Privatizing School Nurses: SMART Clinics in Providence Public Schools

From College Hill Independent reporters Olivia Cruz Mayeda and Mara Cavallaro: “By removing union school nurses and implementing private clinics directed by a for-profit business, the district has fundamentally restructured relationships of care in its public schools. There are now private incentives governing care where there previously were none. All of these concerns emphasize how privatization of healthcare undermines community control of basic medical and mental health services.”

Rhode Island News: Privatizing School Nurses: SMART Clinics in Providence Public Schools

April 12, 2021, 1:53 pm

By and

Note: This piece, written by Olivia Cruz Mayeda and Mara Cavallaro, was originally published by the College Hill Independent on April 8, 2021.

On February 3, the Providence Public School District removed Tammy Lafreniere and Madeline Crowell from their positions as school nurses following the launch of privately-run SMART Clinics at their respective schools. First proposed last March, the SMART Clinics – a self-proclaimed “business model” owned and directed by Ginn Group Consulting and locally staffed by employees of the non-profit Providence Community Health Center – offer access to medical and psychological services that go beyond the capacity of the schools’ previous facilities. Without school nurses, however, Band-aids, sanitary pads, prescription medications, and Tylenols for headaches all require interactions with the new private clinic. Clinic costs (including a flat rate paid to the for-profit Ginn Group Consulting firm) are covered by Partnership Rhode Island and CVS Health via the Rhode Island Foundation until June 30, 2023. But when the SMART center deems provisions of care to be “office visits,” they bill students’ insurances and charge teachers copays. They treat uninsured students free of charge. 
Overall, the district’s lack of transparency surrounding clinic access to medical records, billing, and their removal of three faculty members who voiced criticism continues to raise community concerns. The Indy investigated these removals and the impacts of SMART Clinic implementation.

For the last couple of weeks, faculty at Mount Pleasant High School in Providence have been wearing stickers that read, “SMART: Save Mt’s Awesome Registered (Nurse) Teacher.” In the upper left-hand corner of the white label – the kind you can buy in sheets of 30 at office supply stores – is a smiling cartoon Mickey Mouse, a reference to school nurse Tammy Lafreniere. “Everyone knows that she loves Disney,” Devon Johnson, a graduate of the school, told the Indy.

Just a little over five miles from Mount Pleasant, teachers at Roger Williams Middle School made T-shirts in support of their former nurse, Madeline Crowell. In one photo, 11 faculty members wearing the shirts sit on the concrete steps of the school in solidarity. One teacher holds a poster of Crowell with a stethoscope over her shoulders. Known to her students as Enfermera Maddy, Crowell graduated from Hope High School and later returned to serve the predominantly Latinx community that she was raised in. “I’m a product of Providence,” Crowell told the Indy. “My whole family lives in Providence, like, right near Roger Williams. And that’s my neighborhood.”

The district removed both Lafreniere and Crowell when their schools implemented School Health Model for Academics Reaching All Transforming Lives (SMART) Clinics, a privately-owned healthcare model focused on embedding integrative health services in schools. In sharp contrast to the rest of Mount Pleasant, which is fairly dated, the SMART Clinic is brand new. The entire facility – virtually indistinguishable from a typical private health clinic – is freshly coated in light blue, and the scented vapor of an aromatic diffuser sifts into the clinic hallway. The SMART clinics can perform many of the roles and responsibilities of a primary care doctor – physicals, immunizations, diagnoses, prescriptions – as well as mental health assistance for faculty, students, and even family members of students regardless of their health insurance or documentation status. 

Ginn Group Consulting (GGC) presents SMART as a “student centered tool to break the cycle of poverty” but has a clear financial motivation – the firm makes revenue from the existence and expansion of SMART clinics. According to Angela Elles, GGC’s director of communications, the firm charges donors, in this case the Rhode Island Foundation, an “agreed-upon flat rate… to implement the SMART Clinic Model.” GGC declined to reveal how much they were paid to implement SMART Clinics in Providence. The firm’s goal, as per their contract with the Providence Public School District  (PPSD), is to “scale across the PPSD as an embedded infrastructure to create a legacy.” GGC has already announced a third clinic at a to-be-determined Providence public school. 

“They painted a beautiful picture,” Crowell said. Both she and Lafreniere voiced support for the initial concept behind the private clinics, and were falsely assured by Superintendent Harrison Peters that their roles would remain the same. However, when the clinics opened, Crowell and Lafreniere began to question the priorities and intentions of the SMART clinics and their director, the for-profit GGC. 

Like both nurses, State Representative David Morales supported implementation of the clinics when the district first discussed them. Now, alongside Representative Sam Bell, he is leading the charge on criticizing their presence. In February, after meeting with the two nurses, Morales and Bell released a statement addressed to Education Commissioner Angélica Infante-Green condemning the private clinics and the displacements of Crowell and Lafreniere. They denounced the district’s undermining of the teachers’ union for their “blatant lack of transparency surrounding for-profit services,” clinic billing of students’ health insurances, attempts to “gain private health information on students,” and distribution of $5 CVS gift cards to students who consented to treatment at the clinic. 

By removing union school nurses and implementing private clinics directed by a for-profit business, the district has fundamentally restructured relationships of care in its public schools. There are now private incentives governing care where there previously were none. All of these concerns emphasize how privatization of healthcare undermines community control of basic medical and mental health services.  

A union-busting private model

A week before the district removed Crowell and Lafreniere from their respective schools, Superintendent Peters and Director of Policy and Planning at the School Board, Yvonne Graf, sent both nurses letters congratulating them on their “new roles” and asking them to confirm them by submitting a resume and application to the Providence Community Health Center (PCHC)/SMART clinic. 

The district chose to keep the Providence Teachers Union – of which both nurses are members – in the dark. Maribeth Reynolds-Calabro, the president of the union, told the Indy, “we have been excluded from the process from the very beginning.” The new roles would have made both nurses subcontractors – half of their paycheck would have come from the school district and the other from the PCHC. This model would have saved the district money while undermining the union’s bargaining power and disempowering its teachers. It is yet another example of austerity policies working to defund education and undermine both community control over healthcare resources and established relationships of care. Crowell and Lafreniere refused to sign the paperwork that would make them part-time subcontractors, a transition that Reynolds-Calabro said would violate their union contracts and undermine their pensions and healthcare. 

The Providence Teachers Union, Crowell, and Lafreniere filed three separate grievances to the school board, citing violations of the nurses’ union contracts and arguing that their removals took away the union’s ability to collectively bargain. On March 17, Crowell and Lafrienere met with the superintendent, a union representative, and a union lawyer in a Zoom meeting room. Here, the school committee insisted that the superintendent has the authority to require the role of the nurse to be a subcontracted one. “They never asked us a question,” Lafreniere told the Indy, “we never spoke, we never said anything. We just sat there.” Their grievance claims were denied by the school board, but will now go to arbitration – the nurses and the school board will choose an arbitrator who will hear their arguments and make a judgement. The union has also filed a Title 16 violation lawsuit against the district and an Unfair Labor Practice Claim that will go before the Labor Board.

Although Roger Williams and Mount Pleasant are the only schools in Rhode Island with SMART Clinics, they are not the first in the country. Gordo Elementary and Gordo High School in Alabama have shared a SMART Clinic since the fall of 2019, but Gordo High’s school nurse, Kandi Dyer, told the Indy that she was never asked to subcontract with the clinics nor told that she would be removed if she refused. Dyer retains the same position and office space – the SMART clinic has its own separate facility. 

However, the school nurse section of the SMART Clinic agreement signed by Melanie Ginn of GGC and Infante-Green reads, “no person or entity within the school shall serve as a gatekeeper between students and a SMART center.” This is a departure from the relationship between the school nurses and the SMART clinic at Gordo Elementary and High School, but the incentive that GGC has to prevent school nurses as ‘gatekeepers’ is clear. The more office visits the clinic books, the more student and faculty insurances they are able to bill, and the more successful the clinic appears, the more likely GGC is to continue receiving donor funding to direct SMART clinics. 

GGC’s school/district application for SMART clinics requires answers to both “How are your school nurses allocated within the district?” and “Do your school nurses belong to a union?” The outcomes at Mount Pleasant High School and Roger Williams Middle School indicate the reasoning behind these questions: to assess how easy it will be for GGC to insert themselves as the first line of care. 

At Oakman Elementary School in Alabama, GGC terminated an initial contract they had with the school from 2016. A nurse in Alabama told the Indy that the SMART Clinic wanted to require students to visit the clinic before they could see a school nurse. But the superintendent and the Alabama Board of Nurses intervened to ensure that the school nurse was the first line of care for students and faculty, at which point the clinic left the school. Regarding the removals of Lafreniere and Crowell in Providence, where the district approved the SMART Clinics as gatekeepers to care, the Alabama nurse told the Indy, “It breaks my heart. [School nurses] do need to be the first line of who that child goes to because she’s probably known them for years.” Another school in the same Alabama district, Aliceville High, also ended their contract with their SMART Clinic in the last few years. GGC’s Angela Elles told the Indy that “the stakeholders at those schools did not continue to operate in fidelity to the SMART model,” but declined to clarify what that meant. Superintendent Jamie Chapman could not be reached for comment as to why both schools terminated their contracts.

Lack of transparency 

The implementation of SMART clinics and the privatization of healthcare in Providence public schools should have been community decisions. Instead, they were institutional choices made by Infante-Green and the district that have thrived in obscurity. In a public letter to Commissioner Infante-Green, Senator Bell and Representative Morales named the “blatant lack of transparency surrounding the for-profit services being offered to students and their families, many of whom are low-income or non-English-speaking.”

SMART Clinic waivers were sent home to students with little to no explanation of what they were. Mount Pleasant senior Aarifah Smith remembers getting the form in the mail and not understanding what exactly it was for. She told the Indy that she did not sign it. “I don’t like signing things I don’t know about,” she said. 

Additionally, students and parents were not universally informed that Lafreniere and Crowell had been removed. “A lot of parents think that we’re still in the schools, taking care of their kids and we’re not,” Crowell told the Indy. Lafreniere still goes to MPHS to conduct COVID testing for the school’s sports teams every Thursday. When she sees her students, they ask her why she left them, as they were never officially notified of her removal or given an explanation. “I leave there and cry everytime I leave,” Lafrienere said. “It feels terrible. It feels like I let them down.”

Concerns regarding both the district and SMART clinics’ lack of transparency were echoed by Enrique Sanchez, a former substitute teacher at Mount Pleasant. In February, Sanchez’s teaching assistant went to the clinic with a headache and was disturbed when clinic staff asked about her health insurance information. Sanchez raised concerns over Twitter about the impact that the privatization of nursing would have on students, teachers, and school nurses. He also questioned why the district and GGC had chosen two schools with some of the largest populations of English language learners – he felt that the clinics and the district were taking advantage of a community they knew would not have the time or resources to hold them accountable. 

Sanchez’s March 2 Tweets read, “I am very disappointed with @pvdschools and @RIDeptEd. They never posted the Zoom links or made the information sessions open to the public in regards to the ‘Smart Clinics’… Parents are currently disengaged with school activities and their students’ academics in the Providence school district. What a complete lack of transparency, professionalism and responsibility for people who actually care about our kids…” The information session to which he referred – on March 2 – was poorly advertised and scheduled for 6:30 PM at Mount Pleasant. The district sent out emails to parents with Zoom information less than three hours before, at 3:55 PM. Clinic staff told Sanchez that only one parent attended.

A week later, on March 10, the district removed Sanchez, and school administrators told him that his recent Tweets had offended a parent. 

Lafreniere, Crowell, Morales and Bell have also denounced the district’s lack of transparency surrounding the access that GGC has to students’ private health information. A memo from GGC to a Providence Public School District (PPSD) official reads, “the SMART Clinic has an agreement with the District that designates the SMART Team as ‘school officials providing institutional services and functions on behalf of Mt. Pleasant High School,’ and therefore they are included in the district FERPA guidelines.” This language is reproduced on the school’s website, and both Lafreniere and Crowell told the Indy that SMART Clinical Operations Manager at GGC, Dr. Tameka Hines, and the School Board’s Yvonne Graf referenced an ‘agreement’ while asking the nurses to provide information on student medical records. However, during a clinic tour and interview with the Indy, Principal David Conrady, PPSD Spokesperson Audrey Lucas, and PCHC Spokesperson Brett Davey all denied any knowledge of the referenced agreement. 

Clinic staff, Dr. Hines, and district administrators also asked the nurses to hand over medical records of students without their individual consents, which both Crowell and Lafreniere refused, as this would have violated federal regulations that protect medical and educational information, namely Health Insurance Portability and Accountability Act (HIPPAA) and Family Educational Rights and Privacy Act (FERPA), respectively. 

In later joint email correspondences with Lucas, Davey, GGC CEO Melanie Ginn and GGC’s Elles, all three parties declined to comment on how the agreement legally grants the clinics access to student medical information without individual parental consent and while in compliance with HIPAA and FERPA. Lucas told the Indy over email that “the consent form signed by the patient or his/her parent or guardian authorizes access to medical records.” It remains unclear what information the SMART clinic has access to, and what legal document grants them the access they claim to have. 

Relationships of Care 

For six years, students would visit Nurse Tammy’s office for medications and screenings, but also if they were struggling with anxiety or needed someone to talk to. Her office on the second floor – which the school converted into a break room for SMART Clinic staff – was usually adorned with seasonal decorations. When the Indyfirst spoke with Lafrienere over Zoom in early March, a paper shamrock dipped in glitter for St. Patrick’s Day hung on the wall behind her. A few years ago, when a student had told her that their parents could not get a Christmas tree that year, Lafrienere hauled one into her office and invited students to decorate the tree with her and eat cookies.

Aarifah Smith told the Indy that Lafreniere was “very good at keeping our mental health together. She was one of the only people we trusted.” A couple years ago, a student with agoraphobia completed an entire school year from the nurse’s office. As the student settled into the space each morning, Ms. Tammy would collect her classwork. Last spring, at the start of the pandemic, Lafreniere and the school social worker delivered groceries and goodie bags with coloring books to students’ homes. And at 10 AM every morning Lafreniere’s alarm still goes off, a reminder to text her former student to take her pills. “I love [my students] like they’re my own,” Lafreniere told the Indy. “It’s not a joke when I say I get told I love you a million times a day.”

Though Crowell had been at Roger Williams for just over a year, she similarly had solidified relationships with her students and their parents. When COVID hit, she too delivered food to students’ families. To honor Crowell’s commitment to her students, she was chosen for a portrait as part of the public art initiative Mi Gente Responde, which expresses gratitude for community healthcare professionals. A pastel banner outside America’s Food Basket on Broad Street features Crowell – or Enfermera Maddy – in pink scrubs and a white lab coat. Crowell still maintains relationships of care with her former students that range from texts with concerned parents to raising money for students’ medical care. “For them to just pluck us out of our schools, with no explanation to our families that the school nurse is no longer in the building is so disheartening.” 

Neither Lafreniere nor Crowell have uncommon relationships with the students and families they serve. Rather, both understand and explain the role of a school nurse as requiring deep care for their communities. “[The clinicians are] wonderful people, and it’s not their fault. But they don’t have the relationship that we have built with these parents,” Crowell told the Indy. “It takes a lot of work to be able to make a parent comfortable having a stranger take care of your kids when they have medical issues.” 

The district’s abrupt removal of Lafreniere and Crowell was an institutional undervaluing of long term reciprocal relationships of care. Displacing these two nurses ruptured established connections and community trust, leaving students feeling abandoned and confused. Even during the week Lafreniere was stationed in the SMART clinic before her removal, the clinicians wouldn’t let her see the kids that came in looking for her. She told the Indy that when one student adamantly refused to see anyone but Nurse Tammy, she had to leave the clinic for a ‘visit’ with him in the locker-lined hallway. Most students were ushered into office visits, for which the SMART center would charge their insurances. 

Provider-Patient Relationships

The removal of school nurses from Mount Pleasant and Roger Williams has meant that all students seeking care must now pass through the SMART center. Revealingly, SMART, PPSD, and PCHC representatives were unable to define what exactly constitutes an office visit and thus when and how much insurances get billed. A SMART clinician at Mount Pleasant told the Indy that visits are determined on a case-by-case basis, meaning a headache could potentially become an office visit if it turns into a consultation. Representatives similarly did not answer how much insurances are being billed, only that billing is done according to “standard protocols.” Before, with a standing order – a parent authorization that allows nurse administration of medicines like Tylenol, Pepto Bismol, and Ibuprofen – students would be treated and sent back to class in minutes. Now, a Mount Pleasant guidance counselor told the Indy, one student visit to the clinic for a headache and an Advil reportedly entailed a call home about insurance and took over 45 minutes. Although picking up sanitary pads does not constitute an office visit, senior Aarifah Smith told the Indy that one of her peers was asked about insurance when she requested a menstrual pad. “I already carried [pads] with me, so after that I really made sure I carried all my stuff with me, including headache medicine” she said. “Who knows what [the SMART Clinic] is going to say or do the next time I need it?” 

For students who have not signed the SMART clinic waiver and who had previously been administered medications by school nurses, care has become more complicated. Crowell told the Indy about a student whose mother refused to sign the waiver. “I’m not signing anything for any clinic, and I don’t want my insurance charged,” she recalled the mom telling her. For situations like these, the nurse at the PPSD school closest to Roger Williams – the Juanita Sanchez Complex – has to travel to the school to administer the medication now that the district removed Crowell. 

The clinic’s style of care cannot be separated from its structure as GGC’s privatized “business model.” The clinic and GGC are forced to balance inward-facing financial priorities and the outward-facing priority of care, and doing so means establishing bureaucratic provider/patient relationships with students. It means questions about insurance and waivers, it means rigid appointment scheduling, and it means billing. Although the clinic guarantees access to students without insurance, just being questioned about healthcare plans when seeking out care can be intimidating, and can feel both detached and invasive. 

The SMART clinic is a private model that provides transactional bureaucratic care and is bound, out of necessity, to GGC and private revenue. While clinic costs are to be covered by Partnership Rhode Island and CVS Health via the Rhode Island Foundation until June 30, 2023, the clinic is operating with the goal of generating enough funds to sustain itself from that date on. A local Alabama paper reporting on the Oakman SMART clinic notes that following the center’s “three year plan,” the clinic “should be self-sustaining… according to GGC.” Elles told the Indy that the revenue that PCHC receives from billing insurance pays for the clinics’ medical supplies and pays the salaries of the clinic staff. 

It makes sense, then, that the clinic denied Lafreniere opportunities to provide care prior to her removal. Student visits to the school nurse are not in the clinic’s financial self-interest, as is pointedly accounted for in the center’s own contract. The privatization of public services – exemplified by the SMART clinics – continues to undermine community relationships and input. 

This tension between private services and public needs reinforces the idea that universal healthcare is necessary. In Rhode Island, the political winds are starting to turn towards this idea – a couple weeks ago, 77 people testified in favor of Rhode Island Senate Bill #0233, which would introduce a statewide Medicare for All system. Their stories totaled over six and a half hours of testimony, but the Senate, led by Josh Miller, voted to hold the bill in committee. While the SMART center does provide healthcare free of charge to students who are uninsured, as well as provide clinical treatments and preventative visits that school nurses couldn’t, at its core the clinic is still tied to corporate interests. Care has become liable to private incentive structures. SMART clinics are a reminder that healthcare at its best is provided publicly, without billing insurances, without copays or deductibles, and with transparent communication. It is at its best when coming from a communal prioritization of healthcare as a human right.

The illustration accompanying this piece is by Mara Jovanović.