Schools across the nation have been closed for weeks and many are questioning whether or not they will re-open. We don’t have answers today as the COVID-19 pandemic rages on and experts predict we will experience another wave this fall. Millions of families who are juggling work while home-schooling their restless children have found a renewed appreciation for teachers. Yet there is another group of individuals, who often go unrecognized, quietly working behind the scenes caring for our young ones. They are the nurse practitioners who work in school-based clinics, filling a critical societal gap in primary care. While school may be on hold right now, these clinicians work tirelessly throughout the year ensuring every student’s healthcare needs are met.

I had an opportunity to speak with my friend and fellow nurse, Sharon Kobak, ARNP, MSN, RN who is a primary care nurse practitioner at one of Denver Health’s School-based Health Centers (SBHC), a large network of health clinics located within the Denver Public School campuses that serve over 13,000 students each year at 18 locations.

1. Sharon, can you tell me a little bit about your background and why you decided to go into nursing?
 
I grew up in Nicaragua and come from a large family of nurses on my mom’s side - my mom is a retired nurse and my aunts are nurses as well. My mom was a pediatric nurse at the local children’s hospital and that was my first introduction. I would visit the children’s hospital with my mom and really admired the work that she did. It was always in the back of my mind that I would go into medicine to be a physician or nurse. When we moved to the U.S., I worked as a pharmacy technician and my parents tried to convince me to become a pharmacist, but I wanted to be more hands-on, so I decided to go into nursing. I attended the University of South Florida for my bachelor’s degree and began my career in pediatrics. While working full-time I went back to school for my nurse practitioner degree specializing in Family Practice.
 
2. You have an advanced nurse practitioner degree and decided to work in a school-based clinic. What led you down that path?
 
When my husband and I moved to Norfolk, Virginia, I worked in the hospital on an adult gastroenterology unit for 10 years. My husband’s work brought us back to Colorado where he did his residency training and we reconnected with an old friend, one of the physicians here in Denver who was in charge of the school-based clinics at the time. I had no idea we had health services in the school system. I wanted to return to pediatrics once we moved back, as I love adolescent medicine. After speaking with our friend at length and providing him with my background and training, I was offered a school-based position as a primary care nurse practitioner.
 
3. Can you describe a typical day working at the clinic?
 
A nurse practitioner and a medical assistant will usually staff the student health clinic, and as a provider in this role, you need to be very independent. Our goal is to see 12-14 patients each day; I have seen up to 15 kids on a busy clinic day. Students can see us autonomously after age 11 if a parent signs a consent form at the beginning of the school year. Once consented, the students can be seen for the entire academic year. They are in charge of their health and if they aren’t feeling well, they can make an appointment with me. Similar to a pediatric clinic, I’ll see kids that are sick with upper respiratory infections, migraines, asthma, or various diabetic issues. I do regular physicals and sports physicals as well. We try to see every single student that is consented. We perform risk assessments using personal tablet devices that are loaded with questionnaires to assess mental health, sexual health, safety, diet, and nutrition as well as drug and alcohol use. The software analyzes the answers and will red flag items such as elevated body mass index (BMI), sleep issues, depression, anxiety, substance use and high risk sexual behaviors. That gives us an idea as to where we need to focus our efforts for that student. If they are high risk for depression or anxiety, we have a mental health therapist available at the clinic. All information is confidential, it is a safe environment. We ensure they feel comfortable talking about their issues.

We also have an opportunity to educate them about things like sexual health. That part is very important, because when kids visit their pediatric provider in a clinic with their parents, it’s a different environment. In SBHC most patients are being seen on their own and can feel more comfortable talking about these issues with that provider - not feeling ashamed or fearful that they will get into trouble.
 
I enjoy seeing teens become adults, taking charge of their health and being responsible. But it’s scary as a parent; I also have a teenager and I would want my teenager to be comfortable talking with someone, an adult that is going to give them the right information and the right tools to hopefully make the right decisions.
 
We can also be a student’s medical home. We see kids with insurance and kids without insurance. We really want to reach those kids without insurance as we may be the only health care they have access to. If they are sick, we have an outlet pharmacy with medications – antibiotics, topicals, inhalers, oral contraceptives and other birth control methods for confidential visits. I am able to prescribe and dispense medications, if they are available. We spend a lot of time with these kids, often more than they would with their personal primary care provider.
 


4. How do you work/collaborate with other health care providers on issues that do arise with students?
 
It depends on which health care providers. Confidential issues are never shared and are documented in a safe place. We do use EPIC, a computer system that is connected with local hospitals in which we can share information on mutual patients. I also have relationships with specialty clinics. For example, if the child is seeing a gastroenterologist for a chronic GI condition or a neurologists for migraine headaches, I would talk to the patient to make sure it is ok for me to share that information.
 
5. The COVID-19 pandemic has obviously closed schools across the country. If schools re-open this fall, COVID-19 will certainly have a tremendous impact. How do you foresee the virus affecting your work and the clinic?
 
Our school-based clinics have adapted to conduct telehealth. Three clinics have remained open for students that need well child care visits, medications and immunizations during the pandemic. Mental health services are still available for kids that have anxiety or other mental health issues, such as students that may not have transitioned well to not being able to go to school or see their friends.
 
We don’t know what the fall will look like – how the schools will reopen - we are watching it closely. I think telehealth will be utilized to a greater extent at that time and nurse practitioners will be employed more in that format, especially for kids that have no other source of healthcare. We will certainly modify things at our physical locations, similar to doctors’ offices - use masks, clean rooms before and after each patient and limit the number of students in the clinic. We’ll plan to have our clinics open to service our students in the fall.
 
6. What specific skills are needed by nurses to work in a school-based clinic?
 
For school-based clinics, you need to be a medical provider – nurses should have an advanced degree such as a pediatric or family nurse practitioner. You need to be a team player as we collaborate with mental health therapists, psychiatrists, dental hygienists, dentists, and health educators. We also have supervising physicians we can consult at any time. You need to be comfortable working independently and have a couple of years of experience under your belt.
 
7. What do you enjoy most about your job?
 
This is my dream job. I love working with adolescents and watching these teens transform into young adults, and witnessing their successes, making the right choices, and making it through school. Seeing them go from 8^th or 9^th grade to graduation is very special to me.
 
8. What are the biggest challenges that you face? 
 
Sometimes we get overwhelmed with students who do not have insurance, trying to navigate them to get the help that they need with chronic illnesses and giving them the support that they may not receive at home from their families. There may be dysfunctional family dynamics and their only resource is school. That’s their safety network. How do we help them get to where they need to be mentally and physically? How do we support them with all their challenges at home? I often feel that I am putting in more work to help them succeed and that’s very difficult for me.
 
9. Do you have any advice for nurse practitioners interested in this specialty?
 
It’s challenging, but it’s very rewarding at the same time. You have to love it, to love what you do, love working with that population. You need to be aware of the challenges… the plan you have for that student may not work all the time.
 
Thank you, Sharon! I’ve learned a great deal during our conversation. I also have two teenagers at home and knowing they have this invaluable resource, that can be accessed in full confidentiality, gives me great solace. Our children, whose lives shifted so abruptly from their normal routines to unstructured and somewhat inconsistent homeschooling, are subject to great anxiety and other adverse effects during this time. For children who do not have strong support systems at home, who lack health care insurance, whose parents are unemployed due to the mandatory lockdowns, and who rely on our public schools for nutritious meals, the impact will be even more profound. It’s reassuring to know that student health care services have not been suspended completely and that those high-risk students and their families are still able to attain necessary mental and physical care during the pandemic.
 
A note about Denver Health. Denver Health’s School-based Health Centers form a large network of clinics located within Denver Public School (DPS) campuses that serve any DPS student as well as children enrolled in DPS-affiliated Early Childhood Education programs at no charge to families. The clinics provide a range of services including:

• Well child/well adolescent checks that meet the requirements of school, sports, camp and employment physicals
• Prescriptions and medications and routine lab tests
• Care for chronic conditions such as asthma and depression
• Care for acute injury and illness
• Reproductive health services including pregnancy testing and birth control evaluation, dispensing and management
• Testing and treatment of sexually transmitted infections
• Individual, group and family mental health counseling
• Dental screenings, routine cleanings and preventive health (at select locations)
• Parent and child education

 
Many thanks to all the primary care and community health providers within our school systems across the country who give so selflessly to a very vulnerable segment of our population.