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Nursing Services at CPS
The Outsourcing Epidemic: On the Verge of a Health Crisis

Promoted as a cost-savings move, the Chicago Public Schools outsourced the management of school nurses to an east coast company with defense contracts in the summer of 2015. Six months into this four-year contract, nurses from the Chicago Teachers Union report on the drastic failure of this company to meet its contractual obligations, putting nearly 400,000 Chicago students in danger.

Introduction

At the June 2015 Chicago Board of Education meeting, the Chicago Public Schools voted unanimously to approve a $30 million, 4 year contract with RCM Technologies for supplemental nursing services, professional development and scheduling. Nine months after the RCM contract was signed, CTU nurses report shocking stories of untrained nurses who cannot perform basic tasks like opening epi pens, completing progress notes for case files, or showing up for work assignments. Too often, CTU nurses report that agency nurses refuse to do their assigned tasks because RCM did not specify those particular tasks when they were scheduled.

The contract claims that CPS will save money by providing nursing services more “efficiently.” This is not the first time CPS has contracted with a nurse staffing agency: the district has actually been contracting with various companies since the early 1990’s, partly due to a supposed nursing shortage, but also to provide temporary nursing services to disabled students whose needs change and increase throughout the year. The current contract with RCM is for the same $7.5 million per year CPS spent with the previous nursing agencies. However, RCM will receive 50% of the cost savings CPS realizes, and the resulting savings to CPS will hardly be worth the decline in services to students.

The RCM contract also encourages cost savings, although it does not reward quality of care. Underbidding CPS’ previous nurse staffing contracts by nearly $5 million each year – with added administrative responsibilities such as scheduling, training and recruiting – this contract also includes a gain sharing arrangement whereby RCM will receive money from CPS as a reward for reducing the cost of providing vital health care services to students with IEP’s and 504’s.

CPS continues to claim that there is a shortage of nurses, yet staffing agencies are employing hundreds of nurses. At the June 24, 2015, CPS Board of Education meeting, former interim CEO Jesse Ruiz provided talking points to the board members to justify the RCM Technologies contract: “CPS lacks enough District nurses to deliver services to our students due to state and national nursing profession shortages1.”

CTU members contend that CPS practices undermine nurse hiring. In the summer of 2015, the district waited until well after the suburbs had already done so to post job announcements, removed the job postings after only a few days, and then waited until October to respond to applicants. CTU members attempted to improve this process, but CPS would not listen.

CPS has partnered with five area universities since 2007 to provide nurse interns to the schools, under the supervision of the Certified School Nurse’s2. Yet, in all this time, CPS not figured out how to recruit the nurses after they graduate. Is it possible that these interns decide after their internship experience that CPS is too difficult to work for, that the caseloads and stress are too much to handle?

In 1998, there were 300 Certified School Nurses and 60 Licensed Practical Nurses. The numbers have gradually declined. This is not all attributed to a nursing shortage but a lack of recruiting efforts by CPS. Zero dollars were spent recruiting at nurse hiring fairs and nursing hiring sites like Nurse.com. CPS does not spend money for recruiting.

The RCM Technologies contract is different from previous ones. The Chicago Teachers Union contends that it is intended to eventually eliminate the union nursing positions, replacing them with temporary nurses without job protections or employment benefits such as health care and a pension. Previous nurse contracts only included provisions for the staffing of temporary Health Service Nurses and Licensed Practical Nurses. The RCM contract includes Certified School Nurses (CSN), professional development, scheduling and recruiting. On February 4, 2016, RCM advertised for a Clinical Nurse Supervisor, with a job description that fits that of CSNs.

This scenario puts 400,000 students’ lives at risk. Sixty-five years of school nursing in Chicago provide the experience and insight to understand school health services are best provided by certified nurses with teaching licenses who have a trusting relationship with the students, which takes time to build. Temporary nurses do not have the ability to create that trusting relationship with the students they are serving, particularly with young students, who need many hours of contact with nurses. CTU nurses have reported a high turnover rate of RCM nurses, exacerbating relationship issues even more.

Just as CPS is “broke on purpose,” it is also dysfunctional on purpose. With rising levels of diabetes and allergies, not to mention the high number of CPS students who do not receive preventative health care services outside of school, entirely privatizing the nursing department will create a health disaster in Chicago. Rather than fully funding Certified School Nurses, CPS is cutting corners with private contracts which fail to save money and have serious health impacts on kids. Their budget practices and priorities are starving students of adequate health services.

The CTU is therefore recommending that CPS end this contract with RCM Technologies and employ a full-time Certified School Nurse (CSN) in every school and enough Licensed Practical Nurses (LPN’s) and Health Service Nurses (HSN’s) to ensure that every CPS student receives proper preventative and required service care.

Chicago Teachers Union Recommendations

There are clear and easy solutions to improve health service delivery to Chicago students. Listening to the CTU nurses, who have decades of experience and an arsenal of research to back up their suggestions, is certainly a start. CPS is apparently opposed to working collaboratively with its staff and specifically with the Union. This is short-sighted and, as indicated by experiences during the last six months of outsourcing to RCM, has the potential for a crisis in school health care.

Recommendation #1: Allocate more money for health services

Redirect increased Medicaid funding to provide better resources to students via qualified, consistent nursing services, keeping in-house, the $7.5 million that CPS spends annually on outside nursing vendors.

This should be obvious. CPS will receive more Medicaid reimbursements if staff members have the time and ability to submit more paperwork and identify more students who qualify for services. CPS will also receive more money if more students attend school on a daily basis, which they could do if health issues were not preventing them from staying home or leaving school early.

Hire more certified school nurses; serve fewer schools each

Adequate health services simply cannot be provided by 141 school nurses driving all over the city every day, trying to put out fires.

Have a nurse substitute pool

When a nurse is unable to come to work, there is no one to cover his or her duties, forcing other nurses nearby to rush over to a school if an emergency arises – and there are ALWAYS emergencies. A substitute pool of cadre nurses who are retired or perhaps only want to work part-time would solve this issue. Many Chicago suburbs hire nurses as substitutes.

Recommendation #2: Recognize Nurses as Faculty

Since nurses do not typically have their own office and only work at a given school one or two days each week, they are not treated as school faculty like the full-time staff are. Nurses need to be included in school meetings and regarded by all staff, students and parents as part of the school community. Student health is a vital component to academic achievement and therefore nurses deserve more recognition for their contribution to the school’s success.

Nurses need space to provide services

Every school should be equipped with a nurse’s office that includes a bathroom, a sink, a refrigerator, a bed, and lockable file cabinets.

Recommendation #3: Create a Nurse Pipeline

CPS already contracts with local universities for nurse interns, yet there is not a graduate recruitment program in place to hire nurses once they finish school. CPS has a new opportunity, with the Crane Medical High School, to create a pipeline for CPS students. The CTU is also recommending a “Grow Your Own Nurse” program similar to Illinois’ Grow Your Own Teacher program. This program should include support to help current Health Service Nurses become Certified School Nurses. In the Chicagoland area, there are two school nurse certification programs and thirteen schools of nursing which produce hundreds of registered nurses each year. CPS has access to these nurses and can begin to develop cohorts of nurses trained on the job while completing the school nurse certification program.

Recommendation #4: Eliminate the RCM Contract

As much of the research literature on outsourcing concludes, government agencies save more money and get better services when they provide and manage the services themselves. Outsourcing is more expensive with little to no accountability. Managing the outsourced relationship is a waste of time and effort – it creates more of a bottleneck than the typical government “bureaucracy” that supposedly needs to be eliminated to improve efficiency and reduce costs.

RCM has already demonstrated in the last six months that it is unprepared to schedule nurses, communicate the students’ needs to all involved parties, and to run professional development that improves service delivery. In other words, it is defaulting on its contract.

The Important Work of School Nurses

School nursing is challenging work that improves the health of school children and positively impacts their ability to learn. It is a specialty of public health nursing. From the onset of CPS’s school nursing initiative, registered nurses had a minimum of a bachelor’s degree and took required courses in education, child development and public health and became certified by the city as teacher nurses. They identified children with health problems and helped families resolve the problems insofar as possible. They referred the children for medical care and helped families access medical resources to obtain the care their child needed. They prevented contagious diseases by implementing immunization requirements and encouraging cleanliness. They were considered part of the faculty and helped teachers recognize children whose learning may be affected by a health condition (e.g., vision impairment, sickle cell disease) and what to do about it in the classroom. They provided one on one health teaching and also some health teaching in the classrooms. They initiated and carried out health promotion programs.

School nurses are health educators. They teach children about hygiene, sexual education, preventing pregnancy, sexually transmitted diseases, nutrition, and diabetes management. School nurses also organize health activities, such as health fairs. School nurses developed CPS healthcare policy manuals. They have also had a lasting impact on students, inspiring some to enter the medical field.

School nurses play a significant role in obesity prevention, promoting physical activity, assisting students with mental health issues (e.g. ADHD), and monitoring chronic health issues such as asthma, allergies, epilepsy, diabetes, and hypertension. Nurses identify and refer students with infectious diseases. Nurses provide services such as tube feedings for nutrition, catheterization for urinary elimination and tracheostomy care to maintain breathing.

The role that nurses play in special education is quite significant as well. They address the students’ health issues in IEP development so each student will have the accommodations, services, and health related goals needed to succeed to the best of their ability at school. School nurses are central to the development of Section 504 plans for students with major or chronic health issues who do not require special education services. The 504 plans provide for awareness of the students’ major health conditions (e.g. peanut allergy, arthritis, chemotherapy for cancer) and the services and accommodations they need to be healthy, safe, and successful at school.

Nurses have a team-based approach in CPS, working with all of the disciplines – not just for IEP’s, but also for professional development and co-teaching. Nurses play a key role in Response to Intervention (RTI).

In CPS in the 2015-2016 school year, there are 52,231 students with IEP’s.3 In the 2012 school year, 19,414 students had asthma and 305 had diabetes.4

In school districts where schools are fortunate enough to have a full-time nurse (about 45% nationwide, according to the National Association of School Nurses), students also receive first aid and preventative health care. A nurse’s office can provide important respite for a student who needs to lie down and recuperate before heading back to class, or have a private conversation with a licensed health care provider. As reported by the Robert Wood Johnson Foundation:

Research shows that the daily presence of school nurses advances the twin goals of improving health and educational outcomes, particularly where nurse-to-student ratios are at workable levels. Milwaukee Public Schools recently added additional registered nurses, with the goal of a 1-to-750 nurse-to-student ratio, and made impressive gains in immunization rates, identification of asthma and life-threatening conditions.5

CPS school nurses have always worked very hard with huge caseloads, but working with children and positively impacting lives has made it a rewarding career. Unfortunately, the program has usually been underfunded. Getting involved in the Chicago Teachers Union “saved our jobs and the whole program,” according to retired nurse Dorothy Goushas, who worked for CPS from 1955 to 1992.6

School Nursing Services in CPS

Chicago began systematically providing nursing services in the schools in 1951 after the U.S. Public Health Service found that the city of Chicago was not providing systemized and effective medical and nursing services to children. Chicago was the only major city at that time without a school health program.7 There was actually a nursing program in CPS that began at the turn of the 20th century and peaked with 100 nurses working in the schools in 1914. From the end of WWI until the Great Depression, there were drastic cuts in the number of nurses and their roles and responsibilities in the schools. By 1932, only 25 nurses worked for the school health program and their only task was to check for communicable diseases and administer vaccines. It wasn’t until 1951 that there was once again a renewed effort to treat and prevent health problems (e.g., communicable diseases and vision impairment) so that children could fully participate in school.

The nursing program was threatened with elimination due to budget issues in the early 1970’s and again at the turn of 21st century. In 1981, the state threatened to withhold funding if CPS did not comply with the School Health Code:

It was good that they decided to enforce the School Code, but all of the responsibility for accomplishing this fell to the school nurse. It was a Herculean task as far as record keeping. All of these records had to be submitted and the nurse had to collect them. Lists of 700 or 800 students or more had to be made with the dates of all their inoculations. Later, the computer helped in getting this task done but it was still very time-consuming. It took away time that could have been spent with students, teachers, and parents in health education or health counseling. We should have had clerical help from the onset but clerical help was not provided with the program. – Ursula Levy Korup, CPS school nurse from 1968 – 1991.8

Nurses were responsible for administering immunizations, following up on children who were screened for vision and hearing loss to make sure they received the medical care, glasses and hearing aids they needed, checking for communicable diseases, and for health education on topics such as hygiene, nutrition, the importance of physical education, and pregnancy prevention.

For many years children with severe health problems and disabilities either attended the Spalding School for Children with Disabilities9 or did not attend school at all. When federal law PL94-142 was passed in 1975, it required that all children be entitled to a free and equal public education. Thousands of children with mild to profound illnesses and disabilities newly enrolled in regular public schools. Each student was assessed and a plan made to meet the child’s individual needs.

Teacher nurses were renamed school nurses in the 1970s when certification was done by the state rather than by the city. Nurses had to pass a written test to be certified by the State of Illinois including a constitution test. When certification was done by the city, both a written and oral test had to be passed but there was no test on the constitution.

Teacher nurses were part of Chicago Teachers Union ever since they started working in the Chicago Public Schools. They were classified as teachers and paid the same union dues as teachers did. Health aides, LPNs, and non-certified registered nurses were always classified as para-professionals and paid union dues at that rate.

Today, there are three levels of nurses employed by CPS: Certified School Nurse (CSN), Health Services Nurse (HSN), and Licensed Practical Nurse (LPN). The CSN’s have bachelor’s degrees in nursing and are also licensed teachers. They are currently required to be licensed in Illinois with a Professional Educator’s License with an Endorsement in School Nursing. HSN’s are Registered Nurses (RN’s) with two to four years of education but do not have teacher licenses, and LPN’s are Practical Nurses with around 18 months of education. The LPN’s do more of the hands-on work such as providing medications, insulin shots and feeding tubes and work under both the HSN’s and the CSN’s.

According to the 2005 CPS School Nurse Handbook the job descriptions include:

CSN HSN LPN
Job Goal: To coordinate a school health program including the delivery of services to students and serving as a health resource to staff members in order to enhance health and wellness in the school community. Responsibilities: Nursing Care (11), Teaching (3), Communication (10), Organization (2), Special Education (5), Professional Development (2) To provide direct nursing services to students and staff to maximize health and wellness in the school community. Responsibilities: Nursing Care (7), Communication (13), Organization (3), Special Education (3), Professional Development (2) To provide direct nursing services to medically fragile students and other duties as assigned under the supervision of a licensed registered nurse. Provides direct services according to the student’s IEP/504. Monitoring and providing appropriate care to the medically fragile student to and from school. Maintains safe and healthy environment. Maintains records. Data recording and weekly computer upload. Works cooperatively with all school personnel. Performs other duties related to the health maintenance of medically fragile students as assigned by the school/registered nurse in the building, nurse coordinator, or school principal

From the Office of Specialized Services School Nurse Mission Statement10 :

The School Nurse is committed to the prevention of disease and the promotion and maintenance of health for all students in order to prepare them for healthy lifestyle choices. This will foster their physical and mental well-being as well as improve the quality of life in regard to their education, environment, recreation, community, social, and spiritual well-being.

Despite Medicaid reimbursement and other funding, health services have not been a priority for CPS. Only those services required by legislative mandates have been considered essential. In Illinois, this includes compliance with physical exams, immunizations, dental exams, and vision and hearing exams. The CSN is responsible for ensuring that every student in CPS has complied with these exams.11 Thus, health education and having office hours to care for students without IEP’s or 504 plans are not functions that CPS considers essential.

School nurses have not been hired in the numbers needed to effectively serve all children. The National Association of School Nurses (NASN) recommends 1 school nurse per 750 students, and 1 per 125 for students with “complex health needs”.12 CPS currently employs 141 Certified School Nurses (CSN’s) for a district of 344,890 students13 with a resulting ratio of 1:2,446! Since 2009, there has been a 4% drop in student enrollment but a 29% drop in the number of CSN’s, thus the loss of school nurses is not proportional to the loss of students – it’s seven times the rate of the loss of students.

CSN’s in CPS typically service five to six elementary schools each or two high schools. This translates into each school having a CSN on site for 1 – 2 days per week.

# of Schools per Type of Nurse
CSN HSN LPN
Average 4.2 3.6 1.6
Max 11 6 4
Minimum 1 2 1

According to the “Related Services Personnel” (RSP) file that CPS sent to the CTU in October 2015, fifteen schools do not have a CSN assigned to them at all. Nineteen have a CSN assigned but with zero hours allotted. The vast majority (61%) of schools have only one certified school nurse assigned for one day a week or less. Thirty-five schools do not have an HSN assigned to them and only 111 schools have an LPN assigned. Only 28 schools have at least one CSN, HSN and LPN assigned to them each week. A full 20% of schools have a CSN for only two hours each week.

During those limited hours, the CSN is mostly in IEP or 504 meetings, working on re-evaluations for those IEP’s or 504’s, and signing off on the work of the LPN’s. In other words, children without an IEP or 504 plan may have little or no access to a nurse. There may be no nurse available for emergency care and follow-up, and children presenting early signs of physical or mental health problems often receive little if any attention. At most schools, the principal and clerk are the de facto first aid providers: when a student does not feel well, they are sent to the main office since most schools do not have a nurse’s office or a nurse on duty to take care of them.

This practice led to the tragic and preventable death of a 7th grade student in 2010 who had a severe allergic reaction to peanut sauce at a school event and the school staff were unable to administer an epi pen to her.14 Illinois passed a state law one year laterxiv, allowing all schools to stock and administer epi pens; prior to this change in the law, schools were not allowed to stock and administer epi pens to any students without an explicit prescription and indication of the presence of allergies in their student health profiles.

During the six year period between September 2009 and September 2015, (the first year in which employee position files are publicly available), CPS has lost 58 school nurses. During this time, the number of LPN’s has increased by 3 while HSN’s has decreased by 5: LPN’s are the lowest paid of the three categories of nurses.

Job Title15 September 2009 September 2015 Difference: Actual
Budgeted Vacancy Actual Budgeted Vacancy Actual
HSN 56 2 54 54 5 49 -6
LPN 75 1 74 84 7 77 +3
CSN 203 4 199 163 22 141 +58
TOTAL: 334 7 327 301 34 267 =60

Insert Figure 1: Nursing_Figure1.png
(Alt Description: Figure one is a line graph of total nurses from 2009-2015.There is a clear drop of CSN between 2009 and 2015.)
Note: these job titles are from the CPS position file and are slightly different than what is used throughout the paper and in CPS documents and contracts. Hospital Licensed Prac Nurse refers to Licensed Practical Nurse and School Nurse refers to Certified School Nurse. Employee Position Rosters can be found here: http://www.cps.edu/About_CPS/Financial_information/Pages/EmployeePositionFiles.aspx

CPS often eliminates vacant positions every year, thereby decreasing the total number of nurses, except for the category of LPN’s. The LPN’s primarily assist with the disabled students since they are not licensed to administer any medication. For the last 25 years, CPS has been supplementing the HSN and LPN staffing with temporary nurses from staffing agencies to help fulfill the legal requirements to provide services specified in student IEPs and 504 plans.

CPS is not alone in eliminating nursing positions as a means to save money in a tight budget: The Robert Wood Johnson Foundation reports:

School support services, including nurses, are often targeted when budgets are tight…and nurse positions are sometimes under-filled with licensed practical nurses or health aides…Educators [here, meaning administrators] are worried about test scores. If they don’t have the experience to understand how school nurses help students stay healthy so they can learn, they see under-filling nursing positions as an easy way to cut the budget.16

School nurses help improve attendance, and since ISBE pays CPS based on average daily attendance, CPS would have additional state funding for health services if the nurses had the time and ability to provide preventative and intervention care for more students. Similar to research published on truancy reduction that showed that a truancy program would pay for itself since it would result in an increased average daily attendance rate (ADA), allowing school nurses the time to provide more preventative healthcare services would result in more students attending school every day. According to the National Collaborative on Education and Health, “Asthma is one of the leading causes of school absenteeism, accounting for 1/3 of all days missed instruction.”17 Nearly 20,000 CPS students suffer from asthma.

Ironically, if CPS would only provide time and assistance to complete all the necessary paperwork for Medicaid reimbursements, there would be a lot more funding available to provide health services. In the 2015 CPS audit18, the district reported that Medicaid funding was $5 million under budget due to “slower claiming.” In fact, Medicaid reimbursements have declined over the years despite the fact that IEP and 504 plans have increased. There are very specific rules regarding what activities can be claimed for Medicaid reimbursements and CPS has reduced nursing and other clinician services to those primarily. Additionally, only 50% of the administrative cost of filing the reports and paperwork are reimbursable and CPS has never provided clerical support for this.19

Insert Figure 2: Nursing_Figure2.png
(Alt Description: Figure two is a bar graph of medicaid reimbursement revenue over time.)

Medicaid reimbursements pay for CPS nursing services (in addition to all of the other clinician services – speech therapy, physical therapy, occupational therapy, mental health service and special transportation). The revenue has fluctuated considerably over the years, which CPS partly blames on changes in federal regulations over what types of services are reimbursable. CPS pays a consulting firm about $2 million each year to help it maximize its Medicaid reimbursement.

For fiscal year 2016, CPS projects $48 million in Medicaid reimbursement funding, the same as FY15.20 CPS states in the FY16 budget that it hopes to increase Medicaid revenue this year by claiming for additional services which are eligible for reimbursement but previously had not been claimed, and to increase enrollment through outreach. Please see the Appendix for more information on Medicaid reimbursements.

Simultaneous to a decline in the number of nurses employed by CPS has been a dramatic increase in the amount of money the district is spending on outsourcing nursing services through private contracts:

Insert Figure 3: Nursing_Figure3.png
(Alt Description: Figure three is a line graph of CPS nurse staffing contracts. Since 2004 nurse staffing contracts have grown.)

It is unclear how CPS is saving money with this new $30 million contract with RCM. The combined salaries of CTU CSN’s, HSN’s and LPN’s is less than $20 million and the salary of administrative staff is about $3 million. The RCM nurses are currently all LPN’s, who are paid the same hourly rate as CPS LPN’s (on average). It would cost roughly $7 million to bring these LPN’s into CPS full-time, and CPS is paying RCM $7.5 million each year of the contract. It seems that the remaining $5 million could easily be reabsorbed into the ODLSS budget for administration and Medicaid processing.

Hourly rates for nursing staff:

Agency
Position CPS Maxim Favorite ATC RCM
CSN $52.64 n/a n/a n/a $39.85
HSN $34.00 $36.00 $45.95 $39.00 $38.85
LPN $29.00 $32.00 $31.95 $34.00 $29.85
LPN-Multi-School $30.95
Medical Assistant $21.85
Health Aide $18.00
Vision/ Hearing Technician $20.00
Medical Records Clerk $28.00
Medical Biller $32.00
Medical Coder $48.00
Admin Assistant $31.00
Scan Technician $27.00

The table above also includes administrative staff hired by RCM, the equivalent of which was unavailable for CPS or the previous nurse staffing agencies. Maxim, Favorite and ATC have each been contracted with CPS for several years. None of these other staffing agencies provided CSN’s for CPS, but the RCM contract states that it is possible that the company will add this category of nurses. For a history of the nursing contracts from 2000 to 2015, please see the appendix.

A Crisis Waiting to Happen: the Dangers of Understaffing Nurses

Like most departments at CPS, the central office department in charge of nurses has changed many times over the years through constant reorganization:

  • 2009 – 2010: Office of Specialized Services
  • 2011 – 2013: Office of Special Education Supports
  • 2014 – Present: Office of Diverse Learners and Specialized Services

Currently, two offices, the Office of Health and Wellness, and the Office of Diverse Learners and Student Support (ODLSS), provide health and preventative care for students. Health and Wellness focuses on audio and visual screening, nutrition and physical activity, as well as managing the thirty school-based health centers. CPS nurses, speech pathologists, psychologists and social workers are managed by ODLSS (with some audio visual techs as well). As previously mentioned, the bulk of the work of school nurses is in the management of student IEPs and 504 plans.

Currently, two offices, the Office of Health and Wellness, and the Office of Diverse Learners and Student Support (ODLSS), provide health and preventative care for students. Health and Wellness focuses on audio and visual screening, nutrition and physical activity, as well as managing the thirty school-based health centers. CPS nurses, speech pathologists, psychologists and social workers are managed by ODLSS (with some audio visual techs as well). As previously mentioned, the bulk of the work of school nurses is in the management of student IEPs and 504 plans.

At the June 2015, CPS board meeting, the unelected board members voted to enter into a four-year, $30 million contract with a New Jersey company called RCM Technologies, Inc. to manage the nursing services and employ temporary nurses due to a supposed nursing shortage and a desire to improve “efficiency”.

CPS has actually been claiming this shortage since the early 1990’s when it first began contracting with temporary nurse staffing agencies to provide LPN’s and HSN’s, mostly for disabled students who need assistance with feeding or breathing apparatus or students who need insulin shots and asthma inhalers.

Is there really a nursing shortage and how will RCM save the district money?

Insert Image 1: Nursing_Image1.jpg
(Alt Description: Image of CPS website claiming new CPS nursing contracts to improve efficiency in services and better meet students needs.)
Source: http://cps.edu/News/Press_releases/Pages/PR2_06_24_2015.aspx

“There’s no shortage of people willing to do the job, says Sandi Delack, president of NASN; the issue is funding.”21

According to CTU nurses, as late as March of 2015, CPS officials were telling them that they do not know where or how to recruit CSN’s. CPS told a CTU officer that “there are no CSNs available for hire and indeed it is extremely difficult to find eligible candidates” yet CPS never advertises on the Department of Public Health – Certified School Nurse list-serve or the Illinois Association for School Nurses (IASN) job board.

Currently on the IASN job board22, there are 51 suburban school districts with nursing job announcements. The Chicago Public Schools does not have one single job announcement and these positions date back to July 9, 2015. Additionally, three districts have positions that were posted in the last four weeks (January 22nd – February 11th, 2016) for positions available in the 2016-2017 school year – seven months from now. CTU nurses have reported that CPS does not utilize the IASN job board to post open positions. An extensive Google search only found posted positions on Indeed.com. When this was mentioned to CTU nurses, none of them had heard of the job search website and responded that most school nurses know to look on the IASN website.

Thus, if this year is indicative of how CPS drags its feet in posting nursing positions online, it is not surprising that the district has difficulty hiring nurses. CTU nurses, like the rest of the membership, are required to be evaluated through the district’s REACH evaluation process. Receiving one unsatisfactory rating is a cause for dismissal. The REACH evaluation process, which was just introduced three years ago for nurses and other clinicians (four years ago for teachers), is a very complicated process and requires a lot of administrator observation and documentation.

Agency nurses are not managed or evaluated by anyone, as far as the CTU can tell. There are no repercussions for poor performance. The survey that follows highlights an alarming number of instances of poor performance by agency nurses employed by RCM Technologies.

When RCM nurses fail to perform a job assignment or do it poorly, the CTU nurses are legally forced to complete the task because they are licensed healthcare providers and their jobs would be on the line if they did not ensure the task was properly completed, not to mention how this would affect their REACH performance evaluations. When an RCM nurse says that he or she does not “feel comfortable” removing a tracheotomy, the CTU nurse must do it. When the RCM nurse writes sloppy, incomprehensible progress notes, the CTU nurse must rewrite them and upload them to IMPACT.

Besides the legal obligation, CTU nurses are also morally obligated and very compassionate about the care they provide for students. This is why CTU nurses will bend over backwards to ensure that each student is properly attended to. This is also why CPS is undoubtedly in denial that there are major performance issues with the RCM nurses: the work is getting done, so what is the problem? The problem is when the work simply won’t be done because there is not a CTU nurse there to cover it. What if the CTU nurse is busy handling a crisis with another student or not in the building at all because he or she is only assigned to it once a week? Who will step in and help the student then?

Nursing Staff Outsourcing Contracts in Detail

As mentioned previously, CPS began outsourcing part of the student health services to staffing agencies in the early 1990’s. Various companies sent part-time and temporary staff to cover nursing, physical therapy, speech pathology, psychology and other similar services. According to board reports, this has always been to supplement nursing services – it never proposed to replace CPS nurses with staff agency nurses – yet the number of CPS nurses has declined every year.

According to the CPS language in the private nurse staffing contracts, the intended Outcomes of the private nurse staffing agencies has evolved over the years:

Agencies services will enable medically fragile students to achieve better school attendance and improved classroom participation23, 2004 and 2006 contracts.

Vendors services will improve the quality of student care, resulting in increased school attendance and improved academic performance for these students24, 2010 and 2014 contracts.

The Vendor’s services will result in a better quality of care in a fiscally responsible way. By executing the scope of work with excellence, the Board should realize both of these desired outcomes25, 2015 contract.

The June 24, 2015, four-year agreement for school nursing and health management services with RCM Technologies, Inc. is the boldest contract yet. As stated previously: Under-bidding CPS’ previous nurse staffing contracts by nearly $5 million each year – with added administrative responsibilities such as scheduling, training and recruiting – this contract also includes a “gain sharing” arrangement whereby RCM will receive money from CPS as a reward for reducing the cost of providing vital health care services to students with IEP’s and 504’s. The reward will equal 50% of the realized cost savings, calculated by RCM. If RCM fails to save CPS money, then it will owe the district up to $125,000. Additionally, RCM will be penalized for failing to staff schools in a timely manner.

Provider agrees to pay to the Board the following assessment(s) for Liquidated Damages26:

Documentation submission and Approval of Services (Progress Notes) 24 hours is the goal; however, if Provider’s staff has not documented Services within 48 hours of service delivery, Provider shall credit the next month’s invoice $50 per day per documentation that has not been submitted electronically.
Time to Fill: Routine Assignments 24 hours from notice from the Board is the goal, however, if Provider does not fill the assignment within 72 hours of notice of the assignment, Provider shall credit the next month’s invoice $150 per day until such assignment is filled.
Time to Fill: Hard to Fill, including visits, ½ days, bus routs 24 hours is the goal, however, if provider does not fill an assignment within 120 hours of notice of the assignment, provider shall credit the next month’s invoice $150 per day until such assignment is filled.
Time to Fill: Emergency Assignments, Last minute call-off (CPS or agency) Coverage – Fill within 2 hours (on-site within three hours) Last minute call-offs must be filled within 2 hours of CPS notifying RCM and a RSP must be on site within 3 hours of call off or scheduled assignment start time, whichever is earlier. Provider shall credit the next month’s invoice $150 per occurrence.

RCM has a large economic incentive to cut the CTU nursing staff, as the contract stipulates that the company will get a “credit for cost savings” resulting from RCM implementing “more effective scheduling which results in more services delivered or less staff required.”27 As stated in the previous section, the CTU nurses are already stretched to the absolute maximum and struggling to provide the necessary services to comply with the IEP’s and 504 plans, let alone providing any health services for sick or injured students.

RCM Technologies is a publicly-traded company worth $60 million that specializes in staffing and outsourcing in the areas of IT, engineering and healthcare.

Insert Image 2: Nursing_Image2.jpg
(Alt Description: Image from RCM Technologies giving mission statement.)

The company is over 40 years old but only opened a Chicago office in August of 2015. RCM’s stock prices went up when the contract with CPS was announced:

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(Alt Description: MarketWatch image RCM Technologies Inc. stock.)
Source: http://www.marketwatch.com/investing/stock/rcmt

The Chicago office has proven to be very profitable for RCM28:

Insert Image 4: Nursing_Image4.jpg
(Alt Description: Specialty Health Care revenue)

According to the lawsuit filed on September 11, 2015 by ATC Healthcare, one of the nursing agencies whose contract was terminated early by CPS in favor of this new contract with RCM, CPS was complicit in ensuring that RCM receive the winning bid. RCM told CPS it would have no problem taking over the hiring and management of the agency nurses from the other three agencies. ATC became aware of this when its employees reported that staff at RCM were calling them and stating that if they intended to keep working at CPS, they will have to work through RCM.29 The lawsuit also alleges that CPS indicated to RCM that it would win the bid (which seems substantiated by the RCM investor update below) and that CPS illegally gave RCM the phone numbers of all of the agency nurses employed by ATC Healthcare.

It is unclear if there is a connection between RCM and CPS, like the SUPES contract for professional development that former CPS CEO Barbara Byrd-Bennett was federally indicted for on October 8, 2015.30 However, RCM currently employs a person named S. Gary Sondgrass who worked with Frank Clark, the president of the CPS Board of Education, at Exelon a few years ago. Mr. Clark was not yet the CPS board president when this contract was approved (David Vitale still held that position), however the timing and the relationship is worth investigating.

The above quotation from the 2015 2nd quarter investor’s report shows that RCM was quite confident that it would win the bid to provide nurse staffing services at CPS, well ahead of the actual approval at the June 24, 2015 board meeting. In fact, the RFP for the contract was not released until December 201431, so how was it possible for RCM to “elude” to its investors that it would win a contract at the time that the RFP was being released?

CTU Survey on Nursing Issues

In November 2015, the CTU surveyed all CSN, HSN and LPN nurses who are members of the CTU to find out to what extent the RCM nurses have been effective at achieving the stated CPS goal of improving efficiency of nursing services without risk to student health. Of the 95 nurses who responded (a 35% response rate), the majority are Certified School Nurses (CSN’s) and three-fourths of the respondents work at schools alongside RCM agency nurses. 79% of the respondents have at least three years of work experience. CTU also organized two citywide meetings in January and February of 2016 for nurses to share more information and for CTU to ask clarifying and follow-up questions to fully understand the situation with RCM.

Only thirteen of the 95 respondents (14%) reported favorable opinions of the agency nurses. Most of the favorable respondents worked with nurses previously contracted by Maxim to work for CPS in past years. However, even among the nurses who reported positively, many of them still had complaints about RCM – the company is unresponsive, slow to assign nurses, no coverage for absent nurses.

From the survey response, it appears that the agency views school nursing simplistically—to provide medication or other nursing tasks. Agency nurses are licensed professionals but often unaware of the challenges of practicing in a school which requires far more independence than in a hospital setting. The importance of being familiar with a student’s needs, and building relationships with students, family and staff is also underestimated.

The complaints from the dissatisfied CTU nurses ran the gamut from poor company administration to life-threatening ineptness on the part of the agency nurses. With the medical issues facing the students throughout the district – food allergies, asthma, diabetes, epilepsy, among others – there is no room for error.

CTU nurses reported that they complained on numerous occasions to CPS staff regarding the poor work performance of the RCM agency nurses. Several nurses were told in a meeting that there was a “grace” period and that the RCM contract did not fully go into effect until January, 2016. CPS staff went so far as to say that the fact that schools did not even receive any temporary staff in September and October – despite daily calls requesting staff – “did not count” in terms of contract noncompliance. This is not true. The contract clearly began on July 1, 2015; thus, the company has been legally obligated to provide the services specified and at the level of quality stipulated in the contract:

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(Alt Description: Image of Term agreement. Agreement states that the term of the agreement shall commence on July 1, 2015 and shall end on June 30, 2019. The agreement shall have two (2) options to renew for periods of one (1) year each.)
Source: http://www.cpsboe.org/content/actions/2015_06/15-0624-PR6.pdf

As indicated below, RCM has fallen short in numerous instances.

CTU nurses reported that RCM agency nurses are inexperienced, inconsistent, unreliable, have refused to follow orders, showed up late, left early, talked on the phone all day, and that the CTU nurses have to spend too much time training and orienting the inexperienced nurses. The company does not replace nurses who do not show up for work, schedules the nurses wrong, gives the nurses the wrong assignments, does not fully understand the complexities of school nursing duties, and is unresponsive to complaints. This negates the RCM promise of providing a “better quality of care” for the students at CPS schools. In fact, students have had to stay home because the nurse who was supposed to accompany them on the bus or to provide one-on-one services (to shadow the student all day) never showed up. In September, 2015, the Better Government Association (BGA) reported that at least 30 students had to stay home – missing the first two weeks of school – because one-on-one nurses hadn’t been assigned.32

Between the changes brought on by this RCM contract and the voluntary and involuntary mass exodus of staff from CPS central office due to the upheaval caused by the new CEO and the subsequent reorganization of the central office, CTU nurses do not know who is in charge right now. The RCM contract says that the company is responsible for hiring qualified nurses and will train and orient the temporary nurses prior to sending them to any schools, yet it is the CTU nurses who are having to spend precious time training and supervising the agency nurses, especially on using the CPS computer tracking system (IMPACT) and in writing progress reports. Two of CTU CSN’s reported that they have quit working for CPS this past fall because they do not want their nursing license jeopardized by having to sign off on the sloppy work of the unqualified agency nurses.

There is a fear among CTU nurses right now, due to CPS’ self-made budget crisis, that they will be laid off and forced to work for RCM at a lower rate and without benefits. CTU nurses reported in February, 2016, that CPS has stopped hiring LPN’s and HSN’s. However, CTU nurses also insist that this fight against RCM is not simply about keeping their union jobs. This fight is about children’s well-being, their health and safety. On February 4, 2016, RCM placed an advertisement on Indeed.com for a Clinical Nurse Supervisor (see the full ad in the appendix), and the job description appears to be for Certified School Nurses.

RCM has consistently shown over the previous six months that it does not have the expertise needed to schedule staff: too many shifts have been unstaffed, agency nurses show up just to administer insulin and leave before feeding students with feeding tubes, leaving CTU nurses to do the work. RCM is unreachable, despite the contract saying it will have a 24/7 call center:

Provider will operate a live call center to respond to calls and inquiries received from provider’s staff, CPS staff and employees, including but not limited to school nurses, principals, teachers, case managers and central office employees, and parents/guardians of Board students. The Call Center will operate 24 hours a day, 7 days a week to ensure coverage for ALL RSP’s is provided on a daily basis.33.

CTU nurses are very worried what will happen to their workloads and current school assignments once RCM takes over the scheduling in March 2016. The current workloads are already unmanageable, with so much time being spent on reporting, in meetings and in re-evaluations:

My current caseload is 110 students at five school buildings. Every day is team day. The contract nurses didn’t show up the whole first week, and are inconsistent now. The answer is an e-mail to call schools to find out if the agency nurse is there – if not, go and provide service. Our REACH observations are in part based on data, and based on case studies as well as teaching. This is untenable. People quit and are not replaced.

If RCM adds more to their workloads – which the contract indicates will likely happen – then CPS students will have even less time under the care of nurses.

CTU nurses have reported that some of the RCM nurses working in CPS schools have not had background checks, TB testing, or have not been screened. There are several nurses from CPS’s Do Not Hire (DNH) list – who have been fired by CPS – who are working for RCM. It is unclear how many agency nurses are employed by RCM and working in CPS schools because CPS did not respond to a CTU information request for this data in October 2015. However, CPS reported that 171 agency nurses worked in CPS schools in the 2014-2015 school year34 and a business news announcement of the RCM contact with CPS states that RCM will also employ about 170 agency nurses.35 CTU subsequently submitted a Freedom of Information (FOIA) request on February 3, 2016, for “Employee list of all nurses currently employed by RCM Technologies to work at CPS schools, including information on their licensing, credentialing and background checks to ensure they are qualified to work in nursing positions with children.” This FOIA request has currently been assigned.

The RCM nurses are not entering data into IMPACT, which is CPS’ system for tracking the IEP service minutes which is also used for Medicaid reimbursement claims. There have also been reports of RCM nurses fraudulently entering progress notes and in one case entering data for a student who was not enrolled at that particular school.

The table below highlights sections of the RCM Contract with specific promises on service delivery, and the related complaints from CTU nurses:

Conclusion

The goal of for-profit models like RCM is to reduce staffing. This is not appropriate for school nursing services because CPS students need more, not fewer, full-time nurses working at their schools every day. School nurses need sufficient time to care for each student and upload detailed and accurate progress reports into the IMPACT system. Otherwise, CPS is throwing away a considerable sum of money in Medicaid reimbursements. Students also need education to promote healthy lifestyles so they can improve their attendance rates and focus on academics while in school.

The $30 million that CPS paid RCM this year could have been used instead to improve school health with greater retention of and increased numbers of nursing staff, provision of necessary medical services and education to students, professional development appropriate for nurses working in schools, and other needed changes related to nursing services. CPS could have begun the groundwork for developing a continuous source of well-prepared professional nursing staff, better able to serve children in the school setting. CPS needs nurses who know how to properly document and capture lost Medicaid dollars that RCM has mismanaged or not been able to adequately capture.

Privatized nursing is a threat to the health and well-being of all Chicago Public School students, particularly the most vulnerable. These students need full time, professional nurses who know their needs and are dedicated to improving their health. CPS should not be outsourcing the health care of our students.

Appendix

History of CPS Nurse Staffing Contracts

Note: CPS board reports only go back to 2000 online. The rest of the reports are archived at the Harold
Washington Library.

Sample job announcement for RCM nurse supervisor:

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(Alt Description: Image of Indeed online job search for Clinical Nurse Supervisor (RN) with RCM Health Care Services.)

Medicaid Reimbursement

CPS provides a variety of services to students with disabilities such as speech therapy, physical therapy, occupational therapy, mental health service and special transportation. CPS qualifies for Medicaid reimbursement for these covered services to eligible students and the costs of administrative outreach activities.

Medicaid pays for costs of direct, medically necessary services provided to eligible children who have disabilities in accordance with the Individuals with Disabilities Education Act (IDEA). In Illinois, services that may be claimed for School-Based Health Services’ Medicaid reimbursement are: Audiology, Developmental assessments, Medical equipment, Medical services, Medical supplies, Nursing services, Occupational therapy, Physical therapy, Psychological services, School health aide, Social work, Speech/language pathology, and Transportation.

These services are frequently specified as necessary related services in individual education programs (IEP) developed by schools for children with disabilities. When these services are provided under a child’s IEP, the services are eligible for federal Medicaid reimbursement, at the state’s reimbursement rate, approximately half of the established cost to provide the service.

Schools may also claim some costs for the administration of the program. Allowable administrative claims include outreach activities designed to ensure that the entire student community has access to Medicaid covered programs and services, as well as costs incurred for implementing and monitoring the Illinois state Medicaid plan.

Medicaid revenues in FY 16 are expected to remain flat to FY 15 at $48 million. A decline in rates and the more efficient operation on busing in FY 16 is expected to be outweighed by CPS initiatives to claim some services not currently being claimed, and to create a better pipeline for Medicaid enrollment.

http://www.cps.edu/fy16budget/documents/fy16budget.pdf

RCM Positions:

Job Title Qualification Description
Certified School Nurse (CSN) IL State Licensed Registered Nurse (RN); Professional Educators License (PEL) Provides emergency care, case identification and case management for students with a chronic condition. Provides follow-up and evaluation. Implements health services and treatments to students with disabilities. Develops health assessments for students with Section 504 Accommodation Plans and students with IEPs. Develops IEP health goals and accommodations for students with IEPs. CPR certified. Schools have an IEP Team Day every week which requires a CSN to attend. Typical workday is 7 hours for Board CSNs.
Health Services Nurse (HSN) IL State Licensed Registered Nurse (RN) Provides emergency care, case identification and case management for students with a chronic condition. Provides follow-up and evaluation. Implements health services and treatments to students with disabilities. Develops health assessments for students with 504 accommodation plans and students with IEPs. CPR certified. Typical workday is 7.25 hours, without lunch, but may vary based upon individual school operations.
Licensed Practical Nurse (LPN) IL State Licensed Practical Nurse Administer medications via oral, topical, subcutaneous, intradermal and intramuscular routes under the direction of a registered professional nurse (RN). Takes vital signs, blood glucose levels, carbohydrate calculations, insulin administration. Proficient with pediatric as well as adult GT feedings, catherizations, tracheostomy and ventilator care. Provides first aid and emergency care. CPR certified. LPN’s also travel on field trips or out of school locations for those students that require medical supervision. A multi-school LPN visits more than one school per day. Multi-school LPN’s shall not be compensated for travel to and from their home to the workplace. Typical workday is 7.25 hours, but may vary based upon individual school operations.
Health Aide Education- High School Diploma/ GED Assists with collection and maintenance of health records and data. Performs clerical duties such as data entry and filings. Maintains confidentiality of all school records and health related issues. Typical workday is 7.25 hours, without lunch, but may vary based upon individual school operations.
Vision/ Hearing Technican Education- HS Diploma/ 2X3 day certification course + home study The vision and hearing technician provides screening activity for visual acuity, muscle balance, hyperopia, phoria, near/far binocular vision, pure tone audiometric tests, and thresholds tests (when needed). Performs clerical duties such as data entry and filings. Maintains confidentiality of all school records and health related issues. They also identify students that nee further evaluation and refer those students to the appropriate department. Typical workday is 7.25 hours, without lunch, but may vary based upon individual school operations.
Medical Records Clerk HS Diploma Pull charts daily for students who are scheduled and make sure that the date of the service is stamped on the progress notes. Inserts any lab results or other results needed for review by the Provider as per policies and procedures established by the Board and in accordance with licensing and regulatory requirements or as instructed by the Nurse Coordinator. Check for student identifying information in all documents.
Medical Biller HS Diploma; Experience in specific field Medical billing translates health care service into a billing claim. The responsibility of the medical biller is to follow that claim to ensure the practice receives reimbursement for the work the Providers perform. A knowledgeable biller can optimize revenue performance for the practice.
Medical Coder AHIMA and/or AAPC Certification(s) Medical coding professional provide a key step in the medical billing process. Every time a student receives professional health care in a school setting the provider must document that services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create claim to be paid, whether by a commercial payer, the patient or CMS.
Administrative Assistant HS Diploma and relevant experience Administrative assistants perform routine clerical and administrative duties. They organize files, draft messages, schedule appointments, and support other staff.
Scan Technician HS Diploma and 1 year of Scanning experience Medical Record Scanning Technician will be responsible for Recovery, scanning and electronic documentation of medical records from school sites using computer and scanning equipment and accurately transferring the data.