Jonathan, a fourth-grader at a KIPP public charter school in Northwest Baltimore, empties his impossibly stuffed pants pockets before hoisting himself onto the exam table in the doctor’s office.

A Matchbox race car. A robot. Some string. A plastic top.

“That’s quite a collection,” Katherine Connor, Johns Hopkins Children’s Center pediatrician and medical director at KIPP’s health clinic, tells Jonathan. “You could just about open a toy store.”

The young patient smiles bashfully, but suppresses the laughter that’s too often accompanied by fits of coughs and wheezes.

The 1,500-student school is home to one of 16 school-based health centers in the Baltimore City Public Schools system and the only one operated by the Johns Hopkins Children’s Center. Although most of the city’s 171 public schools have health suites where students can get the basics provided by health aides or nurses, the clinic at KIPP, known as the Rales Health Center, offers comprehensive, in-house medical care. In addition to Connor, the clinic has two nurses, a nurse practitioner, a “family advocate” case worker and a medical assistant.

While the nurses care for as many as 100 children each day, Connor and the clinic’s nurse practitioner see a dozen or so students like Jonathan. Dealing with problems ranging from chronic conditions such as asthma and diabetes to scraped knees and bloody noses, the clinic team aims to get kids healthy and focused on learning.

By the looks of a typical morning, students know they’re welcome and safe in the clinic. A child waiting for a visit perches herself on a counter next to the office printer, dangling her feet and singing a song. Another clings to nurse Nasreen Bahreman’s side, following her from room to room.

“It looks more chaotic than it is,” says Bahreman, gently peeling the young girl from her leg.

Jonathan’s asthma makes him a frequent visitor to the clinic. He tells Connor he’s had trouble breathing for almost a week. The boy barely finishes his explanation before rolling, rumbly coughs double him over. His chest feels tight, he says, and the near-constant coughing hurts his head.

“What have you been doing to treat your asthma?” Connor asks, gently thumping Jonathan’s back with her hand as he recovers from the spell.“Using my inhaler,” he says, catching his breath. “And I’m drinking lots of water, like you said.”

Connor tells Jonathan that, in addition to asthma, he shows symptoms of a virus that is making its way around the school. During this visit she’s going to try to get his asthma under control. The doctor quizzes the boy on the difference between preventive and emergency medication.

“What is your red inhaler for?” she asks, suspecting that Jonathan hasn’t taken his medicine properly.

“The red one is for ... aw, man. I forget.”

Connor patiently details a regimen for everyday dosage.

Removing Barriers

This clinic is sponsored by the Ruth and Norman Rales Center for the Integration of Health and Education, a program begun in 2014 at the Johns Hopkins Children’s Center through a gift from the Norman R. Rales and Ruth Rales Foundation. The Rales Center seeks to establish a new approach to primary care by providing urban children in poverty with health and psychosocial care as part of their academic learning environment.

The Rales Educational and Health Advancement of Youth (READY) program is working closely with the school to develop, implement and evaluate a multidisciplinary blueprint for wellness that can be adopted throughout the nation. In addition to running the clinic, the READY team works with parents to strengthen their engagement with the school and helps school administrators and teachers find new ways to promote wellness.

“Rales staff members work hand-in-hand with our teachers, families and community to ensure our students are healthy and ready to learn,” says Marsha Reeves, executive director of KIPP Baltimore. “The center’s staff is able to address students’ chronic and acute health challenges, enabling students to receive compassionate care and stay in class longer, leading to increased attendance rates.”

In the past school year, 165 school absences were avoided, according to program leaders.

The READY program builds upon a school model that is already innovative. The first Knowledge Is Power Program—or KIPP—school was established in Houston in 1994. Today, according to the schools’ parent foundation, there are 209 KIPP schools across the United States. They are large public charter schools that emphasize college readiness and safe, structured, nurturing learning environments.

KIPP Harmony Academy, for grades K through 4, and KIPP Ujima Village Academy, for grades 5 through 8, share a massive three-story building. In addition to health services, the clinic staff helps students and their families overcome barriers that can hinder a child’s learning.

Wilnett Dawodu is the clinic’s family advocate. She performs home visits and helps families connect to resources that can assist with electricity shut-offs, transportation troubles, and even homelessness and abuse.

“A lot of people in the communities we serve are just barely getting by,” says Dawodu. “Like anyone, they want what’s best for their kids. I love being able to help them clear a path for their children to learn.”

The clinic requires standing parental consent to treat children for anything more than basic school-nursing care. Like all pediatric clinics, physician and nurse practitioner visits get billed to patients’ insurance whenever possible.

Connor says they have about two-thirds of parents’ signatures on file and are continually working to get more. Reasons why parents might balk at using the clinic’s services range from concern over insurance copays to worries about medically fragile children, says Connor. “And then, of course, a handful of parents haven’t gotten the word that we’re here,” she says.

Jonathan’s mother is one of the parents who has provided consent.

When Connor determines that Jonathan could benefit from a nebulizer treatment to calm his asthma flare-up, she and the staff begin treatment immediately.

Jonathan sits quietly in a chair, his nose and mouth covered by a rubberized mask connected to the nebulizer machine that delivers the vaporized medicine. As the machine rattles next to him, Jonathan now breathes deeply and easily into the mask, fiddling with the small toys he brought along. Connor calls the boy’s mother.

“Jonathan’s doing fine,” Connor tells her over the telephone. “He came to us with an asthma attack, but we’ve got him on the nebulizer now.”

She explains in detail Jonathan’s inhaler medication regimen.

Later, Connor says it can be easy for parents or guardians to mix up medications or to believe a spouse or other household member has taken care of a child’s medicine needs.

“Getting ready for work or school, catching buses, making breakfasts—weekday mornings can be confusing,” she says. “Many studies have shown that if kids can get their regular meds at school, they’re a lot more adherent.”

With parental consents on file, dozens of KIPP students have their regular asthma, diabetes and other medicines administered by the clinic staff. A quick stop at the clinic is part of their school-day routine.

Building Family Relationships

The KIPP team’s pediatric nurse practitioner Tresa Schumann says getting a child to tell you what’s wrong can be difficult.

“But we’re embedded in the school and in the school’s culture,” she says. “You get to know these kids and to know when something’s bothering them.”

The clinic staff members attend school functions and parent events. Schumann says it’s part of making the clinic more than just a room for kids who don’t feel well during the school day.

Six-year-old Bradley’s mother is patient but looks exhausted as her son wriggles on her lap. She has taken time away from her job to meet with Connor about Bradley’s attention deficit-hyperactivity disorder. She explains to Connor that, since another physician adjusted Bradley’s medication, the boy can’t sit still, focus or concentrate.

“How do you feel, Bradley,” Connor asks the rail-thin first-grader, “since they changed your medicine?”

“Fidgety,” he replies before jumping off his mom’s lap and flinging himself against the doctor’s office door.

“He’s like this all the time,” his mother says, quietly.

Being able to visit her kids’ school and pediatrician in the same place has been a help, says Bradley’s mother, whose daughter graduated from KIPP a year ago.

“This school has been so good for my kids,” she says. “My son gets what he needs here. Dr. Connor has really helped him.”

Connor, Bradley and Bradley’s mother decide together that the boy would benefit from returning to his original prescription. Bradley says he looks forward to feeling better.

“The medicine helps,” he says.

Learn more about the Rales Center.