"That's just plain impossible," she said. "I don't know of any school-based health program that makes money. Ours sure don't."

School nurses are now school system employees. If the health system would assume their duties free of charge, the consultants say, the school system would save $9 million.

"We lose money on our school-based health services," Carter said. In Kanawha County, FamilyCare, a federally qualified health center, runs the school-based health center inside the Mary C. Snow West Side Elementary School. 

"There's no way we could add another salary," Carter said. "This makes no sense."

Today, the state school board is issuing their reaction to the recommendations in that efficiency report, generated by Pennsylvania-based Public Works LLC.

Amber Crist, education director of Cabin Creek Health Systems, which runs four school-based centers in Kanawha County, echoed Carter.

"The problem is that there aren't enough school nurses," she said. "This recommendation does not help with that. It just shifts the cost to the health system. I don't know about the rest of the report, but this recommendation isn't going to solve anything."

Specifically, the audit recommends that legislators pass a law forcing school-based health centers to "perform the duties of a school nurse, free of charge, as payment for the use of school facilities.

"These centers do not pay rent or utilities for the school building space they occupy," the consultants wrote.

"Actually some do pay rent and utilities," Kelli Caseman, director of the West Virginia School-Based Health Assembly, said. The contracts are locally negotiated, she said, so they vary from school to school.

"Our board was stunned when they read that," Caseman said. "Clearly, the auditors didn't understand the magnitude of medical services school-based centers provide for schools and children. It read as if the centers were doing nothing for the schools."

The centers provide more than 100,000 medical treatments for children a year, she said. The consultants did not visit any centers, "to our knowledge."

Janet Allio may make it easier to get a grip on the difference between school nurses and school-based health centers.

Three days a week, Allio is the school nurse at Mary Snow Elementary on Charleston's West Side. Two days a week, she nurses at Piedmont Elementary on the East End.

The school system says neither school can afford a full-time nurse.

At both schools, Allio makes sure kids with type 1 diabetes get their insulin, kids with asthma use their inhalers, kids who need catheters have fresh ones in place. She sees children with seizures and other life-threatening allergies, but she does not provide care that requires a doctor.

Last year, she gave children more than 2,000 doses of already-prescribed medication. She talks with parents every day. "We help families find homes and clothing, whatever affects the kids' health," she said. "We keep a clothes closet." She goes into classrooms to teach about things like household poisons and nutrition. 

Last year, she rode the school bus every morning with a child who needs constant care. 

There is one big difference between her two schools: Mary Snow has a school-based health center. Piedmont does not.

A school-based health center is a medical clinic with a doctor. "If a child has a problem that requires a physician -- strep, a broken bone, whatever -- at Mary Snow, I can send them straight to the pediatrician inside the school," Allio said. Eighty percent of parents have signed permission slips. "I can call the others and give them that option."

At Piedmont, she must call the parent and ask them to come get the child. That can cause parents to miss work. The child may or may not see a doctor, she said. "At Mary Snow, we know they see a doctor."

"We have seen our children come back to school so much more quickly since we got the school-based center," said Mary C. Snow Principal Mellow Lee.

Ninety-six West Virginia schools have services from a school-based center. They have been built with federal and private funding, including more than $3 million from the Claude Worthington Benedum Foundation.

There are more than 700 schools statewide. "Someday, we'd like to have this for all schools," Caseman said.

Federally qualified health centers run most of the centers. No Mary C. Snow parents ever receive a bill for their child's treatment. The center funds itself by billing insurance: PEIA, CHIP, Medicaid and private insurance. A federal program covers children who have no insurance.

Shifting the cost

The consultants say the school system could save $9 million by their recommendations. "To get $9 million in savings, they'd have to cut out the salary and benefits of every school nurse in the state," said Brenda Isaac, lead school nurse for Kanawha County. "That's the only way I can think of that they could come up with $9 million.

"They say the health centers are going to do it for free. The health centers say they can't. I'm not sure how this solves the problem of too little care."

"Even if we thought it was a good idea, we would not be able to do it," Crist said. Insurance companies will not reimburse the centers for school nurse services, she said.

"The state can't force a private organization to provide services," she said. "I suppose they could tell us we have to shut down if we don't do it, but that would not be efficient. It would cause a lot of problems."

Reach Kate Long at 304-348-1798 or katel...@wvgazette.com.