When Pauline Cruz’s son and daughter started school, they were missing class on a regular basis because their asthma symptoms put them in the emergency room.
Though their symptoms still sometimes flare up, both are doing better since they joined the Step Up program at Swansea Elementary School in Denver. The school nurse would go over techniques for inhaling their medication and “reading their bodies” for warning signs, Cruz said.
The connection also meant she could call the nurse if she noticed the kids were struggling, or the nurse could ask her to keep working with them at home on a specific skill.
“That has been a huge, huge, huge help,” she said. “They were able to tell me, ‘Hey, Mom, I need my inhaler.’”
Children’s Hospital Colorado, which works with school nurses and parents of kids with asthma in the Step Up program, received a $2,7 million grant from the National Institutes of Health to test whether it will work in communities outside Denver, and if it can be financially sustainable. The University of Colorado School of Medicine, National Jewish Health and the Colorado Department of Public Health and Environment also are participating.
So far, the hospital and school districts have essentially donated the staff time needed to coordinate kids’ asthma care, because they typically can’t bill insurance, said Dr. Stanley Szefler, director of the pediatric asthma research program at the hospital’s Breathing Institute.
“Hopefully, this could become part of value-based care,” the idea of paying doctors based on patients’ health outcomes, rather than how many treatments they perform, he said.
AAron Ontiveroz, The Denver Post
Alex holds his inhaler on Tuesday, April 27, 2021.
For now, they’re working on establishing contacts in the Montezuma-Cortez School District, Greeley-Evans School District 6 and Falcon School District 49 in El Paso County. They’re also working with multiple districts in the area around Lamar and in a four-county zone from Grand Junction to Ouray.
Representatives for the school districts said they couldn’t comment at this point.
In some areas, like El Paso County, there are plenty of pediatricians and specialty care is nearby, but getting everyone working together is the central issue, Szefler said. In more rural parts of the state, virtual care may be the only way to see a pulmonologist specializing in children. They also may rely more on informal “connectors” — parents who have a child with asthma and want to share what they’ve learned with others, he said.
Children’s Hospital started working with Denver Public Schools about 15 years ago, then gradually expanded to five other districts in the area, Szefler said. When they started, only about 5% of students who had asthma had a plan for how to manage it in school, but now about 80% do, he said.
“Schools are a perfect setting for catching students who aren’t doing well,” he said. “For the most part, it’s a very manageable disease.”
A report from the state health department found that kids who participated in Step Up, or a similar program, in the six school districts had about 80% fewer hospitalizations and emergency room visits than before they joined. They also missed fewer school days, with bigger effects for kids of color and those from low-income families.
Participating schools ask parents if their children have asthma, and if so, how often they’ve had to seek help for breathing emergencies, Szefler said. Then an asthma navigator and the school nurse work with parents and the child’s normal health care provider to address problems that could be worsening the symptoms, from not knowing how to take medication to allergens in the home.
“Housing’s probably the most difficult, because people go to what they can afford,” he said.
Cruz said the asthma navigators introduced her to resources to clean their indoor air, but the kids know they need to take precautions before going outside.
Interstate 70 runs through the Elyria-Swansea neighborhood, and they’re also near the Suncor Energy oil refinery, which both contribute to air pollution that irritates kids’ lungs, she said. Swansea Elementary was one of 10 DPS buildings to install air quality monitoring equipment in 2019, because of relatively high rates of both asthma and poverty, according to Chalkbeat.
Ana Kim, DPS’s district asthma resource nurse, estimated about 9,000 of the district’s 85,000 students have asthma, and about one-third of students with asthma have more-severe symptoms. Nurses who participate in the program learn to triage students so they know who needs extra support, she said.
Nurses meet with students and their parents three times a year to talk about how well-controlled their symptoms are, Kim said. They also can identify problems, she said, giving the example of a recent visit during which she found out a student’s inhaler had broken and probably wasn’t delivering any medicine when the student used it.
AAron Ontiveroz, The Denver Post
Alex Hernandez plays with his uncle’s dog, Bullet, in front of his grandparents’ home on Tuesday, April 27, 2021. Both Hernandez and his younger sister, Aaliyah suffer from asthma along with a large number of kids in their Swansea Park neighborhood. The siblings have both taken part in an in-school training provided by Denver Public Schools and Children’s Hospital that helps kids with asthma to self identify a variety of symptoms and guidelines to care attacks.
Students’ primary care providers typically teach them about managing their disease, but it helps to have someone who can reinforce what they’ve learned, Kim said.
“The problem is that it’s that one moment” in a doctor’s office, she said. “We can do so much from schools, because we see the students every day.”
Cruz said getting support for their asthma in school helped her children. Her son Alex Hernandez Jr., 13, initially was self-conscious about using his inhaler in class, but meeting other kids with the same need gave him confidence. Her daughter Aaliyah Hernandez, 8, has developed a strong relationship with the school nurse, and sometimes the kids can even teach their grandmother, who also has severe asthma, she said.
Cruz said the kids have had some hospitalizations since taking part in the program, but fewer than they did before, and they’re not missing nearly as much school. She said she’d like to see the program expand to Bruce Randolph Middle School, where Alex now attends, and to other buildings that don’t have it.
“It has made a world of difference,” she said.
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