II 113th CONGRESS 2d Session S. 2297 IN THE SENATE OF THE UNITED STATES May 7, 2014 Mr. Tester introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To make demonstration grants to eligible local educational agencies or consortia of eligible local educational agencies for the purpose of reducing the student-to-school nurse ratio in public elementary schools and secondary schools.

1. Short title This Act may be cited as the Nurses for Under-Resourced Schools Everywhere Act or the NURSE Act . 2. Findings Congress finds the following: (1) The American Academy of Pediatrics emphasizes the crucial role of school nurses in the seamless provision of comprehensive health services to children and youth, as well as in the development of a coordinated school health program. (2) The school nurse functions as a leader and the coordinator of the school health services team, facilitating access to a medical home for each child and supporting academic achievement. (3) School nurses promote wellness and disease prevention to improve health outcomes for our Nation’s children. In addition, school nurses perform early intervention services such as periodic assessments for vision, hearing, and dental problems, in an effort to remove barriers to learning. (4) Recent national data indicates 45 percent of public schools have a school nurse all day, every day, while another 30 percent of schools have a school nurse who works part time in one or more schools. (5) The American Nurses Association has reported that when there is no registered nurse on the school premises, the responsibility to administer the necessary medications and treatments, and appropriate monitoring of the children, falls on the shoulders of administrators, educators, and staff who are ill-prepared to perform these tasks. (6) Statistics from the National Center for Education Statistics indicate that 15 to 18 percent of the 52,000,000 students who currently spend their day in school have a chronic health condition. (7) A recent study indicated that from 2002 to 2008, the percentage of children in special education with health impairments, due to chronic or acute health problems, increased by 60 percent. School nurses use their specialized knowledge, assessment skills, and judgment to manage children’s increasingly complex medical conditions and chronic health illnesses. (8) Among adolescents aged 12 to 19 years old, the prevalence of prediabetes and diabetes increased from 9 percent to 23 percent between 1999 and 2008. More than 30 percent of children aged 2 to 19 years old are obese or overweight (defined as having a body mass index of greater than the 85th percentile). In 2008, more than 10,000,000 children in the United States had asthma. The prevalence of food allergies among children under the age of 18 increased 19 percent from 1997 to 2007. (9) According to the American Academy of Pediatrics, students today face increased social and emotional issues, which enhance the need for preventive services and interventions for acute and chronic health issues. School nurses are actively engaged members of school-based mental health teams and spend nearly 32 percent of their time providing mental health services, including universal and targeted interventions, screenings to identify early warning signs and provide referrals to medical providers, and crisis planning. (10) In 2011, the Bureau of the Census reported 9.7 percent of children under the age of 19, which equals 7,600,000 children under the age of 19, were without health insurance. Data shows that uninsured children achieve lower educational outcomes than those with health coverage. Children who cannot afford to see a medical provider miss more days of school, experience increased severity of illness, and suffer from disparities in health. (11) More than 1,600,000 children experience homelessness each year in the United States. Homeless children develop increased rates of acute and chronic health conditions, and the stress of their living situation can negatively affect their development and ability to learn. As a result, schools have become the primary access to health care for many children and adolescents. School nurses serve on the front lines as a safety net for the Nation’s most vulnerable children. (12) Communicable and infectious diseases account for millions of school days lost each year. Data illustrate that when students have access to a registered nurse in school, immunization rates increase. (13) A 2011 study showed that a school nurse in the building saves principals, teachers, and clerical staff a considerable amount of time that they would have spent addressing health concerns of students, including saving principals almost an hour a day, saving teachers almost 20 minutes a day, and saving clerical staff more than 45 minutes a day. This would amount to a savings of about 13 hours per day in the aggregate for such school personnel. (14) Determining a balanced student-to-school nurse ratio by using a formula-based approach, taking into consideration the overall health acuity of the student body and the workload of school nurses, offers a reasonable means for achieving better student outcomes. 3. Reducing student-to-school nurse ratios (a) Definitions In this section: (1) ESEA terms The terms elementary school , local educational agency , poverty line , and secondary school have the meanings given to the terms in section 9101 of the Elementary and Secondary Education Act of 1965 ( 20 U.S.C. 7801 ). (2) Acuity The term acuity , when used with respect to a level, means the level of a patient’s sickness, such as a chronic condition, which influences the need for nursing care. (3) Eligible entity The term eligible entity means— (A) a local educational agency in which the student-to-school nurse ratio in each public elementary and secondary school served by the agency is 750 or more students to 1 school nurse; or (B) a consortium of local educational agencies described in subparagraph (A). (4) High-need local educational agency The term high-need local educational agency means a local educational agency described in paragraph (3)(A)— (A) that serves not fewer than 10,000 children from families with incomes below the poverty line; or (B) for which not less than 20 percent of the children served by the agency are from families with incomes below the poverty line. (5) Nurse The term nurse means a licensed nurse, as defined under State law. (6) Secretary The term Secretary means the Secretary of Education. (7) Workload The term workload , when used with respect to a nurse, means the amount of time the nurse takes to provide care and complete the other tasks for which the nurse is responsible. (b) Demonstration grant program authorized From amounts appropriated to carry out this section, the Secretary of Education, in consultation with the Secretary of Health and Human Services and the Director of the Centers for Disease Control and Prevention, shall award demonstration grants, on a competitive basis, to eligible entities to pay the Federal share of the costs of reducing the student-to-school nurse ratios in the public elementary schools and secondary schools served by the eligible entity, which may include hiring a school nurse to serve schools in multiple school districts. (c) Applications (1) In general An eligible entity desiring a grant under this section shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. (2) Contents Each application submitted under paragraph (1) shall include information with respect to the current (as of the date of application) student-to-school nurse ratio, student health acuity levels, and workload of school nurses in each of the public elementary schools and secondary schools served by the eligible entity. (d) Priority In awarding grants under this section, the Secretary shall give priority to each application submitted by an eligible entity that— (1) is a high-need local educational agency or a consortium composed of high-need local educational agencies; and (2) demonstrates— (A) the greatest need for new or additional nursing services among students in the public elementary schools and secondary schools served by the agency or consortium; or (B) that the eligible entity does not have a school nurse in any of the public elementary schools and secondary schools served by the eligible entity. (e) Federal Share; non-Federal Share (1) Federal Share The Federal share of a grant under this section— (A) shall not exceed 75 percent for each year of the grant; and (B) in the case of a multi-year grant, shall decrease for each succeeding year of the grant, in order to ensure the continuity of the increased hiring level of school nurses using State or local sources of funding following the conclusion of the grant. (2) Non-Federal Share The non-Federal share of a grant under this section may be in cash or in-kind, and may be provided from State resources, local resources, contributions from private organizations, or a combination thereof. (3) Waiver The Secretary may waive or reduce the non-Federal share of an eligible entity receiving a grant under this section if the eligible entity demonstrates an economic hardship. (f) Report Not later than 2 years after the date on which a grant is first made to a local educational agency under this section, the Secretary shall submit to Congress a report on the results of the demonstration grant program carried out under this section, including an evaluation of— (1) the effectiveness of the program in reducing the student-to-school nurse ratios described in subsection (b)(1); and (2) the impact of any resulting enhanced health of students on learning, such as academic achievement, attendance, and classroom time. (g) Authorization of appropriations There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2015 through 2019.