At Nanakuli Elementary School on Oahu’s Leeward Coast, a small on-site health clinic staffed by a registered nurse is part of a new strategy to help stem the school’s high chronic absenteeism rate.

Schools in the Nanakuli-Waianae area bear some of the state’s highest rates of chronic absenteeism, defined as when a student is absent 15 or more school days during the year.

Officials believe student health concerns play a major role in kids missing school. Common health issues among students on the Leeward Coast range from asthma to severe allergies. Those ailments are often triggered by vog, a type of air pollution.

“Parents will initially keep their kids home if they notice any respiratory distress,” said Karisa Deitch, a registered nurse who has been based at Nanakuli since last year.  “They’ll take off work and keep the child home … which impacts their education.”

Deitch was hired through the “Hawaii Keiki: Healthy and Ready to Learn” program, which launched in 2014 by placing nurses with advanced training in five pilot complex areas. Although each of the 256 public schools in the state has access to a school health aide, these aides are limited to administering first-aid and CPR.

The Legislature provided $2.8 million during the last session to expand Hawaii Keiki, which is overseen by the state Department of Education and University of Hawaii Manoa School of Nursing and Dental Hygiene, into all 15 complex areas in the state.

Nanakuli Elementary offers a stark example of the problem of chronic absenteeism. Its rate rose from 24 percent in the 2014-15 school year to 30 percent in 2015-16, according to data from the state Department of Education’s Strive HI Performance System. That far exceeds the statewide chronic absenteeism average of 13 percent for elementary schools for 2015-16.

This school year, the goal is for each complex area — which consists of a cluster of high schools, plus their feeder elementary and middle schools — to have its own advanced practice registered nurse, or APRN, who has the ability to diagnose conditions and prescribe medication.

The $2.8 million will fund the salaries of the 15 nurses, pay for supplies and equipment for school health centers and support the creation of an electronic record system to track student health data, according to Mary Boland, dean of the UH Manoa School of Nursing and Dental Hygiene.

Boland said the complex area superintendent and Hawaii Keiki administrators will decide how the nurses split their time among the schools.

“The Hawaii Keiki nurse is assigned to a base school and that does not change during the school year,” Boland wrote in an email. “However, each nurse is available by cell phone or email to the school health assistants and all schools within the complex area.”

School-based health centers

Hawaii has been slow to establish school-based health centers because of limited resources and challenges in finding the proper staff, according to health professionals.

Statewide, there are three school-based health centers run by nonprofit community health centers — two are located in the Waianae area and one in Oahu’s Koolauloa District. Hawaii Keiki launched six centers last year and plans to open eight more this year, according to its most recent activity report.

“Hawaii is far behind in terms of school-based health centers because there’s too few trained personnel that are part of the school-based system for the number of students in our state,” said May Okihiro, a pediatrician at the Waianae Coast Comprehensive Health Center.

Waianae Coast is a nonprofit that has been independently running health clinics at Waianae Intermediate School and Waianae High School since March 2016.

Okihiro said the “coordination of health care, including with community partners, needs to be a priority” because of the differing health needs and access to care across the state.

“Families from Honolulu have different access issues than kids from very rural areas,” she noted. “Health issues themselves may be different. There are communities around Hawaii that have high rates of asthma, high rates of obesity, mental health issues.”

The first school-based health center of its kind in Hawaii was the Red Raider Health Center at Kahuku High and Intermediate School in Oahu’s North Shore, run by the nonprofit Koolauloa Community Health and Wellness Center.

Housed in a converted classroom, the clinic is staffed by a physician, dentist, two nurse practitioners and support staff. The facility includes two medical rooms, two dental examination areas and a small reception area.

Now in its fourth year, the school-based center provides students a quick way to get their health needs met.

“(Staff) can meet their medical and dental needs at the school. Students come during breaks, study hall, recess,” said Naty Hopewell, Koolauloa’s chief medical officer.

“The reason (the center) evolved was because a lot of students and parents and guardians were missing either school or work. They would have to pick them up and take them to the doctor, spending at least half the day.”

Jude Sells, a doctor who works at Red Raider, said the health center could see anywhere from 10 to 30 kids daily during the school year.

“Even an hour here is better than (having to) take half the day off” to get medical treatment, said Sells, who is a 1998 graduate of Kahuku High.

Kahuku’s school-based health center even offers preventive care to the community at large.

Residents of the surrounding neighborhoods often deal with health issues such as diabetes and hypertension, Sells said. So he’s launched a weekly “Move with the Doc” program where parents can take a mile-and-half walk around the school perimeter with him.

Less Kids Missing School

Deitch, the registered nurse at Nanakuli Elementary, said parents are less inclined to pull their students out of school knowing a trained health professional is based at the school and able to administer care.

“I’m able to gain the trust with the family, reassure them that I’m here on campus, if anything happens,” she said. “Parents will call me and say, ‘My child is in sick. I gave them a couple treatments, they’re stable as of this morning, can you just keep an eye on them?’”

That prevents kids from having to miss any more school than necessary. Before she was placed at the school, kids would come in with a respiratory condition and then be sent home, “because that was the policy before we were placed in the schools,” she said.

Additionally, for families in Nanakuli and nearby Waianae, trips into Honolulu for medical treatment can often take a whole day.

Staff at Waianae Coast Comprehensive Health Center, which is independent of the Hawaii Keiki program, believe their work has helped limit student absenteeism at the two schools where they run student health centers.

“Ninety-three percent of the kids we saw went back to class” in the past year, said Vija Sehgal, chief quality officer and director of pediatric services at Waianae Coast. “In the past, these are kids who would have been sent home.”

In the 2015-16 school year, schools showing the highest chronic absenteeism rates in the state at the middle and high school level were on the Leeward Coast in Oahu. At the elementary school level, the highest absenteeism rates were seen in the Kau-Keaau-Pahoa complex area in Hawaii Island, as well as in the Waianae area.

In 2015-16, for instance, the chronic absenteeism rate at Waianae High was 40 percent. At Waianae Intermediate School, it was 38 percent. At Nanakuli High and Intermediate School, it was 34 percent, according to Strive HI data that year. Statewide, the average for middle schools was 14 percent and 19 percent for high schools, according to the DOE.

Four years ago, a school survey at Waianae Intermediate revealed that the top two reasons kids missed school were due to health and lack of transportation.

John Wataoka, principal of that school, said there is a perpetual habit of parents keeping kids home when they showed the slightest sign of illness.

“Asthma was a huge part of that reason,” he said. “The second was transportation. It’s transportation to and from school and even to get to healthcare. If parents aren’t able to drive (children) to school (as is), when a child is sick, they’re not going to be able to drive them to a doctor.”

Wataoka said parents are encouraged by the addition of the nonprofit-run health center at his school.

“A lot of our families are still adjusting to the fact that we have this service on campus,” he said. “The students absolutely love it, but the families are now only realizing, ‘we can go here.’”

In addition, the health clinic has recently expanded its services to include a mental health counselor.

Expansion of the Hawaii Keiki program is still a work in progress. There is not enough hard data yet to show the effectiveness of the program. And not all of the 15 APRN positions have been filled yet.

But school officials say they are eager to bring access to more advanced care to the schools.

“The goal is to get (kids) to school,” said Ann Mahi, the superintendent of schools for the Nanakuli-Waianae area.