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Schooled in Good Health

Photo courtesy KIPP Baltimore

Schooled in Good Health

Established by Children’s Center leaders in 2014, the Rales Health Center has become a much-valued hub for health and wellness for students of the KIPP charter schools in West Baltimore, and their families — particularly during COVID-19.

On any given day, school nurse manager Lily Mendelson and colleagues at the Rales Health Center at KIPP Baltimore handle 100 to 200 student visits. The team starts each morning by giving scheduled medications to 20 to 25 students, getting blood pressure and weight measurements for a handful of others with kidney conditions, and administering feedings for a couple of students with gastrostomy tubes.

“From there, the day gets going,” Mendelson says, “and teachers send down kids for basically anything and everything.” Whether responding to stomach woes or headaches, playground injuries, allergy or asthma attacks, or a need for clean clothing, Mendelson and her team at the Rales Center are always well-prepared to pivot.

The Rales Center was started by pediatric public health researcher Sara Johnson and others at Johns Hopkins Children’s Center in 2014 to serve as a fully integrated health and wellness program at KIPP Baltimore, which operates two public charter schools on a shared campus in West Baltimore that enroll more than 1,500 students from kindergarten through 8th grade. The center follows an approach to school health informed by the Centers for Disease Control and Prevention’s Whole School, Whole Community, Whole Child model, says medical director Kate Connor. It includes school nursing as well as a school-based health center (a pediatric clinic in the school) and robust wellness offerings including in-class physical activity breaks, a school garden and family activities like healthy cooking demonstrations.

“We’ve had a strong interest in school health, and in thinking about how we can partner with schools and educators to support kids’ long-term academic achievement and well-being,” says Johnson, the Rales Center director. “Particularly, we’re interested in reducing educational inequities, as well as health inequities, and thinking about some of those root causes being the same.”

Balancing Education and Safety During COVID-19

When the COVID-19 pandemic hit, the Rales team members found themselves juggling a whole new set of circumstances as schools shut down and then slowly reopened. Throughout the process, Johnson, Connor and their colleagues have been on the front lines of the public health crisis. While helping students and neighbors of KIPP Baltimore, the Johns Hopkins experts have also served on public health advisory committees for school systems nationwide, and developed a series of guidance documents for educators everywhere struggling to balance education and safety needs during the global pandemic.

During the first weeks of the shutdown, the Rales team focused on helping KIPP students stay safe and healthy at home. They worked diligently to ensure their 300 students diagnosed with asthma and others who received medication at school had the medicines they needed, making home visits on students’ porches and dropping off medications normally stored at school. Meanwhile, family advocate Wilnett Dawodu helped families gain internet access and find food resources.

Next, they turned to technology. The nurses established a health center presence within the online Google Classroom to answer students’ and families’ questions about topics — like what a coronavirus is, or when they could see their friends — and to conduct needed asthma screenings. They created “Wellness Wednesday” videos about subjects such as healthy eating, and staying active during lockdown, and posted them to a new Instagram account. Nurses and staff telephoned caregivers, and posted on Instagram, to remind them how important it was for students to continue to receive routine well-child vaccinations.

“Knowing that kids were online learning, and they were on their computers, we felt like that was how we were going to reach them,” Mendelson says.

The team also continued to provide medical care. The Rales Center was the first school-based health center in the state to provide telemedicine services, through Connor and nurse practitioner Tresa Wiggins. Medical assistant Teresa Bailey conducted intensive outreach to families to support them in accessing the technology. Mendelson and others took calls all day and checked in on some families from their sidewalks and front porches. Wellness program director Ryan Connor collaborated with student and family support teams to identify and prioritize outreach to students with educational, social and emotional needs. And KIPP students continued to receive vision care — including eye exams and eyeglasses — through Vision for Baltimore, a mobile vision program operated through a partnership that began in 2016, between Johns Hopkins, Baltimore City Public Schools and the Baltimore City Health Department.

Megan Collins, a pediatric ophthalmologist from Johns Hopkins’ Wilmer Eye Institute who helps lead the Vision for Baltimore program, says vision issues became a growing concern as distance learning and additional screen time seemed to be leading to an increase in nearsightedness among school-aged children.

“We recognized what a hub schools are, not only for educational advancement but also for a number of other resources,” Collins says. “They’re places where kids get two to three meals a day. It’s where they have supervision during the day, particularly if parents are essential workers and aren’t at home.”

A Resource for Reopening

In summer 2020, the Rales Center became one of the first school-based health centers in the state to reopen for in-person care, including expanded vaccination clinics open to students throughout the district. Mendelson, who is bilingual, cared for Spanish-speaking families.

The next hurdle became thinking about reopening for school. It was “an immense amount of work,” says Mendelson, and they weren’t sure how many students were coming back.

The return started in early March 2021, with two first-grade classes of 11 students each. More students were added slowly, with an eye to those struggling the most with distance learning. By mid-April there were about 250 students in the building — a good start, Mendelson says, for determining variables like how children were going to eat safely, or how much they needed to space apart.

Throughout this time, the Rales team, Collins and Johnson received inquiries from school districts and superintendents from across the country and around the world asking what they should be doing as they planned to bring students back to schools. Could children sit next to each other on buses? Should they close their bathrooms? How much did they need to clean?

“What was really challenging at that time is there really wasn’t any specific guidance yet,” says Johnson, who together with Collins co-directs the Johns Hopkins Consortium for School-Based Health Solutions, to study how school health programs help advance health equity for kids.

They started some informal discussions with schools and became part of public health advisory committees for several school districts around the country, and consulted with leaders in other countries, to discuss ways to prioritize learning while trying to reduce the risk of contracting COVID-19. They followed the rapidly changing science, continually querying colleagues in infectious disease, aerosol science, public health and other disciplines to make informed decisions. As requests piled in, they put together a series of web-based modules to guide school districts in responding to COVID-19. They have been viewed more than 11,000 times.

Work continued into fall 2021 when Baltimore City Public Schools officially reopened for all students, which led to a new challenge — determining processes for handling students who test positive for or are exposed to the virus, and how to isolate them from children presenting to the health center for routine needs or minor illnesses or injuries. Mendelson and nurse Erica Johnson continue to offer guidance to families reporting positive cases, and to call families to let them know of positive test results. At times, the school nurses have performed juggling acts trying to figure out how several children can sit safely, spaced apart or isolated with the door closed, while waiting for parents to pick them up.

“I cannot overstate the critical importance, and intense difficulty, of being a school nurse or school health professional of any kind at this moment,” adds Connor. “School health was underfunded and understaffed in almost every place in the nation prior to COVID. It continues to be, and now folks are being asked to essentially run public health departments out of schools.”

Moving Forward in a New Era

In January 2022, the Rales team worked with the Bloomberg School of Public Health’s International Vaccine Access Center to offer a free virtual course for parents, teachers and school staff. Their goal: to create “vaccine ambassadors” who can speak with people in their communities to overcome hesitancy regarding COVID-19 vaccines.

A lot of what has hurt children and their families during the pandemic has been a confusion of messaging and constantly changing information, Collins says.

“We’ve tried to always be a reliable resource bringing more transparency to the process to give people education that they need in order to help make the best decisions,” she says.

Connor and Mendelson worked with school leaders and teacher representatives at KIPP to craft the health and safety policies that still are in use now. They continue to hold regular meetings with school leaders to provide data about the scope of COVID-19 within schools and make recommendations about any adjustments to procedures.

One of the silver linings of the pandemic, to Collins, has been figuring out new ways to engage and connect with parents, patients and the larger health care community.

“There were a lot of times in schools that we relied on paper information going home to families. Now we were calling families personally and giving them information,” she says. “It’s forced us all to think more about these connections between what happens in the school setting, and how we engage our community health organizations to support those school programs more robustly.”

Adds Connor, “What we learned during COVID is that in-person learning is critically important for students’ overall health and well-being.” Many students were suffering educationally, emotionally and sometimes physically during the shutdown when they weren’t able to access health care and services they normally access, she said. “We really have tried to think about that carefully, and to balance COVID safety and wellness with overall safety and wellness.”
Left to right: Erica Johnson, Ryan Conor, Teresa Bailey, Tresa WigginsPhoto by Jennifer Bishop
Left to right: Erica Johnson, Ryan Conor, Teresa Bailey, Tresa Wiggins (Photo by Jennifer Bishop)
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