s wellness coordinator, said the district previously offered occasional wellness classes at specific schools, say during a professional development day. The latest effort is meant to pull the offerings together at a convenient central location.

Paving the way

Although a handful of districts in Colorado, along with dozens nationally, are experimenting with some version of employee health clinics, it’s not a new concept. Some corporations have been doing it for years, and more recently public entities like cities and counties have added such amenities.

In District 51, talk of an employee clinic began in 2010 around the time Mesa County was preparing to launch its employee clinic. Health care costs were rising and the district was struggling to contain them by raising employee premiums and deductibles.

But that solution backfired, in part because rising deductibles prompted employees to delay or skip going to the doctor altogether, setting the stage for major health problems that produced enormous insurance claims.

About 18 months ago, the district contracted with Grand Junction’s Community Hospital to offer free appointment-based primary care services at an existing community clinic and $25 urgent care services at an existing urgent care center in the city. In addition, about 65 common prescription drugs are available at no cost and the district offers free health coaching to employees dealing with conditions such as obesity or diabetes.

About 1,900 of 3,000 District 51 employees are insured by district health plans and eligible to use the clinic, along with their dependents. District officials initially assumed about 40 percent of those eligible would visit the clinic, but the number is closer to 60 percent.

“A lot of people didn’t even have a physician and now they have a physician within the clinic,” said Sheila Naski, the district’s Risk Manager. “We are really encouraging health and wellness…We’re going to avoid those heart attacks or diabetic comas or whatever it is.”

In Steamboat Springs School District, which has 392 employees, the nearly-one-year-old clinic is somewhat smaller scale. Housed in the district’s central office and run by Healthstat Inc., it contains one exam room, is staffed by a physician’s assistant and receptionist, and is open three days a week for a total of 20 hours.

Clinic visits as well as common prescriptions available on-site are free for employees covered by district health insurance as well as their dependents. Unlike in District 51, the clinic is not meant to be a primary care facility.

“It is well utilized,” said Katie Jacobs, the district’s director of human resources. “They are very busy when they are there.”

Cost containment

The employee clinic in District 51 already seems to have made a significant dent in the district’s annual health care costs. In fiscal year 2010-11, those costs were $11.5 million and the following year they rose to $12.4 million. Then, in 2012-13, costs dropped to $10.8 million, a number that includes the $365,000 cost of the contract with Community Hospital.

She said the clinic is at least partially responsible for the drop in costs.

“It’s probably the combination of the clinic and a good year,” said Naski, noting that health care costs naturally fluctuate depending on the specific claims each year.

While the district’s two-year contract with Community Hospital will come up for renewal next spring, Naski said, “It’s just been so successful. I wouldn’t even think about taking it out of our plan.”

In Steamboat Springs, Jacobs said the district hasn’t yet calculated the return on its clinic investment since it hasn’t even been open for a year.

Still, she said, “This seems to be helping with those costs and keeping our costs down.”

In Poudre, annual health care costs are about $12-13 million, with average yearly increases of about three to four percent, said DeWayne. While that annual increase is relatively modest, he said the district does incur high costs in cases where employees visit the emergency room for problems that could be handled in a clinic.

Therefore, officials anticipate that it will be cheaper to pay for the employee clinic on the front end rather than for the emergency room claims on the back end. DeWayne noted that the $650,000 the district is spending on the new clinic and its other wellness efforts doesn’t represent an additional expense.

“It’s money we already spend. We’re just spending it on the prevention side,” he said.

Unintended consequences

When Denver stopped lunch-shaming, debt from unpaid meals skyrocketed

PHOTO: David Buffington | Getty Images

After the Denver schools chief made a high-profile announcement last August guaranteeing a full meal to students whether or not they had the money to pay, many advocates cheered the end of so-called “lunch-shaming” in the 92,000-student district.

Then came an unpleasant surprise: Debt from unpaid lunches soared, rising to $356,000 from $13,000 the year before.

Denver’s exploding meal debt — amounting to roughly 900 unpaid lunches every school day of the year — illustrates the balancing act districts nationwide face amid growing public support for policies prohibiting lunch-shaming. Such shaming often involves giving students who can’t pay small, alternative meals, putting stickers or stamps on them to remind their parents to pay, or even throwing out their meals.

In the last couple years, a growing number of districts nationwide have established policies to curb lunch-shaming. Some states, including New York, Iowa, and New Mexico, have passed statewide legislation with the same goals. The idea behind such measures is to free students from the burden of debt they have no power to pay and ensure they don’t go hungry at school. But with school districts obligated to pay for the meals, food service leaders are often left scrambling to cover mounting costs.

The school lunch debt is one reason Denver district officials quietly introduced snacks such as Doritos and Rice Krispies Treats in elementary school cafeteria lines late this past winter. The new additions, seen as unhealthy by some parents, helped generate around $41,000 in new revenue for the nutrition services department.

Diane Pratt-Heavner, director of media relations for the School Nutrition Association, said she hasn’t yet heard of another district with a debt increase the size of Denver’s following the introduction of a lunch-shaming prevention policy. But she said it’s an issue the group, which represents school food service employees, plans to watch closely.

“In many districts, allowing all kids to automatically get a free meal …. can turn into a real financial challenge for the program,” she said, noting that it can take away the incentive for parents to fill out the free and reduced-price meal application.

Nearly one-third of the district’s lunch debt last year came from families who were eligible for free or reduced-price meals, but signed up part-way into the school year, after their children had already received free school lunches. The federal government covers lunch costs for students eligible for free lunches and part of the cost for students who qualify for reduced-price lunches. For elementary school students in Colorado (and starting next year for middle-schoolers), the state covers the remaining cost of reduced-price lunches.

Another 68 percent of Denver families with unpaid meal debt don’t qualify for free or reduced-price meals. Still, district officials said it’s impossible to determine how many of those families would qualify for subsidized lunches if they applied, how many struggle financially but just miss the cut-off for eligibility, and how many can afford to pay for school lunches but choose not to.

Theresa Peña, regional coordinator for outreach and engagement in Denver’s nutrition services department, supports the district’s new lunch-shaming prevention policy, which ended the practice of giving students with lunch debt cheese sandwiches or graham crackers and milk.

Still, district officials didn’t expect the ballooning lunch debt, which at one point was projected to hit a half-million dollars, she said.

Peña said the district is stepping up efforts to get every family to fill out the free- and reduced-price meal application for next year — an extra challenge in the current political climate in which some immigrant families fear leaving a paper trail.

Last year, in addition to adding new revenue-generating snacks in elementary schools, the district tried to recoup the debt by making weekly robocalls to parents, working with principals to do outreach to families, and in some cases sending letters home with students.

“We made a pretty hard push,” Peña said. “It did make an impact, but not as great an impact as we had hoped.”

A national problem

Most districts nationwide accrue some debt for unpaid meals.

A 2016 survey by the School Nutrition Association found that three-quarters of school districts rack up unpaid meal debt, up slightly from 71 percent two years before.

In Denver, the amount of lunch debt ranges widely by school, with some accruing less than $50 and others accruing thousands. Omar D. Blair Charter School had the highest lunch debt among Denver schools last year at $11,500. Meanwhile, Florida Pitt Waller, Joe Shoemaker Elementary, Thomas Jefferson High School, and Cheltenham Elementary all reported lunch debts between $2,500 and $5,000.

At Shoemaker, where two-thirds of students are eligible for free or reduced-price meals, Kitchen Manager Chris Juarez said he believes much of the school’s $4,000 in lunch debt came from families who would have qualified for subsidized lunches but didn’t apply. Sometimes, he said, families don’t realize they have to re-submit their application each year; this fall, he plans to meet with returning families — in addition to new families — to emphasize that fact.

Other parents don’t realize they have to add to the form if a related child joins their household, he said. And language barriers may still be a problem, even though the form is available in many languages. In addition, some may worry that filling out the form means their immigration status can be tracked. A 2017 Denver school board resolution specified that the district does not collect or maintain any information on students’ immigration status.

Juarez suspects only a small percentage of Shoemaker families can afford to pay for their children’s lunches, but choose not to.

Shoemaker Principal Christine Fleming, said her top priority is making sure kids get to eat lunch, no matter what. She sees non-payment as a “parent issue,” and said, “I don’t want 5-, 6-, 7- year olds to carry that burden.”

Fleming said she’s always reserved some money in a special “principal’s account” to cover the cost of unpaid lunches, including in 2017–18, when she set aside a few hundred dollars.

Previously, that practice was common across the district, Peña said, but once the lunch-shaming policy took effect, “a lot of them said, ‘Zero out my principal account. I’m not going to do that anymore.’”

In 2016–17, when the district’s lunch debt was just $13,000, an online fundraising campaign and a contribution from a private donor covered the outstanding balance. But not this year.

A district grant of $100,000 paid off lunch debt from students who were eventually eligible for free or reduced-price lunch last school year but whose parents may not have signed up right away. Peña said the district has not finalized how the remaining $256,000 will be paid, and has until June 30 to make a decision.

Is it junk food?

Before this year, elementary schools in Denver sold some snacks — officially called a la carte items — in their cafeterias. These included turkey sticks, granola bars, popcorn, string cheese, and yogurt.

Peña said the district decided to add more a la carte items in February, a few months after district food service supervisors visited nearby districts, including Jeffco and Cherry Creek, and learned that “a la carte sales were a big deal” there.

The additions include more than a half-dozen kinds of chips, Rice Krispies Treats, gummy fruit snacks, and pistachios. All of the items — some of which are slightly reformulated versions of the same products sold on grocery store shelves — adhere to federal rules governing school snacks. Parents were not informed of the new snack offerings when they were introduced.

Susan Scovell, who has two children at Bradley International School in southeast Denver and works part-time as a personal chef, said of the new snacks, “It’s pretty much total junk food.”

She got wind of them when her second-grade daughter began mentioning that friends routinely bought Doritos and Cheetos at lunch time.

“It took me months to figure out this was going on,” she said. “Most parents really had no idea.”

Scovell said the new snacks stand in stark contrast to the district’s efforts to emphasize scratch cooking and other kinds of healthy eating initiatives, such as the week-long fruit- and vegetable-tasting event at Bradley this spring.

Peña, who said the district plans to communicate better about the snack options this coming year, said parents can prevent their children from buying certain snacks. To do so, they need to contact the school’s kitchen manager and request that a note be added to the student’s school meal account citing the restriction. She conceded that the process may not be obvious or easy for all parents, and said the department will look to address that.

Peña also said that principals or kitchen managers have the option to limit the sale of a la carte snacks at their schools. For example, they can choose not to sell certain items, or restrict the sale of a la carte items to the last 15 minutes of the lunch period or to certain days of the week.

Denver is hardly unique in offering a la carte snacks at elementary schools.

Other large Colorado districts, including Douglas County, Jeffco, and Cherry Creek, also offer such items to grade school students. All three districts allow parents to limit or block their children’s snack purchases.

Carol Muller, state director of Colorado Action for Healthy Kids, which promotes nutrition and exercise initiatives in schools, said one of the top concerns she hears from parents across Colorado is about a la carte snacks. At the same time, she understands the financial pressures school cafeterias are under.

“It’s a really tough issue for everyone involved, including us,” she said. “We certainly support food service staff. We don’t want to add a bigger burden to them, but on the other hand, as a parent, I don’t find all the snacks acceptable either.”

survey says

More bullying reported at New York City schools, study shows

PHOTO: Anthony Lanzilote

More New York City students say there is bullying in their schools, a report released Monday showed. The findings also revealed that many schools reporting the greatest number of violent incidents on campus have no social workers on staff.

The report was commissioned by New York City Comptroller Scott Stringer.

Stringer also released an audit of how school safety matters are recorded, and concluded that the education department should provide more oversight and streamline incident reporting rules.

“The audit found clear breakdowns in communication in the reporting and tracking of incidents and actions taken,” according to a press release from Stringer’s office.

The education department disputed some of the comptroller’s findings, and in a written statement, spokeswoman Miranda Barbot wrote: “We have detailed protocols in place to ensure allegations of bullying are immediately reported, investigated and addressed, and are investing in both anti-bullying initiatives and mental health supports.”

But the pair of reports raises scrutiny of Mayor Bill de Blasio’s school discipline reforms, which favor  “restorative” practices that emphasize mediation over punishment, and make it harder to suspend students.

Advocates of the de Blasio reforms say the shift is necessary because black and Hispanic students are more likely to be arrested or disciplined at school. Research has shown such disciplinary action can lead to higher dropout rates. Critics of the reforms, meanwhile, say the changes have created more chaotic schools.

The findings are also likely to add to a chorus of parents and elected officials who say more emotional supports are needed for the city’s most vulnerable students. Students who experience a mental health crisis during the school day may be handcuffed and shuttled to hospitals. The city’s latest budget, which was approved last week, includes an additional $2 million to hire social workers and guidance counselors in schools that currently don’t have any.

Here are some highlights from the reports.

More students report there is bullying in their schools — but the data comes with a catch.

Last year, the education department’s annual survey showed that 82 percent of students said their peers “harass, bully, or intimidate others in school.” That’s up year over year, and up significantly from 65 percent of students in 2012, which was the lowest rate recorded since at least 2010. (De Blasio’s discipline reforms started to take effect around 2015.)

A note about these numbers: Prior to 2017, the survey asked whether students harass, bully or intimidate other students none, some, most, or all of the time. The most recent survey responses were slightly different: none of the time, rarely, some of the time, or most of the time — a change that may have artificially inflated the bullying numbers.

That’s enough to render the survey data unreliable said Max Eden, a researcher who has studied school climate for the conservative-leaning Manhattan Institute — a critic of the mayor’s discipline reforms. Still, taken with other findings, it’s reasonable to think that bullying is on the rise at city schools, he said.

Among the other evidence: A first-of-its-kind report, released this month under a new city law, that showed substantiated bullying incidents are on track to increase this year.

Schools that log the most violent incidents often lack mental health supports.

Guidance counselors and social workers are key when it comes to creating safe schools because they can help address the root cause of violent or troublesome behavior, advocates who want more mental health supports say.

But many of the city’s neediest schools go without that help.

Of the schools reporting the most violent incidents on campus, 36 percent lack a full-time social worker, the comptroller found. On campuses where there are social workers, caseloads are a staggering 700 to one. That far exceeds the recommended ratio from the National Association of Social Workers of 250 general education students per social worker — and it’s higher than the citywide average of 612 students per social worker, according to the comptroller.

The comptroller’ compares that to the ratio of New York Police Department school safety agents who are placed in schools: There is one safety agent per 228 students, according to the report.

“Our city is failing to meet the social and emotional needs of our students,” Councilman Mark Treyger, of Brooklyn, who has pushed the city to report more up-to-date bullying data and to hire more school counselors, said in an emailed statement.

Schools may be underreporting violent incidents, something the education department disputes.

In a separate audit, the comptroller compared logs kept by school safety agents to incident reports filed by school leaders. In 21 percent of cases, incidents that were noted by safety agents were not reflected in the school reports.

The school data, in turn, are used to report incidents to the state for its Violent and Disruptive Incident Report, or VADIR. The discrepancy could raise questions about the already-controversial reporting system. (VADIR has been criticized for classifying schoolyard incidents as serious offenses, and the state has tweaked its definitions in response to those kinds of concerns.)

This finding also comes with some caveats. The comptroller looked at only 10 schools — a tiny sample of the city’s portfolio of about 1,800. And the education department took issue with the methodology.

In its response to the audit, education department officials said that the police data doesn’t align with the state’s reporting categories, and that the information may not be comparable because of student privacy concerns and recordkeeping issues on campuses where multiple schools share a building.