Overcoming Resource Shortages: Creative Solutions for Nurse-Directed Student Health Services
Making difficult choices about priorities is a part (albeit an unwelcome one) of every health center director’s job. However, for nurse-directed health centers, which tend to start life as smaller services with just one or two care providers and maybe one administrative staff member, resources are even tighter, choices are even fewer, and doing a good job depends on successfully juggling four or five roles. In this situation, having a well-equipped, properly staffed and funded health service may seem to be an unrealistic proposition, but as many nurse directors have discovered, expansion is achievable with creativity, persistent networking and more than a little patience.
The challenges of nurse-directed health services are similar across the board. According to a 2004 New York State College Health Association (NYSCHA) survey, nurse-directed health services are more isolated than their counterparts; they have a lack of financial and human resources, which additionally means they have difficulty meeting state mandated immunization requirements; and they find it difficult to provide a full range of services while staying within their scope of practice.
Shari Shapleigh, BSN, RN, MS, FNP, is the nurse director and only care provider at Tompkins Cortland Community College’s health center, which serves 3,000 students and was set up fewer than 18 months ago. The findings of the NYSCHA survey resonated with her.
“The range of services that we can offer is limited to what I can do,” she explains. “I am the only practitioner here. Not only do I see patients and prescribe medication, I run the office and make referrals. I have a state license to run labs, but that takes time, and it’s time I could be using for other things.”
Deloise Williams, BSN, nurse director of Lincoln University of Missouri, which has 3,200 on-campus students, agrees.
“When I first started, I was the receptionist, the medical records person, I did everything,” she relates. “You feel stretched to the limit, you feel as though you’re not doing a good job at everything you have to do. You just do the best you can.”
The feeling of isolation mentioned in the survey findings can partly be attributed to the lack of options for uninsured students, who can make up a sizeable proportion of campus populations at those institutions without mandated health insurance. Without insurance, health centers cannot refer them to outside providers, and there is increased pressure to perform all services in-house, which adds an extra burden to already strained resources. Plus, with too much work and too little time, many nurse directors end up focusing on the pressing daily concerns of their health center rather than taking time out to meet with local providers or even other departments on campus.
Tracking immunizations is a large part of the workload of staff at most student health centers. But for the smaller student health service, it can be overwhelming. Tompkins Cortland Community College recently hired a full time medical office assistant, who is responsible for some administration and immunization tracking. Shapleigh explains that it is only after hiring this extra person, and using an electronic practice management system that can “talk” to the campus records system and manage the process electronically, that the health center was even able to track immunizations.
“The Dean of Students’ office was tracking it before that, and it was still partly done on paper,” she says. “Even now, it’s a challenge, since there are two of us and we have to review every single record that’s going through here. In spring, we instigated a rule that all students have to be compliant with immunization requirements before they can even register for a class, so the records have to be updated every 24 hours.”
If all this wasn’t enough, state law can add another layer of complexity to the running of nurse-led services; in 28 states, nurse practitioners have to collaborate with or receive authorization from physicians. This may consist of reviewing some or all of the nurse’s charts and looking through the medical protocols. The availability of the physician may impact the type of care nurse providers can offer.
Offsetting these common challenges are the opportunities and benefits that nurse directors can bring to student health services. The American College of Nurse Practitioners (ACNP) cites a study that found that the cost of similar quality care by nurse practitioners was 20 percent less than the cost of care by physicians. No longer are nurse directors only hired by small colleges to run small health centers; increasingly, larger universities are seeing that they can be both cost-effective and provide a more extensive and flexible menu of services by utilizing nurse directors, as long as they’re prepared to break away from traditional models that were designed for physician-led services.
“I think there’s a trend toward nurse directed health services across the board,” explains Williams. “When I started going to ACHA’s nurse directors meetings, I was surprised as to how many large universities had nurse-directed health centers. They provide access to physicians by either contracting out; or, if they have medical schools attached, they utilize medical students and residents.”
Nancy Anderson, BSN, RN, BC is nurse director of health services at the College of Wooster, which has around 1,850 students on campus. She understands the difficulties that health centers with one or two care providers face. “Historically, we were very isolated, without much interaction with the rest of campus - we didn’t even attend student affairs meetings,” she reveals. But Anderson is proof that many of these obstacles can be overcome with a combination of time and persistence. Wooster’s Longbrake Student Wellness Center has an incredible 11,000 visits per year — that’s an average of nearly six visits per student — and offers 24-hour access to a registered nurse. Her staff includes counseling and health promotion personnel. But it wasn’t always this large.
“A lot of the resources I’ve got, I’ve gone under contract for or got grants for to expand upon the basic, more sparsely-staffed facility,” explains Anderson. “The problem is finding the time to cultivate these resources. It’s exhausting to do that when you’re a one-person show.”
With that caveat in mind – that realistically, long-term gain will involves short-term pain, mostly in the form of working even more evenings and weekends – here are Anderson’s and Williams’ tips for expanding the capabilities of your health center.
1. Develop an internal network
“Discover how the health center is seen in the larger picture of the college campus,” counsels Anderson. “Find out where your support network is – who within the Dean of Students office values your services and who is prepared to be an advocate for you.” Don’t forget that this can include students. Have regular meetings with other departments on campus. “Wellbeing is not just the absence of disease,” says Anderson. “We work with residential life, safety and security and student affairs – we’re an integral part of the community.”
2. Get students involved
Getting your students involved as peer educators or in other capacities is valuable not just from the human resource angle but because you can see more accurately how your health center is perceived by students and adapt accordingly. Williams explains that she initially thought the low number of visits to her health center was due to several services not being offered. “In fact, a lot of students thought the health center was just for STDs. There was a stigma attached to coming here.” She has developed a peer education program that, combined with other health promotion efforts, have helped increase the number of visits from 1,000 six years ago to more than 4,000 today for a campus of 3,200 students.
3. Develop an external network, including contractual agreements with local providers
Building relationships with health professionals and organizations in your community is vital for any nurse-directed health service. Lincoln University of Missouri has such a good relationship with the local physicians that come in to the student health center two mornings per week that they authorize prescriptions over the phone when they’re not in the health center. In fact, they even accept students referred to them outside the allocated time slots at no extra charge. Williams admits, “We have a wonderful working relationship with them!”
Having a contractual agreement with physicians that practice locally to come in on a part-time basis is one way to boost human resources and offer more to your student patients. However, there are other contracts that you can set up that will also expand the services you provide. Anderson elaborates:
“We have a contract with Mansfield health department to do HIV testing, we have one with local substance abuse program STEPS, and we have a contract with massage therapists that doesn’t cost us anything, because the student pays for the treatment. It brings more people into the health center.”
This kind of networking can even lead to receiving lower rates on some lab tests or using a clinic’s interns part-time – don’t be afraid to negotiate!
4. Make a business case for your health center
Treating your health center as a business, albeit one that may not be designed to make a profit, makes sense for a number of reasons. It’s easier to market your services if you have a mission statement, and a strategic plan will keep you focused on what your next developmental steps are. Collect data on important trends so that when you request a bigger budget, you can be very specific about what you need it for and why it is important to the mission of your health center.
5. Go electronic
Automation can have several benefits. One major one is the ability to collect and analyze data easily. Another is electronic immunization tracking, which cuts the immunization workload significantly. But additionally, if you have an Internet-based application, it means that a physician can review charts remotely at any time. And Internet-based applications also tend to require a lower up-front investment, which is a bonus for health centers with small budgets. “In our area, I am one of the first NPs to practice without a physician on site,” reveals Shapleigh. “An electronic medical record makes it much easier.”
Anderson adds, “It’s worth remembering that automation can really save time when you can’t have the staffing you need.”
6. Consider other health insurance options
If you don’t already have mandatory health insurance for students, it may be worth considering; this way, you can refer students to outside health services and won’t be burdening your health center with tests or procedures that drain your resources.
Alternatively, accepting commercial health insurance and then outsourcing billing to a third party may also be worth considering; although it is not a solution that will be practical for every nurse-directed health center, it should, if your health center receives enough visits, pay for itself and can even raise extra revenue.
7. Research other sources of funds
Your health center may be eligible for a number of grants. First, find out if there’s someone on campus that is responsible for writing grants that can help you. Start simply and see if your regional college health association offers grants. Even if it doesn’t, the association may have a list of available grants offered by other organizations or foundations. Additionally, Anderson advises to negotiate with the university to keep any funds left over from your budget each year in a health promotion account, so you have some fund to utilize when you want to support a program on campus.
8. Use national and regional channels of support
Your regional health association is always a good resource. On a national level, the American College Health Association (ACHA) has a nurse director’s group (ACHA members can read its semi-annual newsletters here) and can put you in touch with others in a similar situation. The SHS listserv is also a great forum for questions you may have. Instructions to join can be found here.
9. Give yourself time
Finally, acknowledge that increasing resources for your nurse-directed health center is a task that cannot be completed overnight. “This is not a fast process,” counsels Anderson. “Pick one thing at a time to work on, and realize that it may take 10 years.”
Deloise Williams and Nancy Anderson will be co-presenting “Nurse Director's Workshop: What Are You Working With” featuring content relevant to all sizes of nurse-directed health services at this year's ACHA conference in Orlando.
Deloise Williams’ pick of programs at ACHA for nurse directors:
- TH227: Improving the Use of Health Services Among College Students Through Outreach Projects
(Thursday, 8:00 – 9:30 a.m.) - TH023: A Campus Strategy for Enhancing Health Care and Reducing Student Fees Through Contracted Management
(Thursday, 10:00 – 11:30 a.m.) - FR030: Pulling It All Together: Working Together to Implement Mandatory Insurance and Third Party Billing
(Friday, 8:00 – 9:30 a.m.) - FR027: Collaborative Proactive Model of Campus Crisis Management
(Friday, 3:45 – 5:15 p.m.) - FR046: Strategies to Increase Cultural Competency and Decrease Health Disparities
(Friday, 3:45 – 5:15 p.m.)